Attitudes of medical students toward psychiatry in a Chilean medical school

OBJECTIVE

The authors assess the attitudes of seventh-year medical students with regard to psychiatry and patients with psychiatric illness during the psychiatry clerkship.

METHODS

A 32-item questionnaire regarding attitudes toward psychiatry and patients with psychiatric illness was administered at the beginning of the psychiatry clerkship.

RESULTS

One hundred and ten seventh-year students participated in the study, providing responses anonymously. Average negative attitude item score was 2.45 ± 0.3 (range 1.7-3.3). Eighty-three students (75 %) responded to all the questions with an average negative attitude item score of 2.43 ± 0.3 (range 1.7-3.3) and a total negative attitude item score of 77.9 ± 10.3 (range 55-104).

CONCLUSIONS

Undergraduate students of a Chilean medical school showed fairly positive attitudes toward psychiatry and toward patients with psychiatric illness.

Development and validation of a delirium predictive score in older people

BACKGROUND

delirium is frequently under diagnosed in older hospitalised patients. Predictive models have not been widely incorporated in clinical practice.

OBJECTIVE

to develop and validate a predictive score for incident delirium.

DESIGN AND SETTING

two consecutive observational prospective cohorts (development and validation) in a university affiliated hospital.

SUBJECTS

inpatients 65 years and older.

METHODS

in the development cohort patients were assessed within the first 48 h of admission, and every 48 h thereafter, using the confusion assessment method to diagnose delirium and data were collected on comorbidity, illness severity, functional status and laboratory. Delirium predictive score (DPS) was constructed in the development cohort using variables associated with incident delirium in the multivariate analysis (P < 0.05), and then tested in a validation cohort of comparable patients, admitted without delirium. Receiver operating characteristic (ROC) analysis and likelihood ratio (LR) were calculated.

RESULTS

the development cohort included 374 patients, incident delirium occurred in 25. After multivariate analysis incident delirium was independently associated with lower functional status (Barthel Index) and a proxy for dehydration (elevated urea to creatinine ratio). Using these variables, DPS was constructed with a performance in the ROC curve area of 0.86 (95% CI: 0.82-0.91) and (-) LR = 0.16 and (+) LR = 3.4. The validation cohort included 104 patients and the performance of the score was ROC 0.78 (95% CI: 0.66-0.90).

CONCLUSIONS

This simple predictive model highlights functional status and a proxy for dehydration as a useful tool for identifying older patients that may benefit from close monitoring and preventive care for early diagnosis of delirium.

A risk prediction model for severe intraventricular hemorrhage in very low birth weight infants and the effect of prophylactic indomethacin

OBJECTIVE

Develop a risk prediction model for severe intraventricular hemorrhage (IVH) in very low birth weight infants (VLBWI).

STUDY DESIGN

Prospectively collected data of infants with birth weight 500 to 1249 g born between 2001 and 2010 in centers from the Neocosur Network were used. Forward stepwise logistic regression model was employed. The model was tested in the 2011 cohort and then applied to the population of VLBWI that received prophylactic indomethacin to analyze its effect in the risk of severe IVH.

RESULT

Data from 6538 VLBWI were analyzed. The area under ROC curve for the model was 0.79 and 0.76 when tested in the 2011 cohort. The prophylactic indomethacin group had lower incidence of severe IVH, especially in the highest-risk groups.

CONCLUSION

A model for early severe IVH prediction was developed and tested in our population. Prophylactic indomethacin was associated with a lower risk-adjusted incidence of severe IVH.

[Nutritional status, metabolic syndrome and insulin resistance in children from Santiago (Chile)]

BACKGROUND

The origin of most non-communicable diseases (NCDs) is in early life. Consequently obtaining information on risk factors for NCDs is important for preventive purposes. However, there is no information available on the prevalence of obesity, metabolic syndrome (MS) and insulin resistance (IR) in Chilean children.

OBJETIVES

To determine the prevalence of nutritional status, MS and IR, and secondly, to study the associations among them.

METHODS

Cross-sectional study conducted during 2009-2011 in 20 public schools of Puente Alto County, Santiago, Chile. Anthropometry, blood pressure and pubertal status were assessed. A blood sample was obtained for determination of lipids, blood glucose and insulin. Abnormal Homeostasis model assessment index (HOMA-IR) was based on a national standard.

RESULTS

3325 children had a mean age of 11.4 ± 1 years old (range 10-15 years). The prevalence of obesity, MS and IR was 16.1%, 7.3% and 25.9%, respectively. The prevalence of IR and MS was higher in obese children. MS and IR were strongly associated with an OR of 8.0 (95% CI= 5.9-10.7). Multivariate analysis showed that all MS components were associated to IR.

CONCLUSIONS

There is a relatively high prevalence of risk factors in this sample of children. The strong positive association between nutritional status, IR and MS points out the need to early identify risk factors for NCDs allowing for prevention.

[Risk factors for post partum depression]

BACKGROUND

Postpartum depression (PPD) is a public health problem with high prevalence in Chile. Many factors are associated with PPD.

AIM

To analyze the factors associated with the incidence of depressive symptoms (SD) in women with low obstetric risk.

MATERIAL AND METHODS

Cross-sectional analytical study on a sample of 105 postpartum women with low obstetric risk assessed by the Edinburgh Depression Scale at the eighth week postpartum.

RESULTS

A 37% prevalence of depressive symptoms was found. Univariate analysis showed that the perception of family functioning, overcrowding and number of siblings, were significantly associated with postpartum depressive symptoms. A multiple regression model only accepted family functioning as a predictor of depression.

CONCLUSIONS

Perception of family functioning was the only variable that explained in part the presence of depressive symptoms in women with low obstetric risk.

Phytosterol and cholesterol precursor levels indicate increased cholesterol excretion and biosynthesis in gallstone disease

In hepatocytes and enterocytes sterol uptake and secretion is mediated by Niemann-Pick C1-like 1 (NPC1L1) and ATP-binding cassette (ABC)G5/8 proteins, respectively. Whereas serum levels of phytosterols represent surrogate markers for intestinal cholesterol absorption, cholesterol precursors reflect cholesterol biosynthesis. Here we compare serum and biliary sterol levels in ethnically different populations of patients with gallstone disease (GSD) and stone-free controls to identify differences in cholesterol transport and synthesis between these groups. In this case-control study four cohorts were analyzed: 112 German patients with GSD and 152 controls; two distinct Chilean ethnic groups: Hispanics (100 GSD, 100 controls), and Amerindians (20 GSD, 20 controls); additionally an 8-year follow-up of 70 Hispanics was performed. Serum sterols were measured by gas chromatography / mass spectrometry. Gallbladder bile sterol levels were analyzed in cholesterol GSD and controls. Common ABCG5/8 variants were genotyped. Comparison of serum sterols showed lower levels of phytosterols and higher levels of cholesterol precursors in GSD patients than in controls. The ratios of phytosterols to cholesterol precursors were lower in GSD patients, whereas biliary phytosterol and cholesterol concentrations were elevated as compared with controls. In the follow-up study, serum phytosterol levels were significantly lower even before GSD was detectable by ultrasound. An ethnic gradient in the ratios of phytosterols to cholesterol precursors was apparent (Germans > Hispanics > Amerindians). ABCG5/8 variants did not fully explain the sterol metabolic trait of GSD in any of the cohorts.

CONCLUSION

Individuals predisposed to GSD display increased biliary output of cholesterol in the setting of relatively low intestinal cholesterol absorption, indicating enhanced whole-body sterol clearance. This metabolic trait precedes gallstone formation and is a feature of ethnic groups at higher risk of cholesterol GSD.

The relationship between knowledge of HIV, self-perceived vulnerability and sexual risk behavior among community clinic workers in Chile

OBJECTIVE

Testing the hypothesis of an association between knowledge and sexual risk behaviour (SRB) amongst community-clinic workers in Chile, explained by the confounding effect of self-perceived vulnerability to HIV.

METHODS

A cross-sectional survey was analyzed; it was nested within a quasi-experimental study of 720 community-clinic workers in Santiago. The SRB score combined the number of sexual partners and condom use (coded as "high"/"low" SRB). Knowledge of HIV (a 25-item index) was coded as "inadequate"/"adequate" knowledge. Self-perceived vulnerability to HIV was categorised as being "high"/ "moderate"/"low". Control variables included socio-demographics, religiousness and educational level. Percentages/averages, Chi-square tests and logistic regression (OR-estimations) were used for descriptive, association and confounding analysis.

RESULTS

Respondents were 78.2 % female, 46.8 % married and 67.6 % Catholic. Mean age was 38.9 (10.5 SD) and 69 % had university/diploma level. Self-perceived HIV vulnerability was "low" in 71.5 % cases. A negative association between knowledge and SRB was found (OR=0.55;CI=0.35-0.86), but self-perceived vulnerability did not have a confounding effect on this relationship. This relationship also persisted after being adjusted for multiple control variables (e.g. age, sex, type of primary centre, educational level, and religiousness).

CONCLUSIONS

Some community-clinic workers had inaccurate knowledge of HIV, which was associated with SRB. Self-perceived vulnerability did not have a confounding effect; however, future studies should further analyze occupational risk of HIV as a possible driving factor in health workers' perception of their risk. Focused training programmes should be developed to enhance basic knowledge of HIV in this group.

[Normal plasma insulin and HOMA values among Chilean children and adolescents]

BACKGROUND

Plasma insulin and HOMA (homeostasis model assessment) index, used to determine insulin resistance, do not have local standard values for children and adolescents in Chile.

AIM

To establish the normal reference intervals for insulin and HOMA in children and adolescents aged 10-15 years, according to sex and puberal maturation.

MATERIAL AND METHODS

A cross-sectional study of 2,153 children and adolescents from Puente Alto County was performed, during 2009 and 2010. Anthropometry and self-report of puberal maturation were assessed. Fasting glucose (hexoquinase) and insulin blood levels (chemiluminiscence), were determined and HOMA index was calculated. Percentile distributions of these variables were calculated.

RESULTS

The reference group included only subjects with normal body mass index and fasting blood glucose (n = 1,192). Girls had higher insulin and HOMA values than boys (12.5 ± 6.0 and 9.1 ± 4.9 μϋ/mL (p < 0.01) and 2.7 ± 1.4 and 2.1 ± 1,1 (p < 0.01), respectively). Subjects with Tanner I and II pubertal stages had lower insulin and HOMA mean values than subjects with Tanner III and IV (9.0 ± 4.3 and 12.5 ± 6.2μϋ/ml (p < 0.01) and2.0 ± 1 and2.8 ± 1.4 (p < 0.01), respectively).

CONCLUSIONS

The 90th percentile of insulin and HOMA distributions according to sex and maturation, was selected as the upper cut-off point to identify individuals with insulin resistance. HOMA cutoff point for Tanner I and II boys was 3.2, for Tanner I and II girls was 4.1, for Tanner III and IV boys was 4.2 and for Tanner III and IV girls was 5.0.

[Competences on hypoglycemia management among healthcare professionals in a clinical hospital]

BACKGROUND

A tight glycemic control of hospitalized patients increases the risk of hypoglycemia, whose management is not always optimal.

AIM

To assess the hypoglycemia management competences of a multidisciplinary team in a clinical hospital.

MATERIAL AND METHODS

An anonymous questionnaire about hypoglycemia management was answered by 11 staff physicians, 42 residents and 28 nurses of the department of medicine and critical care unit ofa university hospital.

RESULTS

Respondents had a mean of 60% of correct answers, without significant differences between groups. The capillary blood glucose level that defines hypoglycemia was known by most of the respondents, but the value that defines severe episodes was known only by 60%. The initial management and follow up was well known only for severe episodes. Less than 50%o knew the blood glucose value that required continuing with treatment.

CONCLUSIONS

Although most professionals are able to recognize hypoglycemia, the knowledge about is management if insufficient.

[Effect of a tele-care model on self-management and metabolic control among patients with type 2 diabetes in primary care centers in Santiago, Chile]

BACKGROUND

Telephone based self-management support may improve the metabolic control of patients with type2 (DM2) diabetes if it is coordinated with primary care centers, if telephone protocols and clinical guidelines are used and if it is provided by nurses trained in motivational interviewing.

AIM

To assess the efficacy of a tele-care self-management support model (ATAS) on metabolic control of patients with DM2 attending primary care centers in a low income area in Santiago, Chile.

MATERIAL AND METHODS

Two primary care centers were randomly assigned to continue with usual care (control group, CG) or to receive additionally 6 telecare self-management support interventions (IG) during a 15 month period. Glycosylated hemoglobin (HbA1c) was used to measure metabolic control of DM2; the "Summary of Diabetes Self-care Activities Measure" and the "Spanish Diabetes Self-efficacy" scale were used to measure self-management and self efficacy, respectively. Changes in the use of health services were also evaluated.

RESULTS

The IG maintained its HbA1c level (baseline and final levels of 8.3 +/- 2.3% and 8.5 +/- 2.2% respectively) whereas it deteriorated in the CG (baseline and final levels of 7.4 +/- 2.3 and 8.8 +/- 2.3% respectively, p < 0.001). The perception of self-efficacy in the IG improved while remaining unchanged in the CG (p < 0.001). Adherence to medication, physical activity and foot care did not change in either group. In the IG, compliance to clinic visits increased while emergency care visits decreased.

CONCLUSIONS

The ATAS intervention, in low income primary care centers, significantly increased the probability of stabilizing the metabolic control of patients with DM2 and improved their use of health services.

[Methodology for evaluating cost-effectiveness in primary health care centers in Chile]

OBJECTIVE

Present a methodology for evaluating cost-effectiveness in primary health care centers (PHCs) in Chile based on the family health care model promoted in Chile and evaluate the results of the first two years of operation of the first pilot center to work under this new primary-care model.

METHODS

A cost-effectiveness study with a social perspective and a one-year time frame was conducted. In order to compare the university health center in question with the control (a municipal health center), a Family Health Center Composite Quality Index (FHCCQI) was devised. It combines technical indicators and user perceptions of the health centers in six areas: access, continuity of medical care, a preventive and promotional clinical approach, problem-solving capability, participation, and a biopsychosocial and family approach. In order to calculate the costs, the centers' expenses, the savings realized in the rest of the health system, and patients' out-of-pocket expenditures were considered. The incremental cost-effectiveness ratio (ICR) was estimated and a sensitivity analysis was performed.

RESULTS

The university health center was 13.4% more expensive (an additional US$8.93 per annum per enrollee) and was more effective (FHCCQI 13.3% greater) than the municipal one. Accordingly, the ICR is US$0.67 for each additional percentage point of FHCCQI increase.

CONCLUSIONS

According to the PHC evaluation model that was implemented, the centers that follow the Chilean family health care model are more effective than traditional PHC centers, as measured by both technical indicators and user ratings.

[Depressive symptoms among patients with acute myocardial infarction. Relationship with revascularization therapy]

BACKGROUND

Persistence of depressive symptoms after myocardial infarction (MI) is associated with an adverse outcome. The relationship between depression and Invasive Revascularization Therapy (IRT) is not yet fully understood.

AIM

To compare the frequency of depressive symptoms and other psychosocial variables among patients with MI, undergoing or not undergoing IRT.

MATERIAL AND METHODS

Prospective evaluation of 45 patients aged 58 +/- 11 years (87% males) with a diagnosis of MI (Killip I and II). On admission to hospital and at follow up 3 months after discharge, all patients completed the Beck Depression Inventory (BDI), the Zung Anxiety Inventory (ASI), and the Medical Outcomes Study (MOS) social support survey. Depressive symptoms were considered to be present if the BDI score was over 10.

RESULTS

Thirty seven percent were hypertensive, 15% diabetic and 44% smokers. Sixty four percent of patients underwent IRT (11.1% revascularization surgery and 53.3% coronary angioplasty). Forty four percent of patients scored over 10 in the BDI at baseline assessment and 26.5% at 3 months follow-up (p < 0.01). At baseline BDI score was 10.2 +/- 5.1 and 9.1 +/- 4.4 among patients subjected or not subjected to IRT, respectively (NS). The figures at 3 months of follow up were 9.9 +/- 5.6 and 4.1 +/- 2.5, respectively (p < 0.01). At baseline and three months BDI, anxiety and perceived social support were significantly correlated.

CONCLUSIONS

Depressive symptoms were frequent after MI in this group of patients, and decreased at follow up only among patients not subjected to IRT.

Tobacco smoking in urban neighborhoods: exploring social capital as a protective factor in Santiago, Chile

INTRODUCTION

Research examining the relationship between social capital and health in Latin America has been limited. The aim of this study is to evaluate the association between social capital and tobacco use in four low-income neighborhoods in Santiago, Chile.

METHODS

A multistage probability sample was used to select households in 4 of the 10 poorest neighborhoods in the district of Puente Alto, in Santiago, Chile. A cross-sectional survey of 781 participants (81.2% response rate for households) included sociodemographic variables, questions pertaining to neighborhood social capital, and questions pertaining to tobacco. Main analyses were carried out at the individual level by performing a multiple logistic regression of individual tobacco use on individual perceptions of community social capital.

RESULTS

The prevalence of smoking was 43.9% of the surveyed population. A five-factor structure for social capital was identified, including "perceived trust in neighbors," "perceived trust in organizations," "reciprocity within the neighborhood," "neighborhood integration," and "social participation." An inverse relationship between trust in neighbors and tobacco smoking was statistically significantly with an adjusted odds ratio of 0.95 (95% CI: 0.91-0.99). Trust in neighbors was also significantly inversely associated with the number of cigarettes smoked.

DISCUSSION

Tobacco control remains a significant challenge in global health, requiring innovative strategies that address changing social contexts as well as the changing epidemiological profile of developing regions.

[Helicobacter pylori infection in symptomatic patients with benign gastroduodenal diseases: analysis of 5.664 cases]

Infection with Helicobacter pylori (H. pylori) is highly prevalent in Chile, but there are no systematic studies in patients with upper gastrointestinal symptoms.

AIM

To determine the prevalence of H. pylori infection, according to age, gender and endoscopic pathology in a large sample of patients.

METHODS

We studied 7,893 symptomatic patients submitted to upper gastrointestinal endoscopy between July 1996 and December 2003 in the context of a screening program of gastric cancer in a high risk population. H. pylori infection was determined by rapid urease test (RUT) in antral mucosa. We excluded 158 patients with gastric cancer (2%) and 2,071 patients without RUT.

RESULTS

We included 5,664 patients, mean age 50.7 +/- 13.9 years, women 72.1%. Endoscopic diagnoses were normal in 59.3%, erosive esophagitis in 20%, gastric ulcer (GU) in 8.1%, duodenal ulcer (DU) in 6.4%, and erosive gastropathy in 6.2%. RUT was positive in 78% of patients. After adjusting for age and sex and with respect to patients with normal endoscopy, frequency of H. pylori infection was 86.6% in DU (OR 2.1, 95% CI 1.5-2.8, p < 0.001); 81.4% in GU (OR 1.8, 95% CI 1.4-2.4; p < 0.001 ); 79.9% in erosive gastropathy (OR 1.4, 95% CI 1.03-1.8; p = 0.03) and 77.4% in erosive esophagitis (OR 1.1, 95% CI: 0.9-1.3; p = NS). The probability of H. pylori infection decreased significantly with age, more markedly in men with normal endoscopy.

CONCLUSIONS

Prevalence of H. pylori infection is very high in symptomatic Chilean patients and even higher in those with gastroduodenal ulcer or erosions, while in patients with erosive esophagitis is similar to those with normal endoscopy. The frequency of infection decreases with age, probably as a consequence of rising frequency of gastric mucosal atrophy.

Cluster analysis using multivariate mixed effects models

A common situation in the biological and social sciences is to have data on one or more variables measured longitudinally on a sample of individuals. A problem of growing interest in these areas is the grouping of individuals into one of two or more clusters according to their longitudinal behavior. Recently, methods have been proposed to deal with cases where individuals are classified into clusters through a linear model of mixed univariate effects deriving from a longitudinally measured variable. The method proposed in the current work deals with the case of clustering and then classification based on two or more variables measured longitudinally, through the fitting of non-linear multivariate mixed effect models, and with consideration given to parameter estimation for balanced and unbalanced data using an EM algorithm. The application of the method is illustrated with an example in which the clusters are identified and the classification into clusters is compared with the true membership of individuals in one of two groups, which is known at the end of the follow-up period.

Impact of delirium on short-term mortality in elderly inpatients: a prospective cohort study

BACKGROUND

Delirium is an important problem especially in older medical inpatients.

OBJECTIVE

The authors asked whether delirium and its duration are associated with higher mortality in a 3-month follow-up period.

METHOD

In this prospective cohort study, inpatients age 65 and older were assessed every 48 hours with the Confusion Assessment Method.

RESULTS

Of 542 patients enrolled, 192 (35.4%) developed delirium. After 3 months, mortality in the delirium cohort was 25.9%, and in the nondelirium cohort was 5.8%. Delirium was independently associated with mortality, and increased by 11% for every 48 hours of delirium.

CONCLUSION

Delirium and increased delirium durations are significantly associated with higher mortality.