Una reflexión ética sobre la telemedicina / A reflection about the ethical implications of telemedicine

Recognizing the role of technology in the development of medicine and the impact of telecommunication advances, we reflect on the meaning and ethics of the use of Telemedicine, both in its general dimension for the use and distribution of knowledge, as well as in the delivery of health actions, scientific research, and data management. Teleconsultation is discussed in greater detail, analyzing its process and application, reviewing its possible advantages and disadvantages, from the point of view of providers and patients. We highlight the need to carry out an appropriate evaluation of each instance, from the point of view of both the patient and the professional who uses it. The importance of maintaining a doctor-patient relationship in agreement with the nature and practice of Medicine, respecting people's dignity, is emphasized. We mention the ethical conditions that must be bore in mind for the proper use of telemedicine. We discuss the eventual influence that this practice will have on the concept and practice of medical care, while suggesting the need to legislate on the matter.

Objeción de conciencia y acciones de salud / Conscientious objection in medical actions

Conscientious Objection arises as a response to a regulation that is judged as immoral. Faced with a law that is considered unfair, the citizen can respond accepting it against his will, exercising conscientious objection on a personal level or, collectively reaching civil disobedience or revolutionary violence. This is an old discussion known since ancient Greece. The current enactment of laws that allow actions previously judged as crime, and that contravene medical tradition, reactivated the discussion about such objection. Some people, such as Savolescu, who denies the legitimacy of conscientious objection invoked by doctors, arguing that it is inefficient, leads to inequality and is inconsistent. He proposes that the values of these professionals can be tolerated privately but should not be determinant in the public sphere. These arguments are critically examined, mentioning pertinent answers from theoretical and practical points of view. We highlight that ethics should not differ in public and private spheres and the principles should be the same, but exercised in different fields. It is concluded that conscientious objection is acquiring legitimacy and that it is necessary to reflect on the underlying reasons that lead to invoke it. It should be considered a civilized resource against determinations of power that are considered to be an attempt against personal values and moral integrity.

Colitis de Crohn: resultados del tratamiento quirúrgico y evolución alejada / Outcome of surgery for Crohn's colitis: review of 28 cases

Background: Exclusive involvement of the colon or rectum in Crohn's disease, called Crohn's colitis, (CC) occurs in about 25% of these patients. Aim: To analyze early surgical results and long-term outcomes of patients undergoing surgery for CC. Material and Methods: Review of a prospective database, identifying patients with Crohn's disease operated between 2003 and 2015 and excluding those with ileocecal disease. We analyzed demographic data, pre and postoperative pharmacological treatment, operations, morbidity and the need for a second bowel resection at follow-up. Results: We reviewed data from 28 patients aged 17 to 72 years (15 men). Twenty-seven (96.4%) had previous pharmacological treatment, 11 received monoclonal antibodies. The most common indications for surgical treatment were failure of medical treatment in 15 cases, acute severe colitis in 12 and anemia/malnutrition in eight. Total colectomy was performed in 17 (61%) patients, proctocolectomy in 8 (29%) and segmental colectomies in 3 (11%). Sixteen (57%) were operated laparoscopically. Major postoperative complications were observed in 5 (18%). Four needed a reintervention. There was no operative mortality. During a 55 months median follow-up of 27 patients, seven (26%) required a second bowel resection, one of them for recurrence. Nineteen (70%) patients had an ostomy, which was permanent in 11. Fifteen patients are without medical treatment. Conclusions: Most of the reviewed patients required total colectomy for the control of the disease with a low surgical morbidity. Two-thirds required an ileostomy, which became permanent in half of them.

¿Tiene cabida, hoy, el "privilegio terapéutico"? / Does therapeutic privilege have a place in modern medicine?

During the last years, bioethical discussion has highlighted the role of the patients' autonomy, being informed consent its particular expression, about decisions that they should make about their own health. The Hippocratic tradition, the deontological positions of the Geneva Declaration of the World Medical Association and numerous codes of ethics in various countries, require that the physician, above all, should ensure patients' health. In this context the discussion on pros and cons for the so-called "therapeutic privilege" are discussed. The "therapeutic privilege" refers to the withholding of information by the clinician during the consent process in the belief that disclosure of this information would lead to harm or suffering of the patient. The circumstances and conditions in which this privilege can become valid are discussed. Special reference is made in order to respect multiculturalism and to the possibility of obtaining advice from health care ethics committees. The role of prudence in the doctor-patient relation must be highlighted. Disclosure of information should be subordinated and oriented to the integral well-being of the patient.

Algunas amenazas actuales a la confidencialidad en medicina / Some current threats to confidentiality in medicine

Social, technical and legal conditions of the current practice of medicine make it necessary to insist on certain actions and circumstances that may jeopardize the confidentiality of information, offered by patients to their health providers. Therefore, some effects of the current Chilean law are analyzed in this respect, regarding access to data from the clinical record of a patient. Also, the risks of putting certain data on social networking sites are analyzed, as well as some of its effects on clinical practice. The reasons because of mandatory reporting of diseases, meaning danger to public health, is allowed, are mentioned. We also discuss the difficulties involved in managing the results of preventative health screenings and its knowledge by third parties, as well as some possible violations of personal privacy, regarding dissemination of some people health information and its further mention or figuration in mass media. We conclude that it is a must for both physicians and other health team members, to safeguard confidentiality of data to which they have had access, as well as the need to know the relevant law, in order to respect human dignity of patients, each one as a person. We address the attention to the possibility that, practicing in a different way, it could endanger the reliability of clinical records, also impairing the quality of people’s health care.

Resección ileocecal por enfermedad de Crohn: resultados y seguimiento / lleocaecal resection for Crohn's disease: results and follow-up

Introducción: Aproximadamente el 50 por ciento de los pacientes con Enfermedad de Crohn (EC) necesitarán de un tratamiento quirúrgico en algún momento de su evolución. La resección ileocecal (RIC) es una de las operaciones más frecuentes en pacientes con EC. Objetivo: Identificar las indicaciones quirúrgicas y determinar el porcentaje de recurrencia de la enfermedad a largo plazo de los pacientes sometidos a RIC por EC. Material y método: Se incluyeron todos los pacientes sometidos consecutivamente a RIC entre Enero 1970 y Diciembre 2006 y se analizaron características demográficas, indicación operatoria, variables intraoperatorias, complicaciones y, en el seguimiento, la recurrencia de la enfermedad. Resultados: 28 pacientes fueron operados en el periodo mencionado. 17 mujeres (60,7 por ciento), edad promedio del diagnóstico de EC: 34,8 años (i: 14-60) y de la RIC: 43,3 años (i: 16-68). Seis pacientes habían sido operados previamente por EC (3 sobre el periné y 3 resecciones parciales de intestino, no RIC). Una o más de las siguientes condiciones contribuyeron a la indicación quirúrgica: Obstrucción intestinal intermitente en 21 pacientes, refractariedad a tratamiento médico en 10, fístula enteral en 2 y hemorragia digestiva baja en 2. Nueve pacientes (32,1 por ciento) tuvieron una o más complicaciones postoperatorias, 3 (10 por ciento) de los cuales fueron reintervenidos (2 por filtración de la anastomosis, uno por hemoperitoneo). La mediana de estadía postoperatoria fue 9 días. No hubo mortalidad operatoria. En el seguimiento a largo plazo, 3 pacientes desarrollaron Íleo mecánico por bridas. Todos ellos resueltos quirúrgicamente. Cuatro pacientes (14 por ciento) fueron reintervenidos por recidiva de la EC con tiempo medio desde la RIC de 63 meses. La sobrevida a 5 años fue de 96 por ciento. Conclusión: La RIC por EC, se indica principalmente por obstrucción intestinal debida a estenosis. La estenosis en la recidiva de la enfermedad es baja.

Background: Approximately 50 percent of patients with Crohn's disease (CD) will need a surgical treatment in the long term course of the disease. The ileocaecal resection (ICR) is the most common operations in patients with CD. Aim: To identify the surgical indications and to determine the rate of recurrence in late follow up of the patients who underwent ICR for CD. Material and method: Consecutive inclusion of patients submitted to ICR between 1970 and 2006. Demographic characteristics, surgical indications, intraoperative findings, postoperative complications and recurrence of the disease were analyzed. Results: 28 patients had an ICR inthisperiod. Average age at diagnosis of CD 34.8 years (r: 14-60), ICR 43.3 years (r: 16-68). 60.7 percent female gender. Six patients were previously operated for CD (3 over perine and 3 partial resection of small bowel, no ICR). One or more of the following clinical conditions were considered surgical indications: Intermittent intestinal obstruction in 21 patients, failure of medical treatment in 10, enteral fistulae 2 and lower intestinal bleeding 2. Nine patients (32.1 percent) had one or more postoperative complications. 3 (10 percent) of them were re-operated (2 for leakage and fistulae, one for hemoperitoneum). The median postoperative stay was 9 days. There was no postoperative mortality (30 days). In the long term follow up, 3 (10 percent) patients developed intestinal obstruction due to adhesions. All of them needed an operation. Four patients (14 percent) were reoperated for CD with a mean time of 63 months since the ICR. Two of them for stenosis of ileocolic anastomosis and two for perianal abscess and fistulae. The 5 year survival was 96 percent. Conclusion: Stenosis and intestinal obstruction of the terminal ileum is the main indication for ICR.

Evolución de los pacientes con enfermedad de Crohn de colon operados con el diagnóstico de colitis ulcerosa / Analysis of the outcome of patients with Crohn's colitis after surgery with the diagnosis of ulcerative colitis

Introducción: La proctocolectomía con reservorio íleal y anastomosis reservorio anal, (RIARA) es actualmente el procedimiento de elección en el tratamiento quirúrgico electivo de la colitis ulcerosa (CU). La colectomía total y anastomosis íleorrectal (AIR), está indicada en un seleccionado grupo de pacientes. Algunos pacientes sometidos a estas operaciones por aparente CU pueden evolucionar como una enfermedad de Crohn (EC). Objetivo: Comunicar el curso y pronóstico de pacientes que evolucionaron como EC luego de un tratamiento quirúrgico por una aparente CU. Materiales y métodos: Se identificaron a los pacientes que tuviesen tratamiento quirúrgico por CU, en el periodo 1978 al 2003. Se seleccionaron a los pacientes en los cuales en su evolución se cambió el diagnóstico a EC. En ellos se analizaron las variables quirúrgicas y su evolución posterior. Resultados: En el periodo mencionado se operaron 114 pacientes por CU. En 9 pacientes (8 por ciento) el diagnóstico cambió a EC, basado principalmente en la evolución clínica alejada y/o por estudio histológico: 3 de 20 (15 por ciento) después de una colectomía total con AIR y 6 de 84 (7 por ciento) después de una proctocolectomía con RIARA. Las localizaciones más frecuentes de las manifestaciones de la EC fueron el canal anal y periné. El tratamiento incluyó procedimientos quirúrgicos y tratamiento médico con antiinflamatorios y/o inmunomoduladores. Dos pacientes con una colectomía con AIR necesitaron una proctectomía e ileostomía. Se extirpó el reservorio en 1 de 6 pacientes con RIARA. En resumen, una minoría de pacientes sometidos a tratamiento quirúrgico con el diagnóstico de CU evoluciona posteriormente como una EC. El tratamiento combinado médico quirúrgico contribuye a una baja incidencia de pérdida del reservorio ileal.

Bakground: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is at present the procedure of choice for elective surgical treatment of ulcerative colitis (UC). Colectomy and ileorectal anastomosis (IRA) can be indicated in selected patients. Some patients submitted to these operations for apparent UC may subsequently evolve as Crohn's disease (CD). Objective: To report the course and prognosis of patients who evolved as CD after surgical treatment for apparent UC. Material and method: All the patients who had a surgical treatment for UC, from 1978 to 2003 were included. We identified the patients in which on follow-up the diagnosis changed to CD. Of these patients surgical variables and follow up were analyzed. Results: 114 patients were operated in this period for UC. In 9 patients (8 percent) their diagnosis changed to CD, based principally on subsequent clinical course and/or histological study: 3 of 20 (15 percent) after a total colectomy and IRA and in 6 of 84 (7 percent) after a proctocolectomy with IPAA. The anal canal and perineum were the most frequent localization of CD. Treatment included surgical procedures and medical treatment with anti-inflammatory and/or inmunomodulators. Two patients with a colectomy with IRA needed a proctectomy and ileostomy. Removal of ileal pouch was necessary on 1 of 6 with IPAA. In conclusion a minority of patients operated with the diagnosis of UC evolved as CD. Combined medical and surgical treatment contributed to a low rate of ileal pouch lost.

Infliximab en el tratamiento de la enfermedad de Crohn: Estudio preliminar / Infliximab in the treatment of patients with Crohn's disease: Preliminary report

Background: Tumor necrosis factor alpha, interleukin 6 and 1 have a pathogenic role in Crohn's disease. Infliximab, a monoclonal antibody against tumor necrosis factor, is useful in the treatment of Crohn's disease, specially when the disease is active and associated to fistula formation. Aim: To assess the effectiveness of Infliximab in patients with Crohn's disease. Material and methods: Twelve patients with Crohn's disease (aged 16 to 63 years, 10 women) refractory to treatment with steroid, 5-aminosalicylic acid, antimicrobials and immunomodulatory drugs, were studied. A single intravenous 5 mg/kg dose Infliximab was administered. The Crohn's disease activity index (CDAI) was measured before and one week after the administration of the drug. Results: CDAI before and after Infliximab administration was 357±62 and 138±122 score points, respectively (p <0.005). According to this score, five patients had a severe and seven a moderate disease flare. The disease remitted in 7 (58%) and a clinical response was observed in 75%. Conclusions: A single dose of Infliximab was effective to induce remission of the disease in 75% of this selected group of patients with Crohn's disease.

Colectomía total de urgencia por colitis ulcerosa grave / Emergency total colectomy caused by acute ulcerative colitis

A pesar de los progresos en el tratamiento médico de la crisis grave (CG) de colitis ulcerosa (CU), aproximadamente un tercio de los pacientes necesitarán de resolución quirúrgica. Dado las malas condiciones generales de estos pacientes, el tratamiento quirúrgico se ha asociado a una elevada morbilidad y mortalidad operatoria. La oportunidad de la indicación quirúrgica sería uno de los factores más importantes en el logro de resultados satisfactorios. A partir de 1978 el equipo de Enfermedades Inflamatorias Intestinales estableció un protocolo prospectivo para tratamiento médico de la CG de CU. Los pacientes con CG recibieron tratamiento médico intensivo de la crisis. Se indicó la colectomía en aquellos pacientes que no respondieron al tratamiento médico al cabo de 7 días y a los que sufrieron agravamiento en este período o que presentaron alguna complicación como: hemorragia digestiva baja masiva, megacolon tóxico o perforación. Entre enero de 1978 y mayo 2000, 119 pacientes fueron operados por CU. De estos 73 (61,3 por ciento) por CG que no respondió al tratamiento médico. Edad promedio 35 años, 41 mujeres (56 por ciento). A todos los pacientes se les practicó una colectomía total con ileostomía terminal y cierre del muñon rectal. La morbilidad global fue de 45 por ciento. En el subgrupo de pacientes con complicaciones (megacolon tóxico, perforación y hemorragia digestiva baja masiva) ésta alcanzó el 70 por ciento (p=0,001). Se observa una significativa menor frecuencia de complicaciones en los pacientes operados antes de 10 días de tratamiento médico intensivo de la crisis (11 por ciento vs 47 por ciento respectivamente)(p=0,001). Sólo un paciente falleció (mortalidad 1,3 por ciento). El estudio histopatológico demostró CU extensa en el 44 por ciento y una pancolitis en el 53 por ciento de los enfermos. Se concluye que la indicación quirúrgica antes de 10 días de tratamiento médico de la CG de CU disminuiría la morbilidad operatoria.

Diagnóstico de Muerte / The diagnosis of death

This paper undertakes an analysis of the scientific criteria used in the diagnosis of death and underscores the importance of intellectual rigor in the definition of medical concepts, particularly regarding such a critical issue as the diagnosis of death. Under the cardiorespiratory criterion, death is defined as ½the irreversible cessation of the functioning of an organism as a whole¼ and the tests used to confirm this criterion (negative life-signs) are sensitive and specific. In this case, cadaverous phenomena appear immediately following the diagnosis of death. On the other hand, doubts have arisen concerning the theoretical and the inner consistency of the criterion of brain death, since it does not satisfy the definition of ½the irreversible cessation of the functioning of an organism as a whole¼, nor the requirement of ½total and irreversible cessation of all functions of the entire brain, including the brain stem¼. There is evidence to the effect that the tests used to confirm this criterion are not specific enough. It is clear that brain death marks the beginning of a process that eventually ends in death, though death does not occur at that moment. From an ethical point of view, the conflict arises between the need to provide an unequivocal diagnosis of death and the possibility of saving a life through organ transplantation. The sensitive issue of brain death calls for a more thorough and in-depth discussion among physicians and the community at large (Rev Méd Chile 2004; 132: 95-107).

Adenocarcinoma de intestino delgado asociado a enfermedad de Crohn / Adenocarcinoma of the small intestine associated with Crohn disease

Es característico en la Enfermedad de Crohn (EC) el proceso inflamatorio crónico, que puede comprometer cualquier segmento del tubo digestivo. Cuando se mantiene por un período prolongado existen posibilidades que se produzcan cambios histopatológicos que pueden evolucionar hacia una neoplasia. El presente artículo describe las características clínicas y anatomopatológicas de un varón de 59 años, portador de una EC de ubicación ileal de 10 años de evolución, complicada con obstrucción intestinal incompleta recurrente. Fue sometido a una laparotomía exploradora, en la cual se resecó un segmento de ileón distal. El estudio histopatológico mostró, además de la EC, la presencia de un adenocarcinoma en el sitio comprometido por la enfermedad. Se discuten aspectos de esta interesante e infrecuente asociación.

Colitis ulcerosa y embarazo / Evolution of ulcerative colitis in pregnancy

Background: The evolution of ulcerative colitis in pregnancy is far from clear. While some authors state that the disease aggravates during this period, others do not share this opinion. Aim: To assess the evolution of ulcerative colitis in pregnancy. Patients and methods: A paired case-control design was used in which 15 women, with diagnosed ulcerative colitis at the moment of becoming pregnant, were followed for 12 months and the activity of the disease was compared with that of the 12 months preceding the pregnancy. The activity of the disease in the period preceding the pregnancy was gathered retrospectively from the patient's charts. Results: The mean age of the first ulcerative colitis crisis was 24 years. It was moderate in 49 percent and severe in 35 percent of women. During pregnancy 55 percent of women did not have a crisis, compared with 26.7 percent during the period preceding pregnancy (relative risk of not having a crisis during pregnancy of 1.7). During both periods, seven women had digestive complications, whereas extra digestive complications were not observed in 60 percent of patients during pregnancy and 11.8 percent of patients during the preceding period. Perinatal results were similar to those of the general population. Conclusions: In our group of patients the evolution of ulcerative colitis was better during pregnancy, reflected by a lower number of crisis

Colitis ulcerosa: experiencia de 18 años en el tratamiento quirúrgico / Ulcerative colitis: experience of 18 years in the surgical treatment

La colitis ulcerosa (CU) es considerada en Chile una enfermedad de alta morbilidad y mortalidad operatoria cuyo tratamiento con frecuencia necesita dejar una ileostomía definitiva. El objetivo de esta comunicación es dar a conocer la experiencia global en el tratamiento quirúrgico de la CU, con especial atención en las alternativas quirúrgicas para evitar una ileostomía definitiva. Se revisaron los registros de todos los pacientes intervenidos por CU en el período enero 1974-diciembre 1992. La serie consta de 70 pacientes; 42 (60 porciento) mujeres, con una edad promedio de 36,7 años (9-74). La indicación operatoria fue electiva en 27 pacientes (39 porciento) con curso crónico de la CU; de urgencia en 31 (44 porciento), con crisis grave que no respondió al tratamiento médico y de emergencia en 12 (17 porciento) (megacolon tóxico 8, hemorragia masiva 3 y perforación de colon en 1). Las operaciones practicadas fueron: 55 (79 porciento) colectomías totales con ileostomía (CT+I), 28 de ellas de urgencia, 11 de emergencia y 16 electivas. 10 proctocolectomías (PR+I) (14 porciento) 7 de ellas electivas; 4 (6 porciento) colectomías totales con anastomosis ileorrectal (AIR) todas ellas electivas y una colectomía total con reservorio ileal (RIARA). Dos pacientes de la serie fallecieron (mortalidad operatoria 2,9 porciento), ambos del grupo de pacientes no electivos (mortalidad operatoria 4,7 porciento). Un tercer paciente falleció 4 meses después del alta por causas no relacionadas a su intervención. Complicaciones postoperatorias presentaron 5 de 27 pacientes (18 porciento), operados electivamente y 22 de 43 (51 porciento) (p<0,05) intervenidos de urgencia o emergencia. El estudio histopatológico de las piezas quirúrgicas confirmó el diagnóstico de CU con compromiso total de colon en el 90 porciento de los casos. De los 52 pacientes que sobrevivieron a la CT+I, 49 se han reintervenido: en 34 se practicó un RIARA, en 14 una AIR y en un paciente se practicó una proctectomía