Competencias en medicina legal para médicos recién egresados: opinión de experto / Competences in legal medicine to recently graduated doctors: expert opinions / Competências em medicina jurídica a médicos recentemente graduados: opiniões de expertos

El escenario actual en el ámbito de la salud y del derecho, plantea cambios que ponen de manifiesto la necesidad de mayor conocimiento en materias concernientes a la medicina legal: la judicialización del ejercicio médico y el aumento exponencial de reclamaciones por malpraxis, demandan una profundización en la formación deontológica. Además, la implementación de la Reforma Procesal Penal, exige fortalecer el nivel judicial y forense, máxime cuando varias disposiciones legales establecen que la actividad pericial no es privativa de los especialistas que laboran en el Servicio Médico Legal. Con el propósito de contribuir a la formación de los futuros médicos en el ámbito de la Medicina Legal considerando las actuales normativas jurídicas involucradas en el área de la salud, se realizó una investigación cualitativa, exploratoria, descriptiva, con una muestra no probabilística, intencionada, por conveniencia, conformada por un médico especialista en Medicina Legal, previa firma Consentimiento Informado. Para recolectar los datos se recurrió a una entrevista en profundidad. El análisis y recogida de ellos se realizó en forma simultánea a través del método de comparación constante, siguiendo un esquema de reducción progresiva. La rigurosidad científica del estudio estuvo determinada por cuatro criterios de rigor: valor de verdad (credibilidad), aplicabilidad (transferibilidad), consistencia (dependencia) y neutralidad (confirmabilidad), realizándose la triangulación por investigadores. En el nivel 1 se encontraron 9 categorías: "muerte", "autopsia", "lesiones", "salud mental", "sexología", "laboratorio forense", "documentos medicolegales", "reforma procesal" y "competencia genérica". En el Nivel 2 se identificaron tres núcleos temáticos "Requisitos de Tanatología en el Plan de Estudio", "Aspectos a considerar en el Plan de Estudio con respecto a Lesionología" y "Relación teórico práctica de los contenidos de Medicina Legal". En el Nivel 3: emerge un dominio cualitativo: "Competencias disciplinares y genéricas a considerar en el Plan de Estudio con respecto a contenidos de la Asignatura de Medicina Legal". Lo disciplinar incluye la Tanatología, Lesionología, Sexología Forense, Evidencia Física. Lo genérico en función a la relación médico paciente y su responsabilidad profesional. Considerando que el propósito del estudio es contribuir a la formación de los futuros médicos en el ámbito de la Medicina Legal mediante el rediseño del programa de la asignatura, a través del experto, se puede deducir que todos los contenidos están explícitos en la actividad curricular. Además, es importante señalar que la terminología utilizada es similar a la consignada a nivel nacional. Sin embargo, las actividades prácticas de estos aprendizajes no están claramente explicitadas. Los resultados corroboran la inexistencia de las competencias disciplinares y genéricas en el ámbito de la Medicina Legal para la labor asistencial de un médico que se desempeña en un Servicio de Urgencia o en la Atención Primaria de Salud. Esto induce a continuar la línea de trabajo en orden a consultar a los egresados(as), en relación a su formación de pregrado en todos los aspectos forenses considerando diferentes áreas y ámbitos laborales.

The current scenario in the field of health and law, poses changes which seek for more knowledge in matters concerning legal medicine: the prosecution of medical practice and the exponential increase in claims for malpractice, seeking a deepening of ethics training. In addition, the implementation of the Criminal Procedure Reform requires strengthening the judicial and forensic level, especially when several statutory provisions establish the expert activity is not exclusive to the specialists working in the Legal Medical Service. In order to contribute the training of future doctors in the field of Legal Medicine considering the current legal regulations involved in the area of health, a qualitative research was conducted, exploratory, descriptive, with a non-probabilistic, intentional sample, convenience, made by a medical specialist in Legal, Medicine prior Informed Consent signature. To collect the data an in-depth interview was used to. The analysis and collection of them was conducted simultaneously through the constant comparison method, following a progressive reduction scheme. The scientific rigor of the study was determined by four criteria of rigor: truth value (credibility), applicability (portability), consistency (dependence) and neutral (Confirmability), carried out by researcher's triangulation. At level 1, 9 categories were found: "Death," "autopsy", "injury", "mental health," "sexology", "forensic laboratory", "legal medical documents", "judicial reform" and "generic competition". At Level 2 three important thems were identified "Thanatology requirements in the Curriculum", "Aspects to consider in the Study Plan regarding "damage" (Lesionología) and "practical theoretical ratio of the contents of Legal Medicine". In level 3: qualitative domain emerges: "Disciplinary competences and generic to be considered in the Study Plan regarding contents of the Subject of Legal Medicine". The discipline includes Thanatology, Damage (Lesionología), Forensic Sexology, Physical Evidence. The generic depending on the doctor-patient relationship and professional responsibility. Whereas the purpose of the study is to contribute to the training of future doctors in the field of Legal Medicine by redesigning the program of the subject, through the expert, one can deduce that all of the contents are explicit in the curricular activity. It is also important to point out that the terminology used is similar to that recorded nationally. However, the practical activities of these learnings are not clearly explicit. The results confirm the existence of disciplinary and generic in the field of Legal Medicine for the welfare work of a doctor who serves on an emergency service or primary health care. This leads to continue the line of work in order to consult graduates (as), in relation to their undergraduate training in all aspects forensic considering different areas and fields of work.

O cenário atual no campo da saúde e do direito, Propõe mudanças que procuram mais conhecimentos em matéria de medicina legal: O julgamento da prática médica eo aumento exponencial de reclamações por negligência, Buscando um aprofundamento do treinamento em ética. Além, a implementação da Reforma Processual Penal requer o fortalecimento do nível judicial e forense, especialmente quando várias disposições legais estabelecem que a actividade de peritos não é exclusiva dos especialistas que trabalham no Serviço Jurídico Médico. A fim de contribuir com a formação de futuros médicos no campo da Medicina Legal considerando as atuais normas legais envolvidas na área de saúde, foi realizada uma investigação qualitativa, exploratório, descritivo, com uma amostra não-probabilística, intencional, conveniência, feita por um médico especialista em Legal, Medicina assinatura de Consentimento Livre e Esclarecido. Para recopilar os dados são utilizados numa entrevista em profundidade. A análise e coleta dos mesmos foi realizada simultaneamente através do método de comparação constante, Seguindo um esquema de redução progressiva. O rigor científico do estudo foi determinado por quatro critérios de rigor: valor de verdade (credibilidade), aplicabilidade (portabilidade), consistência (dependência) e neutro (Confirmabilidade), realizado pela triangulação do investigação No nível 1, foram encontradas 9 categorias: "morte", "autópsia", "lesão", "saúde mental", "sexologia", "laboratório forense", "documentos médicos legais", "reforma judicial" e "concorrência genérica". No Nível 2 foram identificados três temas importantes "requisitos de Tanatologia no Currículo", "Aspectos a considerar no Plano de Estudo referentes ao" dano "(Lesionología) e" razão teórica prática dos conteúdos da Medicina Legal "". No nível 3: domínio qualitativo emerge: "Competências disciplinares e genéricas a serem consideradas no Plano de Estudo sobre os conteúdos do Sujeito de Medicina Legal". A disciplina inclui Thanatology, daño (Lesionología), Sexología Forense, Evidencia Física. El genérico depende de la relación médico-paciente y de la responsabilidad profesional. Considerando que o objectivo do estudo é contribuir para a formação dos futuros médicos no campo da medicina forense por redesenhar o programa do assunto através do perito, se pode deduzir a totalidade do conteúdo são explícitos na actividade curricular. Também é importante ressaltar que a terminologia utilizada é semelhante à registrada nacionalmente. No entanto, as atividades práticas desses aprendizados não são claramente explícitas. Os resultados confirmam a existência de disciplina e genéricos no campo da Medicina Legal para o trabalho assistencial de um médico que presta serviços de emergência ou cuidados primários de saúde. Isto leva a continuar a linha de trabalho, a fim de consultar os graduados, em relação à sua formação de graduação em todos os aspectos Considerando diferentes áreas forense e campos de trabalho.

Aprendizaje basado en problemas (ABP) como estrategia para adquisición de competencias genéricas: estudiantes de nutrición y dietética, Universidad de La Frontera / Problem-based learning as a strategy for acquisition of generic skills: students of nutrition and dietetics, Universidad de La Frontera

The study of generic skills in the training of health professionals has become an instrument of increasing value to the institutions of higher education and health centers. In order to know in detail the opinions of students of the career of nutrition and dietetics of the Faculty of Medicine, Universidad de La Frontera, Temuco-Chile related to the generic competences acquired during their training process, 5th year students took part in two focus groups, after signing an informed consent. The analysis of data followed a scheme of progressive reduction of them, validating by triangulation of researchers. The results represent the consistency that must exist between study and educational plan didactics in the development of the generic competences, so necessary nowadays for the work insertion of health professionals.

El estudio de competencias genéricas en la formación de profesionales de la salud se ha convertido en un instrumento de valor creciente para las instituciones de educación superior y centros asistenciales. Con el objetivo de conocer en detalle las opiniones del alumnado de la Carrera de Nutrición y Dietética, de la Facultad de Medicina de la Universidad de La Frontera, Temuco-Chile relacionadas con las competencias genéricas adquiridas durante su proceso de formación, se realizó una investigación cualitativa, mediante estudio de caso. Participaron estudiantes de 5° año en dos grupos focales, previa firma de consentimiento informado. El análisis de datos siguió un esquema de reducción progresiva de ellos, validándose por triangulación de investigadores. Los resultados representan la congruencia que debe existir entre el plan de estudio y didáctica educativa en el desarrollo de competencias genéricas, tan necesarias en el mundo actual para la inserción laboral de profesionales de la salud.

A randomized clinical trial with two doses of a omega 3 fatty acids oral and arginine enhanced formula in clinical and biochemical parameters of head and neck cancer ambulatory patients.

INTRODUCTION: Postsurgical patients with head and neck cancer could have a high rate of ambulatory complications. The aim was to investigate whether oral ambulatory nutrition of head and neck cancer patients with recent weight loss, using two different doses of an omega 3 fatty acids and arginine enhanced diets could improve nutritional parameters. DESIGN: At Hospital discharge post surgical head and neck cancer patients (n=37) were asked to consume two or three cans per day of a designed omega 3 fatty acid and arginine enhanced supplement for a twelve week period. RESULTS: Albumin, prealbumin, transferrin and lymphocytes levels improved in both groups. Weight, fat mass and fat free mass improved during supplementation in group II (3 bricks per day). No differences were detected in anthropometric parameters in group I. Gastrointestinal tolerance with both formulas was good, no episodes were reported. There are no differences between both formulas on postsurgical complications rates. CONCLUSIONS: Omega 3 and arginine enhanced formulas improved blood protein concentrations and lymphocyte levels in ambulatory postoperative head and neck cancer patients. A high dose of arginine and omega 3 fatty acids formula improved weight, too.

Effect of a commercial hypocaloric diet in weight loss and post surgical morbidities in obese patients with chronic arthropathy, a randomized clinical trial.

INTRODUCTION: The aim of our study was to evaluate in patients with obesity and surgical indication of orthopaedic surgery for chronic osteoarthritis (hip or knee), the impact on weight loss, metabolic control and post surgical co morbidities of a hypocaloric commercial formula (Optisource®) versus conventional nutritional advice before orthopaedic surgery. MATERIALS AND METHODS: 40 patients were randomized in both branches: diet I with lunch and dinner substituted by two Optisource® (1109.3 kcal/day, 166.4 g of carbohydrates (60%), 63 g of proteins (23%), 21.3 g of lipids 17%) and intervention II with nutritional counselling that decreases 500 cal/day of the previous dietary intake. Previous and after 3 months of the treatment, a nutritional and biochemical study was realized. Postsurgical co-morbities have been recorded. RESULTS: 20 patients finished in each group. The improvement in weight (-7.56 ± 5.2 kg vs -5.18 ± 5.1 kg: p < 0.05), body mass index (-3.15 ± 2.2 vs -2.1 ± 1.9 kg/m2: p < 0.05), fat mass (-5.5 ± 5.9 kg vs -3.0 ± 2.6 kg: p < 0.05), insulin (-3.6 ± 3.8 mUI/L vs -3.0 ± 2.6) p < 0.05) and HOMA (-0.5 4 ± 1.2 vs -0.33 ± 1.14): p < 0.05) was higher in group I than in group II. All post surgical recorded parameters such as minutes of orthopaedic surgery, length of stay, vein thrombosis episodes, general infections complications, haemoglobin levels and days till independence of walking were similar in both groups. CONCLUSIONS: Obese patients with chronic osteoarthritis subsidiary of surgery, lose more weight, fat mass and improve more resistance to insulin treated with a mixed diet with a commercial formula hypocaloric that patients treated only with dietary advice.

Opinión de estudiantes de enfermería sobre el examen clínico objetivo estructurado / Nursing students’ opinion about the objective structured clinical examination

Investigación educativa bajo el paradigma cualitativo, a través de un estudio de caso, cuyo objetivo es conocer el significado que tiene para los estudiantes de segundo año de la Carrera de Enfermería el sistema de evaluación ECOE al finalizar la práctica clínica, Módulo Enfermería Básica del Niño, Adolescente y Adulto, del cuarto nivel académico, año 2007. Los estudiantes a partir de sus historias personales individuales, al final del ECOE respondieron una encuesta semiestructurada donde debían mencionar ventajas, desventajas, sugerencias. El análisis de datos siguió el esquema de Miles y Huberman, a través de la reducción progresiva de ellos (separación de unidades, agrupamiento, identificación y clasificación de elementos), disposición, transformación y obtención de conclusiones verificables, validándose a través de la triangulación por investigadores. En las ventajas se identificaron 88 unidades de significado, finalizando en tres dominios cualitativos “proceso de evaluación”, “reconocimiento de competencias genéricas adquiridas en el proceso de evaluación ECOE” y “proceso de gestión y administración del ECOE”. En las desventajas hubo 139 unidades de significado, originando dos dominios cualitativos “reconocimiento de competencias genéricas adquiridas en el proceso de evaluación ECOE” y “proceso de gestión y administración del ECOE”. Los resultados evidencian que el ECOE al igual que cualquier sistema de evaluación provoca en los estudiantes ansiedad, estrés. Reconocen que mide destrezas, actitudes y favorece la retroalimentación con el examinador. Para futuros ECOE, de acuerdo a las opiniones de los educandos, se debe considerar el momento de su aplicación y minimizar el tiempo de espera para ser examinados.

Educational research under qualitative paradigm through a case study aiming to raise awareness of the meaning that OSCE assessment system has for second year Nursing students at the end of the clinical practice of Basic Nursing in child, adolescent and adult modules, given in the fourth level, 2007. At the end of the OSCE and from their own personal stories the students answered a semi-structured survey where they had to mention advantages, disadvantages and suggestions. Data analysis followed the scheme proposed by Miles and Huberman (1994), through the progressive reduction of the data (separate units, clustering, identification and classification of items), provision, processing and obtaining verifiable findings, validating them through researcher triangulation. As for the advantages, 88 units of meanings were identified, ending up in three qualitative domains “evaluation process”, “recognition of generic skills acquired in the OSCE assessment process” and “administration and process management of the OSCE.” 139 units of meanings were identified as disadvantages, creating two qualitative domains: “recognition of generic skills acquired in the OSCE assessment process” and “process management and administration of the OSCE”. The results of this study show that the OSCE as well as any system of student assessment results in anxiety and stress. However, they recognize that measures skills, attitudes and encourages feedback from the examiner. For future, according to the student opinions OSCE should consider the time of application and minimize the time out for examination.

Cinta suburetral transobturatriz libre de tensión para el tratamiento de la incontinencia de orina de esfuerzo: 3 años de seguimiento / Tension-free subureteral tape for stress urinary incontinence

Objetivos: Evaluar nuestros resultados en la corrección de la incontinencia de orina de esfuerzo (IOE) con una técnica de cinta suburetral transobturatriz modificada (TOTm) con malla desnuda de polipropileno y anestesia local, midiendo efectividad, calidad de vida y grado de satisfacción por 3 años de seguimiento. Método: Evaluación prospectiva de 56 pacientes operadas entre los años 2003 y 2005, con IOE moderada o severa, según diagnóstico por clínica y cistometría simple. Se logró realizar un seguimiento del 87 por ciento de las pacientes, por 37,9 meses (19-51 meses). Se realizó control con examen físico y se aplicó una encuesta de satisfacción en visita domiciliaria por un grupo independiente de encuestadores. Resultados: Un 88 por ciento de las pacientes se encuentra sin IOE en el examen físico. A la encuesta de satisfacción, las pacientes manifestaron sentirse mejor o mucho mejor en frecuencia miccional diurna (79 por ciento), disfunción del vaciamiento vesical (69 por ciento), dolor pelviano (58 por ciento), urgeincontinencia (84 por ciento) y función sexual (53 por ciento). Un 90 por ciento manifiesta sentirse mejor o mucho mejor de la IOE que antes de la operación. La urgencia o urgeincontinencia de novo apareció en un 6 por ciento. Conclusiones: La técnica TOTm utilizada por nuestro grupo tiene resultados comparables con las técnicas TOT originales, con mejoría significativa en la calidad de vida de las pacientes.

Objective: To review our results in the correction of stress urinary incontinence (SUI) with a modified TOT technique using polypropylene mesh and local anesthesia, measuring effectiveness, quality of life and degree of satisfaction during 3 years of follow-up. Method: Prospective evaluation of 56 patients operated between 2003 and 2005, with modérate or severe SUI, or mixed urinary incontinence with effort predominance, according to clinical diagnosis and simple cystometry. A follow-up of 87 percent of the patients over a period of 37.9 months (19-51 months) was achieved. A physical examination was realized and a survey of satisfaction was applied by a team of independent interviewers on home visits. Results: On physical examination, 88 percent of patients are without SUI. In the survey of satisfaction, the patients manifested feeling better or much better in terms of daytime voiding frequency (79 percent), voiding dysfunction (69 percent), groin pain (58 percent), urge incontinence (84 percent) and sexual function (53 percent); 90 percent manifested feeling better or much better about their SUI than before the operation. De novo urgency or urge incontinence appeared in 6 percent. Conclusions: The modified TOT technique used by our group obtains results that are comparable to those of the original TOT techniques, with a significant improvement in the quality of life of patients.

[Effects of a diet with products in texture modified diets in elderly ambulatory patients]. / Efecto de una dieta con productos modificados de textura en pacientes ancianos ambulatorios.

BACKGROUND: Decrease in the capacity to deglution solids and liquids is a problem in many people, this problem decreases quality of life. The main objective of our work was to evaluate the influence in elderly ambulatory patients with dysphagia of a texture modified diet ready to use on nutritional parameters and quality of life. METHODS: We enrolled 29 patients from Nutrition Department with dysphagia and an age over 70 years. Patients received a texture modified diet supplemented with dehydrated nutritional products (Resource Ready) (1,633 kcal, 59,9 g proteins (16%), 52,1 g lipids (29%), 231,7 g carbohydrates (57%), 11,1g de fiber, 82 mg cholesterol). Before and after 3 months of starting the treatment, we recorded a blood analysis, nutritional anthropometric evaluation (tricipital skinfold, midarm circumference, midarm muscle circumference, weight, height and body mass index), a bipolar bioimpedance and a dietary questionnaire of 3 days. SF36 as a questionnaire of quality of life was used before and after nutritional treatment. RESULTS: A total of 29 patients were recruited with a sex distribution of (18 females and 11 males), and an average age of 79,5+8,59 years. A 25,7% of patients had head and neck tumors, a 24% dementia and a 41,3% chronic neurological deterioration. After treatment, we detected an improvement in weight, fat mass, fat free mass, total proteins, albumin, transferrin and lymphocytes. Caloric, protein fat and carbohydrate intakes increased in a significative way. Caloric intake corrected by weight improved (26.1 +/- 5.7 cal/kg vs 28.9 +/- 4.5 cal/kg: p < 0.05). Quality of life improved significantly (SF 36 score 94.7 +/- 15 points vs 99.3 +/- 10 points; p < 0.05). CONCLUSION: A texture modified diet with dehydrated nutritional products improved dietary intake, nutritional status and quality of life of ambulatory elderly patients with dysphagia.

Aprendizaje basado en problemas multiprofesional: Estudio cualitativo desde la perspectiva de los tutores / Problem based learning from the perspective of tutors

Background: Problem based learning is a student centered learning technique that develops deductive, constructive and reasoning capacities among the students. Teachers must adapt to this paradigm of constructing rather than transmitting knowledge. Aim: To interpret the importance of tutors in problem based learning during a module of Health research and management given to medical, nursing, physical therapy, midwifery, technology and nutrition students. Material and methods: Eight teachers that participated in a module using problem based learning accepted to particípate in an in depth interview. The qualitative analysis of the textual information recorded, was performed using the ATLAS software. Results: We identiñed 662 meaning units, grouped in 29 descriptive categories, with eight emerging meta categories. The sequential and cross-generated qualitative analysis generated four domains: competence among students, competence of teachers, student-centered learning and evaluation process. Conclusions: Multiprofessional problem based learning contríbutes to the development of generic competences among future health professionals, such as multidisciplinary work, critical capacity and social skills. Teachers must shelter the students in the context of their problems and social situation.

[Comparison of short term acceptability of three oral nutritional supplements]. / Comparación de la aceptabilidad de tres suplementos nutricionales.

BACKGROUND: Although liquid supplements are formulated to provide extra energy, minerals, vitamins and proteins, much of the success of supplementation depends upon the acceptability of the product and the ability of the patients to take large volumes over a period of time. OBJECTIVE: This study was set up to evaluate the acceptability by haematological cancer patients of 3 commercially available nutritional supplements. DESIGN: A population of 32 haematological cancer patients with reduced food intakes (less than 50% of calorie requirements by Harrist Benedict formula) was enrolled. Supplements were randomly assigned to each patient. Patients could try the drinks over 2 days period. They were asked to rate the acceptability of supplement, rating the product with a visual scale from 1 to 5 points with five parameters (color, taste, smell, texture, and temperature). RESULTS: Ten patients received first ONS (oral nutritional supplements), 12 second ONS, and 10 third ONS. No epidemiological differences were detected among three groups. Total calorie and macronutrient consumption improved with all supplements. Average values of color, taste, smell, temperature and texture were similar on three oral nutritional supplements (ONS). Analogic scale was analyze in a categoric way with frequencies, too. Frequencies of 1 and 2 points (very good and good responses) with taste were better with second ONS (85%; p < 0.05) than first ONS (50%) and third ONS (55.5%). Frequencies with smell were better with second ONS (83.3%; p < 0.05) than first (55.5%) and third ONS (62.5%). Frequencies with texture were higher in first ONS (90%; p < 0.05) and second ONS (100%; p < 0.05) than third ONS (66.7%). Temperature and color frequencies were similar in all ONS. CONCLUSIONS: Oral nutritional supplements had different acceptability in haematological cancer patients. Taste, smell and texture could be better in some ONS in these patients.

Tissue electric properties in head and neck cancer patients.

BACKGROUND: The phase angle of the impedance vector was lower because of a decreased Xc component in hemodialysis patients with poorer prognosis, patients with hemodynamic instability, and in critically ill patients. The phase angle is easy to obtain. The aim of our study was to investigate in a case-control study the utility of phase angle and other impedance parameters in a population of male patients with head and neck cancer. MATERIAL AND METHODS: A case-control study was designed. A population of 67 ambulatory post-surgical male patients was enrolled with the following inclusion criteria: oral and/or laryngeal cancer confirmed by biopsy, without a recent loss weight (<5% during previous 3 months) and signed informed consent. As reference group, we selected 70 male subjects from the same geographic region and matched by age, which were selected from a database of healthy people of our hospital. Basal blood sampling was performed for determinations of blood chemistry. Weight, height, body mass index and tetrapolar body electrical bioimpedance were performed in both groups. RESULTS: A total of 67 head and neck cancer male patients were enrolled, mean age was 58.49 +/- 14.54 years, weight 73.32 +/- 11.4 kg and BMI 28.53 +/- 3.5. A total of 70 controls subjects were studied, mean age was 62.33 +/- 12.4 years. Weight 64.31 +/- 8.38 kg and BMI 24.33 +/- 3.2 were significantly lower than in cancer patients (p < 0.05). Renal function and blood sodium levels were similar in both groups. Anthropometric evaluation in cancer patients showed a mean fat mass lower than control patients (13.9 +/- 6.1 vs. 12.1 +/- 6.1 kg; p < 0.05). In control patients, fat-free mass was higher than in cancer patients (58.7 +/- 8.2 vs. 51.23 +/- 8.4 kg; p < 0.05). In cancer patients, reactance (62.3 +/- 17.2 vs. 56.6 +/- 15.1 ohm; p < 0.05) and phase angle (8.02 +/- 1.3 vs. 6.9 +/- 1.5 degrees ; p < 0.05) were lower than in control patients. CONCLUSION: Impedance in male head and neck cancer patients were characterized by a reduced reactance and phase angle. These early altered tissue electric properties appeared with a normal weight and body mass index.

Experience of 6 years with home enteral nutrition in an area of Spain.

OBJECTIVE: The wide spread use of long-term enteral nutrition and the substantive costs dictate a need to study outcome, clinical and epidemiological characteristics of these patients. The aim of our study was to analyze incidence and characteristics of a cohort of patients on HEN during 6 years, after our previous pilot study of 3 years. DESIGN: Prospective observational study. SETTING: Tertiary care. SUBJECTS: Between January 1999 and December 2004, all adult patients living in Valladolid West area who were discharged from the hospital on HEN were prospectively studied and followed up. INTERVENTIONS: Information for each patient was prospectively recorded by the dietitian of the team, and include age, sex, body mass index, tricipital skinfold, midarm circumference, underlying disease, exitus, dates of initiation and discontinuation of HEN, nutrient formula, mode of administration and complications of HEN. During HEN, physicians supervised the home patients and the patients themselves or their close relative, were asked to contact our nutrition team if any problem occurred. Finally the yearly incidence of HEN was calculated each year on the basis of the estimated population in our area of recruitment, assuming almost all HEN patients were reported. RESULTS: In our previous study, incidence of HEN in 1999 was patients 15 per 100,000 inhabitants, 21.3 in 2000 and decreased to 9.52 in 2001. In the new 3 years, the incidence remained in the mean levels of 1999 and 2000, the data were 17.1 per 100,000 inhabitants 26.5 in 2003 and 25.6 in 2004. The mean age of all patients was 56.4+/-17 years. The distribution of patients by diseases was; (43.8%) had a head and neck cancer, (26.8%) had human immunodeficiency virus infection, (9.6%) had a neurological disorders affecting swallowing (cerebrovacular accident and/or dementia), (4.7%) had diseases in digestive tract (fistulae, pancreatic disease, inflammatory bowel disease), (2.5%) had tumors in different locations with anorexia, (5%) had head trauma, and (7.6%) had one of several miscellaneous diseases inducing dysphagia or anorexia. HEN was administered via oral in 258 patients (70.6%) (group I), via a NGT in 95 patients (26.1%), a PEG in 9 patients (2.5%), and a jejunostomy in 3 patients (0.8%) (group II=107 patients). During the course of HEN, 12 patients had diarrhea (3.3%) and 8 (2.2%) constipation, and 4 vomiting (1.1%) that did not require cessation of HEN. No lung aspiration was detected. Hypernatremia (sodium >145 meq/l) appeared only in six cases (1.64%) and 12 cases of hyperglycaemia (3.28%). Ten patients (2.8%) reported a least one problem with the tube. The mean duration of HEN was 148.2+/-104 days. After the follow-up, 19 of the 365 patients (5.2%) had died, 346 (94.8%) were alive. In multivariant analysis, an independent factor associated with death was age (hazard ratio: 1.22; 95% CI: 1.06-1.39), adjusted by sex, route and diagnosis. CONCLUSIONS: HEN has a high incidence in our area and it is a valid and safe technique for nutrition support.

[Mini Nutritional Assessment (MNA) test as a tool of nutritional evaluation in hospitalized patients]. / Mini Nutritional Assessment (MNA) como método de evaluación nutricional en pacientes hospitalizados.

OBJECTIVE: The objective of the study was to identified the prevalence of malnutrition in come patients with MNA (Mini Nutritional Assessment) test as a clinical tool. METHODS: A total of 145 patients were studied in Hospital del Río Hortega (Valladolid), from mars of 2000 till may of 2002. In all patients a MNA test, an anthropometric and biochemical evaluation were performed. RESULTS: Mean age was 57.44 +/- 18.06 years, weight 63.5 +/- 13.7 kg and body mass index 23.4 +/- 4.9 kg/m2. The studied population were 48.6% haematological tumours and other tumours, opposite to the rest of the patients who were presenting cerebro-vascular accidents 2.1%, respiratory problems or infections 16.8%, renal failure 3.5% and neurological diseases or processes of dementia in minor proportion 2.9%. Patients were divided in two groups, malnutrition MNA < 17 (n = 99) (group I) and risk of malnutrition MNA = 17 (n = 43) (group II). The malnutrition prevalence was 68.2% (group I) and risk of malnutrition 29.6% (group II) with test MNA. In biochemical evaluation the malnutrition group I had low levels of albumin (2.9 +/- 0.7 g/dl vs 3.41 +/- 2.71 g/dl; p < 0.05), prealbumin (14.9 +/- 6.2 g/dl vs 17.6 +/- 8.1 g/dl; p < 0.05) and transferrin (152.2 +/- 54.9 g/dl vs 189.9 +/- 32.6 g/dl; p < 0.05. Arm muscular circumference and arm circumference had values under average in patients with malnutrition. On having analyzed the different paragraphs of the test MNA between both groups, it was observed since in the group of undernourished patients the punctuation he was below the average in all the paragraphs. CONCLUSIONS: The risk of malnutrition in hospital was frequent, detected by MNA test.

Early clinical and surgical results of biliopancreatic diversion.

BACKGROUND: Scopinaro biliopancreatic diversion (BPD) for morbid obesity results in significant longterm weight loss and reduction or resolution of obesity-associated co-morbidities. The aim of our work was to describe the early results after BPD. METHODS: 59 morbidly obese patients (BMI >40) underwent open BPD from December 2001 to December 2004. We analyzed a consecutive series of 19 patients who have been followed >4 months. We present the data of basal and early visits (2 and 4 months). RESULTS: Initial excess weight percent loss (IEW%L) was 5.2% at 2 months and 13.7% at 4 months. Glycemia, cholesterol, triglyceride levels and blood pressure improved at each visit. All parameters have significant differences from the basal values. 3 patients had sleep apnea syndrome, and overnight CPAP was able to cease in 2 patients by 4 months. 6 patients (31.5%) had albumin <2.5 g/dl, without clinical findings of malnutrition. Total calorie (857+/-79.8 cal/day) and protein (59.8+/-23 g/day) intakes at 4 months were low, with a low intake of multivitamins and oligoelements from food. There was no mortality in this series. Early postoperative morbidity was incisional hernia (21.1%), anastomotic leak (5.2%), wound infection (15.7%), intra-abdominal infection (5.2%), and intestinal obstruction (5.2%). CONCLUSION: BPD showed early effectiveness in weight loss and co-morbidity improvement. Calorie, protein, oligoelement and vitamin dietary intakes were below recommendations, so that strict multidisciplinary follow-up and supplementation to prevent or treat nutritional deficiencies are mandatory.

Cambios anatómicos post cirugía nasal: medición objetiva mediante rinometría acústica / Anatomic changes post nasal surgery: objective measurement through acoustic rhynometry

Se estudió prospectivamente a un grupo de pacientes sometidos, por diversas indicaciones, a intervención quirúrgica nasoseptal. Se les realizó rinometría acústica (RA) días previos a su cirugía, repitiéndose ésta en el postoperatorio inmediato. Se pretendía objetivar los cambios anatómicos que ocurren en ambas fosas nasales luego de los procedimientos quirúrgicos y correlacionarlos con la clínica. Se utilizó el rinómetro modelo compacto Ecovisión, siguiendo para ello las recomendaciones de Toronto. Los pacientes fueron sometidos a diferentes intervenciones quirúrgicas y en todos se produjeron alteraciones anatómicas objetivas de sus fosas nasales, aunque no todas originaron molestias al paciente

Acciones de la dopamina en las vías aéreas / Work of the dopamine in the airways

Además de su funciones en el Sistema Nervioso Central (SNC), la dopamina modula otros procesos en órganos periféricos. En el aparato respiratorio modula la ventilación a través de su acción sobre el cuerpo carotídeo, también modula el diámetro de los vasos sanguíneos pulmonares, el intercambio de líquidos en el epitelio alveolar y posiblemente participa en la regulación del diámetro de las vías aéreas. Examinamos el posible efecto modulador de la dopamina sobre el tono bronquial administrando dopamina por vía inhalatoria y metoclopramida (MTC)i.v., un bloqueador dopaminérico DA2, en sujetos con varios grados de tono bronquial. Examinamos 56 voluntarios. En todos ellos medimos, antes y después de cada procedimiento, la presión arterial, la frecuencia cardiaca, y por espinometría, la capacidad vital forzada (FVC), el volumen espiratorio en el primer segundo (FEV), el flujo espiratorio forzado máximo FEFmax y el flujo espiratorio forzado al 50 por ciento de la capacidad vital (FEF50). Administramos a) dopamina por vía inhalatoria (0.5µg/kg/min) a 10 sujetos sanos, a 10 con antecedentes de asma sin crisis de broncoespasmo (ASCB) y a 16 pacientes con crisis de asma (CA). b) Administramos MTC, endovenosa (7µg/kg/min) a 10 sujetos y a 10 con ASCB. Por razones éticas no administramos MTC administramos MTC inhalada a sujetos con crisis de asma. La prueba Wilcoxon para muestras dependientes, ANOVA y la prueba de Bonferroni para comparaciones múltiples. La dopamina inhalada aumentó el FEV1, el FVC, el FEFmax, y el FEF50ïen el grupo con CA en relación con el control, pero no hubo modificaciones ni en el grupo de sujetos sanos, ni en el de ASCB. La MTC tampoco produjo cambios de los parámetros respiratorios en los individuos sanos, ni en aquellos con ASCB. La dopamina inhalada, produce inhibición del tono bronquial cuando el tono basal se encuentra aumentado durante las crisis de asma. No modifica el tono basal en individuos sanos, ni con ASCB. El bloqueo DA2 no modifica el tono bronquial basal en sanos ni en sujetos con ASCB. Sugerimos que en humanos la dopamina ejerce un papel modulador del tono bronquial dependiendo del grado de tono basal exigente

Consumo máximo de oxígeno (VO2max) para predecir riesgos posoperatorios en cirugía abdominal electiva / Maximal oxygen uptake (VO2max) for to foretell postsurgical risk in surgical abdominal elective

Cuando el consumo máximo de oxígeno (VO2max), se encuentra por debajo de cierto valor umbral (1 l/min o menos) los riesgos de complicaciones posoperatorias aumentan en pacientes sometidos a cirugía torácica. Esta relación no ha sido bien documentada en pacientes sometidos a cirugía abdominal. Realizamos un estudio prospectivo de tipo descriptivo sobre la capacidad que tiene el VO2max para predecir complicaciones posoperatorias, en 37 pacientes con cirugía abdominal electiva en el Hospital Vargas, Caracas y lo comparamos con la escala de medición de riesgo general, ASA y el Indice Multifactorial de Golman III. A todos los pacientes se les practicó evaluación clínica pre y posoperatorio y los exámenes paraclínicos requeridos. Las complicaciones fueron definidas previamente y los datos obtenidos, de exámenes clínicos diarios y de las historias: quirúrgicas, de anestesiología y del servicio. El VO2max fue obtenido con el método indirecto escalonado de Maneroet al validado en una población latinoamericana mediante mediciones directas de VO2max y es sencillo y de bajo costo. Asigna tres cargas sucesivas de trabajo sub máximo (< 65 por ciento Fc max), que consisten en subir y bajar un peldaño de 25 cm durante 3 min a frecuencias determinadas en cada carga, con un minuto de receso entre ellas. La Fc medida a la carga más alta alcanzada por el paciente, corresponde en las tablas diseñadas por Manero, a un valor de VO2max corregido por edad y sexo. Estadística: X², regresión logística, riesgo relativo (RR), especificidad, sensibilidad y valor predictivo positivo y negativo. El valor promedio de VO2max fue 1.2 ñ 0.38 L/min. En 9 de ellos (24 por ciento) fue menor de 1 L/min y 3 pertenecían a los 7 que presentaron complicaciones posoperatorias. El Vo2max presentó una capacidad de predicir complicaciones posoperatorias mayor que ASA y Goldman III, con un "Odd Ratio" de 3, RR de 2.38, sensibilidad de 42.85 por ciento, especificidad 80 por ciento, valor predictivo positivo de 33 por ciento y valor predictivo negativo de 85,7 por ciento. Recomendamos el uso del consumo máximo de oxígeno para predecir riesgos posoperatorios y el test de Manero para calcular el VO2max

[Evaluation of a dessert in patients with deglutition changes, one more step in advanced basic feeding]. / Evaluación de un postre en pacientes con alteración en la deglución, un paso más en la alimentación básica avanzada.

BACKGROUND: Decrease in the capacity to deglutition solids and liquids is a problem in many people, this problem decreases quality of life. The objective of our work is to evaluate the acceptance degree of a dessert (stewed fruit) (including in the normal diet of the Hospital) in a group of patients with dysphagia. METHODS: Forty seven patients were studied in Hospital Universitario del Río Hortega (Valladolid) in July of 2000. The main pathology of these patients was; (n = 12) 25.5% acute stroke, (n = 16) 34% aerodigestive tumors (Jarynx carcinoma (n = 5), cavum carcinoma (n = 9), oesophagus carcinoma (n = 2)) and 40.4% (n = 19) chronic neurologic disease (Alzheimer, vascular dementia, and parkinson). All patients took a oral triturated diet, a dessert with apple and pear (Resource fruits Instant). All patients took a portion of the dessert and after that a acceptance questionnaire was filled. RESULTS: Global acceptance of the product was 7.25 +/- 1.5, this punctuation was higher in the tumoral group 8 +/- 1.1 points, 6.86 +/- 1.4 in patients with acute stroke and 6.7 +/- 1.5 in patients with chronic neurologic disease (p < 0.05). Different organoleptic characteristics were analyzed, mean punctuation in texture was 1.79 +/- 0.6, color 2.2 +/- 0.5, smell 2.24 +/- 0.59 and taste 1.95 +/- 0.61, in a scale of 1 (very good) until 5 (very bad), a total of 57.9% patients responded very good (1) or good (2) in texture scale, 71.1% in color scale, 60.5% in smell scale and 63.2% in taste scale. CONCLUSIONS: Acceptance of this product in patients with dysphagia has been elevated, showing useful in these patients with nutrition alterations.

[Usefulness of postoperative support by enteral nutrition of patients with epidermoid carcinoma of the larynx]. / Utilidad del soporte con nutrición enteral en el postoperatorio de pacientes con carcinoma epidermoide de laringe.

RATIONALE: At the present time, artificial nutrition has made great strides and enteral nutrition has become the first choice delivery method. The purpose of our paper is to analyze the usefulness of this type of nutrition in the post-operative care of patients with larynx tumours. METHODS: A total of 38 patients were studied, with an average age of 63.2 +/- 10.2 years. On average, in the post-operative period until oral nutrition was restored enteral nutrition lasted for 10.6 +/- 4.9 days. A biochemical and anthropometric assessment of the nutritional condition was effected at the time of admission and 7-10 days into the nutritional treatment. RESULTS: During the post-operative period, no anthropometric changes were detected; the analytical variation, however, showed an improvement on the first review of pre-albumen (12.5 +/- 5.1 mg/dl versus 18.7 +/- 7.9 mg/dl; p < 0.05) and transferrin (132.1 +/- 35 mg/dl versus 159.7 +/- 38 mg/dl; p < 0.05). The nutritional feed using continuous perfusion was gradually increased from the first 24 hours of post-operative care until the pre-established theoretical requirements of the patients were met using polymeric formulas supplemented by soluble and insoluble fibre, presenting very few secondary effects: 13% of diarrhoeas and no cases of aspiration. All of the patients tolerated an oral diet when discharged. The average direct cost (nutrilinea, nasogastric tube and nutrition formulas) for enteral nutrition was 4,723 +/- 1,600 pesetas per day. CONCLUSION: Enteral nutrition is effective in the post-operative care of patients with tumour of the larynx, improving their nutritional biochemistry parameters and allowing easy transition to oral nutrition, with presentation of few side effects and all for low cost.

[A comparison of 2 reference tables in nutritional anthropometric assessment]. / Comparación de dos tablas de referencia en la valoración antropométrica nutricional.

OBJECTIVES: The valuation of nutritional state of an individual is necessary to performed a correct diagnostic approach and therapy in each case. This valuation can be performed by biochemical or anthropometric methods. In our country two tables of anthropometric values are used (Alastrue et al. and Frisancho et al.). The aim of our work was to compare the utility of both tables in the nutritional valuation of a urban and rural population of Valladolid. MATERIAL AND METHODS: A total of 110 patients were valued biochemically and anthropometrically, presenting 65.5% pathology tumoral, with a 61.41 +/- 16.73 year old half age. RESULTS: Tricipital pleat classified the patients in a similar way (agreement 76.5%, kappa 0.68), however the muscular circumference of the arm didn't classify the patients in a same way (agreement 23%, kappa 0.02). in the correlation analysis among anthropometrics and biochemical parameters, positive correlations were detected between tricipital pleat and the index of corporal mass with the glucemia and cholesterol values. Positive correlations were also detected between the muscular circumference of the arm and urea and potassium levels. CONCLUSION: The anthropometric parameters are useful for the nutritional valuation of these patients but it is necessary to keep in mind the possible variations that can exist in function of the used tables. For it Would be useful that each geographical area and each group of pathologies even had its own table of percentiles in its normal population's function.

[Iliac bone for secondary grafting in residual alveolar clefts]. / Injertos óseos con hueso ilíaco en fisuras alveolares residuales.

Iliac cancellous bone has proven efficacy as a bone-graft donor. This study analyses the success of iliac bone autografts in secondary alveolar clefts. The study group was 30 patients with clefts with complete clinical charts and occlusal radiographs with surgery did in Cleft Unit Temuco Regional Hospital (Chile) between 1990-1996. The quality of graft "take" was measured radiologically and clinically. The results were named "excelent-good-regular-bad" and were studied by statistic methods. We did not find complications in donor site. We only had two partial dehiscences in recipient site. In 29 grafts, we feel "bone consistence" in clinical examination. We had one "nontake" graft. 80% of alveolar bone grafts showed similar bone density with respect normal bone. 80% of same grafts had similar height of interdental septum. We had 22 cases with "good result" and 3 cases with "regular result". All of them statistically significant. In our experience, iliac bone graft for alveolar clefts is a good technique for this difficult problem.