Bioética y virtualidad en la relación médico-paciente / Bioethics and virtuality in the doctor-patient relationship

The paper proposes, as the topic of analysis, the emergence of telemedicine, a tool that has been intensively used by doctors and other professionals during the covid pandemic. The essay, divided into two parts, first describes the current situation of telemedicine and afterwards proposes a few precautionary theses, related to telemedicine and the doctor-patient relationship according to the undestanding that the latter has been inherited and transmitted by medical anthropology and the medical humanities. (AU)

Problemas Éticos en la Práctica Médica. Estudio exploratorio desde la perspectiva de médicos de dos hospitales públicos / Perspectives of physicians who work in public hospitals about ethical problems in medical practice

Background: The recognition of ethical problems in medical practice and the potential harmful effects that they may have on patients, underscores the importance of the ethical training of professionals as well as the development of Ethics Committees in Healthcare institutions. However, there is a paucity of national studies about the type of problems faced by professionals and the role of Ethics Committees in hospitals. Aim: To explore the perception about ethical problems in clinical practice of Chilean physicians of different specialties of two public teaching hospitals. Material and Methods: Physicians of both sexes and different specialties working in two teaching hospitals of Metropolitan Santiago, were invited to participate in focus groups of seven to eight participants. They discussed the ethical problems faced during their clinical practice. A content analysis based on the Grounded Theory was performed with the obtained information. Results: Different types of ethical problems could be distinguished according to their content and the actors involved. The data obtained shows that the ethical dimension is present in the daily work of physicians. The evolution of the narrative throughout the interviews corroborated the importance of installing ethical issues and culture in the working routine of health care professionals. Conclusions: Human resources and an adequate institutional environment are required to promote the discussion about ethical issues such as the relationship between physicians and patient, the role of teaching in health care and institutional decisions.

Síndrome de insensibilidad a andrógenos: revisión bibliográfica a propósito de 5 casos / Androgen insensitivity syndrome: literature review about 5 cases

El síndrome de insensibilidad a andrógenos (AIS en la sigla inglesa) es una entidad muy poco frecuente en endocrinología. Se caracteriza por la mutación del receptor de andrógenos de magnitud variable, por medio del cual individuos 46,XY no se virilizan normalmente, a pesar de conservar sus testículos y tener concentraciones de testosterona en rango masculino. El cuadro clínico es variable y depende la profundidad de la alteración del receptor. En un extremo, hay casos de insensibilidad androgénica completa (CAIS) con fenotipo femenino. En el otro extremo hay insensibilidad parcial (PAIS) que se extiende desde el fenotipo femenino, con o sin ambigüedad genital, hasta los casos de hombres infértiles o con subvirilización, que presentan insensibilidad androgénica más leve. En los fenotipos femeninos, los testículos suelen estar en posición ectópica y aquellos ubicados dentro del abdomen tienen riesgo de malignizarse, por lo que suelen extirparse. Estos son los casos de más difícil manejo, pues aparte de la necesidad de gonadectomía seguida de terapia hormonal femenina, existe una vagina estrecha y en fondo de saco ciego y que suele requerir corrección quirúrgica para permitir la actividad sexual. En este trabajo presentamos 5 casos de AIS vistos recientemente en 2 centros clínicos de Santiago y que ilustran la heterogeneidad de presentación. Además, hacemos una revisión actualizada de los criterios diagnósticos, los tratamientos más adecuados y el manejo global de esta condición.

The Androgen insensitivity syndrome (AIS, in its English acronym) is a very rare entity in endocrinology. It is characterized by a variable magnitude androgen receptor mutation, whereby 46, XY individuals are not normally virilized, despite retaining their testicles and having testosterone concentrations in the male range. The clinical picture is variable and depends on the depth of the receptor alteration. At one extreme, there are cases of complete androgenic insensitivity (CAIS) with a female phenotype. At the other extreme, there is partial insensitivity (PAIS) that extends from the female phenotype, with or without genital ambiguity, to cases of infertile or undervirilized men, who have milder androgenic insensitivity. In female phenotypes, the testes are usually in an ectopic position and those located within the abdomen are at risk of malignancy, and therefore are usually removed. These are the most difficult cases to manage because apart from the need for gonadectomy followed by female hormonal therapy, there is a narrow vagina and a deep blind pouch that usually requires surgical correction to allow sexual activity. In this work, we present 5 cases of AIS recently seen in 2 clinical centers in Santiago and that illustrate the heterogeneity of presentation. In addition, we make an updated review of the diagnostic criteria, the most appropriate treatments, and the overall management of this condition.

Metástasis ganglionar como presentación de un carcinoma papilar de tiroides oculto, variedad folicular: reporte de caso / Lymph node metastasis as a presentation of an occult papillary thyroid carcinoma, follicular variety: case report

El carcinoma oculto de tiroides está poco reportado. Se presenta el caso de una mujer de 59 años. Durante un control por hipotiroidismo se solicitó ecografía cervical, la que mostró áreas hipoecogénicas en lóbulo derecho, una formación nodular hiperecogénica circunscrita no sospechosa de 8 mm y una adenopatía cervical periglandular derecha de 20 x 12 x 8 mm con áreas quísticas y microcalcificaciones, asociadas a hipervascularización. Se solicitó punción aspirativa por aguja fina del ganglio linfático, con resultado de citología negativa para células neoplásicas. El examen microscópico es compatible con tiroiditis, por lo que no es posible descartar metástasis. Se realizó biopsia del ganglio linfático, el que se informa como metástasis ganglionar linfática de 1.3 cm, histología de carcinoma papilar variedad folicular, sin invasión extracapsular. Se realizó tiroidectomía total y disección cervical derecha. El estudio anatomopatológico reportó una tiroiditis crónica de Hashimoto con un nódulo fibroso hialinizado de 0,4 cm negativo para tumor maligno y metástasis en 4 de 28 ganglios linfáticos, sin invasión extracapsular. El tamaño de la metástasis fue de 0,3 a 0,9 cm. Posteriormente se administró 100 mci de radioyodo. Actualmente, la paciente está en buenas condiciones y mantiene controles con ecografía y tiroglobulina periódicos.

Occult thyroid carcinoma is under-reported. The case of a 59-year-old woman is presented. During a check-up for hypothyroidism, a cervical ultrasound was requested, which showed hypoechogenic areas in the right lobe, an 8 mm nonsuspicious circumscribed hyperechogenic nodular formation and a 20 x 12 x 8 mm right cervical periglandular lymphadenopathy with cystic areas and microcalcifications, associated with hypervascularisation. Fine needle aspiration of the lymph node was requested, with negative cytology results for neoplastic cells. Microscopic examination was compatible with thyroiditis, so metastasis could not be ruled out. A biopsy of the lymph node was performed, which was reported as a 1.3 cm lymph node metastasis, histology of papillary carcinoma of the follicular variety, without extracapsular invasion. Total thyroidectomy and right cervical dissection were performed. The anatomopathological study reported chronic Hashimoto's thyroiditis with a 0.4 cm hyalinised fibrous nodule negative for malignant tumour and metastases in 4 of 28 lymph nodes, without extracapsular invasion. The size of the metastasis was 0.3 to 0.9 cm. Subsequently, 100 mci of radioiodine was administered. The patient is currently in good condition and maintains regular ultrasound and thyroglobulin monitoring.

Manejo nutricional de ascitis quilosa: Serie de casos y revisión de la literatura

RESUMEN Las ascitis quilosa (AQ) es una entidad poco común producida por el acúmulo de linfa en la cavidad peritoneal. Su incidencia se describe en aumento progresivo, asociándose a una mortalidad de 40-70%. Se incluyeron 3 pacientes con diagnóstico de AQ evaluados en la visita de asistencia nutricional del Hospital Clínico de la Universidad Católica (UC) durante el año 2019. Caso 1: Paciente mujer de 47 años, consulta por dolor abdominal agudo realizándose apendicectomía. Estudio de líquido peritoneal con triglicéridos (TG) de 1.362 mg/dL. Inicia Nutrición Parenteral Total (NPTC) progresando luego a régimen oral. Estudio no revela lesiones de vasos linfáticos ni otras causas. Caso 2: Paciente varón de 68 años con cirrosis por alcohol, Child Pugh B. Ingresa por disnea y ascitis refractaria. Estudio de líquido ascítico y pleural, con TG de 439 mg/dL y 592 mg/dL respectivamente. Se manejó con toracocentesis y paracentesis evacuadoras, tratamiento con régimen hipograso y aporte de triglicéridos de cadena media (MCT) vía oral. Evolución tórpida requiriendo apoyo con NPTC, realizándose drenajes sucesivos, por lo que se instala TIPS. Caso 3: Paciente mujer de 63 años consulta por dolor hipogástrico con masa palpable subcostal derecha. Estudio confirma masa pancreática por lo que se realiza Whipple. Reingresa por náuseas y vómitos profusos, evidenciándose líquido ascítico con TG de 251 mg/dl. Se inicia NPTC, escasos débitos del drenaje iniciándose realimentación progresiva por vía oral. El análisis del líquido tras la paracentesis establece el diagnóstico de AQ pues la clínica es inespecífica. Las principales complicaciones están dadas por la pérdida de quilo: desnutrición, infecciones y sepsis. Las opciones de tratamiento incluyen: medidas dietéticas, fármacos e intervenciones percutáneas o quirúrgicas; siempre orientadas al alivio sintomático, con foco en tratar la causa. Si la tolerancia oral es óptima la primera medida es la supresión de la grasa y la suplementación con MCT para evitar déficit energético. Con el empleo de estas medidas se ha reportado el cierre espontáneo de fístulas y/o defectos de vasos linfáticos en un 75%-80%. Se concluye que no hay guías de recomendación y los estudios se basan en series de pocos casos clínicos. La ascitis quilosa es una entidad patológica rara, que representa una situación clínica crítica con consecuencias inmunológicas y nutricionales; y el tratamiento debe ser etiológico y el paso clave inicial es optimizar el estado nutricional del paciente.

ABSTRACT Chylous ascites (CA) is an uncommon entity caused by the accumulation of lymph in the peritoneal cavity, its incidence has been gradually increasing; being associated with a mortality of 40-70%. This work includes 3 patients with CA diagnosis evaluated by the Nutritional Assistance team in the Hospital Clínico of the Universidad Católica, Chile during 2019. Case 1: 47-year-old female, with acute abdominal pain that resulted in an appendectomy. Peritoneal fluid study showed triglycerides (TG) of 1362 mg/dL. Total Parenteral Nutrition (TPN) was initiated with successive changes to an oral regimen. The case was negative for lymphatic vessel injuries or other causes of AQ. Case 2: 68-year-old male with alcoholic cirrhosis, Child-Pugh B. The patient was admitted for dyspnea and refractory ascites. Ascites and pleural fluid study showed TG of 439 mg/dL and 592 mg/dL, respectively, whichwas managed with thoracentesis and evacuating paracentesis, treatment with a low-fat regimen, and oral medium chain triglycerides (MCT). Case 2 had a poor evolution requiring TPN and successive evacuations, with TIPS installed. Case 3: A 63-year-old female patient with hypogastric pain and palpable right subcostal mass. Study confirmed a pancreatic tumor and Whipple Surgery was performed. Case 3 was readmitted for nausea and vomiting, showing ascitic fluid with TG of 251 mg/dl. TPN was started, with decrease in drainage fluids and successful progressive oral refeeding. The analysis of the paracentesis fluid established the diagnosis of CA since the symptoms were nonspecific. The main complications were due to the loss of chyle: malnutrition, infections and sepsis. Treatment options included: dietary measures, drugs, and percutaneous or surgical interventions; always oriented to symptomatic relief, focused on etiologic treatment. If oral tolerance is optimal, the first measure should be fat suppression and supplementation with MCT to avoid energy deficit. With the use of these measures, spontaneous closure of fistulas and / or lymphatic vessel defects has been reported in 75% -80% of patients. There are no recommendation guidelines for CA and studies are based on series of a few clinical cases. CA is a rare disease, representing a critical clinical situation with immunological and nutritional consequences. Etiologic treatment must be prioritized with a focus on optimization of the nutritional status of the patient

Cáncer Papilar en Quiste Tirogloso. Caso Clínico y Revisión de la literatura / Papillary Cancer in Tirogloso Cyst. Case report and review of literature

INTRODUCCIÓN: Los quistes tiroglosos son las lesiones más comunes de la línea media cervical y se ha descrito el carcinoma papilar de tiroides en el 1%. Debido a su baja incidencia no existe un consenso acerca del tratamiento óptimo. Caso clínico: Paciente mujer de 34 años de edad consulta por aumento de volumen cervical doloroso y se evidencia nódulo doloroso en región cervical media. Ecografía de tiroides visualiza una lesión quística compleja. Se completa el estudio con tomografía computada del cuello con contraste que evidencia quiste del conducto tirogloso con compromiso inflamatorio-infeccioso, por lo que se decide cirugía. Biopsia evidencia cáncer papilar de 0.25 cm en quiste del conducto tirogloso, con bordes quirúrgicos negativos. Por bajo riesgo se decide control imagenológico estricto. DISCUSIÓN: Los quistes del conducto tirogloso comprenden las lesiones cervicales congénitas más frecuentes. Se presentan como masas indolentes y asintomáticas. El diagnóstico es confirmado mediante ecografía y la tomografía es utilizada para ampliar el estudio. La aparición de cáncer tiroideo en estos quistes es poco común, y generalmente son indistinguibles de las lesiones benignas en el preoperatorio. En relación al manejo del cáncer papilar en quiste del conducto tirogloso no existe un consenso de su tratamiento óptimo. Para los casos de bajo riesgo se sugiere control anual con TSH y ecografía tiroidea. Para aquellos pacientes de alto riesgo se sugiere tiroidectomía total y ablación de los restos tiroides con yodo radioactivo, con control anual con niveles de tiroglobulina. El pronóstico es excelente, con tasas de remisión que superan el 95%. CONCLUSIONES: Los carcinomas en quistes de conducto tirogloso son poco comunes y en la mayoría de los casos son lesiones diagnosticadas de manera incidental después de la resección quirúrgica. Para definir necesidad de tiroidectomía, debe realizarse estudio individualizado por un equipo multidisciplinario con amplia experiencia.

INTRODUCTION: Thyroglossal cysts are the most common affection of the cervical midline. Papillary carcinoma has been described in 1% of this cysts. Due to its low incidence a consensus on the optimal treatment does not exist. Clinical case: A 34 year old female with no relevant past medical history, presented with a painful cervical mass of many weeks of appearance. The thyroid ecography showed a complex cystic lesion and the cervical computed tomography with contrast evidenced a cyst of the thyroglossal duct with inflammatory and infectious findings. Surgery with no incidents was performed. Biopsy reported a 0.25 cm papillary cancer in the thyroglossal duct cyst, with negativa surgical margins. Strict follow up with imaging studies was decided. DISCUSSION: the thyroglossal duct cyst are the most common congenital cervical affections. Classically, they present as indolente, asyntomatic masses on the cervical midline. The diagnosis is confirmed with ecography and computed tomography is used to extent evaluation. Thyroid cancer in thyroglossal duct cyst is uncommon and generally indistinguishable from benign lesions in the preoperative phase. A consensus regarding the optimal management of this patients does not exist. For low risk cases, an anual control with THS and thyroid ecography is suggested. For patients with high risk a Sistrunk with total thyroidectomy and radioactive ablation of thyroids remnants is recommend. Follow up with anual thyroglubin levels should be performed. The prognostic is excellent, with more than 95% remission rates. CONCLUSSIONS: Thyroglossal duct cyst carcinomas are rare. In most cases, diagnosis is made incidentally after surgical resection. To decide wheter thyroidectomy is necessary each case should be analyzed individually by a multidisciplinary team with vast experience.

Cáncer de paratiroides e hipercalcemia de difícil manejo: un desafío diagnóstico / Parathyroid cancer and hypercalcemia difficult to manage: a diagnostic challenge

INTRODUCCIÓN: El carcinoma de paratiroides es una enfermedad de difícil diagnóstico, siendo perentorio una detección precoz y un tratamiento oportuno para prevenir las complicaciones. CASO CLÍNICO: Se presenta paciente de 42 años que debuta con hipercalcemia de 16.1 mg/dl, PTH 1573 pg/mL y lesión sugerente de adenoma de paratiroides. Biopsia quirúrgica identifica carcinoma paratiroideo sin invasión, realizándose posteriormente lobectomía derecha con foco de 0,1 mm de carcinoma paratiroideo, con bordes libres. En comité oncológico se decide seguimiento estricto; sin embargo, a los seis meses requiere hospitalización nuevamente por hipercalcemia, a la ecografía cervical presenta dos nódulos hipoecogénicos menores a 1 cm en lecho quirúrgico. Tomografía computada sin evidencia de lesiones. Con estos antecedentes, se decide exploración cervical, encontrándose tumor de 2 cm, multilobulado, paraesofágico. Biopsia evidencia carcinoma paratiroideo con invasión en tejido graso y músculo estriado. Se descarta radioterapia paliativa y quimioterapia debido a escasa evidencia, quedando en cuidados paliativos. DISCUSIÓN: El cáncer de paratiroides es una enfermedad de difícil diagnóstico. En muchos casos se ha descrito la crisis hipercalcémica como presentación inicial. La resección en bloque de la lesión de paratiroides con hemitiroidectomía ipsilateral es el tratamiento estándar. Es un tumor radio resistente y la quimioterapia adyuvante no ha demostrado aumento en la sobrevida. En pacientes con enfermedad inoperable, el pronóstico es pobre, siendo fundamental el control de calcemia y PTH, las cuales son la causa principal de morbimortalidad. CONCLUSIONES: El carcinoma paratiroideo es una enfermedad rara, cuyo diagnóstico y tratamiento representan un verdadero desafío clínico, siendo crucial el alto índice de sospecha. Su curso es crónico y de mal pronóstico, por lo que para pacientes de alto riesgo debe considerarse una cirugía radical desde el inicio.

INTRODUCTION: Parathyroid carcinoma is a difficult diagnosis, with early detection and timely treatment to prevent complications being imperative. CLINICAL CASE: A 42-year-old patient presenting with hypercalcemia of 16.1 mg / dl, PTH 1573 pg / mL and suggestive lesion of parathyroid adenoma is presented. Surgical biopsy identifies parathyroid carcinoma without invasion, subsequently performing right lobectomy with 0.1 mm focus of parathyroid carcinoma, with free borders. Oncological committee, strict follow-up is decided; However, at six months he requires hospitalization again for hypercalcemia, at cervical ultrasound he presents two hypoechogenic nodules smaller than 1 cm in the surgical bed. CT scan without evidence of injuries. With this background, cervical exploration is decided, finding a 2 cm, multilobed, paraesophageal tumor. Biopsy shows parathyroid carcinoma with invasion of fatty tissue and striated muscle. Palliative radiotherapy and chemotherapy are ruled out due to limited evidence, remaining in palliative care. DISCUSSION: Parathyroid cancer is a difficult diagnosis disease. In many cases the hypercalcemic crisis has been described as an initial presentation. Block resection of the parathyroid lesion with ipsilateral hemitiroidectomy is the standard treatment. It is a radioresistant tumor and adjuvant chemotherapy has not shown an increase in survival. In patients with inoperable disease, the prognosis is poor, with the control of calcemia and PTH being essential, which are the main cause of morbidity and mortality. CONCLUSIONS: Parathyroid carcinoma is a rare disease, the diagnosis and treatment of which represent a real clinical challenge, the high index of suspicion being crucial. Its course is chronic and has a poor prognosis, so for high-risk patients, radical surgery should be considered from the beginning.

Objeción de conciencia y nuevo protocolo del Ministerio de Salud / Conscientious objection and new Ministry of Health protocol

The beginning of the implementation at the institutional level of Law 21.030, relating to the decriminalization of pregnancy for three reasons, has generated concerns, practical difficulties and changes in the dynamics of work teams in hospitals that have had to implementar. These difficulties refer to areas as varied as diagnosis, confirmation of the causes, to the opposition of different professionals in their participation in the process. In this first communication we will summarize the last of the problems arising from the new protocol issued by the Ministry of Health, regarding the Institutional Awareness Objection in Hospitals that, like the HCUCH, have an agreement with FONASA. (AU)

Índice de función sexual en trabajadoras de la salud / Sexual function index in health workers

Objetivo: Determinar la función sexual femenina de trabajadoras de la salud. Método: Estudio cuantitativo, descriptivo, transversal. Universo formado por mujeres que se desempeñan en un hospital de alta complejidad, cuyas edades fluctúan entre 20 a 64 años. Se caracterizó el perfil biosociodemográfico de la trabajadora junto al Índice de Función Sexual Femenina (IFSF). El análisis estadístico se realizó aplicando análisis univariados y bivariados, coeficiente de correlación de Pearson o Spearman y análisis de varianza. Resultados: El puntaje del IFSF logra su máxima expresión alrededor de los 35 a 39 años (29,7 +/- 4,9) y luego disminuye progresivamente (23,0 +/- 8,9). Se observa un 32,6 por ciento de disfunción sexual, 29 por ciento de desorden del deseo, 10,4 por ciento de dificultades de excitación, 5,6 por ciento de problemas de lubricación, 9,7 por ciento de desorden en el orgasmo, 14 por ciento de problemas de satisfacción sexual y 9,9 por ciento de dispareunia. Conclusiones: El IFSF en trabajadoras de la salud varió en concordancia con la edad, menopausia, educación y problemas de sexualidad en la pareja. El estamento auxiliar de servicio alcanzó mayores índices de disfunción sexual.

Objective: To determine the female sexual function of health workers. Method: quantitative, descriptive, cross-sectional study. The universe is made by women who work in a high complexity hospital, ranging from 20 to 64 years old. The biosociodemographic profile of the worker was characterized by the Female Sexual Function Index (FSFI). Statistical analysis was performed using univariate and bivariate analysis. Pearson or Spearman correlation coefficient was used and analysis of variance was applied. Results: The FSFI score achieved its best around 35-39 years (29.7 +/- 4.9) and then it decreases progressively (23.0 +/- 8.9). It shows 32.6 percent of sexual dysfunction, 29 percent of desire disorder, 10.4 percent of arousal difficulties, 5.6 percent of lubrication problems, 9.7 percent of orgasm disorder, 14 percent of problems of sexual satisfaction and 9.9 percent of dyspareunia. Conclusions: The FSFI in health female workers vary in accordance with age, menopause, education and sexual problems in couples. The auxiliary service establishment reached higher rates of sexual dysfunction.

Coinfección pulmonar por Aspergillus fumigatus y Pneumocystis jirovecii en un paciente con VIH-SIDA / Lung coinfection by Aspergillus fumigatus and Pneumocystis jirovecii in an HIV-AIDS patient

Se presenta un caso de coinfección pulmonar por Aspergillus fumigatus y Pneumocystis jirovecii en un paciente con VIH-SIDA. Se diagnosticó con TAC pulmonar, visualización directa con KOH 20 por ciento, tinción de Gomori-Grocott y cultivo del LBA, galactomanano en sangre y de LBA. Se discuten los factores de riesgo, diagnóstico y tratamiento para cada infección.

We report a case of lung coinfection by Aspergillus fumigatus and Pneumocystis jirovecii in a patient with HIV-AIDS. Was diagnosed with lung TAC, direct visualization with KOH 20 percent, Gomori- Grocott staining and culture of BAL, galactomannan in blood and BAL. We discuss risk factors, diagnosis and treatment for each infection.

Profundidad del músculo masetero medido mediante ultrasonido, según índice facial en relación al sexo / Masseter muscle deep measured by ultrasound per facial index related to sex

Para establecer las dimensiones en profundidad del músculo masetero según índice facial en relación al sexo, se realizó un estudio analítico no experimental entre pacientes seleccionados que acudieron al servicio de imagenología del hospital base de Linares, Chile. La muestra quedó determinada por 180 músculos maseteros, 90 de mujeres y 90 de hombres. Se clasificaron según su índice facial en euriprosopos, leptoprosopos y mesoprosopos quedando la muestra conformada por 60 músculos de individuos euriprosopos, mesoprosopos y leptoprosopos, respectivamente. Se realizó la medición de la profundidad de cada uno de los músculos maseteros utilizando para ello un examen imagenológico ecográfico. La muestra se sometió al análisis estadístico ANOVA. La profundidad del músculo masetero varió dependiendo del índice facial y en ambos sexos (p <0,05). Los individuos euriprosopos presentaron músculos maseteros con profundidades promedio de 11,5+/-2,08 mm para el sexo masculino y de 8,8+/-1,4 mm para el sexo femenino. Los individuos mesoprosopos presentaron profundidades de 11,4+/-1,6 mm para el sexo masculino y 7,8+/-1,6 mm para el sexo femenino. Mientras que los individuos leptoprosopos presentaron profundidades promedio para el sexo masculino de 10,08+/-1,2 mm y 7,7+/-1,4 mm para los individuos de sexo femenino. La profundidad del músculo masetero varia dependiendo del índice facial en relación al sexo. Esta diferencia se encuentra entre el grupo de los individuos leptoprosopos y el grupo de los euriprosopos (p< 0,005). Se concluye que el índice facial de los individuos debe ser considerado en el diagnóstico de alteraciones de tamaño de la musculatura masticatoria...

To establish the dimensions of the masseter muscle deep as a facial index in relation to gender, an analytical study was conducted among patients who were attended at the imaging service Linares Hospital, Chile. The sample was 180 masseter muscles, 90 of them belonging to female individuals and 90 individuals belonging to male subjects. The subjects were classified according to facial index in euryprosopous, mesoprosopous and leptoprosopous. Each group was composed of 60 muscles. The depth of each masseter muscles was performing using an ultrasound-imaging test. The sample was subjected to ANOVA statistical analysis. The depth of masseter muscles varied depending facial index in both sexes (p <0.05). Euryprosopous individuals showed an average of 11.5+/-2.08 mm for male and 8.8+/-1.4 mm for female. Mesoprosopous individuals showed an average of 11.4+/-1.6 mm. for male and 7.8+/-1.6 mm for female. Leptoprosopous individuals showed an average of 10.08+/-1.2 mm for male and 7.7+/-1.4 mm. for female. The depth of the masseter muscle varies depending of facial index on both sexes. The difference is significant between muscles of leptoprosopous and euryprosopous subjects (p <0.005). It was concluded that the facial index of individuals should be considered in the diagnosis of altered masticatory muscle size...

Dimensiones del músculo masetero medido mediante ultrasonido, según sexo / Masseter muscle dimensions measured by ultrasound per sex

Introducción: para establecer las dimensiones en profundidad, ancho y largo del músculo masetero según sexo, se realizó un estudio analítico no experimental entre pacientes seleccionados que acudieron al servicio de ecografía del Hospital Base de Linares, Chile entre los meses de julio y septiembre del año 2005. Métodos: la muestra quedó determinada por 180 músculos maseteros, 90 de ellos pertenecientes a individuos de sexo femenino y 90 pertenecientes a individuos de sexo masculino. Se realizaron las mediciones de cada una de las dimensiones del músculo masetero utilizando para ello un examen imaginológico ecográfico. La muestra se sometió al análisis estadístico ANOVA. Resultados: los individuos de sexo masculino presentan músculos maseteros con profundidades promedio de 10,8 ± 1,6 mm y los individuos de sexo femenino profundidades promedio de 8,1 ± 1,4 mm. Conclusión: de acuerdo con lo encontrado, se concluye que en individuos de sexo masculino con una profundidad del músculo masetero mayor a 12,4 mm y en individuos de sexo femenino con una profundidad del músculo masetero mayor a 9,5 mm se podrían considerar el diagnóstico de hipertrofia maseterina.

Introduction: in order to establish the dimensions in depth, width and length of the masseter muscle according to gender, a non analytical experimental observational study was performed on selected patients who attended the echography service at the Base Hospital of Linares-Chile between July and September 2005. Methods: the sample consisted of 180 masseter muscles, 90 from female individuals and 90 from male individuals. Measurements of each masseter muscle were performed utilizing an echographic exam. ANOVA test statistical analysis was performed. Results: the masseter muscle depth on male individuals has an averaged 10.8 ± 1.6 mm and on female individuals an average depth of 8.1 ± 1.4 mm. Conclusion: according to the findings, we concluded that in male individuals with a depth of the masseter muscle higher to 12.4 mm and in female individuals with a depth of masseter higher to 9.5 mm could be considered a diagnosis of masseteric hypertrophy.

Cetoacidosis diabética en adultos: causas y su manejo en un hospital regional / Management of diabetic ketoacidosis: retrospective analysis of 117 episodes

Background: In 2005, the Chilean Ministry of Health developed Clinical Guidelines to ensure the correct diagnosis and acute treatment of diabetic ketoacidosis (DKA). Aim: To analyze the real impact of the use of the Clinical Guidelines, comparing the diagnosis and treatment of DKA beforeand after 2005. Patients and Methods: Retrospective analysis of clinical records of adults with DKA, treated between 2001 and 2008 in a regional hospital. Results: One hundred seventeen DKA episodes, that occurred in 82 patients aged 15 to 90 years (47 percent females), were analyzed. Eightytwo percent of patients were known diabetics. Treatment discontinuation was the cause of DKA in 37 percent of patients, followed by infections in 37 percent and onset of diabetes mellitus in 17 percent. Ninety seven percent of patients previous episode of DKA were using insulin. Two patients died (1.7 percent) and DKA complications were uncommon. Bicarbonate and potassium were over prescribed despite therecommendation of Clinical Guidelines (p < 0.05). The use of infusion pumps increased after the incorporation of the Clinical Guidelines. Conclusions: A low impact of Clinical Guidelines on themanagement of DKA was observed in this group of patients. Insulin users have a higher risk for developing DKA.

La enseñanza de la bioética y su relación con la enseñanza de la clínica. Experiencia de la Escuela de Medicina de la Universidad de Chile / The teaching of the bioethics and its relation with the education of the clinic. Experience of the Medicine School of the University of Chile

This article is intended to describe to clinicians what the Department of Education in Health Sciences means to pre graduation teaching of bioethics, through its historical development,its educational objectives and its contents. There is yet no consensus among different Schools about the methods used to teach the discipline and its purpose, so discussion provokesreflection and alternative decisions. The concept and significance of the “hidden curriculum”, derived from the afore explicit terminology with polisemic interpretation, adds to the debateas it produces new entrances to the pool of meanings, varying from knowledge and culture increments to deliberated and malicious imposition of information. It seems mandatory to all the clinical tutors to assume direct responsibility in students ethics problems analysis, as part of their general competences and reflecting the usual clinical exposure to these situations and the importance that knowing to handle these events has in the medical setting.

El profesor docente y la ética institucional / The educational teacher and the institutional ethics

Organizations develop codes of ethics to give orientations to their members on how to recognize, understand and handle ethical dilemmas in their daily work. In year 2005 a group of faculty members of the Universidad de Chile Faculty of Medicine started an institutional ethics project, acknowledging that all institutional decisions have moral contents. The purpose of this project is to promote an ethical environment in the institution. The first step was to establish a diagnosis by means of the organization of focal groups that collected the perceptions of students, faculty members and non-academic personnel. With a diagnosis in hand, a preliminary document was prepared, the “Universidad de Chile Faculty of Medicine declaration of principles and values”. Members of all groups that participated in the diagnostic phase had the opportunity to discuss this preliminary document and check if their agreement with its contents. Given the relevance of the ethical aspects of the learning and teaching process for the positive modeling of students from all health-related professions, special emphasis is given to its discussion.

Inmunohistoquímica de los cambios degenerativos del sistema nervioso central en paraparesias esp sticas asociadas al virus linfotrópico humanoTtipol(HTLV-l) / Immunohistochemistry of degenerative changes in the central nervous system in spastic paraparesis associated to human T lymphotropic virus type I (HTLV-I)

Background: Human T lymphotropic virus type I is associated with tropical spastic paraparesis, that is a chronic and progressive disease which damages specially the cortiespinal tracts. The pathogenesis of this degenerative process remains unknown. Aim: To identify histopathological aspects that could suggest a pathogenic hypothesis we studied immunohistochemical features in spinal cords obtained from patients that died due to progressive spastic paraparesis. Patients and Methods: Five males and five females, who died between 1990 and 2000, with a mean age of 52 years and mean disease duration of 8.6, were studied. All had a complete clinical and virological diagnosis. Samples were obtained from the frontal motor cortex and spinal cord (cervical, dorsal and lumbar segments), were fixed in formol (10 percent), included in paraffin, and stained with Haematoxylin and Luxol-fast-blue. Immunohistochemical study was made with anti-neurofilament antibodies 1:100 (M0762, DAKO), anti-APP 1:20 (Rabbit Pre Amyloid protein 51-2700 ZYMED), anti-tau 1:100 (A0024DAKO) and anti-ubiquitine 1:50 (NCL UBIQm Novocastra). Results: All cases had demyelinization and axonal loss in the cortico-spinal tracts; distal and segmental demyelinization of Goll tract; axonal thickening, amyloid precursor protein deposits in the white matter; tau protein aggregation in the spinal cord oligodendrocytes; axonal ubiquitination of sensitive and motor tracts, and subcortical white matter. Neurona! injury was absent. Conclusions: The systematic damage of motor and sensitive tracts of the spinal-cord and the absence of neurona! damage, defines a degenerative process limited to axons. This central axonopathie could be caused by a disturbance of axoplasmic transport.

Fibrosis retroperitoneal: caso clínico y revisión de la literatura / Retroperitoneal fibrosis: clinical case and literature review

La fibrosis retroperitoneal constituye una afección infrecuente y de causa generalmente no identificable, sin embargo, se ha descrito su asociación con algunas drogas, enfermedades del tejido conectivo y patología neoplásica. Se caracteriza por el depósito de tejido fibroso en el retroperitoneo y manifestaciones secundarias a la compresión ureteral o de estructuras vasculares. Las técnicas de imágenes (principalmente la tomografía axial computarizada) resultan importantes en su sospecha y diagnóstico diferencial, con utilidad en la exclusión de una enfermedad tumoral subyacente. La biopsia abierta se considera el gold standar para establecer el diagnóstico, cobrando especial relevancia en los casos sin una causa evidente. El enfrentamiento terapéutico tradicional se basa en la cirugía (ureterolisis) y suspensión de drogas potencialmente injuriantes, pero diferentes terapias médicas han sido planteadas, incluyendo el uso de corticoides, inmunosupresores y tamoxifeno, ya sea en forma exclusiva o asociados a técnicas intervencionistas o quirúrgicas propiamente tales.