Perceived benefits and limitations of a psychoeducation program for patients with fibromyalgia: an interpretative phenomenological analysis.

Objective: To analyze the perceived benefits and limitations of a pain psychoeducation program as a non-pharmacological treatment for patients with fibromyalgia. Methods: An interpretative phenomenological analysis was applied to analyze the subjective experiences of 11 patients with fibromyalgia who participated in a pain psychoeducation program. This program includes educational sessions that address pain understanding, coping strategies, and relaxation techniques. Semi-structured interviews were conducted, transcribed, and analyzed using ATLAS.ti software. Results: Patients reported significant improvements in cognitive-functional capacity and socio-emotional ability, including better disease understanding and management, emotional stability, and interpersonal relationships. Despite these benefits, they identified limitations in program individualization and insufficient coverage of certain topics, such as sexual health and legal aspects of disability. Enhanced self-management skills were evident, with observed shifts in disease perception and coping strategies. Conclusion: The psychoeducation program was viewed positively, influencing functional, cognitive, and emotional enhancements. Nonetheless, the need for increased program personalization and expanded socio-economic support was noted. Future research should focus on the long-term impacts of psychoeducation and the feasibility of tailored interventions.

Efecto de la incorporación de registros adicionales a la presión arterial en la Encuesta Nacional de Salud, Chile 2010 / Effects of incorporating additional blood pressure measurements during The National Health Survey in Chile

Background: It is of utmost importance to identify hypertensive subjects in a country, in order to use efficiently public resources. The National Health Survey 2009-10 in Chile incorporated a third measurement of blood pressure (BP) during the home visit performed by a nurse, and a second day of measurement in a representative sub-sample. Aim: To study the effect of these two additional actions over both the average value of BP and the national prevalence of hypertension. Material and Methods: A third blood pressure measurement was carried out in 5,058 subjects, and it was measured in a second day in 930 individuals. The effect of these additional measurements on absolute blood pressure values and the prevalence of hypertension were assessed. Results: A small but statistically significant reduction in mean systolic pressure (0.52 mmHg) and the prevalence of hypertension (1%) was observed after the incorporation of the third blood pressure measurement. No effects in these figures were observed after the measurement performed on a second day. Conclusions: These findings should be considered when designing the new National Health Survey in Chile.

Cyproterone acetate induces a wide spectrum of acute liver damage including corticosteroid-responsive hepatitis: report of 22 cases.

BACKGROUND & AIMS: Cyproterone acetate (CPA), an anti-androgenic drug for prostate cancer, has been associated with drug-induced liver injury (DILI). We aim to expand the knowledge on the spectrum of phenotypes and outcomes of CPA-induced DILI. METHODS: Twenty-two males (70 ± 8 years; range 54-83) developing liver damage as a result of CPA therapy (dose: 150 ± 50 mg/day; range 50-200) were included. Severity index and causality by RUCAM were assessed. RESULTS: From 1993 to 2013, 22 patients were retrieved. Latency was 163 ± 97 days. Most patients were symptomatic, showing hepatocellular injury (91%) and jaundice. Liver tests at onset were: ALT 18 ± 13 × ULN, ALP 0.7 ± 0.7 × ULN and total serum bilirubin 14 ± 10 mg/dl. International normalized ratio values higher than 1.5 were observed in 14 (66%) patients. Severity was mild in 1 case (4%), moderate in 7 (32%), severe in 11 (50%) and fatal in 3 (14%). Five patients developed ascitis, and four encephalopathy. One patient had a liver injury that resembled autoimmune hepatitis. Eleven (50%) were hospitalized. Nineteen patients recovered after CPA withdrawal, although three required steroid therapy (two of them had high ANA titres). Liver biopsy was performed in seven patients (two hepatocellular collapse, one submassive necrosis, two cholestatic hepatitis, one cirrhosis with iron overload and one autoimmune hepatitis). RUCAM category was 'highly probable' in 19 (86%), 'probable' in 1 (4%), and 'possible' in 2 (9%). CONCLUSIONS: CPA-induced liver injury is severe and can be fatal, and may occasionally resemble autoimmune DILI. The benefit/risk ratio of this drug should be thoroughly assessed in each patient.

Metodología para la evaluación de la relación costo-efectividad en centros de atención primaria de Chile / Methodology for evaluating cost-effectiveness in primary health care centers in Chile

OBJETIVO: Presentar una metodología para la evaluación de la relación costo-efectividad en centros de atención primaria de salud (APS) a partir del modelo de atención familiar promovido en Chile y evaluar los resultados de los dos primeros años de funcionamiento del primer centro piloto que funciona bajo este nuevo modelo de atención primaria. MÉTODOS. Se realizó un estudio de costo-efectividad, con una perspectiva social y un horizonte temporal de un año. Para comparar el centro intervenido (universitario) con el centro de control (municipal) se construyó el índice compuesto de calidad de los centros de salud familiar (ICCESFAM), que combina indicadores técnicos y la percepción de los usuarios de los centros en seis dimensiones: accesibilidad, continuidad de la atención médica, enfoque clínico preventivo y promocional, resolutividad, participación, y enfoque biopsicosocial y familiar. Para calcular los costos se tomó en cuenta el gasto en los centros, el ahorro producido al resto del sistema sanitario y el gasto de bolsillo de los pacientes. Se estimó la razón costo-efectividad incremental (RCEI) y se realizó un análisis de sensibilidad. RESULTADOS: El centro de salud universitario resultó 13,4 por ciento más caro (US$ 8,93 anuales adicionales por inscrito) y más efectivo (ICCESFAM 13,3 por ciento mayor) que el municipal. Estos resultados hacen que la RCEI sea de US$ 0,67 por cada punto porcentual adicional que aumenta el ICCESFAM. CONCLUSIONES: Según el modelo elaborado de evaluación de centros de APS, los centros que siguen el modelo de salud familiar chileno son más efectivos, tanto por sus indicadores técnicos como por la valoración de sus usuarios, que los centros de APS tradicionales.

OBJECTIVE: Present a methodology for evaluating cost-effectiveness in primary health care centers (PHCs) in Chile based on the family health care model promoted in Chile and evaluate the results of the first two years of operation of the first pilot center to work under this new primary-care model. METHODS: A cost-effectiveness study with a social perspective and a one-year time frame was conducted. In order to compare the university health center in question with the control (a municipal health center), a Family Health Center Composite Quality Index (FHCCQI) was devised. It combines technical indicators and user perceptions of the health centers in six areas: access, continuity of medical care, a preventive and promotional clinical approach, problem-solving capability, participation, and a biopsychosocial and family approach. In order to calculate the costs, the centers' expenses, the savings realized in the rest of the health system, and patients' out-of-pocket expenditures were considered. The incremental cost-effectiveness ratio (ICR) was estimated and a sensitivity analysis was performed. RESULTS: The university health center was 13.4 percent more expensive (an additional US$ 8.93 per annum per enrollee) and was more effective (FHCCQI 13.3 percent greater) than the municipal one. Accordingly, the ICR is US$ 0.67 for each additional percentage point of FHCCQI increase. CONCLUSIONS: According to the PHC evaluation model that was implemented, the centers that follow the Chilean family health care model are more effective than traditional PHC centers, as measured by both technical indicators and user ratings.

Competencias médicas requeridas para el buen desempeño en Centros de Salud Familiares en Chile / A survey about the competences required by primary health physicians in Chile

Background: Primary health care is considering the cornerstone of health care in Chile. Its efficiency is strongly influenced by the quality and competences of physicians that are responsible for health care at this level. Aim: To define the features and competences that should have primary care physicians. Material and methods: A group of experts that could be physicians or other professionals working in primary health care were invited to answer electronically a structured questionnaire containing a list of 71 competences, for a basic and an expert level of physician, using the Delphi method. Competences were classifying as "desirable" or "indispensable". If there was lack of consensus in the importance given to a specific competence, the researchers defined its importance. Results: Thirty-eight professionals (50 percent physicians) were inviting to participate and 16 answered the questionnaire. The competence profile defined for basic physicians has 13 knowledge items, 24 skills and 16 attitudes. The figures for advanced physicians are 29 knowledge items, 37 skills and 20 attitudes. Conclusions: This list of competences should been considered by medical schools to adapt undergraduate training of future physicians.

[Smoking interventions in primary health care: smoking profile of women and beliefs and attitudes of local health care teams]. / Tabaquismo en Atención Primaria: Perfil de fumadoras consultantes, creencias y actitudes de los equipos de salud y oportunidades de intervención.

BACKGROUND: Chile has one of the highest prevalence rate of smoking in the world. Brief counseling interventions for smoking cessation at the primary health care level are effective. Compliance with counseling intervention is strongly associated with beliefs and attitudes of the primary health care team that deliver it. The effectiveness of these interventions improve if they are applied to smoking populations with higher motivation of change and high self-efficacy for quitting. AIM: To study the smoking profile of a group of smoking women in Santiago and to identify beliefs and attitudes of the primary health care team members to implement smoking cessation interventions. MATERIAL AND METHODS: A cross-sectional design that included 306 women smokers attending two primary health care clinics in Santiago. Perceptions, beliefs and attitudes of 34 primary care team members from three clinics in Santiago were explored using a qualitative methodology. RESULTS: The study identified a subgroup of 18% of women highly motivated to quit (decisional stage of change) and a 58% with a high self-efficacy. Beliefs and attitudes of staff at the clinics were characterized by invisibility, ambivalence and fatalism regarding the effectiveness of smoking cessation interventions. CONCLUSIONS: There is a subgroup of smoking women with a high probability of quitting if they receive an appropriate counseling. Developing a systematic approach for smoking cessation intervention at the primary care setting in Chile should consider the invisibility, ambivalence and fatalism of primary health care team members towards this topic.

Improving physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: results of a school-based controlled trial.

Regular physical activity is associated with a reduced risk of all-cause mortality, and mortality due to cardiovascular disease and cancer. Among adolescents, physical activity is associated with benefits in the prevention and control of emotional distress, and improvement of self-esteem. Countries in transitional epidemiological scenarios, such as Chile, need to develop effective strategies to improve physical activity as a way to face the epidemic of chronic diseases. The objective of this study was to evaluate the effects of a school-based physical activity program on physical fitness and mental health status of adolescents living in a low socioeconomic status area in Santiago, Chile. A quasi-experimental design was used to evaluate the effects of the program over one academic year. The study included 198 students aged 15 years old. Two ninth grade classes were randomly selected as the intervention group, with two classes of the same grade as controls. A social planning approach was used to develop the intervention. The program was designed and implemented based on student preferences, teachers' expertise and local resources. Changes in physiological and mental health status were assessed. After the intervention, maximum oxygen capacity achieved a significant increase of 8.5% in the intervention versus 1.8% in the control group (p < 0.0001). Speed and jump performance scores improved significantly more in the intervention versus the control group (p > 0.01). Anxiety score decreased 13.7% in the intervention group versus 2.8% in the control group (p < 0.01), and self-esteem score increased 2.3% in the intervention group and decreased 0.1% in the control group after the end of the program (p < 0.0001). No significant change was observed in the depressive score. Student participation and compliance with the program was > 80%. To conclude, a school-based program to improve physical activity in adolescents of low socioeconomic status, obtained a high level of participation and achieved significant benefits in terms of physical fitness and mental health status.

Two homozygous mutations in the 11 beta-hydroxysteroid dehydrogenase type 2 gene in a case of apparent mineralocorticoid excess.

The human microsomal 11 beta-hydroxysteroid dehydrogenase type 2 (11 beta HSD2) metabolizes active cortisol into cortisone and protects the mineralocorticoid receptor from glucocorticoid occupancy. In a congenital deficiency of 11 beta-HSD2, the protective mechanism fails and cortisol gains inappropriate access to mineralocorticoid receptor, resulting in low-renin hypertension and hypokalemia. In the present study, we describe the clinical and molecular genetic characterization of a patient with a new mutation in the HSD11B2 gene. This is a 4-yr-old male with arterial hypertension. The plasma renin activity and serum aldosterone were undetectable in the presence of a high cortisol to cortisone ratio. PCR amplification and sequence analysis of HSD11B2 gene showed the homozygous mutation in exon 4 Asp223Asn (GAC-->AAC) and a single nucleotide substitution C-->T in intron 3. Using site-directed mutagenesis, we generated a mutant 11 beta HSD2 cDNA containing the Asp223Asn mutation. Wild-type and mutant cDNA was transfected into Chinese hamster ovary cells and enzymatic activities were measured using radiolabeled cortisol and thin-layer chromatography. The mRNA and 11 beta HSD2 protein were detected by RT-PCR and Western blot, respectively. Wild-type and mutant 11 beta HSD2 protein was expressed in Chinese hamster ovary cells, but the mutant enzyme had only 6% of wild-type activity. In silico 3D modeling showed that Asp223Asn changed the enzyme's surface electrostatic potential affecting the cofactor and substrate enzyme-binding capacity. The single substitution C-->T in intron 3 (IVS3 + 14 C-->T) have been previously reported that alters the normal splicing of pre-mRNA, given a nonfunctional protein. These findings may determine the full inactivation of this enzyme, explaining the biochemical profile and the early onset of hypertension seen in this patient.

[Cost-effectiveness analysis of a preventive program for gallbladder disease in Chile]. / Análisis de costo-efectividad de un programa preventivo de enfermedad vesicular en Chile.

BACKGROUND: Chilean women have one of the highest mortality rates from gallstone disease in the world. There is no primary prevention for the disease and the benefits of prophylactic cholecystectomy in high risk groups have not been studied. AIM: To analyze the cost and effectiveness of a screening program for gallbladder disease in the Chilean women population. METHODS: A decision analytic model is used to compare lifetime cost and effectiveness of standard care with three screening strategies. The first two strategies consider "universal ultrasound screening" for all women 40 years old and laparoscopic cholecystectomy for those with gallstones ("elective intervention") or with calculous > or = 3 cm ("high risk intervention"). The third strategy is based on "selective screening" for obese women. RESULTS: The lifetime probability of a 40 years old Chilean woman of dying from gallbladder disease is reduced by 70% in the universal screening/elective intervention, by 63% in the high risk intervention and by 18% in the selective screening strategy. Her lifetime expectancy increases by 5.25, 4.64 and 1.24 months respectively. The incremental cost-effectiveness ratio of each screening strategy is US$ 180, US$ 147 and US$ 481 respectively. CONCLUSION: A screening program for gallbladder disease in a high risk population achieves significant benefits at a low incremental cost and acceptable cost-effectiveness.

La medicina general en la organización médica actual / General medicine in the present medical organization

This is a round table organized by the Medical Society of Santiago, with the participation of physicians working at high positions at the Faculties of Medicine, Health Ministry and General and Familial Medical Society. Each one undertakes undergraduate and postgraduate aspects of the issue from the perspective and requirements of his institution

Rendimiento de los criterios de Light en la diferenciación de transudados y exudados pleurales / Performance of Ligth's criteria in the differentiation of pleural transudates and exudates

Los criterios más usados para diferenciar entre exudado y transudado en derrames pleurales han sido los propuestos por Light (Ann Int Med 1972; 77:507-13) que consideran que existe un exudado ante la presencia de por lo menos una de las siguientes alteraciones: relación proteínas pleura/plasma > 0,5; relación LDH pleura/plasma > 0,6; LDH pleural > 200 U/L. Por no existir consenso sobre el rendimiento de estos criterios, decidimos evaluar su contribución diagnóstica en nuestro medio. Se estudió los pacientes ingresados en nuestro hospital entre marzo 1987 y diciembre 1988 y se formuló el diagnóstico a través de la aplicación de criterios clínicos, citológicos, histológicos o bacteriológicos. Se excluyó los casos mixtos o que no reunieron elementos de certeza suficientes. Quedaron 98 líquidos para análisis que se clasificaron según su etiología: 32 transudados (insuficiencia cardíaca 18, cirrosis hepática 14) y 66 exudados (Tbc 13, neoplasia 36, paraneumónicos 3, empiemas 8, enfermedad tejido conectivo 5). Paralelamente y sin el conocimiento del diagnóstico clínico se calificó el derrame pleural según los criterios de laboratorio expuesto. En nuestros pacientes, la sensibilidad para exudados fue de 100%, similar al 99% de Light, y la especificidad fué de 78%, lo que resulta muy inferior al 98 de Light. Concluímos que con los criterios analizados la detección de los exudados es muy satisfactoria (0% de falsos negativos) pero que el error de calificar transudados como exudados es frecuente (22% de falsos positivos)

Utilidad de la concentración de colesterol en derrames pleurales para diferenciar entre transudados y exudados / Pleural fluid cholesterol concentration permits differentiation between transudates and exudates

El método usual de diferenciación entre transudados y exudados a través de la concentración de proteínas y LDH en líquido pleural y plasma puede conducir a errores hasta en un 30% de los casos. Se ha comunicados recientemente que la concentración de colesterol es significativamente mayor en los exudados por lo cual se decidió estudiar su valor diagnóstico en comparación a las proteínas y LDH. Para ello medimos estos indicadores en 80 muestras de líquido pleural con diagnóstico etiológico único y comprobado. De acuerdo a la etiología 20 fueron transudados y 60 exudados. En los primeros la concentración de colesterol fue de 19,5 ñ 10,5 y en los segundos 83,5 ñ 37,2 mg/dl (p < 0,001). Se ensayó diversos puntos de corte resultando más útil el de 45 mg/dl: sobre este nivel, la sensibilidad para exudados fue de 88% y la especificidad de 100%. Hubo 7 exudados falsos negativos: 2 neoplasias y 5 de 9 empiemas. Los transudados mal calificados por proteínas y/o LDH bien identificados por el nivel de colesterol y los exudados erróneamente calificados por colesterol fueron bien calificados por proteínas y/o LDH. Ningún derrame fue mal calificados por ambos métodos. Concluímos que una concentración de colesterol sobre 45 mg/dl asegura que el derrame es un exudado, pero puede haber falsos negativos en aproximadamente un 12%. Nuestros resultados suguieren que la sola determinación del colesterol podría reemplazar a las 4 determinaciones que exigen las proteínas y LDH en pleura y plasma para la diferenciación inicial de exudados y transudados, pero que si se sospecha empiema debe preferirse el último método