Impacto del cambio climático en la salud / The impact of climate change on health

Climate changes evidenced by an increase in our planet's mean temperature, changes in rainfall, increased sea level and extreme weather conditions, favor air and soil contamination, ocean acidification, droughts, floods, heat waves and forest fires, which affect the health and wellbeing of exposed populations. These changes will exert negative effects on respiratory and cardiovascular systems, nutritional status, burden of infectious diseases, especially vector-borne infections, and human mental health. Moreover, environmental damages, such as loss of biodiversity, ecological collapse and deterioration of socioeconomic factors such as agricultural and fishery production, and the loss of habitable land, will impulse massive migrations. This article summarizes the impact that climate change is expected to have on respiratory, cardiovascular and infectious diseases and its repercussions on people of extreme ages. It is imperative to achieve the immediate commitment of worldwide national governments to control green-house gas emissions. The appropriate technology does exist, but political will is urgently needed to accomplish this goal.

Síndrome de Austrian: reporte de caso / Austrian syndrome: report of one case

Austrian syndrome is a triad characterized by pneumonia, meningitis and endocarditis, as a result of a Streptococcus pneumoniae bacteremia. We report a previously healthy 49 year-old male, who consulted at the emergency care unit with a history of one week of pleuritic pain, fever leading to an altered level of consciousness and seizures. A diagnosis of community-acquired pneumonia and meningitis was reached, isolating Streptococcus pneumoniae in the cerebrospinal fluid and blood cultures. Antibiotic treatment was started but the patient had an unsatisfactory response. During hospitalization a new heart murmur was found in the physical examination. An echocardiography was performed and a massive aortic valve insufficiency was found along with vegetations and a perforation of the same valve. The valve was replaced by a prosthetic one and the patient responded satisfactorily to the surgical and antibiotic treatment, without complications.

Endocarditis marántica como presentación de cáncer de páncreas: caso clínico / Non-bacterial thrombotic endocarditis: report of one case

Marantic or nonbacterial thrombotic endocarditis is characterized for the presence of vegetations formed by a meshwork of fibrin and other cellular material similar a blood clot, without the presence of microorganisms. It is often related with tumors and chronic inflammatory states. We report a 49 years old female with a history of weight loss and asthenia, presenting with multiple cerebrovascular attacks and fever. Blood cultures were negative and the fever did not subside with antibiotic treatment. Trans esophageal echocardiogram showed a mitral valve vegetation and thickening of the free edge of both leaflets. In search of the etiology of such a case, a primary pancreatic cancer with distant metastases was found. We cannot rule out the differential diagnosis with bacterial endocarditis with negative blood cultures, although the clinical context supports a non-infectious etiology.

Logro de metas de prevención secundaria, prescripción farmacológica y eventos cardiovasculares mayores en pacientes con enfermedad coronaria / Achievement of cardiovascular prevention goals, pharmacologic prescription and major cardiovascular events among patients with coronary disease

Background: Implementation of health programs to reduce cardiovascular risk, are needed for secondary prevention of cardiovascular diseases. Aim: To evalúate achievements of secondary prevention goals, pharmacologic prescription and major cardiovascular events in patients with coronary artery disease. Material and Methods: Patients who had a first event of acute coronary syndrome, angioplasty or revascularization surgery, between January 2008 and June 2010, were contacted for a clinical and laboratory evaluation between June and October 2011. Results: Seven hundred and two medical records were reviewed and 245 eligible patients were identified. Ofthese, we assessed 202 patients aged 64 ± 10 years (70% males). Sixty seven percent had two ormore cardiovascular riskfactors. A goal ofHDL cholesterol level over 40 mg/dL was achieved in 91 % of patients, smoking cessation in 84% and a total cholesterol < 200 mg/dL in 66%. A blood pressure below 130/85 mm Hgwas achieved in 30% of patients, a normal BMI in 19% and LDL cholesterol levels below 70 mg/dL in 18%. At the moment of assessment, 87%> were using aspirin, 78%> statins, 74% angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists and 66%o were using β - blockers. Twenty two percent of patients had a major cardiovascular event during the follow up, which lasted 28 ± 8 months. Conclusions: A low percentage of cardiovascular goals achievement was observed in this sample of patients, with a high prevalence of overweight and obesity. A high percentage quit smoking after their first cardiovascular event. Despite the high percentage of drug prescription, hypertension and dyslipidemia were not fully controlled.

Factores asociados a síndrome metabólico en la comuna de Temuco, Chile / Risk factors for metabolic syndrome in a case control study in Temuco, Chile

Background: Metabolic syndrome is becoming an important public health problem in affluent societies. Aim: To identify factors associated to metabolic syndrome in a Southern Chilean city. Material and methods: Using a case control design, 200 participants, aged 35 to 70 years with at least three criteria for metabolic syndrome according to the National Cholesterol Education Program (NCEP_ATPIII) and 200 subjects with less than three criteria, were studied. Both groups were compared in terms of ethnic background, educational level, family history of diabetes and coronary artery disease, menopausal status, smoking, stress and depression, physical activity, changes in body mass index in the last five years and diet. Results: Among subjects aged more than 54 years, among males and among overweight individuals, having a Mapuche origin was a risk factor with odds ratios (OR) of 7.2; 88 and 3.9 respectively. Among subjects aged more than 54 years, among women and among overweight individuals, a family history of diabetes was a risk factor with OR of 17.7; 3.2 and 3.9 respectively. Among subjects aged more than 54 years and among women a change in body mass index of more than three points was a risk factor with OR of 12.5 and 7.4, respectively. Depression also was a risk factor among subjects aged more than 54 years (OR 3.3). Regular consumption of wine was a protective factor among participants of more than 54 years, with an OR of 0.17. Conclusions: The risk factors for metabolic syndrome detected in this group of participants, were having a Mapuche origin, a family history of diabetes mellitus and depression. Wine consumption was associated with a lower risk.

Impacto del plan AUGE en el tratamiento de pacientes con infarto agudo al miocardio con supradesnivel ST, en hospitales chilenos / The impact of Chilean health reform in the management and mortality of ST elevation myocardial infarction (STEMI) in Chilean hospitals

Background: In 2005 the Chilean government started a health care reform (AUGE) that guarantees medical treatment for acute myocardial infarction. Aim: To quantify the impact ofAUGE on the management and inhospital mortality of STEMI in a group of Chilean hospitals. Material and methods: Three thousand five hundred and forty six patients with STEMI from 10 hospitals that perform thrombolysis as the main reperfusion therapy were analyzed. We compared demographic and clinical characteristics, hospital treatments and revascularization proceduresin two periods: before (2,623 patients) and after AUGE implementation (906 patients). Logistic regression was used to assess inhospital mortality according to AUGE in the entire sample and stratified by risk groups. Results: We found no differences in demographic and clinical characteristics between the two groups. During AUGE threre was a significant increase in the use of thrombolysis (50 percent to 60.5 percent), which was associated to an increase of hypotension from 29 percent to 35 percent (p <0.02) and minor bleedings, from 1.6 percent to 3.4 percent (p <0.001). After A UGE there was a significant increase in the use ofbeta blockers (65 percent to 75 percent), angiotensin converting enzyme inhibitors (70 percent to 76 percent), statins (48 percent to 58 percent), and aspirin (96 percent to 97.5 percent) (p <0.05). Global inhospital mortality decreased from 12.0 percent to 8.6 percent (p <0.003) and from 10.6 percent to 6.8 percent (p <0.005) in patients treated with thrombolytics. The adjusted odds ratio for inhospital mortality comparing after and before AUGE, was 0.64 (IC 95 percent, 0,47-0.86). Conclusions: The implementation ofAUGE has been successful in reducing inhospital mortality of STEMI This has been achieved through a better use of evidence based medicine and reperfusion strategies.

Consenso elaborado por la Sociedad Chilena de Endocrinología y Diabetes sobre resistencia a la insulina(RI) y síndrome metabólico (SM): aspectos clínicos y terapéuticos / Chilean society of endocrinology and diabetes consensus on clinical and therapeutic aspects of insulin resistance and metabolic syndrome

Background: The concept insulin resistance as the basis for a series of metabolic alterations and diseases was introduced by Gerald Reaven in 1988, when he described a cluster of alterations that named syndrome X. Aim: To review and discuss the present information about insulin resistance (IR) and metabolic syndrome (MS). Material and methods: The IR concept is defined,the affected metabolic ways, its consequences and relationship with different diseases are presented. The importance of central obesity with its metabolic, inflammatory and prothrombotic consequences playing a key role in cardiovascular risk, is discussed. The cluster of factors focused on cardiovascular disease and eventually diabetes is named MS. Several definitions of MS are analyzed and compared. A proposition is made about the definition to be used in the Chilean population. Differences between IR syndrome and MS are discussed. Diagnostic methods of IR and MS are presented, recommendations are made about their usefulness and reliability. Non pharmacological and pharmacological treatments of IR and MS are analyzed. Other related diseases, such as polycystic ovary syndrome, non alcoholic steatohepatitis and sleep apnea are discussed. Conclusions. Until further studies are made to define a local waist circumference cut-off associated with high risk, the ATPIII MS definition is preferred. A clinical approach is recommended for diagnosis. A search for all components of the MS is important. There is no evidence about the benefits of MS treatment on the prevention of cardiovascular diseases or diabetes. Evidence supports the use of lifestyle changes and some drugs, such as metformin on the prevention of diabetes in prediabetic states.

Factores asociados al uso de anticonceptivos en estudiantes de enseñanza media de la comuna de Temuco / Associated factors with the use of contraceptives in secondary school students from the commune of Temuco

Objetivo: Conocer la práctica sexual de los adolescentes en la comuna de Temuco, uso de anticonceptivos, razones de no uso y factores relacionados. Método: Estudio de corte transversal. Se utilizó muestreo por conglomerados, estratificando proporcionalmente por tipo de establecimiento en 698 estudiantes. Se aplicó un cuestionario anónimo y autoadministrado. Resultados: El 35,4 por ciento manifiesta haber tenido alguna vez relaciones sexuales, la edad de inicio promedio en mujeres fue 15,5 años y en hombres 14,3 (p=0,000), de éstos el 37 por ciento manifiesto haber usado un método en su primera relación sexual. El 17 por ciento de los estudiantes refiere actividad sexual actual, 41,9 por ciento en mujeres y 58,1 por ciento en hombres, diferencias significativas (p=0,013); de este grupo, el 51,2 por ciento usa algún método anticonceptivo (p=0,000). Entre las razones de no uso destacan: relaciones sexuales imprevistas, "no se le ocurrió", vergüenza de solicitarlos en farmacias o consultorios y falta de dinero para adquirirlos, falta de conversación con la pareja y percepción de invulnerabilidad frente a un embarazo. Conclusiones: Se observa tendencia a la disminución del inicio precoz de las relaciones sexuales; asimismo ausencia de protección anticonceptiva en la primera relación sexual. El uso de métodos anticonceptivos es mayor a lo reportado en otros estudios chilenos; factores relacionados con la pareja y la conversación con profesionales de salud se asocian al uso, mostrando el rol de los agentes de salud en la prevención de riesgos en la salud sexual y reproductiva.

Objective: To know sexual practice of adolescents in the commune of Temuco, use of contraceptives, related reasons of nonuse and factors. Method: Cross section study. A sampling by conglomerates was used, stratifying proportionally by type of establishment, obtaining 698 students. An anonymous and self administrated questionnaire was applied. Results: 35.4 percent declare to have had sexual relations, the average age of beginning in women was 15.5 years and in men 14.3 (p=0.000) and, of these only 37 percent declare to have used a contraceptive method in their first sexual relation. 17 percent of the students refer to having sexual activity at present, 41.9 percent in women and 58.1 percent in men, being this statistically significant differences by sex (p= 0.013); of this group, 51.2 percent use some contraceptive method (p=0.000) Some of the reasons for not using, we can emphasize: unexpected sexual relations, "it was not thought of", shame to ask for them in pharmacies or doctor's offices and lack of money to acquire them, lack of conversation with the partner and perception of being invulnerable against a pregnancy. Conclusions: A tendency is observed to the diminution of precocious beginning of sexual relations in adolescents, also absence of contraceptive protection in the first sexual relation. The use of contraceptive methods is greater than those reported in other Chilean studies, factors related to the partner and conversations with health professionals are associated to their use, relieving the roll of health agents in the prevention of risks of sexual and reproductive health.

Utilidad de la terapia trombolítica con estreptokinasa a dosis baja en infarto agudo del miocardio / Usefulness of thrombolytic therapy with low doses of streptokinase in acute myocardial infarction

Background: The optimal dose of Streptokinase in the treatment of acute myocardial infarction is not well established. Apparently, the thrombolytic efficacy would not increase with doses over 750.000 units. Aim: To compare the effectiveness and safety of treatment with low doses of Streptokinase, ranging from 500.000 to 750.000 units, in patients with ST elevation acute myocardial infarction. Patients and methods: From September 1993 to September 1998, the GEMI register of patients with acute myocardial infarction, was carried out in 37 hospitals, incorporating 4,938 patients. Of these, 1,631 patients received streptokinase. According to the administered dose of Streptokinase, patients were divided in two groups: 1,465 patients who received 1.5 millions U in 60 minutes (classical therapy group), and 166 patients with ischemic chest discomfort and either ST-segment elevation or left bundle-branch block on the electrocardiogram, who received 500.000 to 750.000 U streptokinase administered in no more than 30 minutes, with heparin, within 0 to 6 hours of symptom onset. Successful reperfusion, mortality, complications, and hospital outcome was evaluated in both groups. Results: The low dose group of patients had a better reperfusion criteria profile. No differences between groups were observed in patient evolution, mortality, maximum Killip classification, post myocardial infarction heart failure, ischemic complications, arrhythmias or mechanical complications. Conclusions: These results suggest that streptokinase in low doses is at least as effective as classical therapy, in the treatment of ST elevation acute myocardial infarction.

Cambios en el manejo intrahospitalario del infarto del miocardio en hospitales chilenos / Changes in the in-hospital treatment of the acute myocardial infarction in chilean hospitals

Antecedentes: En comunicaciones anteriores se han descrito los cambios en el tratamiento y la evolución del infarto del miocardio (IAM) intrahospitalario durante 2 período de registro en Chile. Objetivo: Evaluar los cambios en el tratamiento farmacológico y las terapias de reperfusión en pacientes con IAM que ingresaron durante 2001 en la red GEMI. Métodos: El registro 2001 (R3) se efectuó entr marzo y diciembre en 23 hospitales de Santiago y regiones. Fue comparado con los registros 93-95 (R1) y 97-98 (R2). Se recolectó información sobre características demográficas, el tratamiento y la evolución intrahospitalaria de los pacientes que ingresaron con el diagnostico de IAM. Resultados: En R3 se incluyeron 1.091 pacientes, cuya edad promedio fue 63 ± 13 años. El 70,4 por ciento fueron hombres. La frecuencia de uso de los medicamentos en R1, R2 y R3 fue respectivamente: aspirina 93 por ciento, 96,1 por ciento y 94,7 por ciento (p=ns); I-ECA 32 por ciento, 53 por ciento y 60 por ciento (p=ns); bloqueadores 37 por ciento, 55,2 por ciento y 60,9 por ciento (p=ns); heparina 59 por ciento, 55 por ciento y 43,5 por ciento (p=ns): nitratos iv 59 por ciento, 67,6 por ciento y 63,7 por ciento (p=ns); antagonista del calcio 23 por ciento, 12,4 por ciento y 6,2 por ciento (p <0,01); trombolíticos 33 por ciento, 33,7 por ciento y 32, por ciento. La angioplastía primaria no se efectuó en R1, pero R2 y R3 fue utilizada en el 9,5 por ciento y el 7,5 por ciento de los pacientes respectivamente. La mortalidad intrahospitalaria fue de 11,6 por ciento durante 2001, comparada con el 10,8 por ciento y el 13,4 por ciento obtenida en los registros 97-98 y 93-95. Conclusión: Se aprecia un aumento de la utilización de los I-ECA y (bloqueadores, fármacos de demostrada eficacia para reducir mortalidad en el IAM. Es racional la reducción del uso del calcio antagonista y probablemente la de antiarrítmicos. No se modifica el empleo de trombolíticos y la angioplastía primaria no aumenta debido a que está limitada a algunos hospitales. Se debe continuar estimulando el uso de terapias que mejoren el pronóstico de los pacientes con IAM, especialmente las orientadas a la reperfusión.

La digoxina es efectiva en el tratamiento de pacientes con insuficiencia cardíaca y ritmo sinusal / Digoxin is effectiveness in the treatment of cardiac failure and sinus rhythm patients

Due to differences in treatment effect in studies on the effectiveness of digoxin in patients with congestive heart failure in sinus rhythm, a cross-over placebo-controlled randomized double blind clinical trial was performed. Thirty one patients, without previous treatment with digoxin, in New York Heart Association (NYHA) functional class II to IV, with a dilated left ventricle and/or ventricular systolic dysfunction were included. Patients received digoxin, adjusted for blood levels, or placebo, during an 8 week period, prior to crossing over to the other treatment for another 8 weeks. The order of tretments was randomly allocated. Outcome measurement were performed at the end of each 8 week period. Digoxin, compared with placebo, improved NYHA class, 6,9 por ciento vs 41.4 por ciento (p=0.013) and increased the treadmill exercise time, 406 ñ 204 s vs 484 ñ 185 s (p=0.003). During the digoxin treatment the left ventricular and systolic diameter was reduced from 52.9 ñ 8.9 to 50.1 ñ 9.7 mm (p=0.009). No significant difference was observed in the left ventricular end diastolic diameter (LVED) of the left ventricle and in a estimation of quality of life. In conclusion, digoxin treatment produced a significant improvement in functional capacity, exercise time and left ventricular performance