Evolución nutricional durante las primeras etapas del trasplante de precursores hematopoyéticos: importancia del ángulo de fase / Nutritional evolution during the early stages of hematopoietic stem cell transplantation: importance of the phase angle

Introducción: el objetivo de este estudio es comparar los cambios en la antropometría, dinamometría e indicadores de la impedancia bioeléctrica (BIA) de pacientes sometidos a trasplante de precursores hematopoyéticos (TPH) autólogo y alogénico luego del periodo de acondicionamiento y una semana postrasplante, así como evaluar si estos cambios precoces se asocian con el desarrollo de complicaciones posteriores. Metodología: estudio de cohorte prospectivo. El estado nutricional se evaluó mediante antropometría, dinamometría y BIA en tres momentos diferentes definidos: T1, momento del ingreso; T2, después del periodo de acondicionamiento mieloablativo; y T3, día + 8 post-TPH. Resultados: un total de 40 pacientes fueron evaluados, 17 recibieron TPH autólogo (TAU) y 23, TPH alogénico (TAL). Los pacientes con TAL presentaron una mayor mortalidad y estadía hospitalaria en comparación con los pacientes con TAU. Aquellos que desarrollaron enfermedad injerto contra huésped (EICH) presentan un menor ángulo de fase (AF) que aquellos que no desarrollaron esta complicación (T2: AF TAL con EICH 4,8° vs. AF TAL sin EICH 5,5°, p = 0,007). Los pacientes que fallecieron durante la estadía hospitalaria son todos del grupo TAL y tenían un AF menor a 5° en T3. Peso, índice de masa corporal (IMC) e índice de masa libre de grasa (IMLG) no mostraron un impacto significativo y todos ellos estaban influidos por el agua corporal total. Conclusiones: la evaluación nutricional precoz de estos pacientes mediante AF parece prometedora, ya que no se ve alterado por la retención de agua y se puede evaluar antes que los cambios antropométricos sucedan.(AU)

Introduction: the aim of this study is to compare the changes in anthropometry, dynamometry and bioelectrical impedance analysis (BIA) of patients undergoing autologous and allogeneic hematopoietic stem cell transplantation (HSCT) after the conditioning period and one-week post-transplantation, and to assess whether these early changes are associated with the development of later complications. Methods: prospective cohort study. Nutritional status was assessed by anthropometry, dynamometry and BIA at three different defined times: T1, time of admission; T2, after the myeloablative conditioning period; and T3, day + 8 post-HSCT.Results: forty patients were evaluated, 17 received autologous HSCT (TAU) and 23 received allogeneic HSCT (TAL). Patients with TAL had higher mortality and hospital stay compared to patients with TAU. Those who developed graft versus host disease (GVHD) presented a lower phase angle (PA) than those who did not develop this complication (T2: TAL PA with GVHD 4.8° vs TAL PA without GVHD 5.5°, p = 0.007). The patients who died during the hospital stay are all from the TAL group and had PA less than 5° at T3. Weight, body mass index (BMI) and fat-free mass index (FMI) did not show a significant impact, and all of them were influenced by total body water. Conclusions: early nutritional evaluation of these patients by phase angle seems promising, since it is not altered by water retention and can be evaluated before anthropometric changes occur.(AU)

[Nutritional evolution during the early stages of hematopoietic stem cell transplantation: importance of the phase angle]. / Evolución nutricional durante las primeras etapas del trasplante de precursores hematopoyéticos: importancia del ángulo de fase.

INTRODUCTION: the aim of this study is to compare the changes in anthropometry, dynamometry and bioelectrical impedance analysis (BIA) of patients undergoing autologous and allogeneic hematopoietic stem cell transplantation (HSCT) after the conditioning period and one-week post-transplantation, and to assess whether these early changes are associated with the development of later complications. METHODS: prospective cohort study. Nutritional status was assessed by anthropometry, dynamometry and BIA at three different defined times: T1, time of admission; T2, after the myeloablative conditioning period; and T3, day + 8 post-HSCT. RESULTS: forty patients were evaluated, 17 received autologous HSCT (TAU) and 23 received allogeneic HSCT (TAL). Patients with TAL had higher mortality and hospital stay compared to patients with TAU. Those who developed graft versus host disease (GVHD) presented a lower phase angle (PA) than those who did not develop this complication (T2: TAL PA with GVHD 4.8° vs TAL PA without GVHD 5.5°, p = 0.007). The patients who died during the hospital stay are all from the TAL group and had PA less than 5° at T3. Weight, body mass index (BMI) and fat-free mass index (FMI) did not show a significant impact, and all of them were influenced by total body water. CONCLUSIONS: early nutritional evaluation of these patients by phase angle seems promising, since it is not altered by water retention and can be evaluated before anthropometric changes occur.

Effect of Smoking History on 30-Day Morbidity Following Bariatric Surgery.

INTRODUCTION: Smoking and postoperative complications are well documented across surgical specialties. Preoperative smoking cessation is frequently recommended by surgeons. In this study, we assessed to what degree documented smoking history increased a patient's risk of postoperative complications. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the years 2015-2018 was used. Patients were included if they underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (LRYGB). Patients with a documented smoking history were assigned to the "SH" cohort and patients without smoking history were assigned to the "NSH" cohort. Patients without documentation regarding smoking history, missing variables, younger than 18, with prior surgery, or lost to follow-up were excluded. 30-day morbidity and mortality data were assessed. Multiple logistic regression analysis was made based on all available patient characteristics and perioperative factors, continuous variables were analyzed using Student's t-test and categorical variables were compared using the chi-square test. RESULTS: After evaluation of 760,076 patients on the MBSAQIP database, 650,930 patients underwent non-revisional bariatric surgery, including 466,270 SG and 184,660 LRYGB. Of the total patients included in the study, 44,606 patients were assigned to the SH cohort and 479,601 were assigned to the NSH cohort. 4628 of patients did not have documented smoking status. Within 30 days SH patients had higher rates of readmission (4.2% vs 3.7%, P < .0001), reoperation (1.3% vs 1.1%, P < .0001), unplanned intubation (.2% vs .1%, P = .0212), and unplanned ICU admission (.7% vs .0.6%, P = .0022). CONCLUSION: SH patients undergoing bariatric surgery were at significantly increased risk of readmission and reoperation within 30 days of procedure. In addition, SH patients were more likely to have unplanned intubation and unplanned ICU admission. Given the higher rates of complications in smoking patients, this study would suggest that preoperative smoking cessation in patients prior to primary bariatric surgery might be beneficial. Further study is warranted to compare short-term cessation vs long-term cessation preoperatively, which was not assessed in our study.

Complexity of Brain Dynamics as a Correlate of Consciousness in Anaesthetized Monkeys.

The use of anaesthesia is a fundamental tool in the investigation of consciousness. Anesthesia procedures allow to investigate different states of consciousness from sedation to deep anesthesia within controlled scenarios. In this study we use information quantifiers to measure the complexity of electrocorticogram recordings in monkeys. We apply these metrics to compare different stages of general anesthesia for evaluating consciousness in several anesthesia protocols. We find that the complexity of brain activity can be used as a correlate of consciousness. For two of the anaesthetics used, propofol and medetomidine, we find that the anaesthetised state is accompanied by a reduction in the complexity of brain activity. On the other hand we observe that use of ketamine produces an increase in complexity measurements. We relate this observation with increase activity within certain brain regions associated with the ketamine used doses. Our measurements indicate that complexity of brain activity is a good indicator for a general evaluation of different levels of consciousness awareness, both in anesthetized and non anesthetizes states.

Rotura traqueal completa asociada a lesión del conducto torácico posterior a trauma torácico cerrado: reporte de un caso / Full tracheal rupture associated with posterior thoracic duct injury to blunt chest trauma: a case report

Antecedentes: La rotura traqueal completa y la lesión de conducto torácico representan complicaciones raras del trauma torácico cerrado. Método: Se presenta el caso de un paciente con rotura completa de la tráquea asociada a rotura del conducto torácico que fue operado en el Hospital del Trabajador. Discusión y conclusiones: La identificación y el manejo oportuno de estas lesiones disminuyen la morbimortalidad asociada a trauma.

Background: Tracheal rupture and thoracic duct lesion are rare complications of blunt thoracic trauma. Method: We present in this article the case of a patient with complete tracheal rupture and thoracic duct lesion treated in Hospital del Trabajador. Discussion and conclusions: Early identification and prompt management of this conditions reduce morbimortality associated with trauma.

Health insurance or subsidy has universal advantage for management of hospital malnutrition unrelated to GDP.

BACKGROUND AND OBJECTIVES: Protein-energy and micronutrient malnutrition are global public health problems which, when not prevented and severe, require medical management by clinicians with nutrition expertise, preferably as a collectively skilled team, especially when disease-related. This study aimed to investigate barriers and facilitators of clinical nutrition services (CNS), especially the use of oral, enteral (EN) and parenteral (PN) nutrition in institutional and home settings. METHODS AND STUDY DESIGN: An international survey was performed between January and December 2014 in twenty-six countries from all continents. Electronic questionnaires were distributed to 28 representatives of clinical nutrition (PEN) societies, 27 of whom responded. The questionnaire comprised questions regarding a country's economy, reimbursement for CNS, education about and the use of EN and PN. RESULTS: The prevalence of malnutrition was not related to gross domestic product (GDP) at purchasing power parity (PPP) per capita (p=0.186). EN and PN were used in all countries surveyed (100%), but to different extents. Reimbursement of neither EN nor PN use depended on GDP, but was associated with increased use of EN and PN in hospitals (p=0.035), although not evident for home or chronic care facilities. The size of GDP did not affect the use of EN (p=0.256), but it mattered for PN (p=0.019). CONCLUSIONS: A worldwide survey by nutrition support societies did not find a link between national economic performance and the implementation of medical nutrition services. Reimbursement for CNS, available through health insurance systems, is a factor in effective nutrition management.

Mejoría en el desempeño académico de estudiantes de medicina en tiempos de reforma curricular / Improvement of medical studentïs academic performances in times of curricular reform

Background: During the last decade, academic life at the medical school of the Pontificia Universidad Cat-lica de Chile has been thoroughly affected by a curricular reform process. Changes started in 1993 and have continued up until now. This reform did not have an experimental design to allow for a scientific evaluation of its effects. However, it seems interesting to study the evolution of indices of academic performance of our students during this period. Aim: To evaluate the academic performance of medical students between 1989 and 1999. Subjects and Methods: All undergraduate students enrolled between 1989 and 1999. Academic performance was evaluated by 1) failure to pass one or more courses, 2) delay to complete the third year of studies, 3) withdrawal from school and 4) medical school grades. Results: All indices of academic performance changed during the period of study. Failure to pass, delay and withdrawal from school significantly decreased, whereas medical school grades improved, particularly in basic and pre-clinical subjects. Conclusions: Academic performance of medical students improved consistently between 1989 and 1999. While specific causal relationships cannot be established, we believe that this improvement is likely related to the curricular reform. This reform included horizontal and vertical integration of academic contents, greater emphasis in problem-based learning and additional instances of evaluation such as the repetition exam

Desempeño académico de los estudiantes de medicina: ¿un resultado predecible? / Academic performance of medical students: a predictable result?

Background: Traditionally, medical schools demand their students a high dedication in time, responsibility and integrity. Aim: To assess the predictive capacity of several specific variables, on the academic performance of medical students. Material and methods: All students who entered during 1984-1995 period were studied. The academeic performance was assessed using two indices: an overall evaluation of successfulness as determined by the approval rate in different courses and grade-point average obtained during the first three years at the Medical School. The variables used to predict academic performance were year of enrollment, high school grades, university admission test scores, biomedical and demographic characteristics. All these were meassured at the time when the student was enrolled. Results: Eight hundred and eight students were studied at the end of the third year. The most important predictive variables selected for both performance indices were: high school grades, admission biology test scores, place were high school studies were done, and previous university studies. In addition verbal and mathematics admission academic performance tests scores were selected for grade-point average index. Although, the overall admission score and high school academic performance were significantly associated with the two outcomes, they were not selected in the final models. Conclusions: The best predictors of an optimal academic performance in these medical students were high school grades, admission bilogy test scores, residing in Metropolitan Santiago and previous university studies

Gradiente transcraneana de citoquinas y permeabilidad intestinal en la injuria cerebral aguda severa / Transcranial cytokine gradient and intestinal permeability in severe brain injury

Background: Acute brain injury is associated with a bimodal hypermetabolic state probably caused by cytokine secretion and high hormone and catecholamine concentrations. In a first stage, the brain would produce these substances and afterwards, another production source, most probably the splanchnic territory, would perpetuate the hypermetabolic state. Aim: To investigate the cytokine production source and to assess intestinal permeability in acute brain injury in the absence of cerebral ischemia and systemic oxygen deficit. Patients and methods: Arterial systemic and cerebral venous bulbar interleukin 1 õ and interleukin 6 levels were measured during the first seven days of evolution in 15 patients with acute brain injury. Serum lactate, the oxygen/lactate ratio, gastric intramucosal pH and intestinal permeability using the lactulose/mannitol test were also assessed in the same period. Results: High arterial and venous interleukin 1 õ and interleukin 6 levels were detected. A positive gradient for interleukin 6 levels was detected throughout the study period with normal intramucosal pH, lactate and oxygen/lactate ratio. There was also an early impairment of intestinal permeability in these patients. Conclusions: High arterial and venous cytokine concentrations were detected in patients with acute brain injury. The positive gradient for interleukin 6 suggests a brain origin for this cytokine. Intestinal permeability is also altered in these patients

Neuropatía diabética: sensibilidad térmica y control metabólico en diabéticos no insulinodependientes / Diabetic neuropathy: thermal sensation and metabolic control in non insulin dependent diabetics

Background: The early detection of peripheral neuropathy in diabetics is important since it is the main riskfactor for lower limb trophic lesions in diabetics. Aim: To assess the relationship between feet thermal sensation threshold and metabolic control in ambulatory non-insulin-dependent diabetics. Pattients and methods: A random sample of 34 non-insulin-dependent diabetic followed for more than five years in a special clinic, out of 368 patients, was selected. Warmth sensation thresbolds were measured in the dorsum of booth feet using a MSTP-III thermostimulator The average value of all glycosylated hemoglobins obtained during the 9.7 ñ 5.3 years of follow up for each patient was calculated. A multiple stepwise regression analysis was performed between thermal sensation as the dependent variable and glycosylated hemoglobin, fasting blood glucose, age and diabetes duration. Results: The regression model disclosed glycosylated hemoglobin as the only independent predictor of warmth sensation threshold (partial r= 0.385; p= 0.043). Fifteen diabetic patients with metabolic control, defined as those with a mean glycosylated hemoglobin of less than 9.5 percent, had a warmth sensation threhold of 35.6 ñ 3.7 ºC, whereas 19 diabetics with a bad control (glycosylated hemoglobin 9.5 percent) had a threshold of 39 ñ 3.8 ºC(p= 0.017). Conclusions: In this group of diabetics there is a relationship between the severity of distal polyneuropathy and the metabolic contrl, assessed with glycosylated hemoglobin levels

Reforma del curriculum de pregrado en la Escuela de Medicina de la Pontificia Universidad Católica de Chile: objetivos, metodología y estado de avance / Undergraduate curriculum reform at the Pontifical Catholic University Medical School. Aims, methodology and advance status

The Medical School of the Pontifical Catholic University is devoted to a reform process aiming to adequate undergraduate training to scientific, technological, cultural and social changes in medical practice in Chile and to incorporate novel teaching methodology. One of the main modifications is the change of the resulting professional from "a general physician capable of resolving most medical problems of rural or urban populatins" to "a physician with a solid general training but qualified for a subsequent specialization". This requires curricular flexibility to obtain different professional profiles. Other important changes are a reduction in curricular contents and their vertical and horizontal integration, modernization of teaching methodologies with the incorporation of computing techniques and problem oriented teaching and the incorporation of new subjects such as molecular biology, clinical genetics, health economics. To achieve these objectives, a semi-flexible curriculum was devised, the curricular mesh has been modified extensively, an outpatient and a nine months elective internship were added. Most modifications have been implemented, remaining changes in 4th and 5th years. These changes required a reorganisation of academic structure, the use of new selection, training and perfecting criteria for teachers, better salaries for outstanding professors and improvement of teaching infrastructure. This reform must be seen as a medium term integral change in the context of an integral academic development plan

Drogas anorexígenas en el tratamiento de la obesidad / Anorexigenic drugs in the treatment of obesity

Obesity is highly prevalent and has several adverse effects on health. Its treatment is thus warranted and must aim to modify dietary and physical activity habits. The opinion of this association is that anorexigenic drugs with cathecolaminergic action (diethylpropion, phentermine, mazindol and phenylpropanolamine) or serotoninergic action (fenfluoramine and fluoxetine) may be used in moderate or severe obesity (BMI >30 kg/m2) after a complete clinical assessment and in the context of an integral medical treatment. This association recommends a close surveillance of the use of these drugs, specially when formulated as non-propietary prescriptions