Hipertensión pulmonar crónica tromboembólica tromboendarterectomía pulmonar / Chronic thromboembolic pulmonary hypertension

A nivel mundial, la tercera causa de muerte por causa cardiovascular es el Tromboembolismo Pulmonar (TEP), después del Infarto agudo de Miocardio y el Accidente cerebrovascular, con una incidencia anual estimada de 40 casos por cada 100.000 habitantes. Se comunica el caso clínico de un paciente de 44 años con diagnóstico de TEP recurrente con Hipertensión pulmonar tromboembólica crónica (CTPH) que fue sometido a tromboendarterectomía pulmonar bilateral (PTE) bajo paro circulatorio con hipotermia profunda. Se informa de los resultados de los medios de diagnóstico y del tratamiento quirúrgico mediante la tromboendarterectomía. Se discute el tema en el contexto de la experiencia internacional y nacional.

Estudio de familia en Atención Primaria: construcción y validación de una herramienta para la valoración familiar / Development of a tool to conduct family studies in primary health care

Background: The Family and Community Health Model (MAIS) establishes the continuity of care as an essential principle. The Family Study, as a clinical strategy, allows to have sufficient and timely information and knowledge about users of health care services, facilitates their accompaniment and is a source of information to improve the quality of care and the management of health centers. Aim: To develop a tool to conduct family studies, devised by experts in Primary Health Care. Material and Methods: Using a qualitative method, an electronic Delphi was conducted on 24 experts on primary health care. Afterwards, the content validation was carried out with the participation of judges. Results: The resulting tool considers two levels of family assessment. It allows to distinguish those families that would benefit from interventions of greater complexity than those derived from the usual care of health centers. Conclusions: The tool to perform family studies responds to the informational and continuity component of Continuity of Patient Care principle. It may be a proposal for the continuous improvement of Chilean primary care.

Participación de los usuarios en las decisiones clínicas en la atención primaria de salud en Chile / User Participation in Clinical Decision-making in Primary Health Care in Chile / Participação dos usuários nas decisões clínicas na atenção primária à saúde no Chile

RESUMEN Objetivo Describir la experiencia de participación en las decisiones clínicas desde la perspectiva de usuarios de Centros de Salud Familiar (CESFAM) de la Atención Primaria de Salud (APS). Métodos Estudio de diseño cualitativo descriptivo; se realizaron grupos focales con usuarios de CESFAM del área sudeste de Santiago, Chile, y análisis temático de la información utilizando el programa Atlas.ti versión 6®. Resultados Se realizaron cinco grupos focales (n = 41). Los principales temas emergentes fueron el rol pasivo de los usuarios en las decisiones y la toma de decisión delegada, basada en la confianza en el profesional. El rol pasivo de los usuarios limita las oportunidades de participación en las decisiones clínicas y mantiene el poder en los profesionales de la salud. A pesar de ello, el establecimiento de una alianza terapéutica les permita sentirse tratados como personas únicas, escuchados y respetados por los profesionales, lo que asegura que las decisiones tomadas por el equipo de salud son confiables, pues velan por sus reales intereses. Conclusión La participación de los usuarios en los encuentros clínicos es aún escasa en el país. Sin embargo, potenciar esta participación es esencial para aumentar la satisfacción usuaria y promover un cuidado centrado en la persona.

ABSTRACT Objective Describe users' experience with participation in clinical decision-making at Family Health Centers (CESFAM) in the Primary Health Care (PHC) system. Methods Qualitative descriptive study. Focus groups made up of CESFAM users were held in southeastern Santiago, Chile, and the information was thematically analyzed using Atlas.ti version 6® software. Results Five focus groups were held (n = 41). The main themes that emerged from the discussions were the passive role of users in decisions and delegated decision-making, based on their trust in the health professional. Users' passive role limits their opportunities for participation in clinical decision-making, ceding power to the health professional. However, establishing a therapeutic partnership allows users to feel that they are being treated as unique individuals whom the professional listens to and respects, ensuring that the decisions of the health team can be trusted, since they look out for the users' real interests. Conclusion Users' participation in clinical encounters is still limited in Chile. However, bolstering that participation is essential for increasing user satisfaction and promoting people-centered care.

RESUMO Objetivo Descrever a experiência de participação nas decisões clínicas dos usuários dos Centros de Saúde Familiar (CESFAM) de atenção primária à saúde. Métodos Estudo qualitativo descritivo conduzido em grupos de discussão formados por usuários dos CESFAM da região sudeste da cidade de Santiago, no Chile. Foi realizada uma análise temática das informações com o uso do programa de software ATLAS.ti® versão 6. Resultados Foram formados cinco grupos de discussão (n = 41). Os principais tópicos abordados foram o papel passivo dos usuários nas decisões e a tomada de decisão delegada aos profissionais na base da confiança. O papel passivo restringe as oportunidades de participação dos usuários nas decisões clínicas e mantém o poder nas mãos dos profissionais da saúde. Apesar disso, ao ser criada uma aliança terapêutica, os usuários se sentem tratados como indivíduos únicos que são ouvidos e respeitados pelos profissionais, o que assegura que as decisões tomadas pela equipe de saúde sejam confiáveis porque protegem os reais interesses dos usuários. Conclusão Os usuários ainda têm pouca participação nas interações clínicas no Chile. Porém, é fundamental reforçar esta participação para melhorar a satisfação do usuário e promover uma atenção mais centrada na pessoa.

Modelo de atención integral en salud familiar y comunitaria en la atención primaria chilena / Model of comprehensive care in family and community health in primary care in Chile / Modelo de atenção integral na saúde da família e da comunidade na atenção básica chilena

RESUMEN Objetivo Describir el estado actual de la implementación de Modelo de Atención Integral en Salud Familiar y Comunitaria (MAIS) en la atención primaria de Chile. Métodos Estudio transversal que evaluó la implementación del MAIS en un total de 1 263 establecimientos de atención primaria. Por medio de correlaciones se estudió la relación entre la autoevaluación (interna) y la evaluación de los servicios de salud (externa) para cada centro. Con los análisis multinivel se evaluaron los factores de establecimientos, comunas y regiones asociados con el nivel de implementación del MAIS. Resultados La correlación entre autoevaluación interna y la evaluación externa de la implementación total del MAIS fue muy alta (0,819, p < 0,001). El eje tecnología presentó mayor implementación (83,0% de cumplimiento) y enfoque familiar (37,8% de cumplimiento), el menor. Los centros de salud familiar, las comunas urbanas, aquellas con mayor número de inscritos y con menor índice de pobreza, fueron los establecimientos que presentaron mayor implementación. No se identificó una asociación estadísticamente significativa entre la implementación del MAIS y los gastos comunales totales (p = 0,132) ni específicos de salud (p = 0,244). Conclusiones La mayoría de los establecimientos de salud de atención primaria han evaluado el nivel de implementación del. MAIS. Las estrategias de acompañamiento para su implementación son prioritarias para establecimientos de atención primaria ubicados en zonas rurales y con bajo número de usuarios inscritos. Aún persiste el desafío de avanzar en la instalación del enfoque familiar y la calidad del cuidado como centro de la atención de salud.

ABSTRACT Objective Describe the current status of the implementation of the Model of Comprehensive Care in Family and Community Health (MAIS, by its acronym in Spanish) in primary care in Chile. Methods Cross-sectional study that evaluated the implementation of MAIS in a total of 1 263 primary care facilities. Through correlations, the relationship between internal self-evaluation and external evaluation of health services for each center was studied. The factors of facilities, communes and regions associated with the level of implementation of the MAIS were evaluated with multilevel analyses. Results The correlation between internal self-evaluation and the external evaluation of the total implementation of the MAIS was very high (0.819, p <0.001). The technology axis presented the highest implementation (83.0% compliance), and family focus the lowest (37.8% compliance). The facilities with the highest implementation were family health centers, the urban communes, those with the highest number of enrollees and those with the lowest poverty index. A statistically significant association was not identified between the implementation of the MAIS and the total community expenses (p = 0.122) nor specific health expenditures (p = 0.244). Conclusions Most of the primary care health facilities have evaluated the level of implementation of the MAIS. The accompanying strategies for its implementation are priorities for primary care facilities located in rural areas and with a low number of registered users. Improving the family focus and the quality of care —key aspects of health care— are still a challenge.

RESUMO Objetivo Descrever o estado atual da implementação do Modelo de Assistência Integral em Saúde da Família e da Comunidade (MAIS) na atenção primária no Chile. Métodos Estudo transversal que avaliou a implementação do MAIS em um total de 1 263 estabelecimentos de atenção primária. Por meio de correlações, foi estudada a relação entre a autoavaliação (interna) e a avaliação dos serviços de saúde (externa) para cada centro. Os fatores dos estabelecimentos, municípios e regiões associados ao nível de implementação do MAIS foram avaliados com análises multiníveis. Resultados A correlação entre a autoavaliação interna e a avaliação externa da implementação total do MAIS foi muito alta (0,819, p <0,001). O eixo tecnológico apresentou maior implementação (83,0% de cumprimento) e foco familiar o menor (37,8% de cumprimento). Os centros de saúde da família, as comunas urbanas, aqueles com maior número de inscritos e com o menor índice de pobreza, foram os estabelecimentos que apresentaram a maior implementação. Não foi identificada associação estatisticamente significativa entre a implementação do MAIS e as despesas totais da comunidade (p = 0,122) nem gastos específicos com saúde (p = 0,244). Conclusões A maioria dos estabelecimentos de atenção primária avaliaram o nível de implementação do MAIS. As estratégias de acompanhamento para sua implementação são prioritárias para estabelecimentos de atenção primária em áreas rurais e com baixo número de usuários cadastrados. Enfatiza-se o desafio de avançar na instalação do enfoque familiar e na qualidade de atenção.

Atributos y características de los principios orientadores del Modelo de Atención Integral de Salud Familiar y Comunitaria desde la perspectiva de expertos en APS / Attributes and features of a community health model from the perspective of practitioners

Background: The Family and Community Health Model is based on three essential principles: user-centered care, comprehensive care and continuity of care. Aim: To describe the attributes and characteristics of the guiding principles of the Family and Community Health Model (FHM) from the perspective of primary care experts. Material and Methods: This was a qualitative study. An electronic Delphi was conducted with 29 national experts on primary care. Results: The experts agree that user centered care must be based on a psycho-social model integrating the multiple factors that influence health problems. It also must integrate patients' individual features, family and environmental issues. The proposed actions promote shared decision making. To promote integral care, anticipatory guidelines should be expanded and health care of patients with chronic conditions should be improved. Continuity of care should be promoted increasing working hours of medical centers and easing access to integrated electronic medical records, thereby generating efficient links between the different care levels. Conclusions: The results of the study can guide the clinical and administrative management of health teams, allowing the strengthening of primary health care according to the local realities.

Principios orientadores del Modelo Integral de Salud Familiar y Comunitario desde la perspectiva de los usuarios / Perception of users about an Integral Model of Family and Community Health care in Santiago, Chile

Background: The integral Model of Family and Community Health care is based on three essential principles: patient centered care, comprehensive care and continuity of care. Aim: To know the perception of primary care clinic users about the elements that should be considered in a patient centered integrated health care. Material and Methods: Ten males and 31 females aged 18 to 78 years, users of two public family primary care centers participated in focus groups, which were recorded. A qualitative descriptive research design based on content analysis according to Krippendorf was done. Results: Seven issues emerged from the description of patients’ experiences: professional-patient relationship, fragmentation of care, continued care with the same professional, promotion and prevention, availability of services and patient records. Conclusions: There are difficulties to install an integral model of family and community health care. The concerns raised by participants should be considered in order to modify the design of these models.

Diseño y validación del instrumento SALUFAM: un instrumento de valoración de la salud familiar con alto valor predictivo clínico para la atención primaria chilena / Design and validation of an instrument to assess families at risk for health problems

Background: There is a paucity of screening instruments with a high clinical predictive value to identify families at risk and therefore, develop focused interventions in primary care. Aim: To develop an easy to apply screening instrument with a high clinical predictive value to identify families with a higher health vulnerability. Material and Methods: In the first stage of the study an instrument with a high content validity was designed through a review of existent instruments, qualitative interviews with families and expert opinions following a Delphi approach of three rounds. In the second stage, concurrent validity was tested through a comparative analysis between the pilot instrument and a family clinical interview conducted to 300families randomly selected from a population registered at a primary care clinic in Santiago. The sampling was blocked based on the presence of diabetes, depression, child asthma, behavioral disorders, presence of an older person or the lack of previous conditions among family members. The third stage, was directed to test the clinical predictive validity of the instrument by comparing the baseline vulnerability obtained by the instrument and the change in clinical status and health related quality of life perceptions of the family members after nine months of follow-up. Results: The final SALUFAM instrument included 13 items and had a high internal consistency (Cronbach's alpha: 0.821), high test re-test reproducibility (Pearson correlation: 0.84) and a high clinical predictive value for clinical deterioration (Odds ratio: 1.826; 95% confidence intervals: 1.101-3.029). Conclusions: SALUFAM instrument is applicable, replicable, has a high content validity, concurrent validity and clinical predictive value.

Eje psicosocial familiar: reporte del diseño e implementación de un programa docente para residentes de los programas de postítulo en Medicina Familiar / Family psychosocial axis: report on the design and implementation of a program teacher for residents of postgraduate programs in Family Medicine

Cada vez más se acepta que la atención integral en salud requiere un foco de abordaje que esté puesto en la persona y su familia y no solo en la enfermedad o sus consecuencias. En concordancia con esta idea, con los objetivos propuestos para los Programas de Postítulo de Medicina Familiar de la Pontificia Universidad Católica de Chile, con las necesidades percibidas por docentes y residentes y con la literatura disponible en relación con el currículo de esta especialidad, se trabajó en la revisión de la formación que los residentes de estos programas recibían con respecto a aspectos psicosociales y familiares. En respuesta a este análisis, se trabajó en la definición de las competencias específicas en el ámbito psicosocial familiar deseables para los egresados de nuestros Programas de Postítulo. De acuerdo con las conclusiones de este trabajo, se revisó y replanteó el currículo vigente. Este artículo resume y presenta el proceso de diseño e implementación de un programa docente específico para la formación en competencias del ámbito psicosocial familiar para los residentes de los programas mencionados. (AU)

- Increasingly it is accepted that comprehensive health care approach requires that the focus has to be placed on the person and his family and not just the disease or its consequences. Consistent with this idea, the proposed objectives of the post graduate programs of Family Medicine at Pontifical Catholic University of Chile, focused on the perceived needs of teachers and residents based on the literature available on this area, we worked in reviewing the training that residents of these programs received regarding family, and psychosocial aspects.In response to this analysis, we worked on the definition of specific skills in the family psychosocial environment desirable for graduatesfrom our post graduate programs. According to the findings of this work the current curriculum was reviewed and reconsidered.This article summarizes and presents the process of designing and implementing a specific educational program for training in skills offamily psychosocial environment for the residents of these programs.(AU)

Factores asociados a dengue grave durante la epidemia de dengue en la ciudad de Iquitos, 2010-2011 / Factors associated to severe dengue during the dengue epidemic in Iquitos, 2010-2011

Objetivo: Identificar los factores de riesgo para dengue grave en la epidemia de Iquitos, 2010-2011. Métodos: Estudio caso-control 1:2. Se definieron como casos (73) a los pacientes hospitalizados por dengue grave, de cualquier edad y sexo, con resultados confirmatorios a dengue por cualquier método diagnóstico. Los controles (153) fueron pacientes hospitalizados o ambulatorios de cualquier edad y sexo, con resultados confirmatorios a dengue por cualquier método diagnóstico. Se incluyó casos atendidos en los hospitales Regional Loreto y Apoyo Iquitos. Se utilizaron las definiciones de caso oficiales para el Perú, los mismos que están basados en recomendaciones de la OMS. Resultados: Mediante regresión logística se identificó como factores de riesgo para dengue grave: ser menor de 15 años (OR: 3.15; IC 95%: 1.48-6.70), tener antecedentes de dengue (OR: 6.65; IC 95%: 2.56-17.27) y retornar al establecimiento de salud para recibir atención por el mismo cuadro de dengue (OR: 4.63; IC 95%: 2.21-9.73). Asimismo, se encontró asociación entre el DENV-2 y dengue grave. El dolor abdominal, el sangrado de mucosas y los vómitos persistentes fueron los signos de alarma más frecuentes; la media del tiempo entre el inicio de síntomas y aparición de algún signo de alarma fue 3.35 días (DS ± 1.5) ; la media del tiempo entre el inicio de síntomas y aparición de algún signo de gravedad fue 4.97 días (DS ± 1.6). Conclusiones: El antecedente de dengue, la edad menor de 15 años y retornar al establecimiento de salud para recibir atención por el mismo cuadro de dengue constituyeron factores de riesgo para dengue grave.

Objective: To identify risk factors to severe dengue epidemic in Iquitos, 2010-2011. Methods: Case-control study 1:2. Cases were defined as patients hospitalized for severe dengue (73), regardless of age and sex, with confirmatory results by any method for dengue diagnosis. Controls (153) were inpatients or outpatients of any age and sex, with negative results by any method for dengue diagnosis. We included cases treated in Hospital Regional Loreto and Hospital Apoyo Iquitos. We used official case definitions for Peru, which are based on WHO recommendations. Results: Through logistic regression risk factors to severe dengue were identified as younger of 15 years (OR: 3.15, 95% CI: 1.48-6.70), a history of dengue (OR: 6.65; 95% CI: 2.56-17.27) and return to the health facility for receive care by the same dengue episode (OR: 4.63; 95% CI: 2.21-9.73). We also found association between DENV-2 and severe dengue. Abdominal pain, mucosal bleeding and vomiting were the most common warning signs; mean time between onset of symptoms and appearance of any sign of alarm was 3.35 days (SD ± 1.5) and mean time between the onset of symptoms and the appearance of any sign of severity was 4.97 days (SD ± 1.6). Conclusions: history of dengue, age younger than 15 years and return to the health facility for care by the same dengue episode are risk factors to severe dengue.