Iris Delgado B

Factores de riesgo para las enfermedades no transmisibles: metodología y resultados globales de la encuesta de base del programa CARMEN: conjunto de acciones para la reducción multifactorial de las enfermedades no transmisibles

Background: In the last decades, chronic non communicable diseases are becoming the main cause of disability and mortality among adults. The risk factor surveillance and management is the most efficient mean of reducing the impact of these diseases. Aim: To report the results of a non communicable disease risk factor surveillance program in Valparaiso, Chile. Material and methods: A random samples of people aged 25 to 64 years old living in Valparaiso, Chile was studied. Subjects were questioned about smoking and physical activity habits. Blood pressure, height and weight were measured using standardized techniques at their homes and blood samples were obtained to measure serum lipid levels and oral glucose tolerance test at the nearest outpatient clinic. Results: Of the initial 3852 homes selected, 752 individuals did no agree to answer the inquiry, therefore 3120 subjects were finally interviewed. Of these, 40.6% were smokers, 15% drank alcohol in two or more occasions per month, 84.6% were physically inactive, 19.7% had a body mass index over 30 kg/m2, 11.1% had high blood pressure, 3.9% were diabetic and 46.9% had high serum cholesterol levels. Conclusions: The basal survey for the CARMEN program shows a high prevalence of cardiovascular risk factors among Chileans.

Equidad de género en el acceso a la atención de salud en Chile

Background: In the last two decades, Chile has experienced advances in economical development and global health indicators. However, gender inequities persist in particular related to access to health services and financing of health insurance. Aim: To examine gender inequities in the access to health care in Chile. Material and methods: An analysis of data obtained from a serial national survey applied to assess social policies (CASEN) carried out by the Ministry of Planning. During the survey 45,379 and 48,107 dwellings were interviewed in 1994 and in 1998, respectively. Results: Women use health services 1.5 times more often, their salaries are 30% lower in all socioeconomic strata. Besides, in the private health sector, women pay higher insurance premiums than men. Men of less than two years of age have 2.5 times more preventive consultations than girls. This difference, although of lesser magnitude, is also observed in people over 60 years. Women of high income quintiles and users of private health insurance have a better access to preventive consultations but not to specialized care. Conclusions: An improvement in equitable access of women to health care and financing is recommended. Also, monitoring systems to survey these indicators for women should improve their efficiency (Rev Med Chile 2003; 131: 669-678)

Inequidad de ingreso y autopercepción de salud: un análisis desde la perspectiva contextual en las comunas chilenas

Background: The correlation between income inequality and life expectancy was demonstrated 10 years ago, but later, several studies suggested that the negative impact of a low economic income on the health status was disappearing. Aim: To assess the independent effects of community income inequality on self rated health in Chile. Material and methods: Multilevel analysis of the 2000 National Socio Economic Characterization Survey (CASEN) data from Chile. Individual level information included self rated health, age, sex, ethnicity, marital status, education, income, type of health insurance and residential setting (urban/rural). Community level variables included the Gini coefficient and median income. The main outcome measure was dichotomized self rated health (0 if excellent, very good or good; 1 if fair or poor). Results: 101,374 individuals (at level 1) aged 18 and above, nested within 285 communities (at level 2) and 13 regions (at level 3) were studied. Controlling for a range of individual level predictors, a significant gradient was observed between income and poor self rated health, with very poor most likely to report poor health (10.5%) followed by poor (9.5%) low (9%) middle (7%), high (6%) and very high (4.5%) income earners. Controlling for individual and community effects of income, a significant non linear effect of community income inequality was observed, with the most unequal communities being associated with approximately 5% higher likelihood of reporting poor health compared to the most equal communities. Conclusions: Individual income does not explain any of the between community differences and neither does it wash the significant effects of income inequality on poor self rated health. The contextual effect of inequality is almost as large as the differential observed in poor health comparing the very poor to the very rich individual income categories (Rev Med Chile 2003; 131: 321-30).

Exposición severa a plomo ambiental en una población infantil de Antofagasta, Chile

Background: In Antofagasta, Chile, lead is gathered in bulk in urban zones, contaminating surrounding schools and houses. Aim: To verify if the environmental lead exposure results in high blood lead levels in children living near lead storage sites. Material and methods: Four hundred eighty six children under 7 years old, living near lead storage sites and 75 children living far away form these sites, were studied. An inquiry was applied and venous blood was drawn. Air, soil and water lead concentrations were also measured. Results: Lead geometric mean concentrations in exposed children were 8.7 µg/dL and 4.22 µg/dL in unexposed children. Forty seven percent of exposed children and no unexposed children had lead levels over 10 µg/dL. The distance of dwellings from lead storage sites, their geographic location and their antiquity were significantly associated with high blood lead levels. Multivariate models disclosed that people living in contaminated sites have an odds ratio of 24.9 for high blood lead levels. Conclusions: Environmental lead contamination is significantly associated with high blood lead levels.

Experiencia de trombolisis sistematizada en infarto cerebral agudo en un hospital público de Chile

BACKGROUND The only accepted treatment for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (t-PA). It was implemented in Chile in 1996, although its use was mainly restricted in Chile to private clinics. Recently, at year 2009, we have implemented this treatment in a public hospital. AIM To describe the results of treatment of acute ischemic stroke with t-PA in a public hospital in Chile. MATERIAL AND METHODS Prospective analysis of all eligible patients with acute ischemic stroke that were admitted within 4 hours of its onset and had no contraindications for thrombolysis. RESULTS In an eight months period, a total of 19 intravenous thrombolyses were performed in 12 males and seven females aged 28 to 79 years old. The mean lapse between onset of symptoms and onset of thrombolysis was 190 ± 57 min. Results were favorable, according to Rankin and National Institute of Health Stroke scales. Ninety days after treatment, 63% of patients had minimal or absent disability, 26% had moderate disability and only one (5%) had severe disability. One patient had a clinically not significant intracranial hemorrhage and one patient died six days after thrombolysis. CONCLUSIONS These results indicate that thrombolysis can be successfully implemented in Chilean public hospitals. The limitations for its use in this setting are mostly administrative.Background: The only accepted treatment for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (t-PA). It was implemented in Chile in 1996, although its use was mainly restricted in Chile to private clinics. Recently, at year 2009, we have implemented this treatment in a public hospital. Aim : To describe the results of treatment of acute ischemic stroke with t-PA in a public hospital in Chile. Material and Methods : Prospective analysis of all eligible patients with acute ischemic stroke that were admitted within 4 hours of its onset and had no contraindications for thrombolysis. Results : In an eight months period, a total of 19 intravenous thrombolyses were performed in 12 males and seven females aged 28 to 79 years old. The mean lapse between onset of symptoms and onset of thrombo- lysis was 190 ± 57 min. Results were favorable, according to Rankin and National Institute of Health Stroke scales. Ninety days after treatment, 63% of patients had minimal or absent disability, 26% had moderate disability and only one (5%) had severe disability. One patient had a clinically not significant intracranial hemorrhage and one patient died six days after thrombolysis. Conclusions : These results indicate that thrombolysis can be successfully implemented in Chilean public hospitals. The limitations for its use in this setting are mostly administrative

Análisis del nuevo Módulo de Salud de la Encuesta CASEN 2000

Background: The National Socioeconomic Characterization Survey (CASEN) was modified in the year 2000, to include an assessment of the inequalities in the access to health services. Aim: To analyze the health issues of year 2000 survey database. Material and methods: During 2000, 38338 urban and 26698 rural dwellings were surveyed, totaling 240000 people analyzing ascription to public or private health services and the need demand and use of these services. Results: A higher risk population (lower income, higher age and women) is ascribed to public health services. Sixty five percent of the population self perceives their health as good, this figure decreases along with age and women have a worse self perception than men. In the 30 days prior to the survey, 13% of the population had a health related event; this figure was higher among women and the lower income quintiles. Expressed health demand was higher among women and lower income quintiles. A multivariate analysis identified an age below 14 years, pertaining to a minority ethnic group, ascription to private health services, residing in rural areas, pertaining to the lower income quintile and male sex, as factors associated to a lack access to health care. In the adjusted model, pertaining to the National Health Fund (a public system) is a protective factor to receive health services. Conclusions: The significant inequalities in the access to health care should be corrected with the new Health Reform. The new module incorporated to the National Socioeconomic Characterization Survey, is usefel to assess the access to health care in Chile (Rev Med Chile 2004; 132: 750-60). (Key Words: Delivery of healthcare; Health care systems; Health surveys; Socioeconomic factors)

Prematuros moderados y tardíos, un grupo de riesgo de menor desarrollo cognitivo en los primeros años de vida

Introduccion: Estudios recientes refieren que los prematuros moderados y tardios (PMT) (Edad Gestacional (EG) 32 a 366), presentan un elevado riesgo de retraso del desarrollo psicomotor (DSM) y dificultades de aprendizaje. Objetivo: Comparar el DSM entre ninos nacidos PMT y recien nacidos de termino (RNT) y analizar los factores de riesgo perinatal asociados. Metodologia: En un centro de salud de Santiago de Chile, entre mayo 2008 y abril 2011, se reclutaron 131 PMT y 119 RNT, pareados por edad, genero y nivel socioeconomico. A los 8, 18 o 30 meses se les aplico la Escala de Bayley III de Desarrollo Infantil-3a edicion. Se comparo el DSM entre los dos grupos y se implemento una regresion lineal multiple. Resultados: Los PMT presentaron un coeficiente de desarrollo significativamente inferior al no corregir EG, equiparandose con los RNT al corregirla (99 ± 10,4 vs 100,8 ± 9,9). Aun con EG corregida, el desempeno cognitivo fue inferior (98 ± 10,4 vs 103,1 ± 11,4 p < 0,05). En la regresion lineal multiple el genero y la EG se asociaron con menor desarrollo cognitivo. Conclusion: El desempeno cognitivo de los PMT fue inferior a los RNT. Se plantea la importancia de implementar un estandar de cuidado y estimulacion para este grupo de ninos.

Aumento del riesgo de consultas cardiovasculares por contaminación atmosférica por partículas: Estudio en la ciudad de Santiago

ResumenIntroduccion: En la literatura se reconoce que la contaminacion del aire por particulas en diversasciudades determina un exceso del riesgo de enfermedades cardiovasculares. Santiago es una de las urbes conmayor polucion de particulas MP 10 y MP 2,5 en el mundo. Objetivo: Estudiar la asociacion entre la concentracion diaria de particulas y la morbilidad cardiovascular en los6 Servicios de Urgencia de la ciudad. Metodos: Se consideraron el numero total de consultas cardiovasculares en el ano 2007, el Infarto miocardico,accidente cerebro-vascular y crisis hipertensiva. La concentracion de particulas se obtuvo de los registrosde 7 centros de la red de Monitoreo de la Calidad del Aire de la Region Metropolitana (MACAM) y lasvariables temperatura y humedad, del Instituto de Meteorologia de Chile. Estadisticamente se implementoun modelo de regresion multiple GAM. Resultados: Se observo que para todo el ano 2007 las concentraciones de particulas ambientales MP 10estuvieron altas, sobre la norma recomendada por la OMS. Ello se asocio a un incremento del 10% del riesgode consultas cardiovasculares durante todo el ano 2007. Para las particulas MP 2,5 el riesgo aumento en un17%. En los meses invernales Junio y Julio, el riesgo aumento en 15% y 28% respectivamente. Todas las cifrasresultaron altamente significativas (p< 0.001). Para la crisis hipertensiva, los aumentos del riesgo fueron 4 y13% , tambien significativos.

Metabolismo mineral en niños en diálisis peritoneal crónica

INTRODUCTION Children with chronic kidney disease (CKD) and receiving peritoneal dialysis (PD) have disorders of mineral metabolism that impact their growth, survival and cardiovascular functions. New molecular markers offer a better understanding of the pathophysiology of this disease. OBJECTIVE To characterize some components of mineral metabolism, with emphasis on FGF23/Klotho and cardiovascular functions (CV) of these patients. PATIENTS AND METHOD Prospective observational cohort study. EXCLUSION CRITERIA serum 25 (OH) vitamin D < 20 ng/ml, peritonitis within the last two months and active nephrotic syndrome. Calcemia, phosphemia, parathyroid hormone (PTH), 25 (OH) vitD3, 1.25 (OH) vitD3, FGF23 and Klotho in plasma were measured. FGF23 and Klotho were quantified in healthy children as a control group. Echocardiography was performed calculating the left ventricular mass index (LVMI). Descriptive statistics analysis, Pearson correlation coefficient for association among variables and multivariate analysis were conducted. RESULTS 33 patients, 16 males, aged between 1.2 and 13.4 years were included. Age of onset for PD: 7.3 ± 5.0 years, time receiving PD: 13.5 ± 14.5 months. The plasma concentration of 25 (OH) vitD3 was 34.2 ± 6.3 pg/ml. Calcemia and phosphemia values were 9.8 ± 0.71 and 5.4 ± 1.0 mg/dl respectively. PTH was 333 ± 287 pg/ml. FGF23 in plasma was 225.7 ± 354.3 pg/ml and Klotho 131.6 ± 72 pg/ml, and in the controls ( n = 16 ), it was 11.9 ± 7.2 pg/ml and 320 ± 119 pg/ml, respectively. The residual and total dose of dialysis (KtV) was 1.6 ± 1.3 and 2.9 ± 1.6, respectively. FGF23 levels significantly correlated with calcium (p < 0.001, r = 0.85), and inversely with residual KtV, showing no relationship with phosphemia. Klotho level correlated negatively with residual KtV and also, it showed a negative association with chronological age and age at onset of PD. LVMI > 38 g/m² was confirmed in 20/28 patients. CONCLUSIONS The values of FGF23, and PTH are elevated in children with CKD on PD. Klotho levels in CKD patients are lower than control children. A strong association of calcemia with FGF23 and PTH is reported. Residual renal function is inversely associated with FGF23 and Klotho. A high incidence of left ventricular hypertrophy was found evidencing a cardiovascular compromise in these patients.Introduccion: Los ninos portadores de Enfermedad renal cronica (ERC) en dialisis peritoneal (DP) presentan alteraciones del metabolismo mineral que afectan su crecimiento, estado cardiovascular y sobrevida. Nuevos marcadores moleculares representan una mejor comprension de la fisiopatologia de esta enfermedad. Objetivo: Caracterizar componentes del metabolismo mineral, con enfasis en FGF23/Klotho, y estado cardiovascular (CV) en este grupo de pacientes. Pacientes y Metodo: Estudio prospectivo observacional. Criterios de exclusion: niveles de 25 (OH) vitamina D 38 g/m2. Conclusiones: Los valores de FGF23 y PTH se encuentran elevados en ninos con ERC en DP. Los niveles de Klotho se encuentran disminuidos en estos pacientes en comparacion a los controles. Destaca una fuerte asociacion de la calcemia con FGF23 y PTH. La funcion renal residual se asocio inversamente a FGF23 y Klotho. Se constato una alta incidencia de hipertrofia ventricular izquierda evidenciando el compromiso cardiovascular en este grupo de pacientes.

Evolución de las Licencias por Enfermedad Grave del niño(a) menor de un año 2004-2008: Certezas e Interrogantes

Background: The increase in expenses of the health care system caused by sick leaves, especially those granted to mothers with children of less than one year of age with severe diseases, is a topic of concern. Aim: To describe the rates of sick leaves granted to mothers with children of less than one year of age with severe diseases from 2004 to 2008. Material and Methods: Analysis of databases containing information about sick leaves coming from Chilean public and private health care subsystems. Leaves granted to mothers with sick children of less than one year were specifically analyzed in terms of days off work and the amount of monetary benefits. Results: A sustained increase, ranging from 20 to 120% in the number of sick leaves motivated by diseases of children of less than one year, was observed. Thirty four percent of maternity leaves concentrate immediately after finishing the legal period (24 weeks after birth) and almost 60% of them occured within the first 6 months after birth. The most frequent diagnoses that motivated the higher number of leaves were gas-troesophageal reflux and bronchitis. Conclusions: There is probably a bad use of the benefit in a percentage of leaves. The benefit is also regressive since it favors mostly mothers of a better socioeconomic condition. The law that will extend the postnatal maternity leave will solve in part these problems.