Perspectivas latinoamericanas sobre medicina centrada en la persona / Latin American perspectives on person-centered medicine

RESUMEN La medicina centrada en la persona (MCP) es un movimiento programático mundial liderado por el International College of Person Centered Medicine. Su ingreso en Latinoamérica es reciente. Reclama el empleo de la investigación científica como instrumento para generar la mejor evidencia clínica, y el humanismo como esencia de la medicina en bien de la humanidad. Su propuesta no es solo combatir la enfermedad, sino, también, promover el despliegue de los potenciales saludables del ser humano hacia el logro de su bienestar y desarrollo integral. Aunque el humanismo de la medicina en Latinoamérica ha sido característica distintiva de su práctica, se aprecia en épocas actuales una preocupante reducción de su influencia en la atención de salud por factores diversos. El presente artículo compendia perspectivas latinoamericanas de cuatro países. Se cotejan necesidades y experiencias y describen respuestas que vienen generándose frente a la influencia deshumanizadora de la tecnología y del manejo de la salud como bien de consumo.

ABSTRACT Person-centered medicine (PCM) is a programmatic global initiative led by the International College of Person-Centered Medicine. It has recently emerged in Latin America. It requires the use of scientific research as an instrument to generate the best clinical evidence, and humanism as the essence of medicine to help mankind. It is focused on not only combatting disease but also promoting the display of healthy human being potentials towards achieving well-being and comprehensive growth. Although the humanism of medicine in Latin America has been a distinctive characteristic of its practice, now, there is a worrying decline in its impact on healthcare. This article summarizes the Latin American perspective from four countries. Needs and experiences are compared and responses that arise in view of the dehumanizing influence of technology and health management as a consumption good are described.

[Latin American perspectives on person-centered medicine]. / Perspectivas latinoamericanas sobre medicina centrada en la persona.

Person-centered medicine (PCM) is a programmatic global initiative led by the International College of Person-Centered Medicine. It has recently emerged in Latin America. It requires the use of scientific research as an instrument to generate the best clinical evidence, and humanism as the essence of medicine to help mankind. It is focused on not only combatting disease but also promoting the display of healthy human being potentials towards achieving well-being and comprehensive growth. Although the humanism of medicine in Latin America has been a distinctive characteristic of its practice, now, there is a worrying decline in its impact on healthcare. This article summarizes the Latin American perspective from four countries. Needs and experiences are compared and responses that arise in view of the dehumanizing influence of technology and health management as a consumption good are described.

Bases y perspectivas latinoamericanas sobre Medicina y Salud Centradas en la Persona / Latin American bases and perspectives on Person-Centered Medicine and Health

Antecedentes: Este artículo emerge como parte de un proceso liderado por la Academia Nacional de Medicina del Perú en estrecha colaboración con otras Academias de Medicina Latinoamericanas, e importantes instituciones universitarias y profesionales relacionadas con la salud. Objetivo: Describir y fundamentar la importancia de la Medicina Centrada en la Persona (MCP) en el contexto latinoamericano. Metodología: Revisión de artículos y experiencias latinoamericanas sobre el tema, realización de reuniones académicas para deliberar sobre contenidos afines, dos preliminares en Lima en diciembre 2013 y enero 2014, una tercera en Buenos Aires, a propósito del 2° Congreso Internacional de Medicina Centrada en la Persona, con la presencia de las Academias de Medicina de Argentina, Bolivia, Chile y Perú (noviembre 2014) y una cuarta en Lima, Reunión de las Academias de Medicina de Bolivia, Colombia, Chile, Paraguay y Perú (diciembre 2014). Resultados: Se puntualizan los precedentes históricos y contemporáneos, universales y locales, pertinentes a la gestación y desarrollo de una re-priorización de la medicina en torno a la persona y su contexto, articulando para el efecto ciencia y humanismo. Se discute el nivel filosófico del concepto Persona en medicina, incluyendo bases terminológicas, históricas, y derechos humanos. Sobre estas bases se examina la evolución de los conceptos centrales de la MCP, resaltando su pertinencia tanto en la medicina clínica como en la salud pública, la atención, educación e investigación y las políticas en salud. Con respecto a la práctica y educación clínicas, se plantea la noción de MCP como principio estratégico fundamental, sus aplicaciones educacionales programáticas, y su posible institucionalización a nivel de facultades de medicina. Se resalta la importancia de la formación en ética y comunicación clínica y del apropiado uso de la tecnología y la evidencia científica al servicio de la persona. Se incluyen posibilidades...

other Latin American National Academies of Medicine and important university and professional institutions related to the area of health. Objective: To describe and substantiate the importance of Person Centered Medicine (PCM) in the Latin American context. Methodology: Review of Latin American papers and experiences on this issue, and organization of academic meetings to deliberate on related problems, two preliminary ones in Lima in December 2013 and January 2014, a third one in Buenos Aires at the Second International Congress of Person Centered Medicine with the participation of National Academies of Medicine of Argentina, Bolivia, Chile and Peru (November, 2014), and a fourth in Lima with the presence of the National Academies of Medicine of Bolivia, Chile, Colombia, Paraguay and Peru (December, 2014). Results: Historical and contemporary, universal and local precedents to the gestation and development of a reprioritization of medicine in relation to the Person and his context are pointed out, articulating for such purpose science and humanism. The concept of Person in medicine from a philosophical point of view, including terminological historical and human rights dimensions, is discussed. Upon these bases the central concepts of PCM are examined emphasizing its pertinence in clinical medicine as well as in public health, clinical care, education, research, and health policies. In regards to clinical education and practice, the PCM concept as a fundamental strategic principle, its programmatic educational applications and its possible institutionalization at medical school level are proposed. The importance of ethical training and clinical communication as well as the appropriate use of technology and scientific evidence on behalf of the Person are highlighted. Available institutional opportunities for health professional interdisciplinary education as well as Latin American educational perspectives are discussed. Scientific research on PCM is...

[Contribution of Chilean research to the formulation of national clinical guidelines]. / ¿Se sustentan las Guías GES en trabajos científicos financiados por los fondos de CONICYT?

BACKGROUND: In Chile, 80 diseases were included in a health care system called Health Care Guarantees (GES) and clinical guidelines were elaborated for their management. AIM: To assess the scientific background of guidelines and if they were based on research financed by the Chilean National Commission for Science and Technology. MATERIAL AND METHODS: The references of the 82 guidelines developed for 80 diseases were reviewed, registering their number, authors, country of origin and funding source. RESULTS: The guidelines had a total of 6,604 references. Of these, only 185 were Chilean (2.8%) and five (0.08%) originated from research financed by the National Commission for Science and Technology. CONCLUSIONS: The contribution of research funded by national agencies to the formulation of clinical guidelines is minimal.

[Porphyria cutanea tarda, hemosiderosis and hepatocellular carcinoma: report of one case]. / Hepatocarcinoma, porfiria y hemosiderosis. Una asociación no reportada en nuestro país: Caso clínico.

Porphyria cutanea tarda (PCT) is a hereditary or acquired disease. It can be unleashed by iron overload, alcohol, estrogens and other conditions. In these patients, hepatic involvement can be associated to cirrhosis, iron overload or C and B viral infections, that are predisposing factors for hepatocellular carcinoma. We report a 69-year-old man with PTC, hemosiderosis and hepatocarcinoma. The tumor was diagnosed during a routine ultrasound examination for early detection of malignant lesions. The patient was subjected to a right hepatic excision. The pathological examination of the surgical piece confirmed the diagnosis and disclosed free surgical margins. After 18 months of follow up, the patient had a relapse and a liver transplantation was performed.

Hepatocarcinoma, porfiria y hemosiderosis. Una asociación no reportada en nuestro país: caso clínico / Porphyria cutanea tarda, hemosiderosis and hepatocellular carcinoma: report of one case

Porphyria cutanea tarda (PCT) is a hereditary or acquired disease. It can be unleashed by iron overload, alcohol, estrogens and other conditions. In these patients, hepatic involvement can be associated to cirrhosis, iron overload or C and B viral infections, that are predisposing factors for hepatocellular carcinoma. We report a 69-year-old man with PTC, hemosiderosis and hepatocarcinoma. The tumor was diagnosed during a routine ultrasound examination for early detection of malignant lesions. The patient was subjected to a right hepatic excision. The pathological examination of the surgical piece confrmed the diagnosis and disclosed free surgical margins. After 18 months of follow up, the patient had a relapse and a liver transplantation was performed.

[The ALANAM statement on public health policy]. / Declaración Pública de la ALANAM sobre Políticas de Salud para Latinoamérica.

The ALANAM (Association of Latin American National Academies of Medicine) statement on public health policy, issued following its 19th Congress, held October 28­30, 2010, in Santiago, Chile, declares that cardiovascular diseases, cancer, accidents and violence are the leading causes of death in the region, while in several of its member nations, emergent and re-emergent infectious diseases, malnutrition, and mother-child illnesses remain prevalent. The statement calls attention to the lack of functioning water supply and sewage systems in many villages and rural areas. After describing the social causes of the present state of public health in Latin America (poverty levels reaching upwards of 44% of the total population, or some 110 million people), it calls on governments, first, to spare no efforts in the task of eradicating extreme poverty in the short-term, and poverty in the long-term. Second, considering that about 15 million 3-to-6 year-olds have no access to education, it recommends extending educational services to these children, and to improve the quality of existing pre-school and primary education. Third, the statement calls for universal health care coverage and for equal access to good quality medical care for everyone, and for programs aimed at promoting healthy personal habits and self-care. In this regard, it also recommends that disease prevention programs be sustained over time, that national sanitary objectives be defined, and that its results be periodically reviewed. Fourth, it recommends that primary health care be extended to everyone, and that it be enhanced by improving coverage and coordination with secondary and tertiary level health care institutions. The statement lays special stress on the need for adopting public health policies aimed at lowering the cost of medicines; to this end, it calls for the creation of an official list of generic drugs. The statement ends by calling on governments to support public health research as a necessary step in tackling with greater efficiency the health problems still prevalent in the region.

[Mutations of hemochromatosis gene in volunteer blood donors and Chilean porphyria cutanea tarda patients]. / Mutaciones del gen de la hemocromatosis en donantes de sangre voluntarios y en pacientes con porfiria cutánea tarda en Chile.

In patients with porphyria cutanea tarda (PCT), hepatic iron accumulation associated to hereditary hemochromatosis (HH) could play a role in the etiology and in the clinical expression of the disease. The H63D and C282Y mutations of the HFE gene frequency were studied in a PCT group of patients and compared with the frequency observed in a group of volunteer blood donors. PCT patients were cataloged as hereditary or acquired PCT carriers, whether or not they presented uroporphyrinogen decarboxilase gene mutations. Fifty percent of PCT patients were carriers of the disease's genetic type. Such percentage is significantly higher than what other authors have previously informed. H63D and C282Y mutations were present in 23% and 2.4% of the volunteer blood donors, respectively. Similar frequencies were informed by others authors in Chilean white ethnic populations, and also in Spaniard and Argentinean populations, but significantly higher than that observed in Chile's Araucanean aboriginal population. Probably the frequency of H63D and C283Y mutations are related to the Spaniard ascendancy dominance of Chile's white ethnic population. The frequency of HFE gene mutations in PCT patients was not different than what was observed in volunteer blood donors. Similarly, there was no statistical difference in the frequency of these mutations among patients with acquired or genetic PCT disease. With the obtained results, it is not possible postulate an association between PCT and the hereditary hemochromatosis of HFE gene mutations carrier conditions.

[Decentralization of health care and medical teaching: the Chilean experience]. / Descentralización en salud y educación: la experiencia Chilena.

In Chile there has been a close interaction between medical teaching and health care. In 1943, the University of Chile School of Medicine (founded in 1833) created Chairs in several public hospitals. The University of Chile School of Public Health (founded in 1943) played a key role in the creation in 1952 of a centralized National Health Service (NHS). The NHS had outpatient clinics and hospitals all over the country and was responsible for health care and for the promotion of health and disease prevention programs. In 1954, the NHS and the School of Medicine set up Residencies and General Practitioners programs aimed at improving the distribution of specialists and general practitioners throughout the country. In 1979, the NHS was replaced with 27 autonomous Health Services headed by the Ministry of Health, while the administration of primary care outpatient clinics was transferred to the municipal government. However, sanitary programs were still managed at the central level. Higher education also expanded and was decentralized. There are currently 60 universities and 17 medical schools, compared to eight and six, respectively, in 1981. The number of students in higher education has increased by 370% in 20 years. At the present time, the Chilean health case system is a predominantly public system with a strong and sizeable private system. Sixty two percent of the population is covered by public health insurance, while 27% is covered by private insurance. New and well equipped private clinics have multiplied. Private non profit institutions manage the prevention and treatment of work related injuries and diseases. Chile's outstanding health indicators (fertility rate: 17.2 x 1,000; mortality: 5.4 x 1,000; maternal mortality: 2.3 x 10,000; neonatal mortality: 4.5 x 1,000; life expectancy: 76 years) are a direct consequence of the improved social, cultural and economic condition of the general populations as well as of the sanitary programs sustained over the past half century.

Estudio prospectivo randomizado de exposición intraoperatoria única A 5-FU en trabeculectomía primaria en glaucoma de ángulo abierto / Randomized prospective study of single intraoperatory exposure A 5-FU in primary trabeculectomy in open angle glaucoma

Propósito: determinar si la aplicación de una dosis única de 5-fluoruracilo (5-FU) intraoperatorio durante la trabeculectomía primaria, resulta en una diferencia en la presión intraocular (PIO), en la tasa de fracaso y en la incidencia de complicaciones, en pacientes con glaucoma de ángulo abierto no controlado bajo tratamiento médico. Método: 68 pacientes con glaucoma de ángulo abierto, primario o pseudoexfoliativo, no controlados medicamente y con PIO mayores a 19 mmHg fueron randomizados para ser tratados con una esponja embebida en agua destilada o 5-FU (50 mg/ml) durante la trabeculectomía. El seguimiento y evolución se hizo en doble ciego por parte de los cirujanos. Se compararon entre ambos grupos, las curvas de sobrevida de la PIO y las complicaciones. Resultados: 23 pacientes en el grupo tratado con 5-FU y 32 en el grupo control tuvieron un seguimiento promedio de 492,8 días (rango entre 114 a 810 días) y 495 (rango entre 90 y 930), respectivamente (p=0,96). No se encontró diferencia significativa en las curvas de sobrevida entre ambos grupos, usando un criterio de fracaso de PIO > 15 mmHg y una diferencia estadística en las curvas de sobrevida con un criterio de fracaso de PIO mayor igual 20 mmHg (análisis de Logrank: =0,552 y 0,048, respectivamete)

5-Fluorouracilo intraoperatorio en trabeculectomía primaria / Intrasurgical 5-fluorouracil in primary trabeculectomy

Pacientes con PIO mayor a 21 mmHg fueron randomizados al momento de la cirugía para recibir ya sea, 5fu o agua destilada sobre la epiesclera por 5 minutos, antes de construir el flap escleral y luego controlados a intervalos definidos en el postoperatorio. El uso intraoperatorio de 5fu no demostró un aumento en el éxito de la cirugía filtrante en pacientes con bajo riesgo de falla de ampolla hasta el tiempo de seguimiento y tampoco determinó una diferencia de importancia clínica en la tasa de complicaciones

Estudio epidemiológico de pacientes operados de várices en el Hospital Sanatorio de Valparaíso / Epidemiological study on varicose patients operated at the Hospital Sanatorio of Valparaíso

Se presenta un trabajo descriptivo emn pacientes operados por patología varicosa en el Hospital Sanatorio de Valparaíso durante 1983, encontrándose que la mayor frecuencia corresponde a pacientes del sexo femenino (64,9%)y la edad más común al momento de la primera consulta, fluctúa entre 40 y 49 años en ambos sexos. En relación a las características propias del cuadro varicoso destaca que los signos y síntomas más frecuentes al momento de consulta son la dilatación venosa (69,3%) y el dolor (33,3%) respectivamente. El territorio venoso más afectado es el de la safena interna, comprometiendo con mayor frecuencia ambas extremidades en forma simultánea. El mayor número de pacientes operados presentan várices en etapa moderada o avanzada al momento de la consultaa. Con respecto a los factores de riesgo o etiopatogénicos se aprecia que un 62,6% de los pacientes tienen sobrepeso o algún grado de obesidad y un porcentaje alto de mujeres (27,7%) presenta obesidad severa. Otro factor analizado fué la paridad, detectándose a éste respecto que el 80,4% de las mujeres operadas eran multíparas y que sólo en el 14,4% las várices aparecieron durante algún embarazo. Finalmente debemos destacar la alta prevalencia del cuadro y la poca información disponible en la literatura nacional, lo que estimula la realización de mayores estudios tanto de orden descriptivo como analítico

Estructura de la demanda de un servicio de emergencia en situación de catástrofe

Se presentan las variaciones ocurridas en las estructura de la demanda del servicio de urgencia de un hospital general de la Región Metropolitana, en el día de ocurrecia y siguientes al sismo de marzo de 1985. En la comparación con igual período del año anterior 1984, se evidencian diferencias en los grupos patologías en cuyo origen tiene influencia el stress, tales como son los trastornos neurofuncionales, el síndrome anginoso, la hemorragia digestiva alta y el asma broquial, siendo estas diferencias estadísticamente significativas. A la inversa las patologías de consulta habitual en un servicio de urgencia y cuya frecuencia o agravación no tiene relación con el stress, no experimentaron variación significativa a raíz del terremoto comparadas con su ocurrencia en fecha similar del año anterior. Se analizan también las variaciones de las patologías relacionadas al stress en términos de sexo y edad, destacándose el predominio de consultantes mujeres afectadas por trastornos neurofuncionales y neurológicas. Se señalan la importancia de la información obtenida en la administración de los recursos de atención en salud en situaciones de emergencia como la en referencia y la posibilidad de preparaar equipo profesionales para afrontar las exigenigencias particulares de la demanda en casos de catástrofe (AU)

Estructura de la demanda de un servicio de urgencia en situación de catástrofe / Estructure of the demand of an emergency service in disasters situation

Se presentan las variaciones ocurridas en la estructura de la demanda del servicio de urgencia de un hospital general de la Región Metropolitana, en el día de ocurrencia y siguientes al sismo de marzo de 1985. En la comparación con igual período del año anterior 1984, se evidencian diferencias en los grupos de patologías en cuyo origen tiene influencia el stress, tales como son los trastornos neurofuncionales, el síndrome anginosos, la hemorragia digestiva alta y el asma bronquial, siendo estas diferencias estadísticamente significativas. A la inversa las patologías de consulta habitual en un servicio de urgencia, y cuya frecuencia o agravación no tienen relación con el stress, no experimentaron variación significativa a raíz del terremoto comparadas con su ocurrencia en fecha similar del año anterior. Se analizan también las variaciones de las patologías relacionadas al stress en términos de sexo y edad, destacándose el predominio de consultantes mujeres afectadas por trastornos neurofuncionales y neurológicos. Se señalan la importancia de la información obtenida en la administración de los recursos de atención de salud en situaciones de emergencia como la en referencia y la posibilidad de preparar equipos profesionales para afrontar las exigencias particulares de la demanda en casos de catástrofes