Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience / Quien está en el servicio de emergencia importa al hablar de tiempo puerta-aguja: experiencia de un centro clínico

Abstract Background The efficacy of intravenous thrombolysis (IVT) is time-dependent. Objective To compare the door-to-needle (DTN) time of stroke neurologists (SNs) versus non-stroke neurologists (NSNs) and emergency room physicians (EPs). Additionally, we aimed to determine elements associated with DTN ≤ 20 minutes. Methods Prospective study of patients with IVT treated at Clínica Alemana between June 2016 and September 2021. Results A total of 301 patients underwent treatment for IVT. The mean DTN time was 43.3 ± 23.6 minutes. One hundred seventy-three (57.4%) patients were evaluated by SNs, 122 (40.5%) by NSNs, and 6 (2.1%) by EPs. The mean DTN times were 40.8 ± 23, 46 ± 24.7, and 58 ± 22.5 minutes, respectively. Door-to-needle time ≤ 20 minutes occurred more frequently when patients were treated by SNs compared to NSNs and EPs: 15%, 4%, and 0%, respectively (odds ratio [OR]: 4.3, 95% confidence interval [95%CI]: 1.66-11.5, p = 0.004). In univariate analysis DTN time ≤ 20 minutes was associated with treatment by a SN (p = 0.002), coronavirus disease 2019 pandemic period (p = 0.21), time to emergency room (ER) (p = 0.21), presence of diabetes (p = 0.142), hypercholesterolemia (p = 0.007), atrial fibrillation (p < 0.09), score on the National Institutes of Health Stroke Scale (NIHSS) (p = 0.001), lower systolic (p = 0.143) and diastolic (p = 0.21) blood pressures, the Alberta Stroke Program Early CT Score (ASPECTS; p = 0.09), vessel occlusion (p = 0.05), use of tenecteplase (p = 0.18), thrombectomy (p = 0.13), and years of experience of the physician (p < 0.001). After multivariate analysis, being treated by a SN (OR: 3.95; 95%CI: 1.44-10.8; p = 0.007), NIHSS (OR: 1.07; 95%CI: 1.02-1.12; p < 0.002) and lower systolic blood pressure (OR: 0.98; 95%CI: 0.96-0.99; p < 0.003) remained significant. Conclusions Treatment by a SN resulted in a higher probability of treating the patient in a DTN time within 20 minutes.

Resumen Antecedentes La respuesta a la trombólisis intravenosa (TIV) es dependiente del tiempo. Objetivo Comparar los tiempo puerta-aguja (TPAs) de neurólogos vasculares (NVs) contra los de neurólogos no vasculares (NNVs) y médicos emergencistas (MEs), y determinar los elementos asociados a un PTA ≤ 20 minutos. Métodos Análisis observacional prospectivo de pacientes con TIV tratados en Clínica Alemana entre junio de 2016 y septiembre de 2021. Resultados En total, 301 pacientes con TIV fueron tratados. El TPA promedio fue de 43,3 ± 23,6 minutos. Un total de 173 (57,4%) pacientes fueron evaluados por NVs, 122 (40,5%), por NNVs, y 6 (2,1%), por MEs; los TPAs promedios fueron de 40,8 ± 23; 46 ± 24,7 y 58 ± 22,5 minutos, respectivamente. Los TPAs ≤ 20 minutos fueron más frecuentes en pacientes tratados por NVs versus NNVs y MEs: 15%, 4% y 0%, respectivamente (odds ratio [OR]: 4,3; intervalo de confianza del 95% [IC95%]: 1,66-11,5; p = 0,004). El análisis univariado demostró que TPA ≤ 20 minutos se asoció con: tratamiento por NVs (p = 0,002), periodo de la pandemia de enfermedad por coronavirus 2019 (COVID-19; p = 0,21), tiempo a urgencia (p = 0,21), diabetes (p = 0,142), hipercolesterolemia (p = 0,007), fibrilación auricular (p < 0,09), puntaje en la National Institutes of Health Stroke Scale [NIHSS] (p = 0,001), presión arterial sistólica (p = 0,143) y diastólica menores (p = 0,21), Alberta Stroke Program Early CT Score (ASPECTS ; p = 0,09), oclusión de vasos cerebrales (p =0,05), uso de tecneteplase (p = 0,18), trombectomía (p = 0,13) y años de experiencia del médico (p < 0,001). El análisis multivariado demostró que ser tratado por NVs (OR: 3,95; IC95%: 1,44-10,8; p = 0,007), el puntaje en la NIHSS (OR: 1,07; IC95%: 1,02-1,12; p < 0,002) y la presión arterial sistólica (OR: 0,98; IC95%: 0,96-0,99; p < 0,003) se asociaron a TPA ≤ 20 minutos. Conclusões El tratamiento por NVs resultó en un TPA menor y en una mayor probabilidad de tratamiento ≤ 20 minutos.

Distribución geográfica de la incidencia de cáncer de beneficiarios de un convenio de atención oncológica en Chile

Cancer incidence reported by The Global Cancer Observatory (GLOBOCAN) is an estimate based on the registries available in each country. Their validity in regions such as Latin America is affected by the lack of reliable data and less access to healthcare among the population. Studying the geographic distribution of the incidence of malignant tumors facilitates the search for risk factors and allows prioritizing health resources. Aim: To estimate the incidence of the main malignant tumors in Chilean people with access to a private healthcare insurance at an oncological institute, and to know its geographical distribution. Material and Methods: Incident cancer cases during 2017 and 2018 were obtained from the institution's Tumor Registry. The incidence was adjusted by age and sex of the Chilean population obtained from the 2017 Census. Cancer rates were calculatedfor each of the 16 administrative regions in Chile. Results: Overall, the incidence of breast, lung, colon and thyroid cancers in the studied population was significantly higher than estimates for Chile reported by GLOBOCANfor 2020, especiallyfor thyroid cancer. There is a higher incidence of breast cancer in Greater Santiago and of lung cancer in men in the Antofagasta Region. Conclusions: The regional differences observed are explained by known risk factors. However the high incidence of lung and colon cancer in the Los Ríos Region requires further studies.

Diffusion-weighted imaging as predictor of acute ischemic stroke etiology / Imágenes por difusión cerebral como predictor de la etiología del accidente cerebrovascular isquémico agudo

Abstract Background: Topographic patterns may correlate with causes of ischemic stroke. Objective: To investigate the association between diffusion-weighted imaging (DWI) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. Methods: We included 1019 ischemic stroke patients. DWI were classified as: i) negative; ii) DWI single lesion (cortico-subcortical, cortical, subcortical ≥20 mm, or subcortical <20 mm); iii) scattered lesions in one territory (small scattered lesions or confluent with additional lesions); and iv) multiple lesions (multiple unilateral anterior circulation [MAC], multiple posterior circulation [MPC], multiple bilateral anterior circulation [MBAC], and multiple anterior and posterior circulations [MAP]). Results: There was a relationship between DWI patterns and TOAST classification (p<0.001). Large artery atherosclerosis was associated with small, scattered lesions in one vascular territory (Odds Ratio [OR] 4.22, 95% confidence interval [95%CI] 2.61-6.8), MPC (OR 3.52; 95%CI 1.54-8.03), and subcortical lesions <20 mm (OR 3.47; 95%CI 1.76-6.85). Cardioembolic strokes correlated with MAP (OR 4.3; 95%CI 1.64-11.2), cortico-subcortical lesions (OR 3.24; 95%CI 1.9-5.5) and negative DWI (OR 2.46; 95%CI 1.1-5.49). Cryptogenic strokes correlated with negative DWI (OR 4.1; 95%CI 1,84-8.69), cortical strokes (OR 3.3; 95%CI 1.25-8.8), MAP (OR 3.33; 95%CI 1.25-8.81) and subcortical lesion ≥20 mm (OR 2.44; 95%CI 1,04-5.73). Lacunar strokes correlated with subcortical lesions diameter <20 mm (OR 42.9; 95%CI 22.7-81.1) and negative DWI (OR 8.87; 95%CI 4.03-19.5). Finally, MBAC (OR 9.25; 95%CI 1.12-76.2), MAP (OR 5.54; 95%CI 1.94-15.1), and MPC (OR 3.61; 95%CI 1.5-8.7) correlated with stroke of other etiologies. Conclusions: A relationship exists between DWI and stroke subtype.

RESUMEN Antecedentes: Los patrones topográficos pueden correlacionarse con las causas del accidente cerebrovascular isquémico. Objetivo: Investigar la asociación entre imágenes ponderadas por difusión por resonancia nuclear magnética (dRNM) y el ensayo de Org 10172 en la clasificación de tratamiento agudo de accidentes cerebrovasculares (TOAST). Métodos: Fueron incluidos 1.019 pacientes con accidente cerebrovascular isquémico. Las dRNM fueron clasificadas como: i) negativa; ii) dRNM lesión única (cortico-subcortical, cortical, subcortical ≥20 mm, o subcortical <20 mm); iii) lesiones disgregadas un territorio vascular (pequeñas lesiones dispersas o confluentes con lesiones adicionales); y iv) lesiones múltiples (unilaterales de circulación anterior [MAC], de circulación posterior [MPC], bilaterales de circulación anterior [MBAC] y de circulación anterior y posterior [MAP]). Resultados: Existió relación entre los patrones de dRNM y la clasificación TOAST (p<0,001). La aterosclerosis de las arterias grandes se asoció con lesiones pequeñas y disgregadas en un territorio vascular (Odds Ratio [OR] 4,22, intervalo de confianza del 95% [IC95%] 2,61-6,8), MPC (OR 3,52; IC95% 1,54-8,03), y lesiones subcorticales <20 mm (OR 3,47; IC95% 1,76-6,85). Cardioembolias se relacionaron con MAP (OR 4,3; IC95% 1,64-11,2), lesiones cortico-subcorticales (OR 3,24; IC95% 1,9-5,5) y dRNM negativas (OR 2,46; IC95% 1,1-5,49). Los accidentes cerebrovasculares criptogénicos se relacionaron con dRNM negativas (OR 4,1; IC95% 1,84-8,69), accidentes cerebrovasculares corticales (OR 3,3; IC95% 1,25-8,8), MAP (OR 3,33; IC95% 1,25-8,81) y lesiones subcorticales ≥20 mm (OR 2,44; IC95% 1,04-5,73). Los accidentes cerebrovasculares lacunares se correlacionaron con lesiones subcorticales de diámetro <20 mm (OR 42,9; IC95% 22,7-81,1) y dRNM negativas (OR 8,87; IC95% 4,03-19,5). Finalmente, MBAC (OR 9,25; IC95% 1,12-76,2), MAP (OR 5,54; IC95% 1,94-15,1) y MPC (OR 3,61; IC95% 1,5-8,7) se relacionaron con accidentes cerebrovasculares de otras etiologías. Conclusiones: Existe relación entre dRNM y subtipo de accidente cerebrovascular.

Violencia contra la mujer durante la gestación y postparto infligida por su pareja en Centros de Atención Primaria de la zona norte de Santiago, Chile / Prevalence and factors associated with partner violence among pregnant and puerperal women in Santiago, Chile

Background: Violence against women (VAW) is a violation of women's fundamental rights and special attention must be paid during the gestational and postpartum period. Aim: To determine the prevalence of violence against women attending antenatal and postpartum controls in Primary Health Centers. Material and Method: The Woman Abuse Screening Tool (WAST) for early detection of VAW was applied to 279 pregnant and 102 puerperal women attending five public primary health centers in metropolitan Santiago. Results: The prevalence ofviolence against pregnant and puerperal women was 5.7 and 5.9%, respectively. In both groups, the factors associated with a greater risk of violence were being immigrants, a history of domestic violence, not having a supportive partner and alcohol consumption by the partner. Conclusions: Violence against these women is a multifactorial, complex and structural phenomenon, which involves the victim, the abuser and the entire social system. Primary health care level and health professionals can be key elements applying early detection strategies, timely referral mechanisms and bringing emotional support for victims.

Low dosis of alteplase, for ischemic stroke after Enchanted and its determinants, a single center experience / Dosis reducida de alteplase en el accidente cerebrovascular isquémico después del estudio Enchanted y sus determinantes, una experiencia de un solo centro

Abstract Background: Low-dose alteplase (LrtPA) has been shown not to be inferior to the standard-dose (SrtPA) with respect to death/disability. Objective: We aim to evaluate the percentage of patients treated with LrtPA at our center after the ENCHANTED trial and the factors associated with the use of this dosage. Methods: Prospective study in consecutive patients with an acute stroke admitted between June 2016 and November 2018. Results: 160 patients were treated with intravenous thrombolysis, 50% female; mean age 65.4±18.5 years. Of these, 48 patients (30%) received LrtPA. In univariate analysis, LrtPA was associated with patient's age (p=0.000), previous modified Rankin scale scores (mRS) (p<0.000), hypertension (p=0.076), diabetes mellitus (p=0.021), hypercholesterolemia (p=0.19), smoking (p=0.06), atrial fibrillation (p=0.10), history of coronary artery disease (p=0.06), previous treatment with antiplatelet agents (p<0.000), admission International Normalized Ratio-INR (p=0.18), platelet count (p=0.045), leukoaraiosis on neuroimaging (p<0.003), contraindications for thrombolytic treatment (p=0.000) and endovascular treatment (p=0.027). Previous relevant bleedings were determinants for treatment with LrtPA. Final diagnosis on discharge of stroke mimic was significant (p=0.02) for treatment with SrtPA. In multivariate analysis, mRS (OR: 2.21; 95%CI 1.37‒14.19), previous antiplatelet therapy (OR: 11.41; 95%CI 3.98‒32.70), contraindications for thrombolysis (OR: 56.10; 95%CI 8.81‒357.80), leukoaraiosis (OR: 4.41; 95%CI 1.37‒14.10) and diagnosis of SM (OR: 0.22; 95%CI 0.10‒0.40) remained independently associated. Conclusions: Following the ENCHANTED trial, LrtPA was restricted to 30% of our patients. The criteria that clinicians apply are based mostly on clinical variables that may increase the risk of brain or systemic hemorrhage or exclude the patient from treatment with lytic drugs.

RESUMEN Introducción: Dosis reducidas de trombolitico (LrtPA) podrían no ser inferiores en muerte/discapacidad. Objetivo: Evaluar el porcentaje de pacientes tratados con LrtPA en nuestro centro después del ensayo ENCHANTED, y los factores asociados con el uso de esta dosis. Métodos: Estudio prospectivo de pacientes consecutivos con infarto cerebral ingresados ​entre junio de 2016 y noviembre de 2018. Resultados: 160 pacientes fueron tratados con trombólisis intravenosa, 50% mujeres; edad media 65,4±18,5 años. 48 casos (30%) recibieron LrtPA. En el análisis univariado, LrtPA se asoció con la edad del paciente (p=0,000), escala de Rankin modificadas (mRS) (p<0,000), hipertensión arterial (p=0,076), diabetes mellitus (p=0,021), hipercolesterolemia (p=0,19), tabaquismo (p=0,06), fibrilación auricular (p=0,10), antecedentes de enfermedad coronaria (p=0,06), tratamiento previo con antiplaquetarios (p<0,000), International Normalized Ratio-INR (p=0,18), recuento de plaquetario (p=0,045), leucoaraiosis en neuroimagen (p<0,003), contraindicaciones para el tratamiento trombolítico (p=0,000) y tratamiento endovascular (p=0,027). Las hemorragias previas relevantes fueron determinantes para el tratamiento con LrtPA. El diagnóstico al alta de imitador de accidente cerebrovascular fue significativo (p=0,02) para el tratamiento con dosis estándar. El análisis multivariado demostró que mRS (OR: 2,21; IC95% 1,37‒14,19), tratamiento antiplaquetario previo (OR: 11,41; IC95% 3,98‒32,7), contraindicaciones para trombólisis (OR: 56,1; IC95% 8,81‒357,8), leucoaraiosis (OR: 4,41; IC95% 1,37‒14,1) y un diagnóstico de imitador de accidente cerebrovascular (OR: 0,22; IC95% 0,1‒0,40) fueron asociados con la dosis recibida. Conclusiones: LrtPA está restringido al 30% de nuestros pacientes. Los criterios para tomar esta decisión se basan en variables que podrían aumentar el riesgo de hemorragia cerebral/sistémica o excluir al paciente del tratamiento con fármacos líticos.

Determinantes del tiempo puerta-aguja en trombolisis endovenosa en el infarto cerebral, experiencia de un centro

Background: Intravenous thrombolysis (IT) in acute ischemic stroke (AIS) is time dependent. The time elapsed from hospital admission to the thrombolytic bolus is named door to needle time (DNT) and is recommend to be of less than 60 min. Aim: To describe the DNT in our center and determine those factors associated with a DNT longer than 60 min. Material and Methods: Prospective analysis of patients treated with IT at a private hospital between June 2016 and June 2019. The percentage of patients with DNT exceeding 60 min, and the causes for this delay were evaluated. Results: IT was used in 205 patients. DNT was 43.6 ± 23.8 min. Forty patients (19.5% (95% CI, 14.4-25.7), had a DNT longer than 60 min. Uni-varied analysis demonstrated that AIS with infratentorial symptomatology (ITS), was significantly associated with DNTs exceeding 60 min. A history of hypertension, a higher NIH Stroke Scale score, the presence of an hyperdense sign in brain tomography (p = 0.001) and the need for endovascular therapy (p = 0.019), were associated with DNT shorter than 60 min. Multivariate analysis ratified the relationship between ITS and DNT longer than 60 min (Odds ratio: 3.19, 95% confidence intervals 1.26-8). Conclusions: The individual elements that correlated with a DNT longer than 60 min were the failure to detect the AIS during triage and doubts about its diagnosis.

Fragilidad: en busca de herramientas de evaluación preoperatoria / Assessment of two frailty scales for the preoperative period

Background: In the perioperative context, a frailty evaluation scale must consider certain characteristics such as validation, execution speed, simplicity, the capacity to measure multiple dimensions and not being dependent on a cognitive or physical test that could not be performed prior to surgery. The test should select patients that could benefit from interventions aimed to improve their postoperative outcomes. Aim: To validate two frailty evaluation scales for the perioperative period. Material and Methods: The Risk Analysis Index with local modifications (RAI-M) were applied to 201 patients aged 73 ± 7 years (49% women) and the Edmonton frailty scale were applied in 151 patients aged 73 ± 7 years (49% women) in the preoperative period. Their results were compared with the Rockwood frailty index. Results: The Edmonton frail scale showed adequate psychometric properties and assessed multiple dimensions through 8 of the 11 original questions, achieving a discrimination power over 80% compared to the Rockwood Index. The RAI- M, demonstrated solid psychometric properties with a tool that examines 4 dimensions of frailty through 15 questions and reviewing the presence of 11 medical comorbidities. This scale had a discrimination power greater than 85% and it was significantly associated with prolongation of the planned hospital stay and mortality. Conclusions: RAI-M is a short and easily administered scale, useful to detect frailty in the preoperative period.

Confección de un modelo predictor para infección de herida operatoria en pacientes adultos intervenidos de artroplastía total de cadera en un hospital de alta complejidad, años 2012 y 2014 / Predictive model preparation for surgical wound infection in adult patients undergoing total hip arthroplasty in high complexity hospital for years 2012 and 2014

Resumen Introducción: Las infecciones de herida operatoria de pacientes intervenidos de artroplastía total de cadera, presentan una incidencia desde 2 a 5%, generando impacto en la estadía hospitalaria, uso de recursos, antibioterapia prolongada y secuelas temporales o definitivas. Objetivo: Generar un modelo predictivo para la infección de herida operatoria en pacientes intervenidos de artroplastía total de cadera, entre los años 2012 y 2014, en un hospital de alta complejidad. Material y Método: Cohorte de pacientes con artroplastía total de cadera. Se efectuó la descripción de las variables epidemiológicas y se generó un modelo predictivo por regresión logística. Resultados: Se analizaron 441 pacientes. El modelo predictivo obtenido incluyó las variables: días de estadía post operatoria (OR 1,11 IC95% [1,03-1,20]), transfusión de al menos una unidad de glóbulos rojos (OR 3,13 IC95% [1,17-10,86]), diagnóstico de depresión previo a la cirugía (OR 5,75 IC95% [1,32-25,32], incumplimiento del tiempo de administración de la antibioprofilaxis (OR 5,46 IC95% [1,68-17,78]; p < 0,001) y pseudo R2 = 0,2293. Punto de corte de "score" de 13 puntos con sensibilidad 44,4%, especificidad de 91,6%, LR (+) 5,29, LR (-) 0,61, considerando además la siguiente clasificación: 1 a 6 puntos "bajo riesgo", 7 a 12 puntos "mediano riesgo", 13 a 18 puntos "alto riesgo", desde 19 puntos como "máximo riesgo". Conclusión: El modelo presenta una buena capacidad de predicción de infección de herida operatoria y representa adecuadamente a la cohorte en estudio.

Introduction: Operative wound infections of patients undergoing total hip arthroplasty have an incidence from 2% to 5%, generating impact on hospital stay, resource use, prolonged antibiotic therapy, including temporary or definitive sequelae. Objective: To generate a predictive model for surgical wound infection in patients undergoing total hip arthroplasty between 2012 and 2014 at the High Complexity Hospital. Material and Method: Cohort of patients with total hip arthroplasty. A description of the epidemiological variables was made and a predictive model was generated by means of logistic regression. Results: 441 patients were analyzed. The predictive model obtained included the variables: days of post-operative stay (OR 1.11 IC95% [1.03 - 1.20]), transfusion of at least one unit of red blood cells (OR 3.13 IC95% [1.17 - 10.86]), diagnosis of previous depression to surgery (OR 5.75 IC95% [1.32 - 25.32], non-compliance with antibioprophylaxis administration time (OR 5.46 IC95% [1.68 - 17.78], P < 0.001) and pseudo R2 = 0.2293. Score point of 13 points with sensitivity 44.4%, specificity of 91.6%, LR (+) 5.29, LR (-) 0.61, 1 to 6 points "low risk", 7 to 12 points "medium risk", 13 to 18 points "high risk", from 19 points as "maximum risk". Conclusion: the model presents a good predictive capacity of operative wound infection and adequately represents the cohort under study.

Estandarización de la fuerza de prensión manual en adultos chilenos sanos mayores de 20 años / Hand grip strength values in normal Chilean subjects

Background: A low hand grip strength is a prognostic factor both in healthy people and hospitalized subjects. Local normal hand grip strength values are needed to define cutoff points of abnormality. Aim: To measure handgrip strength in Chilean people aged 20 to 70 years and propose normal values for healthy people in this age range. Material and Methods: Handgrip strength was measured using a JAMAR hydraulic dynamometer in 436 males and 465 females aged 20 to 70 years and who were free of disease. They were recruited from waiting rooms in several public and private hospitals and outpatient clinics, under self-evaluation of inclusion criteria. Results: The variability of the handgrip strength in women was smaller in than men. Tables containing handgrip strength values by age and sex and the ranges between three standard deviations were prepared. Conclusions: This study contributes with normal handgrip strength values in Chile to be used for the diagnosis and management of various conditions, such sarcopenia, obesity, oncological patients, Intensive Care Unit acquired weakness (ICU-aw) and weaning of mechanical ventilation.

Tamizaje de episodio depresivo en adolescentes: validación del instrumento PHQ-9 / Screening depressive episodes in adolescents: validation of the Patient Health Questionnaire-9 (PHQ-9)

Background: There is a paucity of validated instruments for screening depression in adolescent populations in Chile. Aim: To determine the diagnostic accuracy of the adolescent version of Patient Health Questionnaire-9 (PHQ-9). Material and Methods: The PHQ-9 was transculturally adapted and administered to adolescents aged 15 to 19 years residing in Santiago de Chile, who were then evaluated with a semi structured interview (Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version or K-SADS-PL) and the Beck Depression Inventory. Internal validity, concurrent validity, and discriminatory power of the PHQ-9 were analyzed. Results: We evaluated 245 adolescents aged 16.2 ± 1 years (71% females). Two hundred and ten presented with a depressive episode and 35 were healthy. The sensitivity and specificity of the scale were 86.2 and 82.9% for 11 points, with a positive likelihood ratio of 5.02. Conclusions: The PHQ-9 is sensitive and specific enough to be used as a screening tool in adolescents with suspected depression. At a 11-point cut-off score as proposed, the likelihood to find a positive result in a subject with depression is five times higher.

Adaptación del instrumento WAST para la detección de violencia doméstica en Centros de Salud / Cultural adaptation and translation of the Woman Abuse Screening Tool

Background: The Woman Abuse Screening Tool (WAST) is a screening tool for domestic violence used in Unites States. Aim: To carry out the cultural adaptation of the WAST instrument for early detection of domestic violence in primary health care. Material and Methods: Qualitative techniques for cultural adaptation were used in stages 1 and 2 and quantitative techniques were used in stage 3. The validity of content was assessed using judge tests carried out with experts in the field. Linguistic adaptation was carried out using a focal group technique to ensure semantic and language comprehension. Finally, the culturally adapted instrument was applied to 16 women who were victims of violence and to 28 women without a history of violence. Results: For cultural adaptation, the judges' test added the item of economic violence to the instrument. According to the focus groups, some words were changed to facilitate understanding by the subjects. According to the scores obtained in women with and without a history of violence, a cut-off point of 15 points was defined to determine a history of domestic violence with a sensitivity of 100% and a specificity of 96%. The Cronbach Alpha of the questionnaire was 91%. Conclusions: WAST is an effective and easily applied instrument for the early detection of domestic violence.

Efecto de la vacuna antineumocócica conjugada 10-valente en el área sur de Santiago de Chile, 2009-2015 / Impact of the 10-valent pneumococcal conjugate vaccine on the southern area of Santiago (Chile), 2009-2015 / Efeito da vacina pneumocócica 10-valente conjugada na região sul de Santiago, Chile, 2009-2015

RESUMEN Objetivo El objetivo de este estudio fue evaluar el efecto de la incorporación de la vacuna antineumococica 10-valente (PCV 10) en la incidencia de la enfermedad neumocócica invasora (ENI) y en la neumonía adquirida en la comunidad (NAC) en niños hospitalizados menores de 5 años en el área sur de Santiago de Chile. Métodos Se realizó un estudio ecológico de la incidencia de ENI y NAC en menores de 5 años del área sur de Santiago de Chile de 2009 a 2015. Las fuentes de información utilizadas fueron las de los laboratorios de bacteriología de cuatro hospitales, del Instituto de Salud Pública de Chile (ISP) y los registros de egresos hospitalarios. Resultados Un total de 6 461 casos de NAC y 173 casos de ENI fueron confirmados por el ISP, de los cuales 169 casos fueron diagnosticados en los laboratorios de bacteriología de los hospitales incluidos en el estudio. Al comparar la incidencia de casos de 2010 frente a 2011-2015, la razón de incidencias (RI) de ENI se redujo 10% anualmente (p = 0,026) y la de NAC, 8% en el mismo período (p <0,001). El total de días cama ocupados en el período 2009-2015 fue de 39 565 con una mediana de días cama ocupados entre 4 y 5. Hasta 2012 fallecieron 7 niños y desde entonces no ha habido fallecimientos por estas enfermedades. Conclusiones La incorporación de la vacuna PCV-10 en el Programa Nacional de Inmunizaciones tuvo un efecto positivo, con una reducción significativa de las ENI y NAC y de la ocupación de camas por ENI y evitó casos y muertes.

ABSTRACT Objective The objective of this study was to evaluate the impact of the introduction of the 10-valent pneumococcal conjugate vaccine (PCV10) on the incidence of invasive pneumococcal disease (IPD) and on community-acquired pneumonia (CAP) in hospitalized children under 5 years of age in the southern area of Santiago, Chile. Methods An ecological study was conducted on the incidence of IPD and CAP in children under age 5 in the southern area of Santiago (Chile) from 2009 to 2015. The information used was from bacteriology laboratories in four hospitals, the Chilean Institute of Health Public (ISP), and hospital discharge records. Results A total of 6,461 cases of CAP and 173 cases of IPD were confirmed by the ISP; 169 of these cases were diagnosed in the bacteriology laboratories of the hospitals included in the study. When the incidence of cases in 2010 was compared to 2011-2015, the incidence ratio (IR) of IPD declined 10% annually (p=0.026) and CAP declined by 8% in the same period (p<0.001). Days of hospitalization due to IPD were reduced by 39% (p<0.001). Between 2009 and 2012, seven children died, but since then there have been no deaths due to these diseases. Conclusions The introduction of the PCV-10 vaccine into the National Immunization Program has had a positive effect, with a significant reduction in IPD and CAP and in days of hospitalization due to IPD, while preventing cases and deaths.

RESUMO Objetivo Avaliar o efeito da incorporação da vacina pneumocócica 10-valente (PCV 10) na incidência de doença pneumocócica invasiva (DPI) e pneumonia adquirida na comunidade (PAC) em crianças menores de cinco anos internadas em hospital. Métodos Foi realizado um estudo ecológico da incidência de DPI e PAC em crianças menores de cinco anos na região sul de Santiago, no Chile, de 2009 a 2015. As fontes de informação usadas foram os registros dos laboratórios de bacteriologia de quatro hospitais, dados do Instituto de Saúde Pública do Chile (ISP) e registros de altas hospitalares. Resultados Ao todo, 6.461 casos de PAC e 173 casos de DPI foram confirmados pelo ISP, dos quais 169 casos foram diagnosticados nos laboratórios de bacteriologia dos hospitais participantes do estudo. Ao comparar a incidência de casos entre 2010 e o período de 2011-2015, observou-se um declínio de 10% na taxa de incidência anual de DPI (p = 0,026) e de 8% na de PAC no mesmo período (p<0,001). Os dias de leito ocupado por DPI tiveram uma redução de 39% ao ano (p <0,001). Sete crianças morreram até 2012 e a partir daí não ocorreram mais mortes por estas doenças. Conclusões A incorporação da vacina PCV-10 no programa nacional de vacinação surtiu um efeito positivo: houve uma redução significativa do número de casos de DPI e PAC e da ocupação de leitos por DPI e casos e mortes foram evitados.

Evaluación del consumo de antimicrobianos en una Unidad de Neonatologia: un trabajo en equipo para promover el uso racional de antimicrobianos / Evaluation of antimicrobial consumption in a Neonatology Unit: a team work to promote the rational use of antibiotics

Resumen Antecedentes: Los antimicrobianos (ATM) son uno de los medicamentos más utilizados en recién nacidos (RN) hospitalizados. El uso indiscriminado de ATM trae consecuencias negativas como son el predominio de bacterias resistentes a los ATM usualmente utilizados y asociaciones individuales a morbilidad relevante como son la displasia broncopulmonar, enterocolitis necrosante, sepsis tardía y/o muerte. Objetivo: Registrar y evaluar las tendencias del uso de ATM a lo largo del tiempo en RN hospitalizados en el Servicio de Neonatología (SRN) del Complejo Asistencial Dr. Sótero del Río, con el fin de objetivar los cambios en la práctica habitual de la indicación de ATM. Un objetivo secundario fue evaluar el impacto de estas conductas sobre la resistencia antimicrobiana. Métodos: Estudio de cohorte, prospectivo, observacional, unicéntrico, en todos los pacientes hospitalizados entre enero de 2011 y diciembre de 2014. Se registró el peso al nacer, días de hospitalización, indicación y días de uso de ATM para cada paciente. El uso de ATM fue cuantificado por medio de distintas tasas: días de indicación de un o más ATM para el consumo global (TUA), sumatoria total de días de uso (STUA) como para los ATM más frecuentemente utilizados. Cada tasa calculada por 100 días hospitalizados. Además, se registró la susceptibilidad antimicrobiana de las bacterias más frecuentemente aisladas en nuestro servicio: Staphylococcus coagulasa negativa (SCN) y bacilos gramnegativos (BGNs). Resultados: El 34,7% de los pacientes hospitalizados recibió algún tipo de antimicrobiano, correspondiendo 32,3% a antibacterianos. El ATM más utilizado fue ampicilina (20,2% del total) y luego cefadroxilo (11,6%). El TUA no cambió entre 2011 y 2014. La STUA disminuyó en 10,7% entre 2011 y 2014 (p < 0,05). En el análisis por rangos de peso, en el grupo < 750 g disminuyó la tendencia de uso de vancomicina (descenso de uso en 9,9%) y un aumento de 18,8% para metronidazol. Por otra parte, hubo un aumento en el uso del régimen de piperacilina/tazobactam en el grupo > 1.500 g. Al evaluar la susceptibilidad antimicrobiana, hubo una disminución de la susceptibilidad a cloxacilina en SCN entre 2011 y 2014 desde 27 a 10,3%, respectivamente. Para BGN hubo una disminución desde 76,9 a 40,5% en la susceptibilidad a cefalosporinas de tercera generación, principalmente debido a Klebsiella pneumoniae que pasó a ser el BGN predominante, con un aumento de 6,7 a 50% en los años 2011 y 2014, respectivamente. Para Klebsiella pneumoniae la susceptibilidad a cefalosporinas de tercera generación descendió desde 77 a 22%. Por último, amikacina mostró una actividad sobre 85% en todos los BGNs entre 2011 y 2014. Conclusiones: Es recomendable planificar y mantener un registro continuo del consumo de ATM tanto como terapia y profilaxis, idealmente llevar el TUA, el STUA y siendo categorizado por tipo de ATM y rango de peso de los RN. En forma concomitante, es de considerable importancia analizar y evaluar la susceptibilidad de microorganismos. Es esencial que un equipo interdisciplinario prepare este registro, y que continuamente proporcione retroalimentación a los profesionales que mantienen el funcionamiento de las unidades de cuidados neonatales.

Background: Antibiotics (ATB) are drugs widely used in hospitalized newborns. The indiscriminate use of ATBs promote the rise of resistant bacteria to the most commonly indicated antimicrobials. In addition, ATB prescription presents associations to morbidity, such as bronchopulmonary dysplasia, necrotizing enterocolitis, late sepsis and even death. All of the above leads to an increase in health care costs. Aim: To record and to evaluate trends of antibiotic use over time in hospitalized NB in the Neonatology Unit at Dr. Sótero del Río Hospital, in order to objectify the changes in the usual practice of the ATM indication. A secondary objective was to assess its impact on antimicrobial resistance. Methods: Cohort, observational, prospective unicenter study which included all hospitalized patients between January 2011 and December 2014. Birth weight, hospitalization days, ATB indication and days of ATB use were recorded for each patient. The use of ATB was quantified by means of different rates; days of indication of one or more ATBs for global consumption (RUA), total sum of days of use (TSUA) and for the most frequently used ATBs. Each calculated rate for 100 days hospitalized. In addition, the antimicrobial susceptibility of the most frequently isolated bacteria in our service: coagulase-negative Staphylococcus (SCN) and Gram-negative bacilli (BGN) were recorded continuously. Results: The 34.7% of the hospitalized patients received some type of antimicrobial agent. ATBs were 32.3% of medicines used. The most widely used was ampicillin (with 20.2% of the total) and cefadroxyl (with 11.6%). The RUA did not change during the study time, but STUA decreased by 10.7% between 2011 and 2014 with p < 0.05. When subgroup analyzes were divided by weight ranges, in the < 750 g group, the use of vancomycin decreased in use by 9.9% and an increase of 18.8% for metronidazole was observed. On the other hand, there was an increase in the use of the piperacillin-tazobactam regimen in the range > 1,500 g. When evaluating antimicrobial susceptibility, there was a decrease in susceptibility for oxacillin in SCN between 2011 and 2014 from 27% to 10.3% respectively. In addition, for Gram negative there was a decrease from 76.9% to 40.5% in susceptibility to third generation cephalosporins, mainly due to Klebsiella pneumoniae, which became the predominantly isolated BGN with an increase of 6.7% to 50% between 2011 and 2014, respectively. For K. pneumoniae the loss of susceptibility to third generation cephalosporins decreased from 77% to 22%. Finally, amikacin showed an activity over 85% in all BGNs between 2011 and 2014. Conclusions: It is advisable to plan and to maintain a continuous record of ATB consumption, as well as therapy and prophylaxis, being categorized by ATB type and range of newborn weight. It is of considerable importance to analyze and to evaluate the susceptibility of microorganisms. It is essential that an interdisciplinary team prepare this recording, and to continuously provide feedback to professionals who maintain the functioning of neonatal care units.

Descripción electrofisiològica del síndrome de túnel carpiano según edad en pacientes adultos / Electrophysiological severity of carpal tunnel syndrome according to age in adult patients

Background: Carpal tunnel syndrome (CTS) represents 90% of entrapment neuropathies. Severity may be greater in older patients. Aim: To describe the electrophysiological findings in adult patients with CTS and determine if severity is related to age. Material and Methods: Descriptive and retrospective study of electrophysiological findings in patients over 18 years of age with clinical suspicion of CTS, studied between January 2011 and December 2015. Neurophysiological severity was classified in 3 grades, comparing them by age, gender and laterality. Results: Of 1156 patients subjected to electrophysiological studies due to a clinical suspicion of CTS, 690 (60%) had electrophysiological features of the disease. In 274 patients (24%) the compromise was mild, in 162 (14%) it was moderate and in 254 (22%) it was severe. There was a positive association between age and CTS severity (p < 0.01). Severity was significantly greater in males than females (p < 0.01). Bilateral CTS was present in 471 patients (68%), which was associated with increased age and severity (p < 0.01). Conclusions: Electrophysiological severity in CTS increases with age. Other factors associated with higher severity are male gender and bilateral disease.

Aborto, ¿es un problema de salud pública en Chile en el campo de la salud materno-perinatal? / Is abortion a serious public health problem in Chile in the field of maternal-perinatal health?

Background: The World Health Organization, by 2014, estimates that approximately 22 million unsafe abortions take place every year in the world, almost all of them in developing countries. The Millennium Goals, as part of the fifth compendium, focused on maternal health by proposing that member states should reduce maternal mortality to 75% by 2015. Aim: To determine, using maternal health indicators, if abortion in Chile is a priority health problem. Material and Methods: Data about maternal mortality and its causes between 1982 and 2014, was obtained from the databases available at the Chilean Ministry of Health. Trend analyzes were carried out using linear autoregressive models. Results: Between 1982 and 2012, maternal mortality rates decreased from 51.8 to 18.3 per 100,000 live births. Complications of pregnancy, childbirth and puerperium were the first three causes and the last one is abortion. The proportion of abortions due to unspecified causes, including induced abortion, decreased from 36.6% to 26.1% between 2001 and 2012. Conclusions: Abortion is not a public health problem in Chile. To continue reducing maternal mortality, programs for the early detection of risks such as diabetes, obesity and hypertension should be implemented.

Resultados a largo plazo en calidad de vida en cirugía de contorno corporal: Fase IV en la cohorte Body-Qol® / Long-term outcomes in quality of life after body contouring surgery: Phase IV results in the Body-Qol® cohort

Introducción: La calidad de vida es uno de los resultados en cirugía de contorno corporal más importantes. La evidencia sobre la calidad de vida de estos pacientes a largo plazo es escasa. El objetivo de este estudio fue determinar si la calidad de vida obtenida en el postoperatorio temprano posterior a la cirugía de contorno corporal se mantiene a largo plazo. Métodos: Se diseñó un estudio de cohorte prospectiva compuesta por pacientes postoperados de cirugía de contorno corporal con más de un año de seguimiento. La calidad de vida fue medida con el instrumento Body-Qol®. Se compararon los puntajes preoperatorios, postoperatorios tempranos y postoperatorios tardíos. Se realizó el análisis estadístico con las pruebas de Kruskal-Wallis y Kolmogorov-Smirnov. Resultados: La cohorte se compuso de 112 pacientes con un seguimiento a largo plazo del 75%. En toda la cohorte la calidad de vida mejoró entre el preoperatorio (43,9 ± 14,1 puntos) y ambas mediciones postoperatorias (85,2 ± 16,8 postoperatorio temprano y 83,6 ± 13,5 postoperatorio tardío), siendo estadísticamente significativo (p < 0,0001). Entre el postoperatorio temprano y tardío no existió diferencia (p = 0,112). El análisis por dominios demostró la misma tendencia. Los pacientes con pérdida masiva de peso tuvieron puntajes preoperatorios menores, pero igualaron a la población estética en ambas mediciones postoperatorias. Conclusiones: La calidad de vida mejora significativamente posterior a la cirugía de contorno corporal de forma temprana, y esta mejoría es estable en el tiempo. Esto se observa tanto en los pacientes estéticos como en los posteriores a la pérdida masiva de peso.

Introduction: One of the most important outcomes in patients undergoing body-contouring surgery is quality of life. Data on long-term quality of life is deficient. The main purpose of this study is to determine if short-term QoL after body contouring surgery maintains in the long-term follow up. Methods: A cohort study was designed; patients with at least one-year follow-up from the surgery were included. Quality of life was measured with the Body-Qol© instrument. All patients answered the preoperative Body-Qol© and at least one measurement after one year of follow-up from body contouring surgery. The preoperative scores, short-term scores and long-term follow-up scores were compared. The statistical analysis was made with Kruskal-Wallis y Kolmogorov-Smirnov tests. Results: The cohort was integrated by 112 patients; the long-term follow-up was of 75%. Quality of life improved between the preoperative measure (43.9 ± 14.1 points) and both short-term and long-term measures (85.2 ± 16.8 early postoperative y 83.6 ± 13.5 late postoperative), which was statistically significant (P< .0001). There was no difference between the short-term and long-term measures (P = .112). The domain analysis demonstrated the same tendency. Massive weight loss patients had lower preoperative scores but improved more after BCS, reaching almost cosmetic values. Conclusions: Quality of life improves soon after surgery and is stable over time. This was observed for both massive weight loss and cosmetic patients.

Puntaje predictivo de emergencias médicas en un servicio médico quirúrgico, usando variables clínicas y los diagnósticos de ingreso / A score to predict medical emergencies in hospitalized patients

Background: The medical alert system (MAS) was created for the timely handling of clinical decompensations, experienced by patients hospitalized at the Medical Surgical Service (MSS) in a private clinic. It is activated by the nurse when hemodynamic, respiratory, neurological, infectious or metabolic alterations appear, when a patient falls or complains of pain. A physician assesses the patient and decides further therapy. Aim: To analyze the clinical and demographic characteristics of patients who activated or not the MAS and develop a score to identify patients who will potentially activate MAS. Material and Methods: Data from 13,933 patients discharged from the clinic in a period of one year was analyzed. Results: MAS was activated by 472 patients (3.4%). Twenty two of these patients died during hospital stay compared to 68 patients who did not activate the alert (0.5%, p < 0.01). The predictive score developed considered age, diagnosis (based on the tenth international classification of diseases) and whether the patient was medical or surgical. The score ranges from 0 to 9 and a cutoff ≥ 6 provides a sensitivity and specificity of 37 and 81% respectively and a positive likelihood ratio (LR+) of 1.9 to predict the activation of MAS. The same cutoff value predicts death with a sensitivity and specificity of 80% and a negative predictive value of 99.8%. Conclusions: This score may be useful to identify hospitalized patients who may have complications during their hospital stay.

Fisuras labio-palatinas y fortificación de la harina con ácido fólico en Chile: an exploratory study / Cleft lip/palate and flour fortification with folic acid in Chile

Background: The effect of food fortification with folic acid on the incidence of lip-palate fissures (FLP) is under discussion. Aim: To calculate the rate of hospital discharges due to cleft lip and palate (CLP) and explore whether they decreased after the start of folic acid fortification in Chile. Material and Methods: The hospital discharge databases published by the Chilean Ministry of Health were analyzed. The trends of discharge rates due to CLP of children of less than one year of life (ICD-10 Q350-379 code) and live births (lb) were calculated from 1986 to 2012. Variables such as incidence of rubella, poverty rate, obesity in pregnant women, and percentage of women who smoked or drank alcohol in the last month were included. The relative risk (RR) of CLP pre-fortification (1986-1999) and post-fortification (2000-2010) was calculated. Mixed and Prais-Winsten models were used to adjust other variables. Results: The hospital discharge rate due to CLP decreased from 1.88 x 1,000 lb during 1986-1996 to 1.68 x 1,000 lb (RR = 1.09 (95% CI 1.05-1.14, p < 0.001). Prais-Winsten and Mixed models, determined that folic acid fortification is the variable explaining this decrease. During 2004-2011, hospital discharge rates for cleft lip decreased but there was an increase in the figures for cleft lip and palate. Conclusions: The 9% decrease in hospital discharge rates for CLP is concomitant with wheat folic acid fortification.