Trauma cerrado de aorta torácica, desde el servicio de urgencias hasta el quirófano: revisión narrativa / Blunt trauma of the thoracic aorta, from the emergency department to the operating room: narrative review / Trauma contuso da aorta torácica: do pronto-socorro ao centro cirúrgico, uma revisão narrativa

El trauma es la principal causa de muerte de la población en edad productiva. El abordaje del trauma torácico cerrado todavía es un desafío para el médico de urgencias. Aunque no es una entidad frecuente, se asocia con una alta mortalidad y resultados adversos. El diagnóstico del trauma cerrado de aorta torácica (LCAT) requiere un alto índice de sospecha, dado que los signos y síntomas no son específicos de esta enfermedad (dolor torácico, dolor interescapular, disnea, disfagia, estridor, disfonía). Es importante resaltar que la ausencia de inestabilidad hemodinámica no debe descartar una lesión aórtica. Para su diagnóstico imagenológico se debe tener en cuenta que los rayos X de tórax no tienen el rendimiento adecuado, el patrón de referencia es la angiotomografía y el ecocardiograma transesofágico (ETE) constituye una opción diagnóstica. El manejo incluye líquidos endovenosos y antihipertensivos como medida transitoria, manejo quirúrgico definitivo y, en algunos casos, manejo expectante o diferido. Los pacientes inestables o con signos de ruptura inminente deben ser llevados de manera inmediata a cirugía. El manejo quirúrgico temprano ha impactado en la mortalidad. A pesar de los avances en las técnicas quirúrgicas, la técnica quirúrgica abierta documenta mayor tasa de mortalidad que el manejo endovascular, el cual tiene numerosas ventajas al ser poco invasivo. Esta es una revisión narrativa que destaca algunos aspectos clave sobre los mecanismos de lesión, diagnóstico y manejo inicial del trauma cerrado aorta torácica. Por último, se propone un algoritmo de abordaje de trauma de aorta.

Trauma is the leading cause of death in the productive-age population. Addressing blunt chest trauma is still a challenge for the emergency physician. Although it is not a common entity, it is associated with high mortality and adverse outcomes. The diagnosis of blunt thoracic aortic trauma (LCAT) requires a high index of suspicion, given that the signs and symptoms are not specific to this disease (chest pain, interscapular pain, dyspnea, dysphagia, stridor, dysphonia). It is important to highlight that the absence of hemodynamic instability should not rule out aortic injury. For its imaging diagnosis, it must be taken into account that chest X-rays do not have adequate performance; the reference standard is angiotomography and transesophageal echocardiography (TEE) is a diagnostic option. Management includes intravenous fluids and antihypertensives as a temporary measure, definitive surgical management and, in some cases, expectant or deferred management. Unstable patients or patients with signs of imminent ruptura should be taken immediately to surgery. Early surgical management has impacted mortality. Despite advances in surgical techniques, the open surgical technique documents a higher mortality rate than endovascular management, which has numerous advantages as it is minimally invasive. This is a narrative review that highlights some key aspects about the mechanisms of injury, diagnosis and initial management of blunt thoracic aortic trauma. Finally, an algorithm for addressing aortic trauma is proposed.

O trauma é a principal causa de morte na população em idade produtiva. Abordar o trauma torácico contuso ainda é um desafio para o médico emergencista. Embora não seja uma entidade comum, está associada a alta mortalidade e resultados adversos. O diagnóstico de trauma fechado de aorta torácica (TACE) requer alto índice de suspeição, visto que os sinais e sintomas não são específicos desta doença (dor torácica, dor interescapular, dispneia, disfagia, estridor, disfonia). É importante ressaltar que a ausência de instabilidade hemodinâmica não deve descartar lesão aórtica. Para seu diagnóstico por imagem deve-se levar em consideração que a radiografia de tórax não apresenta desempenho adequado; o padrão de referência é a angiotomografia e a ecocardiografia transesofágica (ETE) é uma opção diagnóstica. O manejo inclui fluidos intravenosos e anti-hipertensivos como medida temporária, manejo cirúrgico definitivo e, em alguns casos, manejo expectante ou diferido. Pacientes instáveis ou com sinais de ruptura iminente devem ser encaminhados imediatamente para cirurgia. O manejo cirúrgico precoce impactou a mortalidade. Apesar dos avanços nas técnicas cirúrgicas, a técnica cirúrgica aberta documenta maior taxa de mortalidade do que o manejo endovascular, que apresenta inúmeras vantagens por ser minimamente invasivo. Esta é uma revisão narrativa que destaca alguns aspectos-chave sobre os mecanismos de lesão, diagnóstico e manejo inicial do trauma contuso da aorta torácica. Finalmente, é proposto um algoritmo para tratar o trauma aórtico.

El maltrato infantil y su rol en el curso clínico de pacientes con trastorno bipolar / History of child abuse among patients with bipolar disorders

Background: A history of child abuse is common and has a significant impact in the clinical course of patients diagnosed with bipolar disorders (BD). Aims: To assess the frequency of child abuse experiences in patients BD type I and to evaluate its association with clinical course and cognitive functioning variables. Material and Methods: 117 patients with BD aged 45 ± 14 years (66% women) answered the Childhood Trauma Questionnaire (CTQ). The clinical course (illness onset, history of suicide attempts and number of hospitalizations) was obtained from medical records. Cognitive functioning was evaluated through social and non-social cognition tasks. Results: 64% of participants reported some type of child abuse. This variable was associated with an early onset of the disease (Odds ratio (OR) = 3.3; p < 0.02), increased risk of suicide attempts (OR = 2.4; p < 0.04) and specific disturbances in social cognitive tasks. Conclusions: Our study supports evidence of a common history of child abuse in patients with BD. Although child abuse predicts a worse clinical course, major clinical practice guidelines, as well as research designs, do not highlight this evidence.

Síndrome opsoclonus-mioclonus-ataxia asociado con un teratoma ovárico maduro en un paciente pediátrico / Opsoclonus-mioclonus-ataxia syndrome associated with a mature ovarian teratoma in a pediatric patient

Resumen El síndrome de opsoclonus-mioclonus-ataxia es una entidad rara que cursa con síntomas motores, neurocognitivos y psiquiátricos, con frecuencia marcadamente debilitantes. El síndrome se reporta con mayor frecuencia en adultos que en niños, la etiología es variada, pero en pediatría se presenta en la mayoría de los casos como un síndrome paraneoplásico. En este contexto la neoplasia más frecuentemente asociada es el neuroblastoma. La evidencia actual apoya la tesis de que este es un síndrome mediado inmunológicamente al haberse identificado una serie de auto-anticuerpos en los pacientes afectados, y a que muchos de ellos responden a terapia inmunosupresora. La importancia del reconocimiento de este síndrome radica en que existe tratamiento médico y quirúrgico que podría mejorar el pronóstico neurológico y psiquiátrico. Presentamos el caso de una paciente que se presentó con este síndrome en nuestra institución.

Abstract The opsoclonus-myoclonus-ataxia syndrome is a rare entity that presents with motor, neurocognitive and psychiatric symptoms, often markedly de bilitating. The syndrome is reported more frequently in adults than in chil dren, the etiology is varied, but in pediatrics it occurs in most cases as a paraneoplastic syndrome. In this context, the most frequently associated neoplasm is neuroblastoma followed by gynecological tumors. The current evidence supports the thesis that this is an immune-mediated syndrome because a series of circulating autoantibodies has been described in the affected patients, in addition to many of them responding to immuno suppressive therapy. The importance of recognizing this syndrome is that there is medical/surgical treatment available that could improve the neu rological and psychiatric prognosis. Next, we present the case of a patient who presented with this syndrome in our institution.

Sintomatologia depresiva y bienestar psicológico en estudiantes universitarios chilenos / Depressive symptomatology and psychological well-being among Chilean university students

Background: Quality of life and psychological well-being are readily hampered by depression. The changes that students face during college life impact their psychological health and well-being, including the emergence of mental health problems like depression Aim: To determine the relationship between depressive symptoms, sociodemographic parameters and psychological well-being in undergraduate university students. Material and Methods: Five hundred eighty university students of both sexes, from the Metropolitan and IX Regions of Chile answered the Beck Depression Inventory (BDI-IA) and the Ryff's psychological well-being scale. Results: Twenty eight percent of respondents had clinically significant depressive symptoms, and these were more frequent in women. There was an inverse and statistically significant relationship between psychological well-being and depressive symptoms. This fact was especially marked in dimensions of autonomy, positive relationships with others and purpose in life. Conclusions: There is a high frequency of depressive symptoms among these students. We discuss whether psychological well-being and depressive symptomatology represent two extremes within a continuum or they are two independent dimensions that can account for differential causal mechanisms linked to mental health and illness.

Carcinoma escamocelular cutáneo del tronco y las extremidades: utilidad del ganglio centinela en su estadificación / Skin Squamous Cell Carcinoma of the trunk and limbs: Role of Sentinel Node Biopsy in its staging

Resumen El carcinoma escamocelular (CEC) tiene un comportamiento biológico más agresivo cuando exhibe factores de riesgo. En este grupo, se comprometen los ganglios linfáticos hasta en 21% de los casos lo que disminuye la supervivenciaa5años. El examen clínico de las cadenas ganglionares puede tener una tasa de falsos negativos cercana a 39%, determinando la necesidad de una herramienta que permita evaluar el compromiso ganglionar de un modo más preciso. La biopsia del ganglio centinela ha sido documentada en la estadificación del CEC de cabeza y cuello, y el CEC de origen anogenital, pero en estas series de casos hay un escaso número de pacientes correspondientes a CEC cutáneo del tronco y las extremidades. El objetivo de esta revisión es describir las indicaciones y la plausibilidad de estadificar la extensión ganglionar usando la biopsia de ganglio centinela en pacientes con CEC cutáneo del tronco y extremidades. © 2017 Instituto Nacional de Cancerologia. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Abstract Squamous Cell Carcinoma (SCC) is associated with a more aggressive biological behaviour in the presence of risk factors. High risk SCC may present with lymph node metastasis in 21% of patients, with the consequent reduction in overall survival. The physical examination lymph nodes can have a false-negative rate between 15% and 39%, thus requiring the need to find a new diagnostic tool that allows a more precise evaluation of lymph node involvement. Sentinel lymph node biopsy has been reported in case series of patients with head and neck SCC, and genital SCC, but there are few case reports about skin SCC of the trunk and extremities. The aim of this review is to describe the indications and feasibility of using sentinel lymph node biopsy to assess lymph node status in patients with skin SCC of trunk and limbs. © 2017 Instituto Nacional de Cancerologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Habilidades clínicas para el manejo de trastornos depresivos en médicos generales en Santiago de Chile / Clinical skills of Chilean general practitioners for the management of depressive disorders

Background: Diverse and sustained efforts have been developed to improve the management of depression by general practitioners (GPs), but they have not improved treatment coverage and quality of services. Aim: To explore the level of knowledge and clinical skills to diagnose and treat depression by GPs in Primary Health Care (PHC) in the Metropolitan Area of Santiago de Chile (RM). Material and Methods: Theoretical knowledge (TK), diagnostic skills (DS) and treatment skills (TS) were evaluated in 56 GPs of the RM with a battery of specially designed instruments. Results: In TK there were significant differences between GPs aged 31 years or less and their older counterparts and between Chilean and foreign doctors. Five percent of observed differences in TK were explained by age and nationality, respectively. Chilean GPs achieved higher scores in recognition of symptoms (RS), one of the dimensions of DS. No significant differences by age or nationality were observed for DS and TS. Conclusions: Achievement of GPs on tests measuring TK, DS, and TS was generally below 50%. This deficiency should be improved.

Changing Communities and Increases in the Prevalence of Depression: is there a Relationship? / Cambios en las comunidades y el aumento en la prevalencia de la depresión: ¿hay una relación?

The article analyses the impact of individualization processes on community-level determinants of health in postmodern societies, taking depression as an example. The analysis shows how the evolution of the broader social context towards forms of organization focused on the individual and on competition in a market economy implies the vanishing of traditional communities and there -fore of their health-supportive functions, thus endangering their ability to fulfill the needs of belonging, mutual support, and identity. The analysis also relates this evolution to cultural phenomena and to recent studies about culture -gene coevolution, implying that the effects of community decline are expected to be even greater in collectivist societies. Through its multidimensional conceptual analysis, this paper aims to contribute to further uncovering the interactions of psychological, psychosocial, and biological factors in mental health.

El artículo analiza el impacto que los procesos de individualización en las sociedades postmodernas tienen sobre los determinantes de salud de nivel comunitario, tomando como ejemplo la depresión. El análisis muestra cómo la evolución del contexto social más amplio hacia formas de organización enfocadas en el individuo y en la competencia de las economías de mercado, implican el desvanecimiento de las comunidades tradicionales y por lo tanto de sus funciones de apoyo a la salud. Es así que ponen en peligro su capacidad para satisfacer las necesidades de pertenencia, apoyo mutuo e identidad. El artículo también relaciona esta evolución con fenómenos culturales y con estudios recientes sobre la coevolución cultura-gen, implicando que los efectos de declinación de la comunidad deberían ser aún mayores en las sociedades colectivistas. A través de su análisis conceptual multidimensional, el artículo busca contribuir a profundizar sobre las interacciones de factores psicológicos, psicosociales y biológicos en salud mental.

Impacto de una capacitación en trastornos depresivos para médicos generales de atención primaria en salud: Resultados cualitativos / Qualitative impact of a training program on depressive disorders for primary care physicians

Background: There are suggestions that, despite training efforts for Primary Health Care physicians, difficulties in making accurate diagnoses and timely treatments persist. Aim: To evaluate the impact of a new training model in Depressive disorders integrated with Mindful Practice, on the diagnostic and therapeutic skills of primary care general physicians. Material and Methods: A voluntary sample of 56 general physicians was studied. The design of this study was experimental and randomized, with two groups attending theoretical sessions followed by differing workshops that were carried out in a parallel fashion. The Quantitative phase of this study considered measuring the impact of training in physician s skills. The Qualitative phase included nine semi-structured interviews and Qualitative Content Analysis. This paper reports the results of the interviews. Results: As a consequence of training sessions, physicians learned that above the mental health problems, other issues such as self-efficacy and self-confidence are important for the management of depressive patients. Conclusions: This qualitative study shows that physicians are obtaining significant benefits from their training sessions.

La depresión como un diagnóstico complejo: Implicancias para el desarrollo de recomendaciones clínicas / A new proposal for the diagnosis of depression

Depression has a high impact on mental health. However its diagnosis is a challenge even for specialists. This problem derives from a failure in an adequate description and differentiation of the disease. This inadequate conceptualization generates these difficulties. Our thesis is that depression should be understood as a complex phenomenon that can be analyzed from multiple perspectives, from genes to behavior, including personality and interaction with the sociocultural environment. The aim of this paper is to review the psychopathological construct of depression from a multidimensional point of view, considering clinical, sociocultural, characterological and pathogenic variables. Finally we provide a proposal for an adequate diagnostic approach.

Percepción de cambios en la práctica médica y estrategias de afrontamiento / A survey about physicians’ professional satisfaction

Background: A change in the social structure of medicine and its impact on clients has occurred in the last decades. Aim: To perform a survey about subjective wellbeing among physicians. Material and Methods: A physician’ professional satisfaction survey consisting in 90 questions, was applied to 580 physicians (70 percent males), working in Metropolitan Santiago. Results: Physicians perceive changes in all the examined professional domains and approximately 50 percent of the changes are evaluated as negative. Change perception is a general phenomena among physicians, since there were no differences in relation to gender and only in few aspects with respect to age and medical specialty. There was a predominant positive attitude, based on the profession, to face changes. Conclusions: The positive evaluation of changes and the frequent use of managing strategies are associated with a higher satisfaction among physicians.

Un ejercicio en psicoanálisis comparativo: el concepto de 'enactment' en algunos autores/orientaciones desde la perspectiva de su fenomenología / An exercise in comparable psychoanalysis: the concept of 'enactment' in some authors/orientations from the perspective of it's phenomenology

El objetivo de este trabajo es explorar si el análisis fenomenológico del evento psicoanalítico que se ha conceptualizado bajo el término de enactment puede servir para encontrar un consenso entre los varios enfoques y orientaciones que cruzan el panorama psicoanalítico contemporáneo. Ellos buscan comparar varios autores desde la perspectiva de cómo describen el enactment desde su propia experiencia clínica subjetiva. En otras palabras, cómo el fenómeno que llamamos enactment aparece en la mente del analista; cómo toma forma en la inmediatez de su experiencia subjetiva. Para lograr esto, hacen una revisión de autores, representativos de distintas corrientes psicoanalíticas de habla inglesa buscando siempre extraer la descripción subjetiva del fenómeno. Finalizan extrayendo las notas comunes a los diferentes autores, destacando las divergencias observadas

The objective of this paper is to explore if the phenomenological analysis of the analytical event that has been conceptualized by the term enactment can be of use in the search of consensus between different psychoanalytical perspectives and orientations. Various authors are compared on the base of how they describe enactments from their own subjective clinical experience. In other words, how the phenomenon that we call enactment appears in the mind of the analyst, how it takes shape in the immediateness of his/her subjective experience. To accomplish this, English speaking authors adhering to different psychoanalytical orientations are revised, always trying to extract their subjective description of the phenomenon. Finally, common grounds between the authors revised are noted and their divergences highlighted

Validación de una escala para medir el bienestar subjetivo de los médicos (BISUMED) / Generation and validation of a scale to measure physicians' wellbeing

Background: The recent and ongoing changes in the structure and social organization of medicine have deeply transformed medical practice. Aim: To study the perception of these changes by physicians, the impact of these changes in their subjective wellbeing and their strategies of adjustment. Material and Methods: A scale, consisting of 54 items grouped in nine dimensions to measure physicians’ subjective wellbeing was devised. It was applied to a random sample of 580 physicians residing in Metropolitan Santiago and affiliated to the Colegio Médico de Chile (the Chilean Medical Association). Results: The internal consistency analysis in the instrument showed a global Cronbach´s alpha of 90 percent. Conclusions: These results support our methodological approach based on an initial qualitative identification of relevant topics in our local context, which afterwards were included as items in the scale to measure specific components of subjective wellbeing.

Apreender a prática dos psicanalistas em seus próprios méritos / Aprehender la práctica de los psicoanalistas en sus propios méritos / Grasping psychoanalysts’ practice in its own merits

Não se pode estudar as convergências e divergências, na clínica psicanalítica, sem se saber o que os psicanalistas realmente fazem em sua prática. É esboçada uma fenomenologia da prática clínica e dos processos de validação das intervenções; são propostas metodologias para estudar a prática em seus próprios méritos.

No se pueden estudiar las convergencias y divergencias en la clínica psicoanalítica sin saber lo que los psicoanalistas realmente hacen en su práctica. Se esbozan una fenomenología de la práctica clínica y de los procesos de validación de las intervenciones; se proponen metodologías para estudiar la práctica en sus propios méritos.

The author considers that the study of convergences and divergences in psychoanalytic clinical practice requires knowledge of what psychoanalysts really do in their practice. He outlines a phenomenology of clinical practice and of processes of validation of the interventions. He also proposes methodologies for studying the practice in its own merits.

Aprehender la práctica de los psicoanalistas en sus propios méritos / Grasping the practice of psychoanalysts in its own merits

No se pueden estudiar las convergencias y divergencias en la clínica psicoanalítica sin saber lo que los psicoanalistas realmente hacen en su práctica. Se esboza una fenomenología de la práctica clínica y de los procesos de validación de las intervenciones; se proponen metodologías para estudiar la práctica en sus propios méritos

La investigación empírica apoya una técnica psicoanalítica relacional y flexible / Empirical research supports a relational and flexible psychoanalytic technique

Se discute desde la perspectiva de la investigación en proceso y resultados en psicoterapia y psicoanálisis, la especificidad de las intervenciones terapéuticas versus el alcance de los factores curativos comunes; la concepción diádica de la técnica y la acción terapéutica de la alianza; y la concepción estratégica en terapia.

Psicoanálisis y psicoterapia: ¿donde están las diferencias?: el aporte de la investigación empírica / Psychoanalysis and Psychotherapy: What are the differences?: The contribution of empirical research

En las instituciones psicoaoalíticas la psicoterapia psicoanalítica ha sido vista desde siempre como un producto secundario, "degenerado" del psicoanálisis propiamente tal. Los psicoanalistas han buscado diferenciar nítidamente entre psicoterapia psicoanalítica y psicoanálisis, poniendo el énfasis en la diferenciación abstracta. Sin embargo, nunca se ha podido establecer, ni siquiera teóricamente, una diferenciación de naturaleza, sólo se llega a diferencias cuantitativas. El autor revisa el aporte de la investigación empírica en proceso y resultados en psicoterapia y psicoanálisis para aportar otra mirada sobre este problema; concluye que los resultados de ambas son mucho menos divergentes que lo que se suponía, en especial si nos situamos desde el punto de vista de los pacientes. La diferencia mayor parece estar en el tipo de pacientes que se benefician con una u otra forma de intervención y el tipo de psicoanalistas que tales pacientes requieren

Validez y validación del método psicoanalítico (alegatosobre la necesidad de pluralismo metodológico y pragmático en psicoanálisis) / Validity and validation of the psychoanalytic method (a discussion about the need of methodological and pragmatic pluralism in psychoanalysis)

El método psicoanalítico ha sido idealizado desde los tiempos de Freud como un instrumento válido y confiable de conocimiento y eficacia terapéutica. Sin embargo, en las últimas décadas esta idealización ha colapsado y desde un punto de vista epistemológico, se hace necesario diferenciar entre el valor heurístico del método clínico y los procedimientos de validación de las hipótesis generadas a través de la aplicación del mismo. El conocimiento psicoanalítico contemporáneo muestra una enorme pluralidad de posiciones teóricas y prácticas. Se sugiere para el psicoanálisis contemporáneo, asumir una concepción pluralista que aplique estrategias de validación que, además de la coherencia y la correspondencia, combinen la utilidad del conocimiento como criterios de verdad.

Bienestar y satisfacción de los médicos con el ejercicio de su profesión en un sistema de salud en proceso de reforma / Comfort and satisfaction of physicians with their medical practice in a reforming health system

The subjective wellbeing of physicians and the degree of dissatisfaction with their practice is nowadays an important issue in English speaking journals. There is an international perception of a growing and deepening crisis in health systems that is affecting the professional and personal life of physicians. A multidisciplinary group, from two main Universities in Chile, has been formed to investigate this situation locally. The results of this investigation will be published in successive issues of Revista MÚdica de Chile (Rev MÚd Chile 2004; 132: 635-6).

Separación (representación) y vínculo en la teoría psicoanalítica del tratamiento: de la ausencia a la presencia / Separation (representation) and bond in the bond in the psychoanalytic theory of treatment: from absence to presence

En este trabajo, el autor pretende demostrar como la corriente histórica central del conocimiento psicoanalítico, basado en hipótesis de pérdida y separación, muestra en las últimas décadas un viraje hacia el descubrimiento progresivo de la importancia terapéutica del vínculo y de la relación terapeuta-paciente. Esto es, del énfasis puesto en la interpretación de las representaciones inconscientes de relaciones de objeto, es decir, del impacto de la ausencia y separación, se ha pasado a la valoración de la presencia, de la relación personal e intersubjetiva como factor de cambio. Esta afirmación es documentada mostrando la evolución de la teoría, desde modelo basado en la noción de pulsión, hacia un modelo basado en el concepto de relación, y en datos de investigación clínica y empírica. Finalmente, se revisa la moderna investigación en ciencias cognitivas, en especial en los tipos de memoria que, según el autor, ofrecen un fundamento al modelo relacional en psicoanálisis.