Implementación de la reforma curricular de la Escuela de Medicina de la Pontificia Universidad Católica de Chile: analizando la experiencia / Implementation of curricular changes at a medical school

The accelerated scientific, technological, and social advances in recent years have posed new challenges for professional training institutions, where universities play a leading role. Medical schools have not been oblivious to this process. This is how Pontificia Universidad Católica de Chile implemented in 2015 a curricular reform derived from the joint work of academics, students and graduates. For this purpose, a model consisting of stages was followed, including the identification of the problem, general assessment of needs, definition of purpose and learning objectives. We worked with surveys, focus groups and committees of academics and students to identify and map content within the mesh, review terminal learning objectives while creating and reviewing courses for the vertically and horizontally integrated delivery of content and competencies. The first cohort of the new curriculum entered in 2015, consisting of 126 students. The implementation required constant follow-up and monitoring, establishing changes and adjustments according to educational needs and unforeseen conditions such as the COVID-19 pandemic. The implementation process of the new curriculum has been positive, adjusting to the defined strategic planning and responding to unexpected events.

[Implementation of curricular changes at a medical school]. / Implementación de la reforma curricular de la Escuela de Medicina de la Pontificia Universidad Católica de Chile: analizando la experiencia.

The accelerated scientific, technological, and social advances in recent years have posed new challenges for professional training institutions, where universities play a leading role. Medical schools have not been oblivious to this process. This is how Pontificia Universidad Católica de Chile implemented in 2015 a curricular reform derived from the joint work of academics, students and graduates. For this purpose, a model consisting of stages was followed, including the identification of the problem, general assessment of needs, definition of purpose and learning objectives. We worked with surveys, focus groups and committees of academics and students to identify and map content within the mesh, review terminal learning objectives while creating and reviewing courses for the vertically and horizontally integrated delivery of content and competencies. The first cohort of the new curriculum entered in 2015, consisting of 126 students. The implementation required constant follow-up and monitoring, establishing changes and adjustments according to educational needs and unforeseen conditions such as the COVID-19 pandemic. The implementation process of the new curriculum has been positive, adjusting to the defined strategic planning and responding to unexpected events.

Reduced burnout and higher mindfulness in medical students after a self-care program during the COVID-19 pandemic.

BACKGROUND: Medical students experience high levels of psychological stress during clinical training. However, most medical curricula do not teach self-care skills. The COVID-19 pandemic has disrupted medical education causing increased distress among students. AIM: To report the implementation and impact of an eight-week multifaceted mindfulness-based self-care program on medical students' distress and well-being during the COVID-19 pandemic. MATERIAL AND METHODS: One hundred twenty-three fourth-year medical students attended the program as part of a mandatory course from April to May 2020, during the rising phase of COVID-19 in Chile. They were evaluated using validated tests before and immediately after the program. The measures included burnout, dispositional mindfulness, perceived stress, traumatic stress reactions, general well-being, resilience, and stress coping strategies. RESULTS: Burnout prevalence decreased from 48% to 24%, whereas students with high dispositional mindfulness increased from 25% to 44%. Burnout reduction was mostly due to decreased emotional exhaustion. Additionally, students reported lower levels of stress, self-blaming, and traumatic stress reactions alongside an increased use of active coping strategies and resilience levels after the program. CONCLUSIONS: A formal educational intervention, teaching self-awareness and self-regulation skills can help reduce medical students' distress and promote their well-being even amidst a pandemic.

Reduced burnout and higher mindfulness in medical students after a self-care program during the COVID-19 pandemic / Reducción del agotamiento en estudiantes de medicina mediante auto-cuidado durante la pandemia COVID-19

ABSTRACT Background: Medical students experience high levels of psychological stress during clinical training. However, most medical curricula do not teach self-care skills. The COVID-19 pandemic has disrupted medical education causing increased distress among students. Aim: To report the implementation and impact of an eight-week multifaceted mindfulness-based self-care program on medical students' distress and well-being during the COVID-19 pandemic. Material and Methods: One hundred twenty-three fourth-year medical students attended the program as part of a mandatory course from April to May 2020, during the rising phase of COVID-19 in Chile. They were evaluated using validated tests before and immediately after the program. The measures included burnout, dispositional mindfulness, perceived stress, traumatic stress reactions, general well-being, resilience, and stress coping strategies. Results: Burnout prevalence decreased from 48% to 24%, whereas students with high dispositional mindfulness increased from 25% to 44%. Burnout reduction was mostly due to decreased emotional exhaustion. Additionally, students reported lower levels of stress, self-blaming, and traumatic stress reactions alongside an increased use of active coping strategies and resilience levels after the program. Conclusions: A formal educational intervention, teaching self-awareness and self-regulation skills can help reduce medical students' distress and promote their well-being even amidst a pandemic.

Antecedentes: Los estudiantes de medicina experimentan altos niveles de estrés y burnout durante la formación clínica. Sin embargo, la mayoría de los planes de estudios médicos no enseñan habilidades de autocuidado. La pandemia de COVID-19 ha conmocionado la educación médica provocando mayor distrés entre los estudiantes. Objetivo: Informar sobre la implementación y el impacto de un programa multifacético de autocuidado -basado en mindfulness (atención consciente)-sobre el distrés y el bienestar de los estudiantes de medicina durante la pandemia de COVID-19. Material y Métodos: Ciento veintitrés estudiantes de medicina de cuarto año asistieron al programa como parte de un curso obligatorio de abril a mayo de 2020, durante la fase ascendente de COVID-19 en Chile. Fueron evaluados mediante pruebas validadas antes e inmediatamente después del programa. Las medidas incluyeron burnout, mindfulness disposicional, estrés percibido, reacciones de estrés traumático, bienestar general, resiliencia y estrategias de afrontamiento del estrés. Resultados: La prevalencia del burnout disminuyó del 48% al 24%, mientras que los estudiantes con alto mindfulness aumentaron del 25% al 44%. La reducción del burnout se debió principalmente a la disminución del agotamiento emocional. Además, los estudiantes informaron niveles más bajos de estrés, autoinculpación y reacciones de estrés traumático junto con un mayor uso de estrategias activas de afrontamiento y mayores niveles de resiliencia, después del programa de autocuidado. Conclusiones: Una intervención educativa formal que enseñe habilidades de autoconciencia y autorregulación puede ayudar a reducir el burnout de los estudiantes de medicina y promover su bienestar incluso en medio de una pandemia.

The Prevalence of Rheumatoid Arthritis in Chile: A Nationwide Study Performed as Part of the National Health Survey.

OBJECTIVE: Genetic and environmental backgrounds influence the development of rheumatoid arthritis (RA). In Latin America, epidemiologic data are scarce. We aimed to determine the prevalence of RA in Chile in a population-based study. METHODS: The National Health Survey was a cross-sectional household survey with a stratified multistage probability sample of 6233 participants performed between August 2016 and March 2017. A screening instrument for RA was applied to a random sample of 3847 subjects > 30 years old. Positive screening was defined by at least 1 of the following: 2 swollen joints for at least 4 consecutive weeks (past/present), and/or a diagnosis of arthritis in the past. Individuals with positive screening had rheumatoid factor, anticitrullinated protein antibodies, and C-reactive protein measured, as well as clinical examination performed by a rheumatologist. Self-report of doctor-diagnosed RA was also performed. RESULTS: The screening questionnaire was applied to 2998 subjects. A positive screening was found for 783 (22.1%). Among subjects with positive screening, 493 (66%) had a clinical evaluation performed by a rheumatologist. Using the American College of Rheumatology/European League Against Rheumatism 2010 classification criteria, prevalence was 0.6% (95% CI 0.3-1.2). Prevalence was higher in women, and 3.3% of subjects self-reported having RA. CONCLUSION: According to this national population-based study, RA prevalence in Chile is 0.6% (0.3-1.2), a value similar to what has been found in developed countries and slightly lower than some Latin American countries. Self-reporting leads to overestimating RA.

[Curriculum reform at the Pontificia Universidad Católica de Chile School of Medicine]. / Reforma curricular de la carrera de Medicina de la Pontificia Universidad Católica de Chile.

The career of Medicine at the Pontificia Universidad Católica de Chile was established from the beginning (1929), with a classical Flexner curriculum design. In seven years, the career is divided in three cycles: basic sciences, clinics and internship. It obtained Chilean accreditation and fulfilled American Association of Medical Colleges accreditation requirements. Changes in the Chilean epidemiological profile and health system, and new teaching methods in medicine, stimulated a process of deep curricular analysis, identifying strengths and weaknesses of the medical career. The curricular strengths were well-developed scientific and clinical components, fully committed students and faculties, well defined learning objectives and excellent clinical campuses. Curricular weaknesses included a poor vertical and horizontal integration, few student centered methodologies and a weak emphasis concerning doctor’s professionalism. Subsequently, the whole community of teachers, students and medical educators worked on the design of a new curriculum, establishing a new graduate profile and designed it oriented by learning objectives, of six years of duration, with an optimized course sequence that melds basic science and clinical concepts, with strong emphasis on humanities and professionalism. It prioritizes an early contact with patients from the first year and expands teaching methods. The main objective of this process was to achieve a new curriculum with an integrative structure. This was implemented in 2015 with an approved protocol to evaluate the outcomes.

[Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis: advances in pathogenesis and treatment]. / Vasculitis asociadas a anticuerpos anti-citoplasma de neutrófilos: avances en patogenia y tratamiento.

ANCA (anti-neutrophil cytoplasmic antibodies) associated vasculitis or AAV are a group of diseases with predominant inflammation of small vessels and the presence of detectable ANCA in serum. Due to these common features, it is considered that AAV share pathogenic mechanisms. Consequently, a similar therapeutic approach has been developed. A new nomenclature has been recently proposed, with AAV including "granulomatosis with polyangiitis" (GPA, formerly Wegener's granulomatosis), "microscopic polyangiitis" (MPA), "eosinophilic granulomatosis with polyangiitis" (EGPA, formerly Churg-Strauss disease) and renal limited vasculitis. Research on AAV has shown significant advances in the last two decades, including advances in the knowledge of pathogenic mechanisms such as the pro-inflammatory role of ANCA, AAV murine models and genetic links. Evidence on previous immunosuppressive therapies has improved significantly and new, promissory drugs have been introduced, Rituximab being the most important. We review the advances of pathogenic mechanisms and treatment for these diseases.

Vasculitis asociadas a anticuerpos anti-citoplasma de neutrófilos: avances en patogenia y tratamiento / Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis: advances in pathogenesis and treatment

ANCA (anti-neutrophil cytoplasmic antibodies) associated vasculitis or AAVare a group of diseases with predominant inflammation of small vessels and the presence of detectable ANCA in serum. Due to these common features, it is considered that AAV share pathogenic mechanisms. Consequently, a similar therapeutic approach has been developed. A new nomenclature has been recently proposed, with AAV including "granulomatosis with polyangiitis" (GPA, formerly Wegener's granulomatosis), "microscopic polyangiitis" (MPA), "eosinophilic granulomatosis with polyangiitis" (EGPA, formerly Churg-Strauss disease) and renal limited vasculitis. Research on AAV has shown significant advances in the last two decades, including advances in the knowledge of pathogenic mechanisms such as the pro-inflammatory role of ANCA, AAV murine models and genetic links. Evidence on previous immunosuppressive therapies has improved significantly and new, promissory drugs have been introduced, Rituximab being the most important. We review the advances of pathogenic mechanisms and treatment for these diseases.

TNF-α blocker therapy and solid malignancy risk in ANCA-associated vasculitis.

ANCA-associated vasculitides (AAV) are small vessel systemic vasculitis syndromes associated with the potential for high morbidity and mortality. This group includes granulomatosis with polyangiitis (Wegener´s, GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (Churg-Strauss, EGPA). The standard treatment consists of a combination of glucocorticoids and potent immunosuppressant drugs. These have broad mechanisms of action as well as important adverse effects. Efforts have been made to investigate novel agents with better-defined and narrower mechanisms of action, such as biologics, including TNF-α blockers. Etanercept, a well-known TNF-α blocker evaluated for GPA in the Wegener's Granulomatosis Etanercept Trial (WGET), was associated with an increase in the development of solid malignancies in comparison to placebo during that trial period. A 5-year follow-up after the WGET trial showed a sustained increase in incidence of solid malignancies, but this could no longer be solely attributed to etanercept exposure. These studies raised concerns about the use of the family of TNF-α blockers in AAV. Here, we review the evidence about the association between therapeutic inhibition of tumor necrosis factor (TNF-α) by etanercept and other TNF-α blockers with the development of solid malignancies in GPA and other AAV.

Enfermedad de Erdheim-Chester. Una causa rara de derrame pericárdico: Caso clínico / Erdhei-Chester disease: Report of one case

We report a 76-year-old male who was admitted due to progressive congestive heart failure lasting several months. An echocardiogram showed a large pericardial effusion with early signs of pericardial tamponade and an irregular surface suggestive of cancer infiltration. The patient was operated, creating a pericardial window and draining 1,200 ml of a brownish yellow fluid with abundant cellularity. Pericardial biopsy showed infiltration by CD68 (+), CD1a (-) and S100 (-) cells. Twenty-eight months earlier, due to fatigue, dyspnea, and a non-specific inflammatory process, an enhanced-contrast-scan showed that aorta was coated with a hypodense tissue that began near the aortic valve and extended until the inferior mesenteric artery, with stenosis of the left subclavian, celiac axis, renal and upper mesenteric arteries. An angioplasty and stent placing was carried out in the last two arteries. Both kidneys had the appearance of "hairy kidneys". A bone scan showed increased uptake in femurs and tibiae and X-ray examination showed osteosclerosis in metaphysis and diaphysis. The diagnosis of Erdheim-Chester disease (non-Langerhans-cell histiocytosis) was made and the patient was treated with steroids and methotrexate.

[Erdhei-Chester disease: report of one case]. / Enfermedad de Erdheim-Chester. Una causa rara de derrame pericárdico: Caso clínico.

We report a 76-year-old male who was admitted due to progressive congestive heart failure lasting several months. An echocardiogram showed a large pericardial effusion with early signs of pericardial tamponade and an irregular surface suggestive of cancer infiltration. The patient was operated, creating a pericardial window and draining 1,200 ml of a brownish yellow fluid with abundant cellularity. Pericardial biopsy showed infiltration by CD68 (+), CD1a (-) and S100 (-) cells. Twenty-eight months earlier, due to fatigue, dyspnea, and a non-specific inflammatory process, an enhanced-contrast-scan showed that aorta was coated with a hypodense tissue that began near the aortic valve and extended until the inferior mesenteric artery, with stenosis of the left subclavian, celiac axis, renal and upper mesenteric arteries. An angioplasty and stent placing was carried out in the last two arteries. Both kidneys had the appearance of "hairy kidneys". A bone scan showed increased uptake in femurs and tibiae and X-ray examination showed osteosclerosis in metaphysis and diaphysis. The diagnosis of Erdheim-Chester disease (non-Langerhans-cell histiocytosis) was made and the patient was treated with steroids and methotrexate.

[Necrotizing pneumonia due to Rhodococcus equi in non HIV immunocompromised host. Case report and review]. / Neumonía cavitada por Rhodococcus equi en paciente inmunocomprometido no infectado por virus de inmunodeficiencia humana. Caso clínico y revisión.

Rhodococcus equi, is a grampositive intracellular bacillus, that causes infection mainly in immunocompromised hosts. We report the case of a 52 years old woman, with a systemic lupus erythematosus and a progressive 10 months evolution with cough, dyspnea, mucous-purulent sputum, occasionally hemoptysis, intermittent fever, and weight loss of 10%. With partial response to antibiotic treatment, radiological evolution of thoracic scanners evidenced the development of multiple bilateral areas of consolidation, some of them nodular. Percutaneous thoracic biopsy showed characteristic histology and microbiological analysis yielded the identification of Rhodococcus equi in both bronchoalveolar lavage and pulmonary biopsy. She received prolonged bi-associated antibiotic treatment with good clinical and radiological response. This agent must be considered in the study of immunocompromised patients that present with a prolonged evolution of pneumonia.

[Clinical features of Wegener granulomatosis and microscopic polyangiitis in Chilean patients]. / Manifestaciones clínicas de la granulomatosis de Wegener y la poliangeítis microscópica en Santiago-Chile, 1990-2001.

BACKGROUND: Systemic vasculitis are a group of heterogeneous diseases characterized by inflammation and necrosis of blood vessel walls. The etiology is not known, but geographic and environmental factors are implicated. AIM: To describe the clinical features of microscopic polyangiitis (MPA) and Wegener's granulomatosis (WG) in a Chilean cohort of patients. PATIENTS AND METHODS: Retrospective review of the medical records of 123 patients with the diagnosis of systemic vasculitis (65 MPA and 58 WG), seen from 1990 to 2001. The diagnosis were made based on the American College of Rheumatology and Chapel Hill criteria. RESULTS: The mean follow-up for MPA was 15 months (1-120) and for WG, 20 months (1-120). The median age (years) at diagnosis for MPA was 61 (19-82) and WG 50 (20-82). Gender distribution was similar in both groups (male: 68% and 57% respectively). The main clinical features in the MPA group were renal involvement (68%), peripheral nervous system involvement (57%), pulmonary hemorrhage (28%), and skin disease (32%). In the WG group were alveolar hemorrhage (62%), renal involvement (78%), paranasal sinus involvement (57%), and ocular disease (26%). In both, creatinine levels above 2.0 mg/dl were associated with a higher mortality (p< 0.01). ANCA by immunofluorescence was performed in 56 MPA patients (75% had pANCA, 4% had cANCA and 21% were ANCA negative) and in 55 WG patients (17% had pANCA, 79% had cANCA and 4% were ANCA negative). Global mortality was 18% and 17% respectively, and the most common causes of death were infections. CONCLUSIONS: The clinical features of our patients are similar to other published data. In our WG and MPA patients the main predictor for death was a serum creatinine above 2 mg/dl.

Cardiovascular risk factors in Chilean patients with rheumatoid arthritis.

OBJECTIVE: Epidemiologic studies have shown an increased mortality rate in patients with rheumatoid arthritis (RA). The most common cause of death in these patients is cardiovascular disease. We estimated the frequency of and examined risk factors for coronary artery disease in Chilean patients with RA. METHODS: Fifty-four patients with RA were studied: 87% were women, with a mean age (+/- standard deviation) of 51 +/- 13 yrs, 92% were rheumatoid factor positive, and 51% had radiological erosions; 32 age and sex matched healthy controls were studied. Traditional cardiovascular risk factors and RA-specific variables were determined. Lipid profile, lipoprotein(a) [Lp(a)], homocysteine, ultrasensitive C-reactive protein (CRP), anticardiolipin (aCL), anti-beta2-glycoprotein I (anti-beta2-GPI) and antioxidized low density lipoprotein (ox-LDL) antibodies were measured. RESULTS: Median concentration of homocysteine was significantly higher in patients with RA than in controls: 10 (range 5.4-37.4) versus 8.3 (3.6-17.8) micromol/l (p = 0.001). Patients with RA who gave a history of cardiovascular disease had the highest concentrations of homocysteine: 15.1 (13.1-19.7) versus 9.9 (5.4-37.4) micromol/l (p = 0.001). We found no differences between patients and controls in lipid profiles or Lp(a), or for other traditional risk factors. Anti-ox-LDL, IgG aCL, and IgG anti-beta2-GPI antibody levels were similar in both groups. IgM subtypes were higher in patients with RA than in controls, but in low titers. CONCLUSION: Our data suggest that a high homocysteine concentration could be an important risk marker for cardiovascular disease in patients with RA.