[Objective structured clinical evaluation to assess clinical skills of international medical graduates]. / Experiencia con el empleo del examen OSCE en el ciclo de evaluación de competencias clínicas de médicos que revalidan su título.

BACKGROUND: Our institution adopted the Objective Structured Clinical Evaluation (OSCE) format to assess clinical skills of International Medical Graduates (IMGs) aiming to practice in Chile. The OSCE has clear advantages over oral exams due to its objective and structured nature. AIM: To report our experience with OSCE. MATERIAL AND METHODS: A team consisting of clinical specialists and medical educators with expertise in clinical simulation organized this OSCE cycle. IMGs were required to pass four clinical examinations (Internal Medicine, Surgery, Pediatrics and Obstetrics & Gynecology) where their respective general medical competences were evaluated. The latter were carefully selected from those issued by the Chilean Medical Evaluation policy-making body (EUNACOM). Each OSCE consisted of ten stations. Initially conceived to last five minutes each, they were afterwards expanded to seven minutes, after it was realized that most candidates had never been exposed to an OSCE examination before. A post-hoc analysis according to qualitative and psychometric quality criteria followed each OSCE. RESULTS: The proportion of candidates passing the first two examinations of the cycle, were 65 and 75% respectively and reached 100% in the last ones. Lack of IMG familiarity with the OSCE system initially hampered their full expression of competencies. Extending the stations' duration to seven minutes subsequently rectified this situation, as well as potential adverse impacts on the validity of results. CONCLUSIONS: This evaluative process, which entails important consequences for the community and the IMGs, requires a meticulous and coordinated planning and post-hoc quality control.

Experiencia con el empleo del examen OSCE en el ciclo de evaluación de competencias clínicas de médicos que revalidan su título / Objective structured clinical evaluation to assess clinical skills of international medical graduates

Background: Our institution adopted the Objective Structured Clinical Evaluation (OSCE) format to assess clinical skills of International Medical Graduates (IMGs) aiming to practice in Chile. The OSCE has clear advantages over oral exams due to its objective and structured nature. Aim: To report our experience with OSCE. Material and Methods: A team consisting of clinical specialists and medical educators with expertise in clinical simulation organized this OSCE cycle. IMGs were required to pass four clinical examinations (Internal Medicine, Surgery, Pediatrics and Obstetrics & Gynecology) where their respective general medical competences were evaluated. The latter were carefully selected from those issued by the Chilean Medical Evaluation policy-making body (EUNACOM). Each OSCE consisted of ten stations. Initially conceived to last five minutes each, they were afterwards expanded to seven minutes, after it was realized that most candidates had never been exposed to an OSCE examination before. A post-hoc analysis according to qualitative and psychometric quality criteria followed each OSCE. Results: The proportion of candidates passing the first two examinations of the cycle, were 65 and 75% respectively and reached 100% in the last ones. Lack of IMG familiarity with the OSCE system initially hampered their full expression of competencies. Extending the stations' duration to seven minutes subsequently rectified this situation, as well as potential adverse impacts on the validity of results. Conclusions: This evaluative process, which entails important consequences for the community and the IMGs, requires a meticulous and coordinated planning and post-hoc quality control.

[Celiac disease: a fertile field for diagnostic errors]. / Enfermedad celíaca: un campo fértil para los errores diagnósticos.

There has been considerable interest in celiac disease both in specialized and lay audiences during the past two decades, after it was shown to be much more prevalent in general population than previously thought. This disease can have a wide variety of clinical presentations, ranging from a silent form to a full-blown, sometimes severe disease. The diagnosis of celiac disease requires a high degree of suspicion, is fraught with potential pitfalls, and is a very rigorous process, given the protean nature of the disease. Clinicians should perform appropriate serum testing and conclude with the diagnostic “gold standard”: documenting the hallmark histological findings in a small bowel biopsy. This paper reviews potential causes of celiac disease misdiagnosis.

En las pasadas dos décadas, el interés en la enfermedad celíaca ha aumentado considerablemente, tanto en los medios especializados como en los legos al demostrarse que la prevalencia de esta entidad es mucho más frecuente en la población general que lo que se creía. Esta patología puede presentarse con una gran variedad de manifestaciones clínicas y con una gradiente de intensidad que va desde la forma silente hasta la plenamente florida, a veces grave. Como enfermedad proteiforme su confirmación implica un riguroso proceso diagnóstico. Éste requiere que los clínicos manejen un alto índice de sospecha y realicen en el paciente un apropiado rastreo serológico de la enfermedad, para culminar con el “estándar de oro” de la confirmación diagnóstica: la documentación de las alteraciones histológicas características en una biopsia de intestino delgado. En este proceso hay múltiples posibilidades de errores diagnósticos. Esta revisión narrativa revisa las potenciales causas de dichas fallas.

Enfermedad celíaca: un campo fértil para los errores diagnósticos / Celiac disease: a fertile field for diagnostic errors

En las pasadas dos décadas, el interés en la enfermedad celíaca ha aumentado considerablemente, tanto en los medios especializados como en los legos al demostrarse que la prevalencia de esta entidad es mucho más frecuente en la población general que lo que se creía. Esta patología puede presentarse con una gran variedad de manifestaciones clínicas y con una gradiente de intensidad que va desde la forma silente hasta la plenamente florida, a veces grave. Como enfermedad proteiforme su confirmación implica un riguroso proceso diagnóstico. Éste requiere que los clínicos manejen un alto índice de sospecha y realicen en el paciente un apropiado rastreo serológico de la enfermedad, para culminar con el “estándar de oro” de la confirmación diagnóstica: la documentación de las alteraciones histológicas características en una biopsia de intestino delgado. En este proceso hay múltiples posibilidades de errores diagnósticos. Esta revisión narrativa revisa las potenciales causas de dichas fallas.

There has been considerable interest in celiac disease both in specialized and lay audiences during the past two decades, after it was shown to be much more prevalent in general population than previously thought. This disease can have a wide variety of clinical presentations, ranging from a silent form to a full-blown, sometimes severe disease. The diagnosis of celiac disease requires a high degree of suspicion, is fraught with potential pitfalls, and is a very rigorous process, given the protean nature of the disease. Clinicians should perform appropriate serum testing and conclude with the diagnostic “gold standard”: documenting the hallmark histological findings in a small bowel biopsy. This paper reviews potential causes of celiac disease misdiagnosis.

[A national online survey applied to patients with celiac disease in Chile]. / Encuesta nacional online aplicada en pacientes con enfermedad celíaca en Chile.

BACKGROUND: Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. Its prevalence in Europe and the USA is 0.5 to 1%. AIM: To analyze epidemiological aspects and degree of compliance with gluten-free diet (GFD) among Chilean individuals with CD. MATERIAL AND METHODS: Subjects with confirmed or suspected CD were invited to answer an online survey published on the web at www.fundacionconvivir.cl. The answers were reinforced with a telephone interview. RESULTS: The survey was answered by 1212 subjects (79% females). Median age at diagnosis was 25.8 years (range 1 to 84 years), with a bimodal curve with two peaks at less than 3 years and at 20 to 40 years of age. The diagnosis was made only by serologic markers in 9%, only by intestinal biopsy in 17.5%, and by a combination of both methods in 70%o. Conditions associated with CD were reported by 30% > of subjects and 20% > had relatives with CD. The GFD was strictly adhered to by 70% >, occasionally by 27% > and never by 3% >. Seventy five percent of subjects with a strict adherence to GFD had a favorable clinical response compared with 42% > of those with incomplete or lack of adherence (odds ratio 4.0, 95% > confidence intervals 2.8-5.7p < 0.01). CONCLUSIONS: In 30% of respondents, the diagnosis of CD was not confirmed according to international guidelines that require serology and duodenal biopsy. One third of subjects recognized a poor compliance with GFD. Those with a strict adherence to it had a more favorable clinical course. However, 25% > did not experience a clinical improvement despite a strict GFD, a finding which requires further study.

Encuesta nacional online aplicada en pacientes con enfermedad celíaca en Chile / A national online survey applied to patients with celiac disease in Chile

Background: Celiac disease (CD) is an immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals. Its prevalence in Europe and the USA is 0.5 to 1 percent. Aim: To analyze epidemiological aspects and degree of compliance with gluten-free diet (GFD) among Chilean individuals with CD. Material and Methods: Subjects with confirmed or suspected CD were invited to answer an online survey published on the web at www.fundacionconvivir.cl. The answers were reinforced with a telephone interview. Results: The survey was answered by 1212 subjects (79 percent females). Median age at diagnosis was 25.8 years (range 1 to 84 years), with a bimodal curve with two peaks at less than 3 years and at 20 to 40 years of age. The diagnosis was made only by serologic markers in 9 percent, only by intestinal biopsy in 17.5 percent, and by a combination of both methods in 70 percento. Conditions associated with CD were reported by 30 percent> of subjects and 20 percent> had relatives with CD. The GFD was strictly adhered to by 70 percent>, occasionally by 27 percent> and never by 3 percent>. Seventy five percent of subjects with a strict adherence to GFD had a favorable clinical response compared with 42 percent> of those with incomplete or lack of adherence (odds ratio 4.0, 95 percent> confidence intervals 2.8-5.7p < 0.01). Conclusions: In 30 percent of respondents, the diagnosis of CD was not confirmed according to international guidelines that require serology and duodenal biopsy. One third of subjects recognized a poor compliance with GFD. Those with a strict adherence to it had a more favorable clinical course. However, 25 percent> did not experience a clinical improvement despite a strict GFD, a finding which requires further study.

CagA antibodies as a marker of virulence in chilean patients with Helicobacter pylori infection.

BACKGROUND: The bacterial and host factors that influence the clinical outcomes of the Helicobacter pylori infection have not been fully identified. Cytotoxin-associated gene product (CagA), one of the virulence factors, has been associated with a more aggressive form of infection. The authors studied the relationship between CagA status and clinical outcome in Chilean children and adults with H. pylori infection. METHODS: One hundred eighty consecutive patients undergoing upper gastrointestinal endoscopic analysis were enrolled after informed consent was obtained. Rapid urease test and histologic analysis were used to detect H. pylori infection. IgA and IgG antibodies to H. pylori whole cell antigen preparation and IgG antibodies to CagA were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: H. pylori infection was detected in 42% of the patients by biopsy or urease test and in 38% and 20% of patients by IgG and IgA antibodies, respectively. The prevalence of H. pylori either by the invasive or the serologic tests was directly related to patient age. Among patients with H. pylori, there was no significant association between age and prevalence of CagA. Nearly 70% of the patients with H. pylori and peptic ulcer disease had CagA-positive strains. In contrast, only 49% of the patients with chronic gastritis alone had CagA-positive strains (P < 0.05). CONCLUSIONS: In Chile, patients infected with H. pylori have a proportion of CagA-positive strains similar to that reported in developed countries. CagA prevalence was not significantly different in adults and children infected with H. pylori, suggesting that variations in clinical outcome may be related to host immune or environmental factors.

[Correlation between phenotype and genotype in a group of patients with cystic fibrosis]. / Correlación genotipo-fenotipo de un grupo de pacientes con fibrosis quística.

BACKGROUND: Cystic fibrosis (CF) is the most common lethal autosomic disease in Caucasians, with a global incidence of 1:3000 newborns. More than 900 mutations have been described, involving the Cystic Fibrosis Transmembrane Regulator (CFTR). The delta F508 mutation is present in 60% of alleles studied worldwide. AIM: To report 25 patients with cystic fibrosis in whom a genetic study was done. MATERIAL AND METHODS: Twenty five patients (14 men, aged between 18 months and 25 years) with a diagnosis of cystic fibrosis based on clinical features plus two abnormal sweat tests are reported. The genetic study considered the 20 most common mutations in cystic fibrosis and was done in genomic DNA of peripheral lymphocytes, by polymerase chain reaction. RESULTS: A mutation was found in 75% of analyzed alleles. delta F508 was present in 50% of cases (delta F508/delta F508 in 8 and delta F508/other in 11). When delta F508 was present, pancreatic insufficiency was always a feature and nutritional status was worse. Respiratory involvement was variable, both for homozygous and heterozygous cases. Other severe mutations such as W128X and G542X were related to clinical manifestations similar to those found in delta F508 mutation. Diagnosis was made before six months of age in 12 patients. The clinical presentation was meconium ileus and there was a family history of the disease in most cases. The majority of cases of early diagnosis presented severe mutations, but milder respiratory symptoms and lesser nutritional compromise at the time of assessment. CONCLUSIONS: Most patients studied had a severe cystic fibrosis mutation, which was associated with more severe respiratory, pancreatic and nutritional involvement. The early diagnosis of the disease, which would allow to improve the prognosis and the quality of life, must be emphasized.

Causas de diarrea crónica infantil / Causes of chronic diarrhea in children

Se estudiaron los hechos clínicos de 100 pacientes consecutivos referidos a un consultorio de gastroenterología por diarrea crónica, dos causas fueron las responsables de los 3/4 de los casos: giardiasis (42 pacientes) y enfermedad celíaca (32 pacientes); esto último documentado histológicamente de acuerdo con los criterios actualmente aceptados

Ulcera péptica en pediatría: experiencia de 10 años / Peptic ulcer in pediatrics: a 10-year experience

Se describe una revisión retrospectiva de 32 casos de úlcera péptica en los últimos 10 años del hospital Luis Calvo Mackenna. Treinta y uno confirmados por endoscopía o estudio radiológico o ambos y uno durante una intervención quirúrgica por perforación duodenal. Desde que se comenzó a utilizar fibroscopía digestiva en 1978, se produjo un aumento significativo del número de casos diagnosticados. Veinticinco pacientes sufrían úlceras crónicas y siete úlceras agudas. Las crónicas se presentaron en 23 pacientes mayores de 6 años y 2 en menores de esta edad. Todas las agudas ocurrieron en menores de 6 años y con mayor frecuencia durante el post operatorio inmediato de la reparación de una coartación de la aorta. Ambos tipos de lesiones se encontraron con mayor frecuencia en el duodeno que en el estómago, y afectan al sexo masculino más que al femenino en una proporción de 1,8:1. En 74% de los pacientes con úlcera crónica habían familiares directos con antecedentes de la misma enfermedad. Todos los pacientes con úlcera aguda presentaron hemorragia digestiva al comienzo de la enfermedad, en cambio los pacientes con úlcera crónica presentaron dolor abdominal recurrente con mayor frecuencia que hemorragia digestiva. Los estudios de acidez gástrica en 11 pacientes con úlcera crónica mostraron valores de débito basal y máximo más elevado que los encontrados en 12 niños con dolor abdominal recurrente sin úlcera comprobada. De 25 casos con úlcera crónica, 19 tuvieron sólo una crisis (76%) y 6 tuvieron dos o más (24%). Ricibiero tratamiento médico exclusivo 21 pacientes y 4 debieron ser operados (16%)