Educación participativa de adultos: el modelo dialogante de Jane Vella: experiencia en Chile / Participative adult education: Jane Vella's dialogue model

Este artículo presenta el modelo de educación de adulto de Jane Vella y su impacto en Chile. Este modelo se origina en las experiencias educativas en África de la Dra Vella y ha sido refinado con su aplicación en distintos ámbitos en distintos países, desde lo comunitario hasta lo universitario. Este es un método ecléctico basado en diversas teorías psicológicas, antropológicas y educativas a partir de las cuales ella integra principios y prácticas en un todo armónico y con sentido. El método habilita para planear, diseñar, ejecutar y evaluar procesos de aprendizaje efectivos en los espacios más diferentes, con aprendices y facilitadores de los más diversos orígenes, preservando sí el eje del proceso: el cuidado a las personas en su dignidad y su libertad. Quizás eso es la razón de su éxito.

We present in this article Jane Vella’s adult education model and its impact in Chile. This model originated in the African experience of Dr. Vella and was refined in community and academic settings in many countries. It is an eclectic method based on diverse psychological, anthropological and educative theories, from which she derives integrated principles and practices. The method enables one to plan, organize, execute and evaluate effective learning processes and sessions in a variety of settings with facilitators and learners from a wide variety of backgrounds. In every circumstance an axis is preserved, the gentle care of persons, real subjects of learning, in dignity and in freedom. Perhaps this is the reason for its success.

Análisis de costo efectividad de un programa preventivo de enfermedad vesicular en Chile / Cost effectiveness analysis of a screening program for gallbladder disease in Chile

Background. Chilean women have one of the highest mortality rates from gallstone disease in the world. There is no primary prevention for the disease and the benefits of prophylactic cholecystectomy in high risk groups have not been studied. Aim: To analyze the cost and effectiveness of a screening program for gallbladder disease in the Chilean women population. Methods. A decision analytic model is used to compare lifetime cost and effectiveness of standard care with three screening strategies. The first two strategies consider "universal ultrasound screening" for all women 40 years old and laparoscopic cholecystectomy for those with gallstones ("elective intervention") or with calculous ü3 cm ("high risk intervention"). The third strategy is based on "selective screening" for obese women. Results. The lifetime probability of a 40 years old Chilean woman of dying from gallbladder disease is reduced by 70 percent in the universal screening/elective intervention, by 63 percent in the high risk intervention and by 18 percent in the selective screening strategy. Her lifetime expectancy increases by 5.25, 4.64 and 1.24 months respectively. The incremental cost-effectiveness ratio of each screening strategy is US$ 180, US$ 147 and US$ 481 respectively. Conclusion. A screening program for gallbladder disease in a high risk population achieves significant benefits at a low incremental cost and acceptable cost-effectiveness

Alta prevalencia de enfermedad tiroidea subclínica en sujetos que concurren a control de salud / High prevalence of subclinical thyroidal disease among individuals attended in occupational health examinations

Background: There is no information about the prevalence of thyroidal diseases in the general Chilean population. Aim: To assess the prevalence of thyroidal diseases in individuals attended in occupational health examinations. Subjects and methods : Four hundred seventy two individuals were examined between 1998 and 1999. In all, serum levels of thyroid hormones, TSH and anti thyroidal antibodies (anti microsomal, anti thyroid peroxidase and anti thyroglobulin) were measured. Results: Forty four subjects were excluded from the study due to an incomplete medical record and 18 due to a personal history of thyroidal disease. Abnormal serum levels of thyroid hormones or TSH were detected in 28 subjects (6.8 percent). Four (1 percent) had hypothyroidism, 23 a subclinical hypothyroidism (5.6 percent) and one (0.2 percent) had hyperthyroidism. In 87 subjects (21.2 percent) at least one of the antibodies was positive. Positive anti thyroid antibodies were found in 14 of 28 subjects (50 percent) with abnormal thyroid hormone levels, compared with 73 of 382 subjects (19.1 percent) with normal thyroid hormone levels. Thyroid dysfunction was twice as frequent in women than in men. Conclusions: In this sample, a 6.8 percent prevalence of abnormal thyroid function tests was detected

Exceso de mineralocorticoides en hipertensos esenciales: enfoque clínico diagnóstico / Evidences for mineralocorticoid excess in essential hypertension: clinic and diagnosis viewpoint

Background: Primary hyperaldosteronism is more frequent among subjects with essential hypertension than previously thought. The prevalence, according to local and international evidence could fluctuate between 9 and 10 percent. Aim: To investigate if subjects with essential hypertension have different aldosterone and renin plasma levels than normotensive subjects. Patients and methods: One hundred twenty five subjects with essential hypertension, not receiving medications for at least two weeks prior to the study and 168 age and sex matched normotensive controls were studied. Blood was drawn between 9 and 10 AM during a sodium free diet to determine plasma aldosterone, plasma renin activity and potassium. Results: Plasma aldosterone was higher in hypertensive subjects than controls (11.6 ñ 7.6 and 9.9 ñ 5.1 ng/dl respectively; p=0.04). Plasma renin activity was lower in hypertensives than controls (1.42 ñ 1.28 and 1.88 ñ 1.39 ng/ml/h respectively; p<0.001). Thus, plasma aldosterone/plasma renin activity ratio was higher in hypertensives (13.8 ñ 13.5 and 8.3 ñ 7.8; p<0.001). A pathological ratio was defined as over 25, corresponding to the mean plus two standard deviations of the control group. Primary hyperaldosteronism was found in 5/125 hypertensives (4 percent) and 1/168 normotensive subject (0.6 percent). None had hypokalemia. Conclusions: Subjects with essential hypertension have higher plasma aldosterone and lower plasma renin activity than normal controls. A plasma aldosterone/plasma renin activity over 25 was defined as abnormal

Alta prevalencia de hiperaldosteronismo primario no diagnosticado en hipertensos catalogados como esenciales / High prevalence of undiagnosed primary hyperaldosteronism among patients with essential hypertension

Background: Classically, primary hyperaldosteronism was diagnosed in no more than 1 percent of patients with hypertension, when hypokalemia was used as the screening test. However, numerous patients with primary hyperaldosteronism do not have hypokalemia and the disease remains undiagnosed. Aim: To assess the prevalence of normokalemic primary hyperaldosteronism among patients classified as having essential hypertension. Patients and methods: One hundred hypertensive patients with a blood pressure over 145/95 were studied. Plasma aldosterone and plasma renin activity were measured in all. A primary hyperaldosteronism was diagnosed when high aldosterone levels (over 16 ng/dl) and low plasma renin activity (below 0.5 ng/ml/h) coexisted in two blood tests or the aldosterone/plasma renin activity ratio was over 50. A probable primary hyperaldosteronism was diagnosed when the ratio was between 25 and 50 and these patients were subjected to a Fludrocortisone test to confirm the diagnosis. A dexametasone suppression test was done to discard glucocorticoid remediable aldosteronism. An adrenal TAC scan was done to all patients with primary hyperaldosteronism. Results: A diagnosis of primary hyperaldosteronism was reached in ten patients. Seven had elevated aldosterone and low plasma renin activity. In three the diagnosis was confirmed with the fludrocortisone test. All ten patients had normal serum potassium levels. Dexametasone suppression test was positive in three patients, that normalized their blood pressure levels. Adrenal TAC scans showed an adenoma in one patient and hyperplasia in another. Conclusions: Primary hyperaldosteronism is more frequent than previously thought, it is overlooked when hypokalemia is used as the screening test and it can only be diagnosed measuring plasma aldosterone and renin activity

Hipertensión arterial y mineralocorticoides: utilidad de las mediciones de renina y aldosterona / Hypertension and mineralcorticoids: usefulness of renin and aldosterone measurements

Recently, some genetic forms of hypertension have been well characterized. These forms can be globally called mineralocorticoid hypertension and are due to different alterations of the renin-angiotensin-aldosterone system (SRAA). Among these, classic primary hyperaldosteronism and its glucocorticoid remediable variety, in which hypertension is secondary to aldosterone production, must be considered. There are also conditions in which mineralocorticoid activity does not depend on aldosterone production. These conditions generate a hyporeninemic hyperaldosteronism, observed in Liddle syndrome, apparent mineralocorticoid hypertension, 11- and 17-hydroxilase deficiency, among others. The detection of these forms of hypertension is only feasible if the renin-angiotensin-aldosterone system is assessed, measuring renin and aldosterone levels. This article reviews these forms of hypertension, their clinical workup and their relevance in the usual hypertensive patients

El programa de medicina familiar y comunitaria de la Pontificia Universidad Católica de Chile: historia, proceso y productos / The family and community medicine program of the Pontificia Universidad Católica de Chile: history, process and products

Este artículo describe el proceso y productos de la implementación de un programa de postítulo orientado a la comunidad, de la Pontificia Universidad Católica de Chile (PUC). El programa de Medicina Familiar y Comunitaria de la PUC comienza en mayo en 1993. El surgimiento del nuevo programa se vio motivado por factores externos e internos, por ejemplo: la transición epidemiológica, el Ministerio de Salud, iniciativas internacionales, médicos recién egresados de la PUC, cambios curriculares y experiencias anteriores en salud comunitaria de la PUC. Las actividades básicas del programa de tres años de duración son: atención ambulatoria clínica en un Consultorio Público, atención ambularoria clínica en un centro médico de la PUC (incluyendo pasada por especialidades), práctica en urgencia, salud comunitaria, cursos y seminarios. La metodología de educación utiliza el "aprendizaje basado en problemas" con la "medicina basada en evidencias" como herramienta importante. El programa fue creado hace cinco años, y actualmente se pueden apreciar resultados positivos como: veinticinco titulados del programa, docencia de pregrado, creación de Centros de Salud Familiar Docentes en la Atención Primaria, publicaciones, educación continua a otros miembros del equipo de salud e intercambio de residentes con otros países

Medición de la actividad de renina plasmática a niveles bajos: optimización del método / Measurement of low levels of plasma renin activity: a methodological improvement

Background: The present method to measure plasma renin activity is cumbersome and imprecise, factors that limit its clinical application. Aim: To assess the importance of blood sampling conditions and the usefulness of increasing incubation time to measure plasma renin activity at low levels. Patients and methods: Twenty hypertensive patients, 14 female, aged 14 to 76 years old, were studied. Two blood samples were obtained after a 10 min rest in the sitting position and after a 30 min rest in supine position. One blood sample, of each condition was sent lo the laboratory at room temperature and the other sample was sent refrigerated. Angiotensin I concentration was determined after 3 h of enzymatic incubation at 37°C and, in subjects with an activity of less than 1 ng/ml/h, after 18 h of incubation. Results: No significant differences in plasma renin activity were observed between the samples obtained with different rest times or different transportation methods. In people with low plasma renin activity, the 18 h enzymatic incubation reduced the lower detection from 0.3 to 0.014 ng/ml/h and the coefficient of variation from 14.4 to 3.2 percent. Conclusions: A simplified blood sampling method does not change plasma renin activity values, and tbe longer enzymatic incubation in people with low plasma renin activity improves both the sensitivitv and accuracy of the determination

Hipertensión arterial tratable con glucocorticoides: comunicación de un caso / Glucocorticoid treatable hypertension: report of one case

Lately, a series of hypertensive syndromes of unknown etiology that respond to new forms of therapy, have been described. One of these is glucocorticoid remediable hypertension, that evolves with suppressed plasma renin activity and normal or high serum aldosterone levels, that lead to an aldosterone/plasma renin activity ratio over 30. We report a 45 years old woman with a severe hypertension, despide the use of antihypertensive medications. She had a plasma renin activity of less than 0.3 ng/ml/h, normal serum aldosterone levels (10 ng/ml) and thus a high aldosterone/plasma renin activity ratio. She had normal serum potassium and sodium levels. Due to the bad results of conventional antihypertensive medications, a treatment with dexamethasone was started normalized blood pressure and allowed to discontinue other antihypertensive medications. This type of hypertension must be sought since non conventional treatments could be used for refractory hypertensive syndromes