[Remarks on the "Dignified death and palliative care" bill]. / Comentarios al proyecto de ley "Muerte digna y cuidados paliativos".

The Chilean House of Representatives is discussing the bill on "Dignified death and palliative care", which regulates the so-called medical assistance in dying or euthanasia. This paper will critically analyze the different aspects of the bill, particularly concerning four main dimensions, namely, the patient's condition at the time of requesting euthanasia; the doctor-patient relationship and respect for the autonomy of both parties; the idea of medicine involved in it; and the possible therapeutic alternatives to euthanasia. This critical analysis raises the need to discuss in more depth a project that has to do with such important decisions about our lives and that implies a radical change in the way of thinking and practicing medicine.

Comentarios al proyecto de ley "Muerte digna y cuidados paliativos" / Remarks on the "Dignified death and palliative care" bill

The Chilean House of Representatives is discussing the bill on "Dignified death and palliative care", which regulates the so-called medical assistance in dying or euthanasia. This paper will critically analyze the different aspects of the bill, particularly concerning four main dimensions, namely, the patient's condition at the time of requesting euthanasia; the doctor-patient relationship and respect for the autonomy of both parties; the idea of medicine involved in it; and the possible therapeutic alternatives to euthanasia. This critical analysis raises the need to discuss in more depth a project that has to do with such important decisions about our lives and that implies a radical change in the way of thinking and practicing medicine.

[Ethical guidelines for medical decision-making during COVID-19 pandemic in Chile]. / Orientaciones éticas para la toma de decisiones médicas en el contexto de la pandemia de COVID-19 en Chile.

The catastrophic emergency experienced by many countries with the COVID-19 pandemic emphasized the importance of bioethics for decision-making, both at the public health (equitable and effective policies) and at the clinical level. At the clinical level, the issues are the fulfillment of medical care demand with adequate health care teams, infrastructure, and supplies, and to cover critical care demands that surpass the available resources. Therefore, ethically correct approaches are required for the allocation of life sustaining resources. There are recommendations for the allocating life support during disasters based on multiple considerations, including ethical ones. However, the ethical criteria of existing guidelines are variable. Ethical principles usually considered are saving the greatest number of lives, saving the greatest number of years of life and the principle of the life cycle or the goal to give each individual equal opportunity to live through the various phases of life. However, the centrality of the human being and the search for the common good should be considered. Knowledge of public perspectives and moral benchmarks on these issues is essential. A successful assignment effort will require everyone's trust and cooperation. Decision making should be planned and discussed in advance, since in-depth deliberation will be extremely complex during the disaster. Our goal is to help the health care teams to wisely allocate resources in shortage periods.

Disforia de género en niños y controversias en su tratamiento: dos concepciones distintas sobre la identidad de género / Disforia de gênero em crianças e controvérsias em seu tratamento: duas concepções diferentes sobre a identidade de gênero / Gender Dysphoria in Children and Controversies about its Treatment: Two Different Conceptions of Gender Identity

Resumen La disforia de género es una marcada incongruencia entre el sexo que se siente o expresa y el que se asigna al nacer, asociada a un malestar clínicamente significativo o deterioro en lo social, que puede darse en niños, adolescentes y adultos. En relación con los pacientes pediátricos, no existe actualmente consenso sobre su tratamiento, así como tampoco evidencia que apoye claramente un enfoque por sobre otro. En la literatura se describen principalmente tres tipos de abordaje en niños preadolescentes: modelo terapéutico, watchful waiting (espera atenta) y modelo afirmativo. En este trabajo se realiza una breve revisión de la literatura existente sobre la disforia de género, se describen los distintos abordajes en niños y se analizan las visiones antropológicas que los sustentan. Plantearemos que existen al menos dos modos de entender la identidad de género, lo que ha dado lugar, en gran medida, a las controversias en los tratamientos propuestos. Por ello, resulta de gran importancia comprender los supuestos antropológicos en que se fundamentan estos modelos, ya que a cada uno de ellos subyacen diferentes maneras de entender la relación sexo-género en la persona y, por tanto, el rol de la corporalidad y de la autoconsciencia en la identidad de género.

Abstract Gender dysphoria is a marked mismatch between the sex felt or expressed by an individual and that assigned to them at birth. It is associated with clinically significant discomfort or social impairment and can occur in children, adolescents, and adults. The literature mainly describes three approaches for preadolescents: therapeutic model, watchful waiting, and gender affirmative model. However, there is currently no consensus on its treatment nor any evidence that favors one approach over another. This paper provides a brief review of the existing literature on gender dysphoria, explains various approaches for children, and discusses the anthropological views behind them. We argue that at least two ways of understanding gender identity have given rise to disagreements over the proposed treatments. It is quite important to comprehend the anthropological assumptions on which these models are based since they underlie different conceptions of the person's sex-gender relationship and, therefore, the role of corporality and self-awareness in gender identity.

Resumo A disforia de gênero é uma marcada incongruência entre o sexo que se sente ou expressa e o que é designado ao nascer, associada a um malestar clinicamente significativo ou a uma deterioração no âmbito social, que pode ocorrer em crianças, adolescentes e adultos. Quanto aos pacientes pediátricos, não existe atualmente consenso em seu tratamento nem evidência que apoie com clareza uma abordagem sobre outro. Na literatura, são descritos três tipos de abordagem em crianças pré-adolescentes: modelo terapêutico, watchful waiting (observação vigilante) e modelo afirmativo. Neste trabalho, é realizada uma breve revisão da literatura sobre a disforia de gênero, são descritas as diferentes abordagens em crianças e são analisadas as visões antropológicas que as justificam. É provável que haja, pelo menos, dois modos de entender a identidade gênero, o que abre espaço a controvérsias nos tratamentos propostos. Por isso, é de grande importância compreender os pressupostos antropológicos nos quais esses modelos estão fundamentados, já que a cada um deles subjazem diferentes maneiras de entender a relação sexo-gênero na pessoa e, portanto, o papel da corporeidade e da autoconsciência na identidade de gênero.

Orientaciones éticas para la toma de decisiones médicas en el contexto de la pandemia de COVID-19 en Chile / Ethical guidelines for medical decision-making during COVID-19 pandemic in Chile

The catastrophic emergency experienced by many countries with the COVID-19 pandemic emphasized the importance of bioethics for decision-making, both at the public health (equitable and effective policies) and at the clinical level. At the clinical level, the issues are the fulfillment of medical care demand with adequate health care teams, infrastructure, and supplies, and to cover critical care demands that surpass the available resources. Therefore, ethically correct approaches are required for the allocation of life sustaining resources. There are recommendations for the allocating life support during disasters based on multiple considerations, including ethical ones. However, the ethical criteria of existing guidelines are variable. Ethical principles usually considered are saving the greatest number of lives, saving the greatest number of years of life and the principle of the life cycle or the goal to give each individual equal opportunity to live through the various phases of life. However, the centrality of the human being and the search for the common good should be considered. Knowledge of public perspectives and moral benchmarks on these issues is essential. A successful assignment effort will require everyone's trust and cooperation. Decision making should be planned and discussed in advance, since in-depth deliberation will be extremely complex during the disaster. Our goal is to help the health care teams to wisely allocate resources in shortage periods.

Argon laser phototherapy in the treatment of refractory fungal keratitis.

PURPOSE: To report the beneficial properties of argon laser as an adjunctive therapy in 2 patients with refractory fungal keratitis. METHODS: Case reports and a review of the literature. Two cases of Fusarium keratitis refractory to topical and systemic antifungals were further treated with argon laser. Before laser treatment, the eye was medicated with proparacaine 0.5%, lidocaine 4%, and a single drop of fluorescein sodium 0.25%. Argon laser irradiation of the affected cornea was performed using argon blue-green wavelength (Coherent Ultima 2000; Coherent, Inc). A spot size of 500 µm, pulse duration of 0.10 seconds, and power ranging from 500 to 900 mW were used. RESULTS: During the first week after laser treatment, both patients showed complete resolution of the infiltrates. Two signs were observed during the procedure: a blanching of the corneal stroma and small cavitations that reached the middle stroma. No adverse effects were observed. CONCLUSIONS: Argon laser phototherapy is useful as an adjunctive treatment of refractory fungal keratitis. More cases are needed to validate our findings.

Brimonidine-timolol fixed combination induced granulomatous inflammation of the eye.

We report on two cases of granulomatous conjunctivitis and uveitis related with the use of a brimonidine-timolol fixed combination. Case report and a review of medical literature. A 64-year-old man was diagnosed with marked granulomatous uveitis and a 57-year-old woman was diagnosed with granulomatous conjunctivitis. Both patients were using a topical fixed combination of brimonidine 0.2 %-timolol 0.5 % for open angle glaucoma. Bilateral granulomatous uveitis and conjunctivitis were diagnosed after 16 months of treatment with a fixed combination of brimonidine-timolol in both cases. Granulomatous inflammation resolved with the cessation of antiglaucomatous drugs and topical corticosteroid treatment. When the inflammation had resolved completely, both patients were rechallenged with topical brimonidine in one eye only to determine causality. Conjunctival hyperemia is a common side effect of glaucoma medications and is sometimes overlooked. Hyperemia may be associated with other signs such as iritis and keratic precipitates or conjunctival inflammation. In such cases, granulomatous inflammation may be considered in the differential diagnosis. The fixed-combination of brimonidine-timolol may cause this clinical picture.

The effect of ketorolac on biofilm of Staphylococcus epidermidis isolated from post-cataract endophthalmitis.

PURPOSE: The purpose of this study is to investigate the effect of ketorolac on biofilm formation of Staphylococcus epidermidis isolated from patients with post-cataract endophthalmitis. METHODS: Forty S. epidermidis strains isolated from postoperative endophthalmitis were used for this study. Biofilms were grown on microtitre plates for 24 h, dyed, and stained with crystal violet. The mean optical density (OD) and the OD ratio (ODr = OD of the treated biofilm/OD of the untreated biofilm) were used for quantification. The biofilms were incubated with 13 mM ketorolac and without ketorolac for controls. RESULTS: The biofilm ODs of the S. epidermidis isolates untreated and treated with ketorolac were significantly different (0.335 ± 0.06 versus 0.158 ± 0.03, respectively; mean ± SD; P < 0.001). Ketorolac reduced S. epidermidis biofilm formation by 47.6 %. CONCLUSIONS: Ketorolac, at a concentration of 13 mM, significantly reduces the formation of biofilm by strains of S. epidermidis that caused endophthalmitis.

Treatment of severe fungal keratitis with subconjunctival amphotericin B.

PURPOSE: To report the beneficial properties of subconjunctival amphotericin B as an adjunctive therapy in patients with severe fungal keratitis. METHODS: Case reports and review of medical literature. Four patients with advanced fungal keratitis were treated with repeated injections of subconjunctival amphotericin B in addition to topical and systemic antifungal treatment. RESULTS: Two to 8 injections were given to each patient. All patients showed rapid clinical improvement after the injections. No serious adverse effects were observed. However, all patients experienced pain during the injections. CONCLUSIONS: Subconjunctival injections of amphotericin B are useful as an adjunctive treatment of advanced fungal keratitis. This treatment assures compliance and may be an alternative to avoid a surgical intervention in an acute stage of advanced fungal keratitis. More cases are needed to validate our findings.

Subconjunctival bevacizumab for corneal neovascularization in herpetic stromal keratitis.

PURPOSE: To report an 81-year-old woman with corneal neovascularization secondary to herpetic stromal keratitis treated with subconjunctival bevacizumab and to discuss the role of this novel antiangiogenic treatment. METHODS: Case report and review of medical literature. RESULTS: A dramatic regression of corneal vessels was observed 1 week after the injection. After a 3-month follow-up, there was no recurrence of corneal revascularization. CONCLUSIONS: Bevacizumab may be a valid complementary treatment in patients with corneal neovascularization caused by herpetic stromal keratitis.