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.

Rinosinusitis crónica en niños: revisión de la evaluación y manejo actual / Chronic rhinosinusitis in children: review of the evaluation and current management

La rinosinusitis crónica (RSC) en niños corresponde a la inflamación de la mucosa de la cavidad nasal y senos paranasales, presentando síntomas como obstrucción nasal, descarga nasal, presión o dolor facial y tos, presentes por más de 12 semanas. Conlleva una gran carga de morbilidad para quienes la padecen, y un alto costo económico. Su diagnóstico constituye un desafío debido a la sobreposición de síntomas con infecciones respiratorias altas y otras condiciones no infecciosas. En los últimos años se han dilucidado nuevos factores contribuyentes como los biofilms , disfunción del microbioma, y el creciente papel de mecanismos inflamatorios no infecciosos. El estudio imagenológico de elección es la tomografía computarizada, preferentemente en casos de duda diagnóstica, falta de respuesta a tratamiento o sospecha de complicaciones. El tratamiento de primera línea es el manejo médico, basado en irrigación nasal, posible uso de antibióticos prolongados y corticoides nasales. Para casos refractarios se plantean intervenciones quirúrgicas, siendo la adenoidectomía la primera elección, principalmente en niños menores; otras intervenciones incluyen la cirugía endoscópica de cavidades paranasales. Nuevas terapias biológicas están siendo estudiadas basadas en los mecanismos inflamatorios no infecciosos de la RSC y su relación con comorbilidades como el asma.

Chronic rhinosinusitis (CRS) in children is the inflammation of the nasal and sinus mucosa, presenting symptoms such as obstruction, nasal discharge, pressure or facial pain and cough, which extends for more than 12 weeks. It represents a great burden for those affected, with high economic cost. Its diagnosis constitutes a challenge due to the overlap of symptoms with other upper respiratory infections and other non-infectious conditions. In recent years, new contributing factors have been elucidated, such as biofilms, microbiome dysfunction, and the growing role of noninfectious inflammatory mechanisms. Diagnosis depends on the recognition of characteristic symptoms and their duration. The imaging study of choice is computed tomography, especially in cases of diagnostic doubt, lack of response to treatment or suspicion of complications. First-line treatment of is based on nasal irrigation, possible use of prolonged antibiotics and nasal corticosteroids. For refractory cases, surgical intervention is proposed, with adenoidectomy being the first choice, mainly in younger children; other interventions include endoscopic sinus surgery. New biological therapies are being studied based on noninfectious inflammatory mechanisms of CRS and its comorbidities such as asthma.

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.

¿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.

Cirugía profiláctica en cáncer medular de tiroides hereditario / Prophylactic surgery in hereditary medullary thyroid cancer

Introducción: Se estima que del total de los cánceres, el 5-10% tendría una base genética. Actualmente es posible identificar a los individuos con predisposición genética en algunos cánceres como manera de intervenir precozmente en el desarrollo de esta enfermedad. Objetivos: Evaluar la utilidad de la cirugía profiláctica en el cáncer medular de tiroides hereditario. Material y métodos: Este trabajo es una revisión de literatura de diferentes estudios extraídos de bibliotecas electrónicas como Scientific Electronic Library Online (SciELO), MedLine-PubMed y UpToDate, mediante la construcción de preguntas clínicas y términos MeSH enfocados principalmente en la búsqueda específica de información sobre el cáncer medular de tiroides hereditario. Resultados: Los estudios revisados demuestran que la tiroidectomía profiláctica con resección linfática cervical representa el único tratamiento eficaz en el caso del cáncer medular de tiroides hereditario. Conclusiones: La cirugía profiláctica ha demostrado una importante disminución del riesgo de cáncer de tiroides y se considera una conducta de rigor en portadores del gen RET en el cáncer medular de tiroides.

Introduction: Approximately 5-10% of global cancer has a genetic base. Nowadays it is possible to identify those who have a genetic predisposition for some cancers, so they can be treated in short term. Objectives: Evaluate how useful is prophylactic surgery on hereditary Medullary Thyroid Cancer. Materials and methods: This investigation is a literature review of different research papers from electronic databases such as Scientific Electronic Library Online (SciELO), MedLine-PubMed and UpToDate. The research was made with clinical queries and MeSH terms, specially focused on hereditary Medullary Thyroid Cancer. Results: This research shows that prophylactic Thyroidectomy with cervical lymph node resection is the only effective and curative treatment for hereditary Medullary Thyroid Cancer. Conclusions: Prophylactic surgery has proof an important role decreasing the risk on Hereditary Thyroid cancer Syndrome and in RET carriers surgery is considered a must.

Cirugía profiláctica en síndrome de cáncer hereditario de mama / Prophylactic surgery in breast hereditary cancer syndrome

Introducción: Se estima que del total de los cánceres, el 5-10% tendría una base genética. Actualmente es posible identificar a los individuos con predisposición genética a desarrollar cáncer de mama, una manera de intervenir precozmente en el desarrollo de esta enfermedad. Objetivos: Evaluar la utilidad de la cirugía profiláctica en el síndrome de cáncer hereditario de mama. Material y métodos: Este trabajo es una revisión de literatura de diferentes estudios extraídos de bibliotecas electrónicas como Scientific Electronic Library Online (SciELO), MedLine-PubMed y UpToDate, mediante la construcción de preguntas clínicas y términos MeSH enfocados principalmente en la búsqueda específica de información del síndrome de cáncer hereditario de mama. Resultados: Los estudios revisados demuestran que la mastectomía bilateral profiláctica (MBP) disminuye en un 90% el riesgo de desarrollar cáncer de mama en las mujeres portadoras de BRCA1 o BRCA2. En cuanto a la salpingooferectomía (SO), reduciría entre un 50-56% el riesgo de cáncer de mama dependiendo de la mutación a la que se asocie. Conclusiones: La cirugía profiláctica ha demostrado importante disminución del riesgo de cáncer de mama, por lo que su uso es recomendado al hallazgo de las mutaciones BRCA1 y BRCA2.

Introduction: Approximately 5-10% of global cancer has a genetic base. Nowadays it is possible to identify those who have a genetic predisposition for breast cancer, so they can be treated in short term. Objectives: Evaluate how useful is prophylactic surgery on Hereditary Breast cancer Syndrome. Materials and methods: This investigation is a literature review of different research papers from electronic databases such as Scientific Electronic Library Online (SciELO), MedLine-PubMed and UpToDate. The research was made with clinical queries and MeSH terms, specially focused on Hereditary Breast cancer Syndrome. Results: This research shows that prophylactic bilateral mastectomy (PBM) decreases 90% risk of developing breast cancer in BRCA1 and BRCA2 carriers. On the other hand, Salpyngo-oophoferectomy (SO) technique decreases around 53% chances of breast cancer, depending on the associated mutation. Conclusion: Prophylactic surgery has shown an important role decreasing the risk on Hereditary Breast cancer Syndrome. So on, in cases of BRCA1 and BRCA2 carriers we suggest to perform prophylactic surgery.

Habilidades semánticas y rendimiento académico en escolares de 2° y 4° año básico / Semantic skills and academic performance in students of 2nd and 4th grade

Durante la etapa escolar los principales cambios lingüísticos se evidencian en el plano sintáctico, semántico y pragmático. Diversos estudios postulan que a mayor edad existe un mayor desarrollo semántico en las habilidades para definir en comprensión léxica y en comprensión de lenguaje figurado. Sin embargo, en el contexto nacional de Chile existe escasa información al respecto. El objetivo de la investigación fue determinar el desempeño en habilidades semánticas en escolares de 2° y 4° año básico y su asociación con el rendimiento académico. Para ello, se realizó un estudio no experimental, analítico, comparativo y transversal con 58 niños de un colegio de Santiago de Chile (28 de 2° año básico y 30 de 4° año básico). Se evaluó el desempeño en las habilidades semánticas con el Test de Vocabulario en Imágenes (TEVI-R) y con una prueba creada para estos fines. El rendimiento académico se consideró según el promedio de calificaciones del segundo trimestre en las asignaturas de Lenguaje, Matemáticas, Ciencias Naturales y Sociales. La prueba creada mostró validez y confiabilidad para evaluar aspectos semánticos relacionados con habilidades para definir y para comprender lenguaje figurado. Se evidenciaron diferencias estadísticamente significativas entre los escolares de ambos cursos en las habilidades semánticas estudiadas, estableciéndose un mejor rendimiento en los niños de 4° año básico. No se encontró relación estadísticamente significativa entre el rendimiento académico y las habilidades semánticas mencionadas. Se concluye que a medida que aumenta la edad, los niños mejoran su desempeño en habilidades semánticas de comprensión léxica, habilidades para definir y comprensión de lenguaje figurado. Sin embargo, no existiría relación entre el rendimiento académico y las habilidades semánticas estudiadas.

Through school years, the main linguistic changes are in semantic, syntactic and pragmatic areas. Many foreign studies propose that older child have a higher semantic development, specifically in word definition skills, lexical comprehension and understanding of figurative language. However, in national context, there is a little information about this topic. The objective was to determine performance in semantic skills in students of 2nd and 4th grade and their association with academic performance. Method non experimental, analytic, comparative and transversal study which considers 58 children of a school in Santiago. The semantic skills were measured with the “Test de Vocabulario en Imágenes” (TEVI-R) and a test of semantic abilities created in this study. The academic performance considered the mean of qualifications during 2nd trimester in subjects of Language, Math, Natural and Social Science. The created test showed validity and reliability to assess semantic abilities relevant with word definition skills and understanding of figurative language. Statistically significant difference was found between both groups performance in semantic skills studies, with a higher performance in 4th grade students. No statistically significant difference was found between academic performance and semantic abilities mentioned. As school grade increases, children improve their performance in semantic skills of word definition, lexical comprehension and understanding of figurative language. However, there is no relation between academic performance and semantic abilities studied.

¿Es ética la utilización de técnicas de simulación en la docencia médica de pregrado? Reflexión bioética / Is ethical to use simulation techniques in undergraduate medical teaching?

The use of simulation models in undergraduate medical teaching is now a reality in Chile. This technology provides scenarios of different complexities, and it has a number of advantages for patients' security as well as comfort. The main benefits, limitations and risks of these simulation techniques are pointed out in this article. It is concluded that its use in teaching medical students is not only ethical, but also an indispensable complement in medical education.

La utilización de modelos de simulación en la docencia de pregrado en medicina ya es una realidad en nuestro país. Pone al alcance del estudiante diversos escenarios de la atención médica, a distintos niveles de complejidad. Tiene muchas ventajas y evita molestias e incomodidades a los pacientes reales. Se proponen sus principales ventajas y riesgos y se concluye que no sólo es ética su utilización, sino que además es un complemento docente indispensable.

Daño hepático agudo inducido por claritromicina. A propósito de un caso / Acute liver injury induced by clarithromycin, case report

Introducción: El daño hepático por fármacos es una lesión secundaria al uso de medicamentos. Posee una baja incidencia, representando la causa más común de muerte por falla hepática aguda. Es importante el diagnóstico y tratamiento precoz para evitar resultados desfavorables. Presentación del caso: Mujer de 73 años, con antecedentes de Hipertensión arterial en tratamiento, colecistectomizada; cursó neumonía adquirida en la comunidad de presentación atípica en tratamiento con claritromicina 500mg/12 horas y al cuarto día de tratamiento presentó ictericia, coluria, hipocolia y astenia. Al examen físico presentó dolor a palpación en hemiabdomen derecho y hepatomegalia. Los exámenes en urgencias mostraron una marcada alteración de las pruebas hepáticas, con leucocitos de 9.020/mm3 y 8% de eosinófilos. Se solicitó ecotomografía abdominal que no evidenció obstrucción de vía biliar. Durante la hospitalización se descartó serología para Virus Hepatitis A, B, C, Epstein Barr, Citomegalovirus y Virus de la Inmunodeficiancia Humana (VIH), junto con un perfil inmunológico no patológico. Se complementó con colangioresonancia que no evidenció obstrucción de la vía biliar, por lo que se indicó biopsia hepática que concluyó "daño hepático secundario a fármacos''. Se suspendió claritromicina, evolucionando favorablemente dándose de alta al séptimo día. Discusión: La claritromicina es un antibiótico usado ampliamente para tratar las infecciones bacterianas, sin embargo, es capaz de inducir daño hepático. El diagnóstico del daño hepático por fármacos es difícil, requiriéndose alto índice de sospecha, en donde las manifestaciones clínicas, la eosinofilia y el descarte de otras patologías son fundamentales para plantear el diagnóstico.

Introduction: Drug induced liver injury (DILI), is a drug hepatotoxicity, with low incidence. However represents the most common cause of death secondary to acute liver failure. Assertive diagnosis and early treatment is important to avoid adverse results. Case report: A 73-year-old woman, with arterial hypertension and cholecystectomy, who suffered community acquired pneumonia with atypical presentation, was treated with clarithromycin 500 mg twice a day. She manifested jaundice, choluria, hipocholia and fatigue after the fourth day in treatment. Additional, physical examination: at palpation showed right and upper abdominal pain, and hepatomegaly. During the emergency room, laboratory tests showed significant alterations in liver function. Total leukocyte count 9020 with 8% eosinophils. Abdominal ultrasound was negative for biliary obstruction. During hospitalization, markers for autoimmune liver disease were non pathological, and viral serologies (Hepatitis A, B, C viruses, Epstein Barr, Cytomegalovirus and Human immunodeficiency virus) were negative. Biliary obstruction was negative according Magnetic resonance cholangiopancreatography. Liver biopsy showed "drug induced liver injury". Clarithromycin was suspended, and the patient achieved clinical improvement and she was discharge at the 7th day. Discussion: Clarithromycin is an antibiotic widely used for several bacterial infections, capable of induced hepatotoxicity. Diagnosis of DILI is difficult, that requires high index of clinical suspicion. Clinical manifestations, eosinophilia and diferential diagnoses are key for an assertive diagnosis

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.

Reflexión bioética sobre trasplantes de pulmón / Bioethics reflection about lung transplant

Despite a substantial improvement in organ transplant techniques and rejections methods, Chile still exhibits an apparent lack of adequate increase of lung transplants. In particular, despite the presence of precise indicactions of lung transplant, the problem of limited donors is a very difficult reality for the receptors. In this work, we offer a comparison amongst Chile and Spain, with special emphasis on bioethical aspects of this process.

A pesar de los avances que ha experimentado la técnica de los trasplantes de órganos y la mejora en manejo del rechazo, en nuestro país no se advierte un crecimiento adecuado a las necesidades de los trasplantes del sistema respiratorio requeridos. Si bien existen indicaciones precisas de trasplante pulmonar, el problema de la escasez de donantes es una dificultad concreta para los enfermos. Se revisa y compara nuestra situación con la de España y se analizan algunos aspectos bioéticos que surgen de este proceso.

Descripción de variantes del acceso transeptoesfenoidal para el abordaje de la patología selar / Description of transseptosphenoidal access variants to sellar pathology approach

El abordaje quirúrgico de la patología selar ha sufrido importantes cambios desde sus primeras descripciones. Inicialmente de manejo neuroquirúrgico, hoy en día el abordaje hipofisiario transeptoesfenoidal se ha transformado en una de las vías de acceso más utilizadas por el otorrinolaringólogo para lesiones a nivel de silla turca. Esta publicación describe un tipo de acceso transeptoesfenoidal utilizado por el otorrinolaringólogo en el Instituto de Neurocirugía Dr. Alfonso Asenjo (INCA) en el abordaje de lesiones selares, tanto en cirugía primaria de hipófisis, cirugía secundaria o en casos con alteraciones anatómicas del septum nasal posterior.

The surgical approach to the sellar pathology has undergone significant changes since its first descriptions. Initially addressed by neurosurgical management, today the transseptosphenoidal pituitary approach has become one of the most used pathways by the otolaryngologist to reach sellar lesions. This publication describes one of the transseptosphenoidal approach used by the otolaryngologist at the Instituto de Neurocirugía Dr. Alfonso Asenjo (INCA) in addressing sellar lesions and its variations in primary pituitary surgery, secondary surgery, multiple interventions and in cases of anatomical variations of the posterior nasal septum.

Estenosis subglótica: reporte de casos / Subglottic stenosis: case report

Introducción: La estenosis subglótica (ES) plantea un desafío clínico constante dado su alta morbimortalidad, diversidad de causas, localización, severidad y variedad de procedimientos terapéuticos. Objetivos: Determinar el perfil de pacientes con diagnóstico de ES, evaluar el tratamiento y sus resultados. Material y método: Estudio descriptivo retrospectivo mediante revisión de fichas clínicas de pacientes con ES entre 2008 y 2011. Se describen las características demográficas, factores de riesgo, sintomatología, tipo y grado de estenosis, tratamiento, porcentaje de decanulación y complicaciones. Resultados: 17 pacientes adultos fueron incluidos. Edad promedio: 51 ± 14,37 años. Sexo: 70,6% femenino, 29,4% masculino. El principal síntoma fue la disnea (76,5%). La ES con compromiso sólo de partes blandas (88,2%) y el grado III de severidad fueron predominantes. El tratamiento incluyó procedimientos endoscópicos (47%) y quirúrgicos abiertos (41%). La cirugía abierta, como único tratamiento o segundo paso presentó un porcentaje de decanulación menor al manejo endoscópico. La dilatación con broncoscopio presentó una tasa de éxito de 63%. La tasa de decanulación general fue 58,8%. Conclusiones: La ES es una patología compleja. La baja tasa de sospecha, sintomatología inespecífica y el retraso en la consulta hace necesaria la creación de equipos de vía aérea multidisciplinarios para su pesquisa y manejo.

Introduction: Subglottic stenosis (SE) pose a constant clinical challenge because it's high morbidity and mortality, diversity of causes, location, severity and variety of treatment procedures. Aim: Determine the profile of patients with SE and evaluate the treatment and its results. Material and method: Retrospective descriptive study by reviewing medical records of patients with SE between 2008 and 2011. Demographic characteristics, risk factors, symptoms, type and degree of stenosis, treatment, decannulation percentage and complications were described. Results: 17 adult patients were included. Average age: 51 ± 14.37 years. Sex: 70.6% female and 29.4% male. The main symptom was dyspnea (76.5%). The SE with only soft tissue involvement (88.2%) and grade III severity were predominant. For treatment endoscopic procedures (47%) and open surgery were used (41%). Open surgical technique as unique treatment or as a second step, was less successful compared to endoscopic treatment. Bronchoscopic dilatation had a success rate of 63%. The overall decannulation rate was 58.8%. Conclusions: The SE is a complex pathology. The low rate of suspicion, nonspecific symptoms and delay in medical consultation requires the creation of multidisciplinary teams for diagnosis and management.

Punto interdomal en técnica cerrada / Interdomal suture in closed approach

El manejo de la punta nasal es un elemento clave en toda rinoplastía. Las primeras técnicas empleadas sacrificaban la estructura del arco alar con resultados posoperatorios indeseables. En la era moderna de la rinoplastía, el manejo de la punta nasal se enfocó en remodelar, preservar y reposicionar los cartílagos alares mediante el uso de suturas. El punto interdomal es una sutura en forma de ocho o loop simple desde la porción más anterior de un domo hacia el contralateral uniendo la región más alta de las cruras mediales. En el presente artículo se realiza una revisión del uso de puntos de suturas en el manejo de la punta nasal, se describen las características del punto interdomal en técnica cerrada y se muestran sus resultados en una serie de casos.

The nasal tip surgery is a key element in rhinoplasty. The first techniques employed sacrificed the alar arch structure with undesirable postoperative results. In the modern era of rhinoplasty, nasal tip surgery focused on reshaping, preserving and repositioning the alar cartilages using reversible sutures. The interdomal suture is a figure-eight or simple loop suture placed from the most anterior portion of one dome to the contralateral joining the highest region of the medial crura. This article reviews the use of suture techniques in nasal tip reshaping and describes the interdomal suture in closed approach and its results in a clinical series.

Prueba de impulso cefálico: bases fisiológicas y métodos de registro del reflejo vestíbulo oculomotor / Head impulse test: physiological basis and registration methods of the vestibulo-ocular reflex

En la historia de la evaluación clínica vestibular, siempre se ha buscado la manera de medir en forma individual los seis canales semicirculares y los cuatro órganos otolíticos. Basados en el conocimiento de la fisiología vestibular, en 1988 Halmagyi y Curthoys describieron la Prueba de Impulso Cefálico o Head Impulse Test (HIT) como un método diagnóstico para evaluar la efectividad del reflejo vestíbulo oculomotor en pacientes con sintomatología vestibular. Esta revisión pretende dar a conocer las bases fisiológicas del HIT y su evolución hasta el video HIT (vHIT) actual.

In the history of vestibular clinical evaluation, it has always been sought the way to measure individually each of the six semicircular canals and the four otolith organs. Based on vestibular physiology, in 1988 Halmagyi and Curthoys described the Head impulse test (HIT) as a diagnostic method to evaluate the effectiveness of the vestibulo-oculomotor reflex in patients with vestibular symptoms. This review shows the physiological basis for HIT and its evolution towards nowdays video HIT (vHIT).

"Curriculum oculto" en medicina: una reflexión docente / The hidden curriculum in medical teaching

Background: Medical education must ascribe to a curriculum but clinical teaching poses special difficulties that go beyond any programming attempt. Attitudes and skills learned during tutored clinical practice are called the "hidden curriculum". The figure and personal features of the teacher, his environment and the atmosphere that projects every particular medical school, are essential to shape the characteristics of the student. Paradoxically, it is almost impossible to measure the impact of this hidden curriculum. This article is a reflection on an issue that is acquiring special relevance in medical education.

Metodología de adaptación de una guía clínica para el manejo de pacientes adultos con neumonía adquirida en la comunidad en una red de salud privada / The adaptation methodology of a guideline for the management of adults with community-acquired pneumonia

Background: Clinical practice guidelines (CPG) are widely used as tools for improving quality of health care. Guidelines developed elsewhere, can be adapted using a valid and systematic process. Aim: To describe the methodology used in the process of adaptation of a guideline for the management of adults with community-acquired pneumonia (CAP) in a private health care organization. Material and Methods: We used the ADAPTE framework involving three main phases. At the set-up phase a guideline adaptation group integrated by medical specialists from different disciplines, a methodologist and a nurse coordinator was formed. At the adaptation phase, the specific clinical questions to be addressed by the guidelines were identified. Results: Twenty five guidelines were initially retrieved. After their assessment, the number was reduced to only three. Recommendations from these guidelines were 'mapped' and focused searches were carried out where 'evidence gaps' were identified. An initial draft was written and revised by the adaptation group. At the finalization phase, the external review of the guideline was carried out and a process for the regular review and update of the adapted guideline was defined. Conclusions: We developed a guideline for the management of adults with CAP, adapted to the local context of our health care system, using guidelines developed elsewhere. This guideline creation method can be an efficient means of saving professional resources.

Corticoides intratimpánicos en el manejo de hipoacusia sensorioneural súbita / Intratympanic steroids in sudden sensorineural hearing loss management

Sudden sensorineural hearing loss (SSNHL) is defined as the loss of at least 30 dB in 3 or more consecutive frequencies in less than 3 days. It’s more frequent in the fifth decade, without gender-related differences. Although It is usually unilateral, 3 percent of patients may have both ears involved. 1 percent of cases are due to a retrocochlear disease. It presents as a rapidly progressive and sudden-onset hearing loss or that appears upon awakening. Over 90 percent of patients report tinnitus and 20 to 60 percent dizziness. Although many theories try to explain its origin, in only 20 percent of cases the etiology can be identified. The myriad of options have only reflected the lack of strong evidence on therapeutic alternatives and the high rate of spontaneous remission. Systemic corticosteroids in high doses have been defined as the standard therapy for SSNHL. Intratympanic steroid therapy has become a new alternative, allowing drugs to reach higher concentrations in the inner ear without the secondary effects of systemic therapy. Positive outcome has only been achieved using intratympanic steroids as salvage therapy. Authors disagree on its effectiveness, patterns of administration and posology. This paper reviews intratympanic steroid therapy, its advantages and disadvantages, its administration technique and its pharmacologic features.

Relacion entre ll indice de masa corporal y el stado nutricional e inmunitarioo de la diada madre -nñña / Relationship between BMI and nutritional and immune status of the dyad mother - child

Diversas patologías del niño y adulto, fueron incubadas en la gestación. Con el fin de valorar la repercusiones del estado nutricional de la madre y estado nutricional e inmunológico de niño al nacer, se evaluó nutricionalmente a madres con el índice de masa corporal (IMC) y se correlacionó con estado nutricional, y respuesta inmunitaria de niños al nacer. De 1200 madres examinadas, ingresaron al estudio 754 madres y niños según criterios de inclusión: Doce horas de nacimiento, madre-niño sanos, 35-40 semanas de gestación, hemoglobina materna normal, embarazo simple, parto normal Criterios de exclusión: Madres con anemia, embarazo gemelar, procesos infecciosos, anomalías congénitas, parto por cesárea, rechazo de la madre. Se midieron el IMC por Atalah (“Abaco IMC nutricional” CRIN), peso, talla, perímetro cefálico APGAR, edad gestacional por Dubowitz. En 254 recién nacidos además se midió tamaño del timo por ultrasonografía. Se encontró buena correlación del peso, talla, perímetro cefálico del niño al nacer con IMC de la madre (p<0,01); 21.1% de los niños tuvieron cerca a 3Kg de madres enflaquecidas , 44.1% normal ( 3,3 kg.); 25.9% sobrepeso (3,7 kg) y 8.6% alrededor de 4kg de madres obesas. La mayor superficie del timo (STB) se encontró en los niños de madre con IMC: normal, comparados con madre con IMC: enflaquecida y de esta con el niño de IMC mayor (sobrepeso, obesidad), Estos resultados sugiere la estrecha relación inmunidad-nutrición y propone la evaluación nutricional con el IMC durante la gestación.

Several diseases in adults and children are incubated during pregnancy. To assess the impact of nutritional status of the mothers and the nutritional and immune status of the children at birth, a nutritional assessment was measured by the body mass index (BMI). This was correlated with nutritional status and immunity response at birth. 1,200 mothers were surveyed, and 754 children and mothers were admitted to study with inclusion criteria: twelve hours of birth, mother-child health, 35-40 weeks of gestation, normal maternal hemoglobin, normal single pregnancy; exclusion criteria: mothers with anemia, infections, congenital anomalies, cesarean deliver, rejection by the mother. BMI is measured by Atalah (“Abacus BMI nutritional”CRIN), weight, height, cephalic perimeter, APGAR, and gestational age by Dubowitz. In 254 newborns, the size of the thymus gland was also measured by ultrasound. There was a strong, positive correlation of weight, height, and head circumference at birth with the mothers BMI (p <0.01); 21.1% of the children had close to 3kg of mothers thinner, 44.1% were normal, 25.9% were overweight (3,7kg.) and 8.6% were around 4Kg, of mother obese. The largest area of the thymus was found in children with mother´s having a normal BMI compared to mother´s having with a low or high BMI. These results suggest the relationship immunity-nutrition and propose evaluation to BMI during pregnancy.