Student survey after ten years of continuous blended teaching of echocardiography.

OBJECTIVE: To analyse the impact of 10 years of blended echocardiography teaching. METHODS AND RESULTS: A questionnaire was emailed to all medical doctors who graduated from the blended learning diploma in echocardiography developed by the University of Chile and taught by a team from Chile and Spain. One hundred and forty of the 210 students who graduated from the program between 2011 and 2020 completed the questionnaire: 53.57% were anaesthesiologists, and 26.42% were intensivists. More than 85% of respondents indicated that the online teaching met their expectations, and 70.2% indicated that the hands-on practice fulfilled the stated objectives. In a retrospective analysis using self-reported data, graduates reported that their use of transthoracic and transoesophageal echocardiography has increased from 24.29% to 40.71% and from 13.57% to 27.86%, repectively, after the programme compared to before the programme. They used echocardiography mainly in the perioperative period (56.7%) and during intensive care (32.3%), while only 11% of respondents used it in emergency care units. Nearly all (92.4%) respondents reported that the skills learned was very useful in their professional practice. CONCLUSIONS: Ten years after its launch, the blended learning diploma in echocardiography was well rated by graduate specialists, and is associated with a significant increase in the use of echocardiography in the perioperative period and during intensive care. The main challenges are to establish a longer period of practice and achieve greater implantation in emergency medicine.

Experiencia inicial del implante percutáneo de válvula aórtica en el Instituto Nacional del Tórax: Experience in 26 patients / Transcatheter aortic valve implantation

Background: Aortic valve stenosis (AS) is the most common valvular disease. Its surgical indication is undisputed in symptomatic severe AS, however, 30% of patients are at high surgical risk or inoperable. Transcatheter Valve Implantation (TAVI) is an alternative for this group of patients. Aim: To describe the clinical outcomes of TAVI in a group of patients treated at the Instituto Nacional del Tórax, Santiago, Chile. Patients and Methods: Prospective study including all patients referred for TAVI due to their high surgical risk or being inoperable. All-cause mortality, secondary stroke, permanent pacemaker implantation, vascular complications, prosthetic and periprosthetic regurgitation, Karnosfky test and Functional Capacity (FC) were assessed as endpoints. Results: We evaluated 26 patients with a mean age of 82 years (74% women) in whom 27 procedures were done. The mean Society of Thoracic Surgeons score was 8.8%. Overall mortality at 30 days, one and two years was 11.1, 18.5 and 29.6% respectively. Karnofsky score increased significantly from 62.3% at baseline to 83.9; 88.6 and 88.8% at six months, one and two years, respectively. Prior to the procedure, FC was 3.1 ± 0.6, decreasing significantly to 1.2; 1.3 and 1 at six months, one and two years of follow up. Conclusions: TAVI is an effective alternative treatment for patients with severe symptomatic AS and high surgical risk.

[Transcatheter aortic valve implantation.Experience in 26 patients]. / Experiencia inicial del implante percutáneo de válvula aórtica en el Instituto Nacional del Tórax.

BACKGROUND: Aortic valve stenosis (AS) is the most common valvular disease. Its surgical indication is undisputed in symptomatic severe AS, however, 30% of patients are at high surgical risk or inoperable. Transcatheter Valve Implantation (TAVI) is an alternative for this group of patients. AIM: To describe the clinical outcomes of TAVI in a group of patients treated at the Instituto Nacional del Tórax, Santiago, Chile. PATIENTS AND METHODS: Prospective study including all patients referred for TAVI due to their high surgical risk or being inoperable. All-cause mortality, secondary stroke, permanent pacemaker implantation, vascular complications, prosthetic and periprosthetic regurgitation, Karnosfky test and Functional Capacity (FC) were assessed as endpoints. RESULTS: We evaluated 26 patients with a mean age of 82 years (74% women) in whom 27 procedures were done. The mean Society of Thoracic Surgeons score was 8.8%. Overall mortality at 30 days, one and two years was 11.1, 18.5 and 29.6% respectively. Karnofsky score increased significantly from 62.3% at baseline to 83.9; 88.6 and 88.8% at six months, one and two years, respectively. Prior to the procedure, FC was 3.1 ± 0.6, decreasing significantly to 1.2; 1.3 and 1 at six months, one and two years of follow up. CONCLUSIONS: TAVI is an effective alternative treatment for patients with severe symptomatic AS and high surgical risk.

Causes of ineligibility in randomized controlled trials and long-term mortality in patients with non-ST-segment elevation acute coronary syndromes.

PURPOSE: To determine the long-term mortality of patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) that are eligible versus those not eligible in randomized controlled trials (RCT), and how each exclusion criteria is associated with outcome. METHODS: Common causes of exclusion in six published RCT on intravenous antithrombotic therapy were prospectively assessed in a cohort of 452 consecutive patients with NSTEACS that were followed for up to 3 years. RESULTS: Forty-one percent of patients had one or more exclusion criteria establishing the ineligible group. These patients were older, more likely to have coronary risk factors, ischemic ECG changes, heart failure at admission, higher creatinine levels and a lower ejection fraction than eligible patients. There were no differences between both groups in the antithrombotic treatment received or in the performance of revascularization procedures during hospitalization or in the prescription of antiplatelet treatment and beta-blockers at discharge. Cumulative 3-year mortality rate was 25% in ineligible patients compared to 9% in eligible patients (p<0.001). The hazard ratio (HR) of mortality was of 9.1 (95% CI: 4.5-18.7) for severe renal dysfunction; 6.0 (3.3-11.4) for concomitant non-vascular diseases; 3.0 (1.6-5.5) for contraindications to anticoagulation; 2.5 (1.1-5.7) for heart failure; and 2.3 (1.1-4.6) for prior cerebrovascular disease. After adjusting for baseline differences, ineligible patients had a HR of total mortality of 1.88 (1.04-3.38), and of cardiac mortality of 2 (1.01-3.98). CONCLUSION: Patients with NSTEACS who are ineligible in RCT have a higher risk profile and a two-fold adjusted long-term mortality than eligible patients, especially those with comorbid conditions and those with contraindications to anticoagulation.

Metodología de la investigación en medicina crítica (II parte): bioestadística básica / Research methodology in clinical medicine (part II): basic biostatistics

En este segundo capítulo abarcaremos los fundamentos de la bioestadística de manera ágil para que los lectores puedan manejar con soltura las herramientas fundamentales que les permitirán recoger, clasificar, resumir, hallar regularidades y analizar los datos de índole biológica o clínica, siempre y cuando la variabilidad e incertidumbre sea una causa intrínseca de los mismos; así como de realizar inferencias a partir de ellos, con la finalidad de ayudar a la toma de decisiones y en su caso formular predicciones. De lo anterior se desprende que la estadística no da fundamento a los hallazgos de un estudio sino que es un método que sistematiza la información de manera útil. También queda de manifiesto que el método estadístico a utilizar queda definido por las condiciones del diseño del estudio antes de su implementación. Cabe advertir que la estadística es fundamentalmente un método matemático muy complejo de resumir por lo que el texto se focalizará en lo prioritario dejando al lector la labor específica de ahondar en aquellos apartados que le son de su interés. El temario que abarcará esta serie será el siguiente: 1. Conceptos iniciales 2. Estadística descriptiva 3. Estadística inferencial 4. Estadística multivariada 5. Sugerencias para la estadística inferencial.

The second chapter will encompass and address the fundamentals of biostatistics from a practical approach so as to enable readers to manage some basic tools for collecting, classifying, summarizing, spotting regularities, and analyzing biological or clinical data, provided that variability and uncertainty be an intrinsic cause of such data. Readers will also be capable of drawing inferences from data in order to get assistance in decision-making processes, and in making predictions, when appropriate. From the preceding statements it can be derived that Statistics does not support study findings but it constitutes a method for systematizing information and make it easily and usefully available. It is also stated that the statistical method to be applied depends largely on the study design features and it is established before its implementation. It must also be said that Statistics is basically a complex and hard-to-summarize mathematical method, therefore our work will be focused on essential material, letting the reader the possibility to search for further information. The Series will address the following topics: 1. Basic Concepts 2. Descriptive Statistics 3. Inferential Statistics 4. Multivaried Statistics 5. Suggestions for Inferential Statistics.

[Previous infection with Chlamydia pneumoniae and long-term prognosis in patients with acute coronary syndrome with non-ST segment elevation]. / Infección previa por Chlamydia pneumoniae y pronóstico a largo plazo en pacientes con síndrome coronario agudo sin elevación del segmento ST.

BACKGROUND AND OBJECTIVE: Contradictory data exists from case-control studies and in patients with stable coronary artery disease on the association of prior exposure to Chlamydia pneumoniae and cardiovascular events. We underwent a prospective study to investigate the prognostic value of C. pneumoniae seropositivity in patients with acute coronary syndromes. PATIENTS AND METHOD: In a prospective cohort of 259 consecutive patients (194 men and 65 women), mean age 65 (10 years) with non-ST elevation acute coronary syndromes, we measured serum levels of IgG antibodies directed against C. pneumoniae. RESULTS: After a mean follow-up of 28 (25, 29) months, the incidence of cardiovascular death or myocardial infarction was of 15% in seropositive patients versus 13% in seronegatives at IgG titers (1:64 (p=0.58); of 14% versus 14% at IgG titers > or = 1:128 (p=0.96); and of 14% versus 15% at IgG titers (1:256 (p=0.82). The relative risks (RR, 95% CI) of these major cardiac events adjusted for possible confounding factors were 1.11 (0.52-2.40); 1.01 (0.52-1.96); and 0.94 (0.48-1.87) respectively. CONCLUSIONS: Chlamydia pneumoniae IgG seropositivity is not associated with a higher incidence of death or myocardial infarction in patients with non-ST segment elevation acute coronary syndromes.

[Differences in the management and prognosis of patients with non-ST segment elevation acute coronary syndrome according to the department of initial admission]. / Diferencias en el tratamiento y la evolución clínica de los pacientes con síndrome coronario agudo sin elevación del segmento ST en función del servico clínico de ingreso.

OBJECTIVES: To assess the influence of the department of initial admission on the hospital management and 3-month prognosis of patients with non-ST elevation acute coronary syndromes. PATIENTS AND METHOD: The data for the 4115 patients admitted to 18 hospitals in the PEPA study were compared according to the department of initial admission. RESULTS: Twenty-six percent of the patients were admitted to the coronary care unit, 53% to the cardiology department, 9% to the internal medicine department, and 12% were discharged from the emergency ward. The baseline risk profile was high in patients admitted to the coronary care unit and decreased progressively in patients admitted to the cardiology, internal medicine and emergency departments (P<.00001). The intensity of medical management was progressively lower in these departments, but not in parallel to their different baseline lower risk profile. Beta blockers were administered to 50%, 45%, 27% and 21% of the patients, respectively; an exercise test was performed in 34%, 44%, 35% and 12%; coronary angiography in 46%, 34%, 19% and 0%; and coronary revascularization in 22%, 12%, 9% and 0% (P<.00001). The 3-month incidence of mortality or myocardial infarction was 12.2%, 6.4%, 8.7% and 3.8%, respectively (P<.00001), differences that became nonsignificant after adjustment for risk profile on admission. CONCLUSIONS: Patients with non-ST elevation acute coronary syndrome admitted to the coronary care unit or cardiology department have a profile of higher risk on admission than patients admitted to the internal medicine department. Also, these patients more frequently receive pharmacological treatments and diagnostic and therapeutic procedures of proven efficacy but not in a manner that parallels their different risk profile on admission. However, these differences in the intensity of in-hospital management do not seem to lead to differences in the 3-month prognosis.

Fisiología del metabolismo del magnesio / Physiology of magnesium metabolism

Se revisan los principales aspectos del metabolismo del Mg. Se señala que el aporte dietario oscila alrededor de los 300 mg diarios y que la absorción ocurre mayoritariamente en el intestino delgado terminal y que sólo alcanza entre el 30 y 50%. La mayor parte de lo ingerido se excreta por las heces (200 mg). La magnesemia fluctúa entre 1,7 y 2,3 mg% y no refleja fielmente lo que ocurre a nivel intracelular que es lo interesante ya que el Mg++ es el ion intracelular más importante después del K+. El adulto normal promedio tiene alrededor de 24 gramos de Mg de los cuales el 60% se encuentra en los huesos, el 35% en los músculos esqueléticos y miocardio y sólo el 1% en la sangre. Se enfatiza el rol del riñón en el metabolismo del Mg. A nivel glomerular ultrafiltran diariamente alrededor de 2.500 mg de Mg de los cuales sólo se excretan unos 100 mg por la orina. De los 2.400 mg no excretados, el 35% se reabsorbe en los túbulos proximales y el 65% en la rama ascendente de asa de Henle. Se mencionan las principales funciones del Mg en el organismo, destacando que, en combinación con el ATP participa en la mayoría de las reacciones metabólicas, en la regulación de la actividad de los ribosomas; en la generación y transmisión del impulso nervioso, etc.

Prevalencia del beber anormal en pacientes hospitalizados en los servicios de medicina y cirugía del Hospital San Juan de Dios / Prevalence of abnormal drink in hospitalized patientes to the medicine internal and surgery service of the San Juan de Dios Hospital

Es ampliamente reconocida la importancia del alcoholismo y beber anormal como problema de salud pública en nuestro país. Sin embargo, son escasos los estudios sobre beber anormal en hospitales generales, considerando los riesgos de la concomitancia entre esta patología y otras condiciones médico quirúrgicas. Según investigaciones nacionales y extranjeras las tasas de prevalencia oscilan entre 10%y 69%para distintas poblaciones de pacientes hospitalizados. En el presente trabajo se estudian 153 pacientes pertenecientes a los servicios de medicina y cirugía del Hospital San Juan de Dios, utilizando la escala breve de beber anormal (EBBA) (Orpinas y Colm. 1987), durante el mes de septiembre de 1987. 15,7%del total de pacientes fueron detectados por la escala como probables casos epidemiológicos. Todos ellos correspondieron a sujetos de sexo masculino y la gran mayoría eran casados. Del total de hombre (N=62) el 38,7%fueron catalogados por la escala como bebedores anormales. La relación hombre:mujer para el total de pacientes fue de 0,68:1. Se observa una mayor importancia relativa de casos en los pacientes quirúrgicos con acumulación de ellos en cuadros digestivos agudos y accidentes y violencias. En el servicio de medicina los cuadros respiratorios presentan una mayor importancia relativa. Estos resultados son ampliamente comparables con lo comunicado por otras investigaciones nacionales al respecto. Se discute el cambio aparente del perfíl diagnóstico médico quirúrgico del paciente alcohólico hospitalizado en establecimientos generales. El uso de instrumentos de tamizado autoadministrados para pesquisar y apoyar el diagnótico clínico del beber anormal constituye junto con algunos indicadores biológicos un avance para los estudios epidemiológicos en este campo

Evaluación de aspectos psiquiatricos en pacientes sometidos a hemodiálisis / Evaluation of psychiatric aspects in patients undergoing hemodialysis

Se efectúa evaluación psiquiátrica de los pacientes en hemodiálisis en la Unidad de Diálisis del Hospital San Juan de Dios (Septiembr 1986). Se apreciaron diferencias estadísticamente significativas entre los puntajes obtenidos en el cuestionario de Sistemas generales (GHQ-28) según sexo. Las mujeres obtuvieron los mayores puntajes, lo que se asoció a un menor tiempo de tratamiento, inestabilidad de pareja y edad. En los hombres se estableció una estrecha correlacción con el apoyo del grupo familiar, la edad y el grado de neuroticidad. Se analizan los resultados de acuerdo a los antecedentes aportados por la literatura y se plantean estrategias terapéuticas

Psiquiatría de enlace / Liaison psychiatry

La Psiquiatría de Enlace ha presentado una rápida evolución en los hospitales generales a partir de 1902, abarcando en forma progresiva las distintas especialidades de la medicina. Se analizan su definición, objetivos y proyecciones, destacando la acción conjunta del psiquiatra y el especialista, tanto en el diagnóstico y tratamiento, como en la investigación y docencia, lo que ha permitido el reconocimiento y comprensión de las influencias psicológicas y sociales en la génesis y mantención de las enfermedades