Carlos Quintana V

Diagnóstico de Muerte

This paper undertakes an analysis of the scientific criteria used in the diagnosis of death and underscores the importance of intellectual rigor in the definition of medical concepts, particularly regarding such a critical issue as the diagnosis of death. Under the cardiorespiratory criterion, death is defined as «the irreversible cessation of the functioning of an organism as a whole» and the tests used to confirm this criterion (negative life-signs) are sensitive and specific. In this case, cadaverous phenomena appear immediately following the diagnosis of death. On the other hand, doubts have arisen concerning the theoretical and the inner consistency of the criterion of brain death, since it does not satisfy the definition of «the irreversible cessation of the functioning of an organism as a whole», nor the requirement of «total and irreversible cessation of all functions of the entire brain, including the brain stem». There is evidence to the effect that the tests used to confirm this criterion are not specific enough. It is clear that brain death marks the beginning of a process that eventually ends in death, though death does not occur at that moment. From an ethical point of view, the conflict arises between the need to provide an unequivocal diagnosis of death and the possibility of saving a life through organ transplantation. The sensitive issue of brain death calls for a more thorough and in-depth discussion among physicians and the community at large (Rev Med Chile 2004; 132: 95-107).

Consideraciones acerca de la “interrupción voluntaria del embarazo”, desde el punto de vista ético-médico (a propósito de un proyecto de ley)

“Voluntary termination of pregnancy” can refer to actions intended to make a delivery easier, to provide medical care to the fetus, or to protect the life or health of the mother. All of these are proper medical actions and are by definition voluntary. In other cases, the expression denotes a termination of pregnancy before the embryo or fetus is viable, leading to the death of the latter. This action is constitutive of abortion under current Chilean law. The product of conception living being, who develops in the womb during pregnancy, is an individual, both in the sense that it is different from its mother and father, and in that it is a biological individual. For these reasons, such living being constitutes another patient in itself. The free and voluntary medical action of health care professionals is geared toward disease prevention or health recovery and medical terminations of pregnancy, as distinguished from abortion, are not criminalized in our country. Therefore, the idea of legalizing abortive terminations of pregnancy so that they become “legitimate health care services” is a call to the medical community, which should engage in a debate about the meaning and consequences of an eventual mandate of the State that would be at odds with the Hippocratic tradition. A woman can feel that her health is at risk due to her pregnancy, and she certainly has the right to request medical help. Health professionals should care both at the medical and emotional level for all those who require their services, especially when such persons are undergoing situations of vulnerability and distress. When requested to perform an abortion, the physician faces dilemmas that should be addressed in line with the present state of the medical art.

El respeto a la intimidad del paciente

Transparency as a general rule for all our professional acts casts doubts about the statement of the Hippocratic Oath that says “Whatever I see or hear in the lives of my patients, I will keep secret, as considering all such things to be private”. Medical secrecy protects the intimacy of patients, who reveal to their physicians their most hidden secrets aiming to recover their health. Therefore, physicians should receive those secrets with reverence and care, as servers and not as their owners. The values associated with the res-pect for personal intimacy are the anthropological basis of medical confidentiality. A medical act is performed by definition between two equally honorable individuals. Therefore, the professional honors the trust of his patient, maintaining strict confidence of what is revealed. Therefore, medical secrecy must be strengthened rather than weakened, pursuing common wealth and dignity.(Rev Med Chile 2014; 142: 506-511)

Evolución de los pacientes con enfermedad de Crohn de colon operados con el diagnóstico de colitis ulcerosa

Introduccion: La proctocolectomia con reservorio ileal y anastomosis reservorio anal, (RIARA) es actualmente el procedimiento de eleccion en el tratamiento quirurgico electivo de la colitis ulcerosa (CU). La colectomia total y anastomosis ileorrectal (AIR), esta indicada en un seleccionado grupo de pacientes. Algunos pacientes sometidos a estas operaciones por aparente CU pueden evolucionar como una enfermedad de Crohn (EC). Objetivo: Comunicar el curso y pronostico de pacientes que evolucionaron como EC luego de un tratamiento quirurgico por una aparente CU. Materiales y metodos: Se identificaron a los pacientes que tuviesen tratamiento quirurgico por CU, en el periodo 1978 al 2003. Se seleccionaron a los pacientes en los cuales en su evolucion se cambio el diagnostico a EC. En ellos se analizaron las variables quirurgicas y su evolucion posterior. Resultados: En el periodo mencionado se operaron 114 pacientes por CU. En 9 pacientes (8%) el diagnostico cambio a EC, basado principalmente en la evolucion clinica alejada y/o por estudio histologico: 3 de 20 (15%) despues de una colectomia total con AIR y 6 de 84 (7%) despues de una proctocolectomia con RIARA. Las localizaciones mas frecuentes de las manifestaciones de la EC fueron el canal anal y perine. El tratamiento incluyo procedimientos quirurgicos y tratamiento medico con antiinflamatorios y/o inmunomoduladores. Dos pacientes con una colectomia con AIR necesitaron una proctectomia e ileostomia. Se extirpo el reservorio en 1 de 6 pacientes con RIARA. En resumen, una minoria de pacientes sometidos a tratamiento quirurgico con el diagnostico de CU evoluciona posteriormente como una EC. El tratamiento combinado medico quirurgico contribuye a una baja incidencia de perdida del reservorio ileal

Resección ileocecal por enfermedad de Crohn: Resultados y seguimiento

Introduccion: Aproximadamente el 50% de los pacientes con Enfermedad de Crohn (EC) necesitaran de un tratamiento quirurgico en algun momento de su evolucion. La reseccion ileocecal (RIC) es una de las operaciones mas frecuentes en pacientes con EC. Objetivo: Identificar las indicaciones quirurgicas y determinar el porcentaje de recurrencia de la enfermedad a largo plazo de los pacientes sometidos a RIC por EC. Material y metodo: Se incluyeron todos los pacientes sometidos consecutivamente a RIC entre Enero 1970 y Diciembre 2006 y se analizaron caracteristicas demograficas, indicacion operatoria, variables intraoperatorias, complicaciones y, en el seguimiento, la recurrencia de la enfermedad. Resultados: 28 pacientes fueron operados en el periodo mencionado. 17 mujeres (60,7%), edad promedio del diagnostico de EC: 34,8 anos (i: 14-60) y de la RIC: 43,3 anos (i: 16-68). Seis pacientes habian sido operados previamente por EC (3 sobre el perine y 3 resecciones parciales de intestino, no RIC). Una o mas de las siguientes condiciones contribuyeron a la indicacion quirurgica: Obstruccion intestinal intermitente en 21 pacientes, refractariedad a tratamiento medico en 10, fistula enteral en 2 y hemorragia digestiva baja en 2. Nueve pacientes (32,1%) tuvieron una o mas complicaciones postoperatorias, 3 (10%) de los cuales fueron reintervenidos (2 por filtracion de la anastomosis, uno por hemoperitoneo). La mediana de estadia postoperatoria fue 9 dias. No hubo mortalidad operatoria. En el seguimiento a largo plazo, 3 pacientes desarrollaron Ileo mecanico por bridas. Todos ellos resueltos quirurgicamente. Cuatro pacientes (14%) fueron reintervenidos por recidiva de la EC con tiempo medio desde la RIC de 63 meses. La sobrevida a 5 anos fue de 96%. Conclusion: La RIC por EC, se indica principalmente por obstruccion intestinal debida a estenosis. La estenosis en la recidiva de la enfermedad es baja

Infliximab en el tratamiento de la enfermedad de Crohn: Estudio preliminar

Twelve patients with Crohn’s disease (aged 16to 63 years, 10 women) refractory to treatment with steroid, 5-aminosalicylic acid,antimicrobials and immunomodulatory drugs, were studied. A single intravenous 5 mg/kgdose Infliximab was administered. The Crohn’s disease activity index (CDAI) was measuredbefore and one week after the administration of the drug.

Colitis de Crohn: Resultados del tratamiento quirúrgico y evolución alejada.

BACKGROUND Exclusive involvement of the colon or rectum in Crohns disease, called Crohns colitis, (CC) occurs in about 25% of these patients. AIM To analyze early surgical results and long-term outcomes of patients undergoing surgery for CC. MATERIAL AND METHODS Review of a prospective database, identifying patients with Crohns disease operated between 2003 and 2015 and excluding those with ileocecal disease. We analyzed demographic data, pre and postoperative pharmacological treatment, operations, morbidity and the need for a second bowel resection at follow-up. RESULTS We reviewed data from 28 patients aged 17 to 72 years (15 men). Twenty-seven (96.4%) had previous pharmacological treatment, 11 received monoclonal antibodies. The most common indications for surgical treatment were failure of medical treatment in 15 cases, acute severe colitis in 12 and anemia/malnutrition in eight. Total colectomy was performed in 17 (61%) patients, proctocolectomy in 8 (29%) and segmental colectomies in 3 (11%). Sixteen (57%) were operated laparoscopically. Major postoperative complications were observed in 5 (18%). Four needed a reintervention. There was no operative mortality. During a 55 months median follow-up of 27 patients, seven (26%) required a second bowel resection, one of them for recurrence. Nineteen (70%) patients had an ostomy, which was permanent in 11. Fifteen patients are without medical treatment. CONCLUSIONS Most of the reviewed patients required total colectomy for the control of the disease with a low surgical morbidity. Two-thirds required an ileostomy, which became permanent in half of them.

Algunas amenazas actuales a la confidencialidad en medicina

Social, technical and legal conditions of the current practice of medicine make it necessary to insist on certain actions and circumstances that may jeopardize the confidentiality of information, offered by patients to their health providers. Therefore, some effects of the current Chilean law are analyzed in this respect, regarding access to data from the clinical record of a patient. Also, the risks of putting certain data on social networking sites are analyzed, as well as some of its effects on clinical practice. The reasons because of mandatory reporting of diseases, meaning danger to public health, is allowed, are mentioned. We also discuss the difficulties involved in managing the results of preventative health screenings and its knowledge by third parties, as well as some possible violations of personal privacy, regarding dissemination of some people health information and its further mention or figuration in mass media. We conclude that it is a must for both physicians and other health team members, to safeguard confidentiality of data to which they have had access, as well as the need to know the relevant law, in order to respect human dignity of patients, each one as a person. We address the attention to the possibility that, practicing in a different way, it could endanger the reliability of clinical records, also impairing the quality of people’s health care.

Organizing health care: an ethical perspective

Health Care at population level is a complex problem. Having this in mind, the purpose of this paper is to focus on the goods that are ethically relevant in the process of caring for health at this level. We briefly analyze some of the Chilean health statistics that, although they show important improvements along the years, demonstrate that certain conditions are to be deemed as inadequate by both healthcare providers and patients. Ethics is a central component to determine how to structure and organize health care systems and how they should operate. We emphasize Human Dignity as an ethical corner stone of the Health Care System, along with other important values such as Justice and Humanization, under the scope of the Ends of Medicine, and other components such as technical competence of providers and the financing of the whole process. We conclude that as far as a health care system is organized in a way that medical practice is well ordered, primarily and fundamentally according the Ends of Medicine and the good of persons, such a health care system is ethically adequate.Health care at population level is a complex problem. Having this in mind, the purpose of this paper is to focus on the goods that are ethically relevant in the process of caring for health at this level. We briefly analyze some of the Chilean health statistics that, although they show important improvements along the years, demonstrate that certain conditions are to be deemed as inadequate by both healthcare providers and patients. Ethics is a central component to determine how to structure and organize health care systems and how they should operate. We emphasize human dignity as an ethical corner stone of the health care system, along with other important values such as justice and humanization, under the scope of the ends of medicine, and other components such as technical competence of providers and the financing of the whole process. We conclude that as far as a health care system is organized in a way that medical practice is well ordered, primarily and fundamentally according the ends of medicine and the good of persons, such a health care system is ethically adequate.Health care at population level is a complex problem. Having this in mind, the purpose of this paper is to focus on the goods that are ethically relevant in the process of caring for health at this level. We briefly analyze some of the Chilean health statistics that, although they show important improvements along the years, demonstrate that certain conditions are to be deemed as inadequate by both healthcare providers and patients. Ethics is a central component to determine how to structure and organize health care systems and how they should operate. We emphasize human dignity as an ethical corner stone of the health care system, along with other important values such as justice and humanization, under the scope of the ends of medicine, and other components such as technical competence of providers and the financing of the whole process. We conclude that as far as a health care system is organized in a way that medical practice is well ordered, primarily and fundamentally according the ends of medicine and the good of persons, such a health care system is ethically adequate.

Dimensión ética en la organización de la atención de salud.

Health Care at population level is a complex problem. Having this in mind, the purpose of this paper is to focus on the goods that are ethically relevant in the process of caring for health at this level. We briefly analyze some of the Chilean health statistics that, although they show important improvements along the years, demonstrate that certain conditions are to be deemed as inadequate by both healthcare providers and patients. Ethics is a central component to determine how to structure and organize health care systems and how they should operate. We emphasize Human Dignity as an ethical corner stone of the Health Care System, along with other important values such as Justice and Humanization, under the scope of the Ends of Medicine, and other components such as technical competence of providers and the financing of the whole process. We conclude that as far as a health care system is organized in a way that medical practice is well ordered, primarily and fundamentally according the Ends of Medicine and the good of persons, such a health care system is ethically adequate.Health care at population level is a complex problem. Having this in mind, the purpose of this paper is to focus on the goods that are ethically relevant in the process of caring for health at this level. We briefly analyze some of the Chilean health statistics that, although they show important improvements along the years, demonstrate that certain conditions are to be deemed as inadequate by both healthcare providers and patients. Ethics is a central component to determine how to structure and organize health care systems and how they should operate. We emphasize human dignity as an ethical corner stone of the health care system, along with other important values such as justice and humanization, under the scope of the ends of medicine, and other components such as technical competence of providers and the financing of the whole process. We conclude that as far as a health care system is organized in a way that medical practice is well ordered, primarily and fundamentally according the ends of medicine and the good of persons, such a health care system is ethically adequate.Health care at population level is a complex problem. Having this in mind, the purpose of this paper is to focus on the goods that are ethically relevant in the process of caring for health at this level. We briefly analyze some of the Chilean health statistics that, although they show important improvements along the years, demonstrate that certain conditions are to be deemed as inadequate by both healthcare providers and patients. Ethics is a central component to determine how to structure and organize health care systems and how they should operate. We emphasize human dignity as an ethical corner stone of the health care system, along with other important values such as justice and humanization, under the scope of the ends of medicine, and other components such as technical competence of providers and the financing of the whole process. We conclude that as far as a health care system is organized in a way that medical practice is well ordered, primarily and fundamentally according the ends of medicine and the good of persons, such a health care system is ethically adequate.