First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry.

BACKGROUND: A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. OBJECTIVE: This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. STUDY DESIGN: We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. RESULTS: Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9). CONCLUSION: A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.

[Worsening situation of tuberculosis in Chile]. / El deterioro de la tuberculosis en Chile.

BACKGROUND: Recent data suggest an increase in tuberculosis (TB) incidence in Chile. AIM: To evaluate recent epidemiological trends, geographic extension and potential factors associated with TB reemergence in Chile. MATERIAL AND METHODS: Data analysis from official sources and trend analysis. RESULTS: TB incidence rate increased from 12.3 (2014) to 14.7 (2017) per 100,000 inhabitants. Morbidity rates also increased in nine out of 15 regions. The proportion of TB cases in specific groups has also increased in the last six years: HIV/AIDS (68%), immigrants (118%), drug users/alcoholics (267%) and homeless people (370%). Several indicators of the national TB program performance have deteriorated including TB case detection, HIV co-infection study and contact tracing activities. Overall results indicate a higher than expected case-fatality ratio (> 3%), high rates of loss from follow-up (> 5%), and low percentage of cohort healing rate (< 90%). This decline is associated with a Control Program with scarce human resources whose central budget decreased by 90% from 2008 to 2014. New molecular diagnostic tools and liquid media culture were only recently implemented. CONCLUSIONS: TB trends and overall program performance indicators have deteriorated in recent years in Chile and several factors appear to be involved. Multiple strategies will be required to rectify this situation.

[Primary resistance to anti tuberculosis drugs in Chile 2011-2012]. / Resistencia primaria a fármacos anti-tuberculosos en Chile 2011-2012.

UNLABELLED: This publication presents the results of the Chilean initial study of resistance to first line anti-tuberculous drugs. The study was carried out between 2011 and 2012 by the National Reference Laboratory of the Institute of Public Health, as part of the Drug Surveillance Resistance in tuberculosis (TB) promoted by the World Health Organization. METHODOLOGY: Cross-sectional study performed using cluster sampling, representative of the entire country as recommended by the World Health Organization. Susceptibility testing to isoniazid, rifampicin, streptomycin, ethambutol and pyrazinamide was performed through the proportion method or Wayne's enzymatic method, as appropriate. RESULTS: 594 susceptibility tests were performed, showing an overall level of TB drug resistance of 8.6% and a prevalence of multidrug resistance of 1.3%. Indeed, the study showed a decrease in streptomycin resistance and an increase of isoniazid resistance in both mono-resistance and accumulated resistance compared to previous studies. No cases of mono-resistance to rifampicin were detected. CONCLUSION: An increased resistance to anti-TB drugs in Chile is observed, which despite being still low, is no less worrisome. Since 2014 the monitoring of drug resistance to TB is universally performed to avoid sub - diagnosis and treat each case according to the susceptibility profile.

Kin rejection: social signals, neural response and perceived distress during social exclusion.

Across species, kin bond together to promote survival. We sought to understand the dyadic effect of exclusion by kin (as opposed to non-kin strangers) on brain activity of the mother and her child and their subjective distress. To this end, we probed mother-child relationships with a computerized ball-toss game Cyberball. When excluded by one another, rather than by a stranger, both mothers and children exhibited a significantly pronounced frontal P2. Moreover, upon kin rejection versus stranger rejection, both mothers and children showed incremented left frontal positive slow waves for rejection events. Children reported more distress upon exclusion than their own mothers. Similar to past work, relatively augmented negative frontal slow wave activity predicted greater self-reported ostracism distress. This effect, generalized to the P2, was limited to mother- or child-rejection by kin, with comparable magnitude of effect across kin identity (mothers vs. children). For both mothers and children, the frontal P2 peak was significantly pronounced for kin rejection versus stranger rejection. Taken together, our results document the rapid categorization of social signals as kin relevant and the specificity of early and late neural markers for predicting felt ostracism.

First trimester screening using ultrasound and serum markers in Panamanians: Factors associated with adverse pregnancy outcomes.

BACKGROUND: There is no published data on the association between serum biochemical and ultrasonographic markers and adverse pregnancy outcomes. Therefore, the aim of this study was to determine the factors associated with perinatal outcomes in singleton pregnancies using ultrasound and maternal serum markers during the first trimester in Panamanians. MATERIALS AND METHODS: This was a prospective observational study of 468 first trimester singleton pregnancies conducted over a 7-year period. All women attending a prenatal screening clinic during the study period were informed of the study and the option to participate. Two maternal serum markers, free ß-human chorionic gonadotropin (ß-hCG) and pregnancy associated plasma protein-A (PAPP-A), and four fetal ultrasound markers, nuchal translucency thickness, nasal bone, flow across the tricuspid valve, and flow in the ductus venosus (DV), were measured by certified maternal fetal medicine specialists. Adverse outcomes included miscarriage, major structural defects, genetic disorders, and major fetal cardiac defects. RESULTS: A total of 454 (97%) pregnancies were unaffected. Median maternal age was 31.5 years (range: 18-50). Maternal age was significantly greater in cases of adverse outcome (P = 0.007). The number of adverse outcomes associated with an absent or hypoplastic nasal bone, tricuspid valve regurgitation, and abnormal flow in the DV were significantly greater relative to unaffected pregnancies (Ps < 0.001). No differences were found in fetal crown-rump length or maternal serum levels of ß-hCG or PAPP-A. CONCLUSION: Abnormal ultrasound markers are associated with adverse outcomes. Women with normal ultrasound and serum markers should be reassured of low risk of adverse pregnancy outcomes.

Maternity protection vs. maternity rights for working women in Chile: a historical review.

Maternity leave in Chile has been a social right since 1919, when the International Labour Organization set the first global standards. From its inception, Chile's labour legislation focused on protecting motherhood and the family. The length of maternity leave has been extended several times since then but its main aim remains the protection of infant health. In 1931, Chile's first Labour Code required anyone employing 20 or more women to provide day care services and facilitate childcare and paid breastfeeding time for all mothers of children under one. Labour laws began to play an important role in accommodating the care of infants within working conditions, though not always effectively. In spite of job protection during pregnancy and breastfeeding, women can be dismissed on grounds other than pregnancy. It was only under Salvador Allende and again in the past two decades that Chile has enfranchised women as holders of health rights. However, many unresolved tensions remain. Chile promotes motherhood, but often considers that working women who demand employment protection abuse the system. Motherhood is a magic wand that represents the selflessness of women, but society throws a blanket of mistrust over women who wish to exercise their maternity rights and to determine the number and spacing of their children.

Diagnostic accuracy of prenatal imaging for the diagnosis of congenital Zika syndrome: Systematic review and meta-analysis.

Objective: The aim of this study was to assess the accuracy of prenatal imaging for the diagnosis of congenital Zika syndrome. Data sources: Medline (via Pubmed), PubMed, Scopus, Web of Science, and Google Scholar from inception to March 2022. Two researchers independently screened study titles and abstracts for eligibility. Study eligibility criteria: Observational studies with Zika virus-infected pregnant women were included. The index tests included ultrasound and/or magnetic resonance imaging. The reference standard included (1) Zika infection-related perinatal death, stillbirth, and neonatal death within the first 48 h of birth, (2) neonatal intensive care unit admission, and (3) clinically defined adverse perinatal outcomes. Synthesis methods: We extracted 2 × 2 contingency tables. Pooled sensitivity and specificity were estimated using the random-effects bivariate model and assessed the summary receiver operating characteristic (ROC) curve. Risk of bias was assessed using QUADAS 2 tool. The certainty of the evidence was evaluated with grading of recommendations. Results: We screened 1,459 references and included 18 studies (2359 pregnant women, 347 fetuses with confirmed Zika virus infection). Twelve studies (67%) were prospective cohorts/case series, and six (37%) were retrospective cohort/case series investigations. Fourteen studies (78%) were performed in endemic regions. Ten studies (56%) used prenatal ultrasound only, six (33%) employed ultrasound and fetal MRI, and two studies (11%) used prenatal ultrasound and postnatal fetal MRI. A total of six studies (ultrasound only) encompassing 780 pregnant women (122 fetuses with confirmed Zika virus infection) reported relevant data for meta-analysis (gestation age at which ultrasound imagining was captured ranged from 16 to 34 weeks). There was large heterogeneity across studies regarding sensitivity (range: 12 to 100%) and specificity (range: 50 to 100%). Under a random-effects model, the summary sensitivity of ultrasound was 82% (95% CI, 19 to 99%), and the summary specificity was 97% (71 to 100%). The area under the ROC curve was 97% (95% CI, 72 to 100%), and the summary diagnostic odds ratio was 140 (95% CI, 3 to 7564, P < 0.001). The overall certainty of the evidence was "very low". Conclusion: Ultrasound may be useful in improving the diagnostic accuracy of Zika virus infection in pregnancy. However, the evidence is still substantially uncertain due to the methodological limitations of the available studies. Larger, properly conducted diagnostic accuracy studies of prenatal imaging for the diagnosis of congenital Zika syndrome are warranted. Systematic review registration: Identifier [CRD42020162914].

Intestinal volvulus in the pump twin of a twin reversed arterial perfusion (TRAP) sequence after laser therapy at 18 weeks: a case report.

BACKGROUND: Twin reversed arterial perfusion sequence is a rare and potentially lethal condition affecting approximately 1% of monochorionic twin pregnancies and 1 in 35,000 pregnancies overall. An apparently normal (pump) twin perfuses its severely malformed cotwin with deoxygenated blood via retrograde flow in direct arterioarterial anastomoses between the umbilical arteries of each twin. Fetal intestinal volvulus is a rare condition usually manifesting after birth. We report a unique case of twin reversed arterial perfusion sequence in association with intestinal volvulus in the surviving pump twin. CASE PRESENTATION: A 32-year-old Hispanic primigravida was referred to our clinic after a fetoscopy procedure of laser photocoagulation of anastomoses at 18 weeks of gestation. Follow up scans in the ex-pump twin revealed dilated bowel loops and a typical "whirlpool sign" at 26 weeks of gestation, and intrauterine intestinal volvulus was suspected. At 29 weeks of gestation, preterm premature rupture of membranes occurred, and an emergency cesarean section was performed. The newborn was diagnosed in the early neonatal period with intestinal perforation. The diagnosis was postnatally confirmed by surgery and histopathology. CONCLUSIONS: The type of fetal intervention and late gestational age of the procedure increase the risk of complications. This case alerts health providers to be vigilant in the follow-up of patients with complicated monochorionic pregnancies.

[Hansen disease, an emergent condition in Chile]. / Enfermedad de Hansen. Una condición emergente en Chile.

Hansen's disease (HD) is caused by Mycobacterium leprae. It has a chronic course and preferentially affects the skin and the peripheral nerves. It's an emergent infection in Chile due to migration waves. This case report affecting a migrant worker from Haiti that presented several compatible skin lesions, with hypoesthesia and unilateral madarosis that appeared before arrival. The diagnosis of a multibacillary form was established by clinical findings, presence of fast acid bacilli on a direct skin smear, and inflammatory cell surrounding nerve endings and granulomas on skin biopsy. Besides, specific rpoB and hsp65 gene segments from M. leprae were amplified from skin samples. Patient was treated with the WHO standard combined regimen for multibacillary forms during one year showing partial regression of skin lesions. Nasopharyngeal samples showed the presence of M. leprae rpoB copies detected by PCR decreasing until six months of therapy. Notifiable diseases databases showed a recent increment of cases, all related to migrant population. Hansen's disease is a new condition in Chile and clinicians should be aware of this possibility. Molecular tools may facilitate diagnosis and follow up.

Características de pacientes con exacerbación aguda grave de enfermedad pulmonar obstructiva crónica que requirieron ventilación mecánica invasiva en un hospital de Santander durante 2014-2020 / Characteristics of patients with severe acute exacerbation of chronic obstructive pulmonary disease who required invasive mechanical ventilation in a Santander hospital during 2014-2020

Introducción: la enfermedad pulmonar obstructiva crónica es una limitación del flujo de aire por anomalías alveolares. En una exacerbación aguda, la ventilación mecánica no invasiva es la primera línea en el manejo, sin embargo, existen ciertos factores de riesgo que hacen más probable el uso de ventilación mecánica invasiva en estos pacientes, que no están apropiadamente descritos en la literatura científica y que pueden guiar hacia una elección de soporte ventilatorio apropiado. Objetivo: describir los factores que se asociaron con mayor necesidad de ventilación mecánica no invasiva en una cohorte de pacientes hospitalizados con exacerbación aguda de la enfermedad pulmonar obstructiva crónica. Métodos: estudio observacional analítico de corte transversal, con muestreo no probabilístico que incluye todos los pacientes que consultaron a urgencias y fueron hospitalizados por exacerbación aguda de la enfermedad pulmonar obstructiva crónica en un hospital de tercer nivel de Santander, Colombia, durante el período 2014-2020. Resultados: fueron incluidos 81 pacientes, 36 requirieron ventilación mecánica no invasiva y 12 ventilación mecánica invasiva; 25 % de los pacientes con ventilación mecánica no invasiva fallaron a la terapia inicial y demandaron el uso de ventilación mecánica invasiva. Las comorbilidades más frecuentes fueron hipertensión arterial (70,3 %) y cardiopatía (49,38 %); 70 % había tenido exposición al tabaquismo como fumador directo. Conclusiones: el uso de ventilación mecánica invasiva estuvo relacionado de forma estadísticamente significativa en pacientes con perfil de disnea severa, acidosis por parámetros gasométricos, escalamiento antibiótico, uso de corticoides intravenosos, requerimiento de unidad de cuidado intensivo, infecciones asociadas al cuidado de la salud y estancia hospitalaria prolongada.

Introduction: Chronic obstructive pulmonary disease is airflow limitation due to alveolar abnormalities. In an acute exa- cerbation, non-invasive mechanical ventilation is the first line of management, however, there are certain risk factors that make the use of invasive mechanical ventilation more likely in these patients, which are not adequately described in the scientific literature and that can guide towards a choice of appropriate ventilatory support. Objective: To describe the factors that were associated with an increased need for invasive mechanical ventilation in a cohort of hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease. Methods: Cross-sectional analytical observational study, with non-probabilistic sampling including all patients who consulted the emergency room and were hospitalized for acute exacerbation of chronic obstructive pulmonary disease in a tertiary care hospital in Santander-Colombia during the period 2014-2020. Results: 81 patients were included, 36 required non-invasive mechanical ventilation and 12 invasive me- chanical ventilation. 25 % of the patients with non-invasive mechanical ventilation failed the initial therapy and demanded the use of invasive mechanical ventilation. The most frequent comorbidities were arterial hypertension (70.3 %) and heart disease (49.38 %). 70 % had been exposed to smoking as direct smokers. Conclusions: The use of invasive mechanical ven- tilation was associated in a statistically significant way in patients with a profile of: severe dyspnea, acidosis by gasometric parameters, antibiotic escalation, use of intravenous corticosteroids, intensive care unit requirement, infections associa- ted with health care and prolonged hospital stay.

Blood-based biomarkers of adverse perinatal outcomes in maternal obesity.

OBJECTIVE: Increasing maternal weight has been shown to predict adverse perinatal outcome, including increases in the relative risk of fetal death, stillbirth, neonatal death, perinatal death and infant death. In order to better understand the pathophysiological factors associated with obesity during pregnancy, the role of biomarkers associated with adverse outcomes in obese pregnant women is under investigation. The purpose of this review study was to examine potential biomarkers that could serve as effective screening strategies in obese pregnant women to reduce fetal and neonatal morbidity, as well as maternal morbidity. METHODS: Electronic databases (Pubmed, Embase) were searched for previously published research studies that investigated biomarkers associated with perinatal outcomes in obese pregnant women and the putative mechanisms underlying biomarker effects on pregnancy outcomes. RESULTS: It is evident that while several biomarkers predict perinatal complications in obese pregnant women, none fulfilled the criteria to be considered clinically useful. CONCLUSION: There is a critical need for reliable blood-based biomarkers associated with an increased risk of adverse perinatal outcomes in obese pregnant women.

Síndrome de Insensibilidad Androgénica: presentación de un caso de discordancia entre ecografía pre y postnatal y estudios genéticos moleculares

Introducción: El síndrome de insensibilidad androgénica es un desorden genético y un tipo de trastorno del desarrollo sexual. Es la feminización de los genitales externos evaluados al nacimiento cuando el genotipo es 46, XY. Objetivo: Presentar la clínica, estudios moleculares, ultrasonidos durante el embarazo y del recién nacido con trastorno de diferenciación sexual. Caso Clínico: Femenina de 35 años con tercer embarazo, feto único, con resultado de cribado genético prenatal no invasivo ampliado de aneuploidías cromosómicas y determinación del sexo fetal a la semana 11 de gestación con sexo genético masculino, ultrasonido con ángulo del tubérculo genital de menos de 30° indicativo de sexo fenotípico femenino y ecografía postnatal con sexo gonadal masculino. Panel molecular genético con una variante patogénica para el Gen AR, en hemicigosis, asociado a Síndrome de Insensibilidad Androgénica. Conclusión: La discordancia sexual fenotipo-genotipo puede indicar una condición genética, cromosómica o bioquímica subyacente. El manejo conjunto interdisciplinario y el consejo genético permite el diagnóstico molecular neonatal temprano de la condición. (provisto por Infomedic International)

Introduction: Androgen insensitivity syndrome is a genetic disorder and a type of sexual development disorder. It is characterized by the evident feminization of the external genitalia at birth in an individual with the 46, XY genotype. Aim: To present the clinic, molecular studies, obstetric ultrasonography of the first trimester and ultrasound of the newborn with sexual differentiation disorder. Clinic case: 35-year-old female with third pregnancy, singleton fetus, with extended non-invasive prenatal genetic screening for chromosomal aneuploidies and fetal sex determination at week 11 of gestation with male genetic sex, ultrasound with genital tubercle angle less than 30° indicative of female phenotypic sex and postnatal ultrasound with male gonadal sex. Genetic molecular panel with a pathogenic variant for the AR gene, in hemi zygosis. Conclusion: Early detection of phenotype-genotype sexual discordance is important as it may indicate an underlying genetic, chromosomal, or biochemical condition, allowing timely critical counseling and postnatal treatment. (provided by Infomedic International)

[Risk groups for tuberculosis in Chile]. / Grupos de riesgo para tuberculosis en Chile.

Tuberculosis (TB) remains a major global and national problem. In Chile the incidence rate has remained at 13 per 100,000 inhabitants for several years without tendency to the expected decline that would allow their elimination by 2020. As a low prevalence country, TB cases have been concentrated in risk groups, reaching 33% in 2013, and this proportion increases as younger people are analyzed. The main risk groups in Chile are HIV co-infection, foreigners and population of prisons. By 2013, the proportion of cases for these three groups was 8.7%, 8.4% and 3.9% respectively, and these percentages vary significantly when regional situation is analyzed. In addition, many of these patients have more than one risk factor, demons-rating the existence of clusters more vulnerable to TB.

Challenges facing the finance reform of the health system in Chile.

Financing is one of the key functions of health systems, which includes the processes of revenue collection, fund pooling and acquisitions in order to ensure access to healthcare for the entire population. The article analyzes the financing model of the Chilean health system in terms of the first two processes, confirming low public spending on healthcare and high out-of-pocket expenditure, in addition to an appropriation of public resources by private insurers and providers. Insofar as pooling, there is lack of solidarity and risk sharing leading to segmentation of the population that is not consistent with the concept of social security, undermines equity and reduces system-wide efficiency. There is a pressing need to jumpstart reforms that address these issues. Treatments must be considered together with public health concerns and primary care in order to ensure the right to health of the entire population.

El financiamiento es una de las funciones claves de los sistemas de salud, el cual contempla los procesos de recolección, mancomunación y uso de los fondos con el objetivo de asegurar el acceso a la atención de salud de toda la población. El artículo analiza el modelo de financiamiento del sistema de salud chileno en cuanto a los dos primeros procesos, constatándose que éste se caracteriza por un bajo gasto público y un alto gasto de bolsillo en cuanto a las fuentes de financiamiento, además de una apropiación de fuentes públicas por parte de las aseguradoras privadas. Respecto a la mancomunación de fondos se aprecia que existe una carencia de solidaridad y distribución de los riesgos, lo que produce una segmentación de la población que no se condice con el concepto de seguridad social, atenta contra la equidad y resta eficiencia al sistema completo. En el contexto de la creación de la comisión de reforma a las instituciones de salud previsional, se establece la urgencia de subsanar estos problemas teniendo en cuenta no sólo atención de las enfermedades, sino también la perspectiva de salud pública y el reforzamiento del modelo de atención primaria para asegurar el derecho a la salud de toda la población.

[The absence of stewardship in the Chilean health authority after the 2004 health reform]. / La ausencia de la función de rectoría en la autoridad sanitaria de Chile tras la reforma de salud del 2004.

Stewardship is the most important political function of a health system. It is a government responsibility carried out by the health authority. Among other dimensions, it is also a meta-function that includes conduction and regulation. The Health Authority and Management Act, which came about from the health reform of 2004, separated the functions of service provision and stewardship with the aim of strengthening the role of the health authority. However, the current structure of the health system contains overlapping functions between the different entities that leads to lack of coordination and inconsistencies, and a greater weight on individual health actions at the expense of collective ones. Consequently, a properly funded national health strategy to improve the health of the population is missing. Additionally, the components of citizen participation and governance are weak. It is necessary, therefore, to revisit the Chilean health structure in order to develop one that truly enables the exercise of the health authority’s stewardship role.

La rectoría es la más importante de las funciones políticas de un sistema de salud, es competencia característica del gobierno, y es ejercida mediante la autoridad sanitaria. Corresponde a una meta función que incluye, entre otras, las dimensiones de conducción y regulación. La Ley de Autoridad Sanitaria y Gestión de la reforma de salud de 2004 separó las funciones de provisión de servicios y de rectoría para fortalecer el rol de la autoridad sanitaria. Sin embargo, con la estructura actual del sistema de salud existe superposición de funciones entre los distintos organismos que producen descoordinaciones e incongruencias, además de una mantención del énfasis en las acciones de salud individuales en desmedro de las colectivas. En consecuencia, no existe un verdadero plan nacional de salud que cuente con los recursos necesarios para avanzar en mejorar la salud de la población. Los componentes de participación ciudadana y gobernabilidad también son débiles. Se necesita, por lo tanto, repensar la estructura del sistema de salud chileno para construir una orgánica que realmente posibilite el ejercicio de la función rectora.

[Towards a comprehensive policy for health workers]. / Hacia una política integral para los trabajadores de la salud.

Health workers are crucial to the performance of a health system. Their situation is critical and this has been recognized as a global problem. The main challenges are their number, distribution, skills and performance conditions. Addressing these issues must necessarily involve a multifactorial, intersectoral and international approach, where determinant factors are: educational policies, forms of recruitment, permanency and termination of contract, issues that arise throughout their working cycle. In Chile, the management of health workers does not follow a comprehensive outlook. The type, number and distribution of technicians and professionals do not respond to a nationwide planning strategy, and there is no coordination between health authorities and universities. The result is that the system is not responding to the health needs of the population, nor is fulfilling the promise of a public service career that encourages good performance, investing in its human resources.

Los trabajadores de la salud son claves en el desempeño de un sistema de salud y su crisis ha sido reconocida como un problema global, siendo los principales retos su número, distribución, competencias y condiciones de desempeño. El abordaje de estos aspectos necesariamente debe ser multifactorial, intersectorial e internacional, considerando como determinantes las políticas educacionales para su producción, así como las formas de reclutamiento, mantención y desvinculación a lo largo de su ciclo laboral. En Chile, la gestión de los trabajadores de la salud no tiene una mirada país, por tanto el tipo, número y distribución de los técnicos y profesionales no responden a una planificación ni a una coordinación de nivel nacional con el sector educación. El resultado es que no se está respondiendo a las necesidades en salud de la población, ni tampoco se está logrando ofrecer una carrera funcionaria pública que estimule el buen desempeño y desarrollo de las personas.

El deterioro de la tuberculosis en Chile / Worsening situation of tuberculosis in Chile

Background: Recent data suggest an increase in tuberculosis (TB) incidence in Chile. Aim: To evaluate recent epidemiological trends, geographic extension and potential factors associated with TB reemergence in Chile. Material and Methods: Data analysis from official sources and trend analysis. Results: TB incidence rate increased from 12.3 (2014) to 14.7 (2017) per 100,000 inhabitants. Morbidity rates also increased in nine out of 15 regions. The proportion of TB cases in specific groups has also increased in the last six years: HIV/AIDS (68%), immigrants (118%), drug users/alcoholics (267%) and homeless people (370%). Several indicators of the national TB program performance have deteriorated including TB case detection, HIV co-infection study and contact tracing activities. Overall results indicate a higher than expected case-fatality ratio (> 3%), high rates of loss from follow-up (> 5%), and low percentage of cohort healing rate (< 90%). This decline is associated with a Control Program with scarce human resources whose central budget decreased by 90% from 2008 to 2014. New molecular diagnostic tools and liquid media culture were only recently implemented. Conclusions: TB trends and overall program performance indicators have deteriorated in recent years in Chile and several factors appear to be involved. Multiple strategies will be required to rectify this situation.

Enfermedad de Hansen. Una condición emergente en Chile / Hansen disease, an emergent condition in Chile

Resumen La enfermedad de Hansen (EH) es una infección secundaria a Mycobacterium leprae, de curso crónico y que afecta preferentemente la piel y los nervios periféricos. Es una condición emergente en Chile debido a la migración humana. Presentamos un caso que afectó a un trabajador inmigrante desde Haití, que presentó antes de su arribo múltiples lesiones cutáneas en placas, con hipoestesia y madarosis unilateral. El diagnóstico de la forma multibacilar se estableció por los hallazgos clínicos, la presencia de bacilos ácido-alcohol resistentes en una muestra cutánea y la detección de células inflamatorias alrededor de los terminales nerviosos y granulomas en una biopsia de piel, desde donde se amplificaron segmentos específicos de los genes rpoB y hsp65 de M. leprae. El paciente fue tratado con el esquema combinado estándar de la OMS para la forma multibacilar durante un año, con regresión parcial de las lesiones. Durante el seguimiento se detectó por RPC una disminución del número de copias del gen rpoB de M. leprae en muestras nasofaríngeas hasta el sexto mes. El registro de enfermedades de notificación obligatoria demuestra un incremento reciente de casos de EH en Chile, todos relacionados con población migrante. La enfermedad de Hansen es una nueva condición clínica y los clínicos deben estar atentos a esta posibilidad diagnóstica. Las pruebas moleculares pueden ayudar en el diagnóstico y seguimiento.

Hansen's disease (HD) is caused by Mycobacterium leprae. It has a chronic course and preferentially affects the skin and the peripheral nerves. It's an emergent infection in Chile due to migration waves. This case report affecting a migrant worker from Haiti that presented several compatible skin lesions, with hypoesthesia and unilateral madarosis that appeared before arrival. The diagnosis of a multibacillary form was established by clinical findings, presence of fast acid bacilli on a direct skin smear, and inflammatory cell surrounding nerve endings and granulomas on skin biopsy. Besides, specific rpoB and hsp65 gene segments from M. leprae were amplified from skin samples. Patient was treated with the WHO standard combined regimen for multibacillary forms during one year showing partial regression of skin lesions. Nasopharyngeal samples showed the presence of M. leprae rpoB copies detected by PCR decreasing until six months of therapy. Notifiable diseases databases showed a recent increment of cases, all related to migrant population. Hansen's disease is a new condition in Chile and clinicians should be aware of this possibility. Molecular tools may facilitate diagnosis and follow up.