Delphi Method to Achieve Clinical Consensus for a BPMN Representation of the Central Venous Access Placement for Training Purposes.

Proper teaching of the technical skills necessary to perform a medical procedure begins with its breakdown into its constituent steps. Currently available methodologies require substantial resources and their results may be biased. Therefore, it is difficult to generate the necessary breakdown capable of supporting a procedural curriculum. The aim of our work was to breakdown the steps required for ultrasound guided Central Venous Catheter (CVC) placement and represent this procedure graphically using the standard BPMN notation. METHODS: We performed the first breakdown based on the activities defined in validated evaluation checklists, which were then graphically represented in BPMN. In order to establish clinical consensus, we used the Delphi method by conducting an online survey in which experts were asked to score the suitability of the proposed activities and eventually propose new activities. RESULTS: Surveys were answered by 13 experts from three medical specialties and eight different institutions in two rounds. The final model included 28 activities proposed in the initial model and four new activities proposed by the experts; seven activities from the initial model were excluded. CONCLUSIONS: The proposed methodology proved to be simple and effective, generating a graphic representation to represent activities, decision points, and alternative paths. This approach is complementary to more classical representations for the development of a solid knowledge base that allows the standardization of medical procedures for teaching purposes.

[Simulation in medical education: a synopsis]. / Simulación en educación médica: una sinopsis.

Clinical simulation is defined as a technique (not a technology) to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Over the past few years, there has been a significant growth in its use, both as a learning tool and as an assessment for accreditation. Example of this is the fact that simulation is an integral part of medical education curricula abroad. Some authors have cited it as an unavoidable necessity or as an ethical imperative. In Chile, its formal inclusion in Medical Schools' curricula has just begun. This review is an overview of this important educational tool, presenting the evidence about its usefulness in medical education and describing its current situation in Chile.

Simulación en educación médica: una sinopsis / Simulation in medical education: a synopsis

Clinical simulation is defined as a technique (not a technology) to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Over the pastfew years, there has been a significant growth in its use, both as a learning tool and as an assessment for accreditation. Example of this is the fact that simulation is an integral part of medical education curricula abroad. Some authors have cited it as an unavoidable necessity or as an ethical imperative. In Chile, its formal inclusion in Medical Schools' curricula has just begun. This review is an overview of this important educational tool, presenting the evidence about its usefulness in medical education and describing its current situation in Chile.

[What was the plague of Athens?]. / Qué fue la plaga de Atenas?

In the year 430 B.C., at the beginning of the second year of the Peloponessian War, a terrible epidemic fell upon Athens and the most populous cities in Attica. It would last for just over four years and it would kill 100.000 people, a quarter to a third of the population. We know about it through the masterly description made by Thucydides in his History of the Peloponnesian War. His narrative has withstood twentyfive centuries due to its medical interest and, above all, its great dramatic force. The description of symptoms and signs, their evolution, and the consequences upon persons and moral and social order has captivated physicians, philologists and classical historians ever since. It has inspired literary works and hundreds of medical articles, with no agreement having been reached upon its cause or consequences, or if it is history or tragedy, or even if there is a single answer to these alternatives.

[Seventy five years of the Medical School of the Pontifical Catholic University of Chile]. / 75 años de la Facultad de Medicina de la Pontificia Universidad Católica de Chile.

Aiming to join academic excellence and an ethical and Christian approach to medical profession, the Medical School of the Pontifical Catholic University of Chile initiated its activities in 1930. Since then, the associated Health Care Network has incorporated all the technological breakthroughs in medicine and developed all the specialties. Undergraduate teaching is oriented to promote creativity and innovation. There is also a special concern about humanity of Medicine, throught the Program of Humanistic Medical Studies and the Bioethics Center. Post graduate education is also an important activity of the School, through specialty training, Master and Doctorate programs. Researchers have also obtained important grants and generated a great number of publications in high impact journals. Our University is defined as "complex", meaning that we must take important challenges, be creative and lead knowledge generation. We must also improve ourselves to serve in the best possible way our students and the Country. Paraphrasing the words of our founder, Monsignor Carlos Casanueva, we must train physicians that will serve our community not only with science but also with humanity.

Analgesia after thoracotomy: epidural fentanyl/bupivacaine compared with intercostal nerve block plus intravenous morphine.

OBJECTIVES: Intercostal nerve blockade plus intravenous (IV) patient-controlled analgesia (PCA) could be an easier and safer alternative to epidural analgesia for postthoracotomy pain, but information about the efficacy of this technique is scarce. The objective of this randomized study was to compare the quality of analgesia and lung function in 2 groups of patients undergoing pulmonary surgery through a posterolateral thoracotomy. METHODS: Two groups were studied: G1 (n = 16) patients received a 5-segment intercostal block plus IV PCA morphine, and G2 (n = 15) patients received a bupivacaine and fentanyl PCA infusion through a thoracic epidural catheter. Resting and dynamic visual analog pain scale (VAS) measurements, forced vital capacity, and forced expiratory volume in 1 second were measured basally, on arrival in the recovery room, then hourly up to 4 hours and then 12, 24 and 48 hours later. Results were analyzed with a 2-way analysis of variance, chi-square, or Fisher exact test. A p value < or =0.05 was considered significant. RESULTS: Resting and dynamic VAS scores were slightly lower in G2 patients, although only resting scores were significant. After the first hour, mean scores were below 4 in both groups. No significant difference was observed between groups in relation to respiratory parameters or side effects. CONCLUSION: The fact that the difference in pain scores is probably not clinically significant shows that an intercostal block with bupivacaine plus IV morphine PCA is a good alternative for postthoracotomy pain management.

Remifentanil requirements during sevoflurane administration to block somatic and cardiovascular responses to skin incision in children and adults.

BACKGROUND: The authors found no studies comparing intraoperative requirements of opioids between children and adults, so they determined the infusion rate of remifentanil to block somatic (IR50) and autonomic response (IRBAR50) to skin incision in children and adults. METHODS: Forty-one adults (aged 20-60 yr) and 24 children (aged 2-10 yr) undergoing lower abdominal surgery were studied. In adults, anesthesia induction was with sevoflurane during remifentanil infusion, whereas in children remifentanil administration was started after induction with sevoflurane. After intubation, sevoflurane was administered in 100% O2 and was adjusted to an ET% of 1 MAC-awake corrected for age at least 15 min before surgery. Patients were randomized to receive remifentanil at a rate ranging from 0.05 to 0.35 microg x kg(-1) x min(-1) for at least 20 min before surgery. At the beginning of surgery, only the skin incision was performed, and the somatic and autonomic responses were observed. The somatic response was defined as positive with any gross movement of extremity, and the autonomic response was deemed positive with any increase in heart rate mean arterial pressure equal to or more than 10% of preincision values. Using logistic regression, the IR50 and IRBAR50 were determined in both groups of patients and compared with unpaired Student t test. A P value less than 0.05 was considered significant. RESULTS: The IR50 +/- SD was 0.10 +/- 0.02 microg x kg(-1) x min(-1) in adults and 0.22 +/- 0.03 microg x kg(-1) x min(-1) in children (P < 0.001). The IRBAR50 +/- SD was 0.11 +/- 0.02 microg x kg(-1) x min(-1) in adults and 0.27 +/- 0.06 microg x kg(-1) x min(-1) in children (P < 0.001). CONCLUSIONS: To block somatic and autonomic responses to surgery, children require a remifentanil infusion rate at least twofold higher than adults.

Reinfarto en el paciente sometido a anestesia para cirugía no cardíaca / Reinfarct in a patient due to non cardiac surgery anesthesia

Con el propósito de evaluar la incidencia de reinfarto del miocardio, se revisaron retrospectivamente las fichas computarizadas pertenecientes a 236 pacientes con el antecedente de un infarto miocárdico previo y que fueron sometidos a cirugía no cardíaca. El diagnóstico de reinfarto se hizo con el cuadro clínico, ECG y cambios enzimáticos. Dos pacientes (0,84%) sufrieron un reinfarto y ambos sobrevivieron. Ambos eran mayores de 70 años, fueron sometidos a cirugía de urgencia, y sufrieron cambios importantes de volumen circulante y episodios de hipotensión arterial en el intraoperatorio

Hiperparatiroidismo primario y embarazo / Primary hyperparathyroidism and pregnancy

Se presenta un caso clínico de hiperparatiroidismo primario y embarazo, asociación infrecuente, pero de trascendencia vital para la madre e hijo, secundaria a la hipercalcemia. Entre los antecedentes de esta paciente de 33 años de edad, se destacan la toxemia e hiperemesis gravídica en un embarazo anterior y dos hospitalizaciones previas al diagnóstico definitivo, también por hiperemesis gravídica. Los axámenes de laboratorio revelaron calcemias elevadas con relativa hipofosfemia, AMPcU alto y PTH normal. Fue tratada con sobrehidratación y diuresis forzada, controlándose la calcemia en límites normales, a las 28 semanas de embarazo hay compromiso general y nuevamente calcio elevado por lo que se indica tratamiento quirúrgico. En la intervención se realiza paratiroidectomía inferior izquierda, el diagnóstico histológico fue: Adenoma paratiroideo. Hubo normalización de la calcemia y AMPcU a los 2 meses y parto de término con niño sano y calcemia normal. El tratamiento quirúrgico debe realizarse en período de organogénesis completa, por cirujanos expertos y con anestesia adecuada al menor riesgo para el embarazo