Análisis de las Carreras del Ambito de la Salud en Chile

Este artículo entrega una visión de las carreras relacionadas a la salud que se estan impartiendo en Chile. No compara entre distintas casas de estudio pero aporta datos importantes.

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Medicina y otras Carreras de la Salud en Chile: Un análisis preliminar.
MEDINA L, Ernesto y KAEMPFFER R, Ana María.
Rev. méd. Chile, oct. 2007, vol.135, no.10, p.1346-1354

Background: During 2006, Chilean universities had 586,000 students, corresponding to 41% of the population aged 18 to 23 years. Aim: To evaluate the situation of health care teaching in Chile. Material and Methods: Data from 6,212 careers were elaborated, considering the area of knowledge taught, level of teaching, geography, number and type of students, admission and tuition fees. Results: There are 537 programs for health care teaching in Chile. Of these, 231 are for nursing or dentistry aide personnel. The system has 60,648 matriculated students and it collected a total of US$250 millions in tuition fees. Only 9,8% of programs are accreditated. The students who chose health careers had the highest scores in the National University Selection Examination or PSU. Between 2000 and 2006, there was a significant increase in the number of medical students and every year, 1,000 new physicians will receive their title. During 2007, 1,634 new posts were offered in medical schools, 3,873 in nursing and 5,671 for kinesiology. Conclusions: There is a disharmonic growth of University teaching in Chile, that will solve historical deficits of professionals such as nurses but will introduce important changes in Chilean medicine

Hipotensión Permisiva: Un Concepto Que Toma Fuerza en el Manejo del Trauma

La editorial de este mes de la Revista Española de Cirugía toca este tema. Aparecen referencias "clásicas" de trabajos que estan mostrando que en ciertas situaciones hay mejores resultados con aporte juicioso de volumen en pacientes con trauma penetrante y contuso.

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Enfermedad Diverticular

Revisión publicada en noviembre de este año en New England Journal of Medicine donde se toca varios aspectos de esta patologia incluyendo la clasificación de Hinchey.

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Algo Más Que Sólo Medicina

Una serie de trabajos publicados en la edición navideña de BMJ aborda una serie de temas que rodean a la medicina en la vida diaria y trata de analizarlos con una vision alternativa. Toca temas como: Mitos médicos (las uñas no crecen después de la muerte o utilizamos más del 10% de nuestro cerebro), terminos "coa" en la medicina, etc.

http://www.bmj.com/cgi/reprint/335/7633/1293

Reflexiones en Torno a la Apendicitis Aguda

Appendectomy: Negative Appendectomy No Longer Ignored
Tetsuji Fujita, MD; Katuhiko Yanaga, MD
Arch Surg. 2007;142(11):1023-1025.

Early appendectomy has been the treatment of choice for patients with confirmed or suspected acute appendicitis. The surgical residents have been taught that although observation may reduce the rate of unnecessary appendectomy, such a policy will increase the rate of perforation, which undoubtedly results in increased morbidity and mortality. Whereas appendectomy has been a safe procedure with a mortality rate of 0.4% to 0.08% for uncomplicated appendicitis,1-2 in some series perforated appendicitis is associated with an unacceptable mortality rate as high as 12%.1 For patients with acute appendicitis, therefore, the perforation rate has been used as an index of quality of care. In a recent study, the association between time from the onset of symptoms and risk of appendiceal rupture was retrospectively studied in 219 patients who had undergone appendectomy for pathologically proven appendicitis.3 The risk was negligible within the first 24 hours.

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Trasplante Facial: Reporte Tras 18 Meses del Primer Caso

Outcomes 18 Months after the First Human Partial Face Transplantation
Jean-Michel Dubernard et al.
N Engl J Med 2007; 357(24):2451-60

Background
We performed the first human partial face allograft on November 27, 2005. Here we report outcomes up to 18 months after transplantation.

Methods
The postsurgical induction immunosuppression protocol included thymoglobulins combined with tacrolimus, mycophenolate mofetil, and prednisone. Donor hematopoietic stem cells were infused on postoperative days 4 and 11. Sequential biopsy specimens were taken from a sentinel skin graft, the facial skin, and the oral mucosa. Functional progress was assessed by tests of sensory and motor function performed monthly. Psychological support was provided before and after transplantation.

Results
Sensitivity to light touch, as assessed with the use of static monofilaments, and sensitivity to heat and cold had returned to normal at 6 months after transplantation. Motor recovery was slower, and labial contact allowing complete mouth closure was achieved at 10 months. Psychological acceptance of the graft progressed as function improved. Rejection episodes occurred on days 18 and 214 after transplantation and were reversed. A decrease in inulin clearance led to a change in immunosuppressive regimen from tacrolimus to sirolimus at 14 months. Extracorporeal photochemotherapy was introduced at 10 months to prevent recurrence of rejection. There have been no subsequent rejection episodes. At 18 months, the patient is satisfied with the aesthetic result.

Conclusions
In this patient who underwent the first partial face transplantation, the functional and aesthetic results 18 months after transplantation are satisfactory

Congreso Chileno de Cirugía 2008

Modelo Experimental de Efecto de Perforación Intestinal en ETCO2 Durante Laparoscopía

Effect of Small Bowel Perforation During Laparoscopy on End-Tidal Carbon Dioxide: Observation in a Small Animal Model
Shmuel Avital, Roye Inbar M, Ron Ben-Abraham, Samuel Szomstein, Raul Rosenthal, Yehuda Sckornik and Avi Weinbroum.
Journal of Surgical Research 2007; 143(2): 368-71

Introduction
There are currently no reports in the literature regarding changes in end-tidal carbon dioxide (ETCO2) when the small bowel is deliberately or inadvertently perforated during laparoscopic surgery. The aim of this study was to assess the influence of small bowel perforation during laparoscopy on ETCO2 in a rat model.

Materials and methods
Two groups of Wistar rats (n = 8/group) were anesthetized, tracheostomized, and mechanically ventilated at a fixed tidal volume and respiratory rate. After a stabilization phase of 30 min, CO2 pneumoperitoneum was established to 5 mmHg in one group and 12 mmHg in the other group, and maintained for 30 min. A small bowel perforation was then created and pneumoperitoneum was reestablished for another 30 min. Blood pressure, heart rate, peak ventilatory pressure, and ETCO2 were recorded throughout the experiment.

Results
No significant changes in blood pressure throughout the experiment were noted in either group. The ventilatory pressure increased in both groups after the induction of pneumoperitoneum. In the 5 mmHg group, there was a modest increase in ETCO2 following the induction of pneumoperitoneum (from 39.4 ± 1.9 to 41.1 ± 1.4, P = 0.014), and a further increase following the small bowel perforation (from 41.1 ± 1.4 to 42 ± 0.8, P = 0.007). In the 12 mmHg group, there was no change in ETCO2 after the induction of pneumoperitoneum; however, there was a substantial increase in ETCO2 following bowel perforation (35.0 ± 2.0 to 49.8 ± 7.1, P = 0.002).

Conclusions
ETCO2 increases when the small bowel is perforated during CO2 pneumoperitoneum. This increase seems more substantial under higher pneumoperitoneal pressures. Small bowel injury may enable the diffusion of CO2 through the bowel mucosa, causing ETCO2 elevation. Therefore, an abrupt increase in ETCO2 observed during laparoscopy may indicate small bowel injury.

Autotransfusión Intraoperatoria en Cirugía de Aneurisma de Aorta Abdominal

Intraoperative Autotransfusion in Abdominal Aortic Aneurysm Surgery:
Meta-analysis of Randomized Controlled Trials
Hisato Takagi; Seishiro Sekino; Takayoshi Kato; Yukihiro Matsuno; Takuya Umemoto.
Arch Surg. 2007;142(11):1098-1101.

Objective
To determine whether intraoperative autotransfusion reduces the percentage of patients undergoing allogeneic blood transfusion.

Data Sources and Study Selection
Using a public domain database (MEDLINE) and a Web-based search engine (PubMed), all intraoperative autotransfusion vs control prospective randomized controlled trials that enrolled patients undergoing elective infrarenal abdominal aortic aneurysm surgery, published between January 1, 1966, and November 30, 2005, were searched. Relevant studies were identified through a manual search of secondary sources including references of initially identified articles.

Data Extraction
Data on detailed inclusion criteria, autotransfusion system type, and incidence of allogeneic blood transfusion were abstracted from each study. Sensitivity analyses were performed by excluding individual trials one at a time and recalculating the pooled risk ratio estimates for the remaining studies.

Data Synthesis
Our search identified 4 randomized controlled trials including data for 292 patients. Pooled analysis demonstrated a statistically significant 37% reduction in risk of allogeneic blood transfusion with intraoperative autotransfusion compared with control (risk ratio, 0.63; 95% confidence interval, 0.41-0.95; P = .03) in a random-effects model. There was statistically significant trial heterogeneity of results (P = .02) but no evidence of statistically significant publication bias (P = .497). Two of 4 sensitivity analyses demonstrated statistically nonsignificant results favoring intraoperative autotransfusion.

Conclusion
Based on a meta-analysis of available randomized controlled trials, intraoperative autotransfusion reduces risk of allogeneic blood transfusion in elective infrarenal abdominal aortic aneurysm surgery.

Prevención de Infecciones por Cateteres Venosos Centrales

Artículo publicado en el número de diciembre de Contemporary Surgery. Da un resumen de recomendaciones para disminuir el riesgo de infecciones por CVC.

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Capacidad para Tomar Decisiones: Diferencias entre Médicos y Abogados

La noción de capacidad de la persona para tomar decisiones, en la práctica médica y legal
Gladys Bórquez, Gina Raineri, Nina Horwitz, Gabriela Huepe.
Rev Méd Chile 2007; 135: 1153-9

La existencia de una relación diferente entre el enfermo y el profesional de la salud, que enfatiza la deliberación y participación conjunta, traduce en el proceso de consentimiento informado. Así, todo paciente bien informado es capaz de tomar todas las decisiones que lo afectan en su vida y en su salud. En este contexto, una decisión es autónoma cuando cumple tres condiciones: voluntariedad, información y capacidad, siendo la capacidad la más difícil de evaluar.
La capacidad en salud, definida como la aptitud para desempeñar una tarea específica, en el caso de los pacientes se refiere a tomar decisiones respecto al diagnóstico, tratamiento, pronóstico y cuidado de su enfermedad. De acuerdo con la gravedad de la decisión a tomar, varían las exigencias de los estándares a medir. En la práctica se confunde la capacidad para tomar decisiones en el ámbito médico y legal, lo que es de suma importancia para las personas, toda vez que la consecuencia de ser declarado incapaz, es el impedimento de seguir ejerciendo ese derecho tan personal. Esta tarea, dependiendo del caso al que nos enfrentemos, le es entregada a un tercero, que puede serlo de forma transitoria o definitiva, dependiendo de su situación legal.
En una publicación anterior, realizamos una extensa revisión de la reglamentación sanitaria y legal vigente en Chile en torno al tema de la capacidad, con relación a los menores de edad, ancianos y enfermos mentales, marco que ha guiado el planteamiento del presente estudio. La relevancia de investigar empíricamente este problema es crucial, cuando en nuestra sociedad se está revisando la legislación en temas que dicen relación con la sexualidad, la salud, la vida y la muerte.
El presente estudio explora cómo se concibe y evalúa la capacidad de las personas para tomar decisiones en la práctica médica y legal en nuestro país, dando cuenta de los siguientes objetivos específicos: identificar la noción de capacidad para tomar decisiones entre médicos y abogados; identificar los procedimientos utilizados en la práctica médica nacional para estos efectos y conocer cuáles son las diferencias para evaluar la capacidad en los grupos de menores, ancianos y pacientes con problemas de salud mental.

http://www.scielo.cl/pdf/rmc/v135n9/art09.pdf