Abstract Annual fish live exclusively in temporary wetlands and are among the shortest-lived vertebrates in the world. These fish persist in these habitats due to drought-resistant eggs, that which, through diapauses are able to detect stimuli from the environment to start the development processes. They are also able to direct their embryonic development in different trajectories with different development times. Our objective in this paper was to describe the different stages of embryonic development of Austrolebias wolterstorffi, a critically endangered annual fish. A total of 27 stages of embryonic development were identified for the two observed developmental pathways (direct and diapause 2). Of these 27 developmental stages observed, 24 were identical between the two types of trajectories and three different. A total of 90% of the embryos that completed their development proceeded normally, without pauses. One embryo had a different development from the others, entering diapause 2, with a pause in development for 48 h. Although the embryonic development of A. wolterstorffi is similar to that of other Neotropical annual fish species, the diapause 2 occurs when the embryo has a large body size and a well-developed brain, indicating that the lack of embryonic information of the genus Austrolebias may hide characteristics still undescribed or even different survival strategies than what has been observed for other annual fish.

Resumo Os peixes anuais vivem exclusivamente em áreas úmidas temporárias e estão entre os vertebrados de vida mais curta do mundo. Esses peixes persistem nesses habitats devido a ovos resistentes à seca, que, por meio de diapausas, são capazes de detectar estímulos do ambiente para iniciar os processos de desenvolvimento embrionário. Eles também são capazes de direcionar seu desenvolvimento embrionário em diferentes trajetórias com diferentes tempos de desenvolvimento. O objetivo deste trabalho foi descrever os diferentes estágios do desenvolvimento embrionário de Austrolebias wolterstorffi, um peixe anual criticamente ameaçado. Um total de 27 estágios de desenvolvimento embrionário foram identificados para as duas trajetórias de desenvolvimento observadas (direto e diapausa 2). Desses 27 estágios de desenvolvimento observados, 24 eram idênticos entre os dois tipos de trajetórias e três diferentes. Um total de 90% dos embriões que completaram seu desenvolvimento seguiu normalmente, sem pausas. Um embrião teve um desenvolvimento diferente dos demais, entrando na diapausa 2, com pausa no desenvolvimento de 48h. Embora o desenvolvimento embrionário de A. wolterstorffi seja semelhante ao de outras espécies de peixes anuais neotropicais, a diapausa 2 ocorre quando o embrião tem um corpo grande e um cérebro bem desenvolvido, indicando que a falta de informação embrionária do gênero Austrolebias pode escondem características ainda não descritas ou mesmo estratégias de sobrevivência diferentes das observadas para outros peixes anuais.

Abstract Ortho-eugenol is a synthetic derivative from eugenol, the major compound of clove essential oil, which has demonstrated antidepressant and antinociceptive effects in pioneering studies. Additionally, its effects appear to be dependent on the noradrenergic and dopaminergic systems. Depression and anxiety disorders are known to share a great overlap in their pathophysiology, and many drugs are effective in the treatment of both diseases. Furthermore, high levels of anxiety are related to working memory deficits and increased oxidative stress. Thus, in this study we investigated the effects of acute treatment of ortho-eugenol, at 50, 75 and 100 mg/kg, on anxiety, working memory and oxidative stress in male Swiss mice. Our results show that the 100 mg/kg dose increased the number of head-dips and reduced the latency in the hole-board test. The 50 mg/kg dose reduced malondialdehyde levels in the prefrontal cortex and the number of Y-maze entries compared to the MK-801-induced hyperlocomotion group. All doses reduced nitrite levels in the hippocampus. It was also possible to assess a statistical correlation between the reduction of oxidative stress and hyperlocomotion after the administration of ortho-eugenol. However, acute treatment was not able to prevent working memory deficits. Therefore, the present study shows that ortho-eugenol has an anxiolytic and antioxidant effect, and was able to prevent substance-induced hyperlocomotion. Our results contribute to the elucidation of the pharmacological profile of ortho-eugenol, as well as to direct further studies that seek to investigate its possible clinical applications.

Resumo Ortho-eugenol é um derivado sintético do eugenol, composto principal do óleo essencial de cravo, que demonstrou efeitos antidepressivos e antinociceptivos em estudos pioneiros. Além disso, seus efeitos parecem ser dependentes dos sistemas noradrenérgico e dopaminérgico. Sabe-se que os transtornos de depressão e ansiedade compartilham uma grande sobreposição em sua fisiopatologia, e muitas drogas são eficazes no tratamento de ambas as doenças. Além disso, altos níveis de ansiedade estão relacionados a déficits de memória de trabalho e aumento do estresse oxidativo. Assim, o presente estudo investigou os efeitos do tratamento agudo de orto-eugenol, nas doses de 50, 75 e 100 mg/kg, na ansiedade, memória de trabalho e estresse oxidativo em camundongos Swiss machos. Nossos resultados mostram que a dose de 100 mg/kg aumentou o número de mergulhos e reduziu a latência no teste da placa perfurada. A dose de 50 mg/kg reduziu os níveis de malondialdeído no córtex pré-frontal e o número de entradas no labirinto em Y em comparação com o grupo de hiperlocomoção induzida por MK-801. Todas as doses reduziram os níveis de nitrito no hipocampo. Também foi possível avaliar uma correlação estatística entre a redução do estresse oxidativo e a hiperlocomoção após a administração do orto-eugenol. No entanto, o tratamento agudo não foi capaz de prevenir os déficits de memória de trabalho. Portanto, o presente estudo mostra que o orto-eugenol tem efeito ansiolítico e antioxidante, sendo capaz de prevenir a hiperlocomoção induzida pela substância. Nossos resultados contribuem para a elucidação do perfil farmacológico do orto-eugenol, bem como para direcionar novos estudos que busquem investigar suas possíveis aplicações clínicas.

Abstract In hyperbaric oxygen therapy, 100% pure oxygen is used in a pressurized chamber with super atmospheric pressures which correspond to 2-3 atmospheres. The mechanism by which this treatment works is related to the physical properties of gases and their physiological behavior in the body, which leads to hyperoxia, the physiological event which allows for diverse beneficial health effects. The evidence in medicine has proven its utility mainly in decompression sickness, severe skin infections and carbon monoxide poisoning. In the otolaryngology field it has been proven useful in diseases like idiopathic sudden sensorineural hearing loss, both as the only treatment and as a concurrent treatment along with corticosteroids, in malignant otitis externa which in conjunction with antibiotic treatment and a surgical approach presents a clear increase in improvement rates. It must be mentioned that hyperbaric chamber treatment has also shown benefits in radiation treatment and post radiation complications in head and neck cancer patients. It is important to note that hyperbaric oxygen therapy is not without risks and patients must meet specific criteria for it to be applied, therefore it must be indicated using careful judgement and only in necessary cases.

Resumen En la terapia con oxígeno hiperbárico (HBO) se utiliza oxígeno al 100% de concentración en una cámara presurizada con presiones supraatmosféricas, que corresponden de 2 a 3 atmósferas. Los mecanismos por los cuales funciona esta terapia se relacionan con propiedades físicas de los gases y su comportamiento fisiológico en el organismo, lo que lleva finalmente a la hiperoxia, evento fisiológico que permite la obtención de diversos efectos beneficiosos. La evidencia en medicina ha demostrado su utilidad mayormente en la enfermedad por descompresión, infecciones cutáneas graves e intoxicación por monóxido de carbono. En el ámbito de la otorrinolaringología ha probado ser útil en algunas enfermedades como la hipoacusia súbita idiopática, tanto como terapia única como asociada al uso de corticosteroides, como en la osteomielitis refractaria del oído externo, la que en conjunto con antibioticoterapia y manejo quirúrgico presenta un evidente aumento en la tasa de mejoría. Cabe mencionar que la terapia con HBO ha demostrado también beneficios en los tratamientos y complicaciones posteriores a la radiación en pacientes con cáncer de cabeza y cuello. Es importante mencionar que la terapia con HBO no está exenta de riesgos y requiere que los pacientes cumplan con características específicas para su utilización, por lo que su indicación debe ser juiciosa y en casos seleccionados.

Abstract Introduction: Tympanoplasty is the treatment of choice for chronic otitis media. In Chile, several studies have been carried out to evaluate the success of tympanoplasty. Here, we assesed the anatomical and functional outcomes, correlating the results with the demographics of our population. Aim: To carry out an epidemiological description of patients with a diagnosis of chronic otitis media who underwent tympanoplasty at our hospital between 2017 and 2019. Material and Method: Retrospective, descriptive study. We reviewed clinical records of patients who underwent surgery between January 2017 and November 2019. This study has been approved by the ethics committee of Arauco health service. Results: 77 tympanoplasties were performed, of which 56 ears met the inclusion criteria. 71.43% were female. The age range is 8 to 64 years. 41% had chronic pathologies. 51.79% were left ear surgeries. 92.86% were type I tympanoplasty. An endoauricular approach was performed in 58.93%. A cartilage - perichondrium composite graft was used in 75% of the surgeries. A medial technique was performed in 94.94%. Anatomical success was achieved in 85.71% of patients. An average gain over 10 dB was obtained in 60.71% of the patients. Conclusion: There were no significant differences regarding the surgical choices with the anatomical and auditory results.

Resumen Introducción: La timpanoplastía es el tratamiento de elección en la otitis media crónica simple. En Chile se han realizado diversos estudios para evaluar el éxito de la timpanoplastía. En nuestro centro evaluamos el resultado anatómico y funcional, correlacionando los resultados con la demografía de nuestra población. Objetivo: Realizar una descripción epidemiológica de los pacientes con diagnóstico de otitis media crónica simple, sometidos a timpanoplastía en el Hospital San Vicente de Arauco entre los años 2017 y 2019. Material y Método: Estudio retrospectivo y descriptivo. Se revisaron las fichas clínicas de pacientes con cirugía realizada entre enero de 2017 y noviembre de 2019. Este estudio cuenta con la aprobación del comité de ética del servicio de salud Arauco. Resultados: Se realizaron 77 timpanoplastías. 56 oídos cumplieron los criterios de inclusión. 71,43% fueron de sexo femenino. El rango de edad es de 8 a 64 años. 92,86% corresponde a timpanoplastía tipo I. Se utilizó un abordaje endoauricular en el 58,93%. El injerto utilizado fue predominantemente compuesto (cartílago-pericondrio) en un 75%. Se usó una técnica medial en un 94,94%. Se obtuvo un éxito anatómico 85,71% de los pacientes. Se obtuvo una ganancia sobre 10 dB en un 60,71% de los pacientes. Conclusión: No se encontraron diferencias significativas importantes que relacionan las elecciones quirúrgicas con los resultados anatómicos y auditivos del procedimiento a mediano plazo.

Resumo Estudos recentes indicam que arrozais contribuem para a conservação de plantas aquáticas, entretanto cultivos repetidos podem reduzir a diversidade de espécies nos arrozais. Cultivos repetidos, aplicação de agrotóxicos e homogeneização ambiental podem reduzir a diversidade de plantas e selecionar espécies mais tolerantes a perturbações. Nossas hipóteses foram: 1) a riqueza e a biomassa de macrófitas reduzem com o aumento do tempo de cultivo dos arrozais; e 2) as espécies de macrófitas aquáticas dos arrozais são subamostras das áreas úmidas naturais e a perda de espécies aumentará com o tempo de cultivo. Nós investigamos três arrozais de cada uma das diferentes idades (antigos, intermediários e novos) e três áreas úmidas naturais temporárias. Cada área foi amostrada quatro vezes ao longo do ciclo de cultivo (resteva, crescimento inicial, crescimento final e pós-colheita). Nossos resultados indicaram que a riqueza e a biomassa média de macrófitas foram similares entre os arrozais de diferentes idades e menor do que nas áreas úmidas naturais. Embora a composição de espécies nos arrozais de diferentes idades não tenha sido marcadamente diferente, houve aninhamento nos arrozais e este aumentou com tempo de cultivo do arrozal. Neste estudo, nós verificamos que a riqueza e biomassa de macrófitas nos arrozais eram menores que nas áreas úmidas naturais e a composição de espécies era diferente entre os tipos de áreas úmidas (arrozais e áreas úmidas naturais), entretanto nossa hipótese de que a riqueza e a biomassa de macrófitas diminuiriam com a idade do cultivo não foi confirmada. Todos os arrozais foram similares quanto à estrutura da assembleia de macrófitas (riqueza, biomassa e composição de espécies). No entanto, a outra hipótese testada foi confirmada, a assembleia de macrófitas dos arrozais é um subconjunto das áreas úmidas naturais e, conforme aumenta a idade do arrozal, as espécies que ocorrem nos arrozais mais antigos são subconjuntos das espécies que ocorrem nos mais jovens.

Abstract Recent studies indicate that rice fields contribute to the conservation of aquatic plants, however, repeated cultivation can reduce the species diversity harbored by rice fields. Repeated tillage, agrochemical application and environmental homogeneity can reduce plant diversity and select for species more tolerant to disturbance. Our hypotheses were: 1) macrophyte richness and biomass decrease with increased rice crop age; and 2) macrophyte species of rice fields are a subsample of natural wetlands and species loss will increase with crop age. We investigated three rice fields of each different ages (old, intermediate and new ones) and three natural intermittent wetlands for this study. Each area was sampled four times throughout the rice cultivation cycle (off-season, initial growth, final growth and post-harvest). Our results showed that the mean macrophyte richness and biomass were similar between rice fields of different ages and lower than that of natural wetlands. Although species composition in the different-aged rice fields was not markedly different, there was nestedness in the rice fields as age increased. In this study, we verified that macrophyte richness and biomass in rice fields was lower than natural wetlands and the species composition was different among wetland types (rice fields and natural wetlands), however our hypothesis that species richness and biomass will decrease with crop age was not confirmed. All rice crops had similar macrophyte assemblage structure (richness, biomass and species composition). However, the another hypothesis tested was confirmed, macrophyte assemblage of rice fields is a subset of natural wetlands and as, the age of a rice field increases, the species that occur in older rice field are subsets of species that occur in younger ones.

Resumen: Este artículo da cuenta de las acciones colectivas, entendidas como nuevas formas de resistencia, que ha desplegado la Asociación Nacional de Mujeres Rurales e Indígenas (ANAMURI), una organización social de mujeres rurales y asalariadas del agro que surge en Chile durante la década de 1990. Basado en fuentes escritas, orales, documentos y observación directa en reuniones y congresos de la organización, el artículo aborda la variada gama de estrategias para hacer frente a la precarización laboral de las “temporeras” que trabajan en agro-exportación.

Abstract: This article gives an account of the collective actions understood as new forms of resistance that have been developed by the National Association of Rural and Indigenous Women (ANAMURI) a social organization of rural women and wage workers of the agricultural sector that emerged in Chile in the 1990s. From written and oral sources, documents and direct observations at meetings and congresses of the organization, this paper addresses the wide range of strategies to face the precarious working conditions of "seasonal workers" working in agro-export sector.

ABSTRACT: The venipuncture, the catheterization and intravenous (IV) injections are some of the common procedures in the clinical practice. The location of the veins may be complex in some patients. In this paper a system able to enhance the vein distribution in a patient’s forearm in order to help, in future works, to locate the veins in a non-invasive way and accomplish the IV procedures, is described. To carry out this work a web cam was used, the filter that blocks out the infrared light has been removed and replaced for one who does not. To increase the vein detection an array of infrared LEDs (830 nm) was attached. The resulting images were processed using the adaptive histogram equalization and then classified by two methods, the first one based on the Fuzzy C-Means Algorithm, and the second based in a Bayesian probabilistic model. For the image acquisition, the anterior-exterior regions of the left and right forearm of each subject were considered to generate a data base. This system also has relevance in the detection of varicose veins since is able to monitor the vein dilatation.

RESUMEN: En el área clínica son procedimientos comunes la venopunción, la colocación de catéteres, inyecciones intravenosas, etc. La visualización de las venas en algunas personas es compleja. En este trabajo se presenta el desarrollo de un sistema capaz de realzar la distribución de las venas en el antebrazo de una persona para, en un trabajo futuro, ayudar de forma no invasiva a localizar las venas en los procedimientos de venopunción. Para llevar a cabo el desempeño de esta tarea se utilizó una cámara web, a la cual se le ha extraído el filtro que impide el paso de luz infrarroja y es sustituido por otro que lo permite. Para mejorar la detección de las venas se le agregó a la cámara un arreglo de LEDs emisores de luz infrarroja (830nm). Las imágenes obtenidas fueron procesadas mediante la ecualización del histograma adaptable y clasificadas por dos métodos, el primero basado en el algoritmo Fuzzy C-Means, el segundo basado en un modelo probabilístico de tipo Bayes, técnicas del área de inteligencia artificial, presentadas como alternativa en el procesamiento de imágenes. Para la obtención de las imágenes se consideraron las regiones anteriores y exteriores del antebrazo izquierdo y derecho de cada sujeto generando una base de datos. Este sistema también tiene aplicación en la detección de venas varicosas debido a que se puede dar un seguimiento a la dilatación de las venas.

Soil biological activity has important implications for soil carbon (C) sequestration. However, very little is known about the environmental factors, particularly the effect of soil mineralogy on availability of C for soil microorganisms. In this study, we have investigated the influences of soil type (clay mineralogy)on C mineralization and its effects on biological activity at different levels of soil organic matter stability. Two soils an allophanic, derived from recent volcanic ash and a kaolinitic, resulting from metamorphic parent materials were physically fractioned in to light(LF, coarse sand 250-2000 µm), intermediate (IF, fine sand53-250 µm) and mineral (MF,silt and clay < 53 µm) fractions. Several biological and biochemical analyses at Ah horizons of mineral soil and physical fractions were conducted: soil respiration, enzymatic activities, carbohydratesand microbial biomass, amongst others soil variables. The results indicated that the bulk soiland physical fractions had a significant impact on cumulative C mineralizedafter 30 days of incubation and soil enzyme activities. More than 76% of total C-CO2 variation was explained by stepwise multiple regression analysis including factors such as soil enzymes (ß-glucosidase, dehydrogenase and phosphatase) and inorganic P. Soil ATP extractionwas agood indicator of microbial activity, because of a positive and significant correlation among ATP and i) C-CO2 and ii) metabolic quotient (soil respiration rate divided by microbial biomass). We also found an inverse and significant relationship between Al pyrophosphate (Al bound to SOM) and the C-CO2 in volcanic soil, whereas the same correlation did not occur in kaolinitic soil. Our results confirmed a greater stabilization capacityof MF in allophanicthan in kaolinitic soils due to the amorphous minerals clay materials.

Oroantral fistula occurs between other causes as a result of the extraction of a molar in relation to the maxillary bone. As a result the patient experiences episodes of sinusitis refractory to medical treatment. Surgical repair remains the best solution, there are different techniques. The aim is to show our experience of one case operated using a rotation and advancement palatal flap and autologous bone graft. The clinical case is a 32 year old woman that two weeks after removal of upper left molar suffers repeated episodes of unilateral sinusitis. Physical examination and computed tomography shown left maxillary chronic sinusitis secondary to an oroantral fistula, due to tooth extraction from maxillary bone. Surgical repair is performed using a rotation and advancement palatal flap and autologous bone graft. Six months following there was no complication neither recurrent sinusitis, with optimal results. Oroantral fistula is a problem that has multiple options for surgery. The use of autologous bone graft and rotation and advancement palatal flap intended to be a good surgical option, allowing closure of the defect.

La fístula oroantral se presenta entre otras causas como resultado de la extracción de un molar en relación al maxilar Como consecuencia el paciente presenta episodios de sinusitis de evolución tórpida y refractaria a tratamiento médico, siendo la reparación quirúrgica su mejor solución, existiendo distintas técnicas. El objetivo de este caso es mostrar la experiencia de un paciente operado mediante la utilización de un colgajo de rotación y avance palatino e injerto de hueso autólogo. Se trata de una mujer de 32 años que dos semanas después de extracción de molar superior izquierdo presenta reiterados episodios de sinusitis unilateral izquierda. Al examen físico y estudio con tomografía computarizada se diagnostica sinusitis maxilar izquierda, secundaria a fístula oroantral por extracción de pieza dentaria del maxilar. Se realiza reparación quirúrgica con utilización de un colgajo de rotación y avance palatino e injerto de hueso autólogo. Se realizó seguimiento por 6 meses con resultados óptimos, sin complicaciones ni recidivas. Las fístulas oroantrales son un problema que tiene múltiples opciones de tratamiento quirúrgico. La utilización de injertos óseos autólogos y la utilización de un colgajo de rotación y avance palatino, pretende ser una buena opción quirúrgica, permitiendo un cierre definitivo del defecto.

THz continuum spectral photometry has new and unique applications in different civil and military areas presenting a number of distinctive advantages on the well known microwaves or mid- to near-infrared technologies. THz sensing is essential to investigate the emission mechanisms by high energy particle acceleration processes. Technical challenges appear to diagnose radiation produced by solar flare burst emissions measured from space as well as radiation produced by high energy electrons in laboratory accelerators. THz filters and detectors have been investigated for the construction of solar flare high cadence radiometers to operate outside the terrestrial atmosphere. Experimental setups have been assembled for testing THz continuum radiation response from distinct detectors: adapted commercial microbolometer array, pyroelectric module, and opto-acoustic (Golay cell). The results permitted the final design of a THz double radiometer using Golay cells to be flown in stratosphere balloon missions.

Brain death is a valid cause of death certification in a patient, especially in terms of organ donation. There are few situations in which the legislator has proposed further examination for certification. We report the case of a patient with Guillain Barré syndrome, which came to simulate a state of brain death due to motor impairment in full, including intrinsic ocular muscles. The lack of a necessary and sufficient condition for declaring the patient's death led to request additional examinations, in this case an electroencephalogram, which determine the normality of brain electrical activity. It emphasizes the need to comply strictly with the criteria for determining brain death and not to request additional examinations inhibited in a position of doubt, even though the law does not always contemplated.

La muerte encefálica es una causa válida en la certificación del deceso de un paciente, especialmente en condiciones de donación de órganos. Existen escasas situaciones en las que el legislador ha propuesto la realización de exámenes complementarios para su certificación. Presentamos el caso de un paciente con un síndrome de Guillain Barré, que llegó a simular un estado de muerte encefálica, debido al compromiso motor completo, incluyendo musculatura ocular intrínseca. La falta de una condición suficiente y necesaria para declarar la muerte del paciente lleva a la solicitud de exámenes complementarios, en este caso un electroencefalograma, los que determinan la normalidad de la actividad eléctrica cerebral. Se recalca la necesidad de cumplir estrictamente los criterios para determinar la muerte encefálica y el no inhibirse de solicitar exámenes complementarios en condiciones de duda, aún cuando la ley no siempre lo contemple.

Ramipril is an angiotensin-converting enzyme inhibitor which has chemical structure susceptible to degradation, therefore in this work forced degradation studies of ramipril were carried out by a developed and validated stability-indicating liquid chromatographic method. Stress testing was performed on drug substance under hydrolysis (0.1 N HCl, water and 0.1 N NaOH), oxidation (3% H2O2), heat (70°C) and photolysis (UV and VIS radiation). The drug was degraded under acidic, neutral, alkaline, oxidation and thermal stress conditions but it was stable under photolysis. Chromatographic separation of ramipril from its degradation products was achieved on a RP-18 column, using a mobile phase consisting of methanol - tetrahydrofuran - phosphate buffer (pH 2.4; 0.01M) (55:5:40, v/v/v) at a flow rate of 1.0 mL min-1 and UV detection at 215 nm. The assay was linear for ramipril concentrations of 50-300 ug/mL. The developed method was stability indicating, specific, accurate and precise for ramipril determination. This method was used to quantify ramipril in tablets. The results showed that the method described here is suitable for quantitative determination and the stability study of ramipril.

Introduction: Due to the high prevalence of patients with cleft lip with or without cleft palate in the city of Arica Chile and the constant increase of new cases, in 1987 we decided to face the problem from a multidisciplinary and interdisciplinary point of view, incorporating the valuable help from the parents of the affected children. Aim: To show our experience in the multidisciplinary manage of cleft lip-palate in the city of Arica during the years 1987 to 2002 Material and method: By the creation and set up of the "Cleft Lip-Palate patient attention program", in the Juan Noé Hospital of Arica during the years 1987 to 2002, we follow 59 patients attending the program. Results: Some preliminary results are displayed, according to the experience of 59 cases of patients attending the program. Conclusion: Complete management of the cleflip patient is a longjob. As important factors outstand age, growth and careful observation ofevolution in every single case. Multidisciplinary team work is a must, evaluating each case together, developing a clear structured plan of action for each patient, as well as periodically evaluating partial results.

Introducción: Frente al alto número de pacientes con fisura labial y/o palatina ya existente en la ciudad de Arica y al incremento constante de nuevos casos, en 1987 decidimos abordar el problema desde un punto de vista multidisciplinario e interdisciplinario, integrando además la valiosa ayuda de los padres de los niños fisurados. Objetivo: Mostrar nuestra experiencia y sus resultados parciales en el manejo multidisciplinario del paciente fisurado en la ciudad de Arica entre los años 1987y 2002. Material y método: Mediante la creación y puesta en práctica del "Programa de Atención del Paciente Fisurado", en el Hospital Juan Noé de Arica entre los años 1987y 2002, se atienden 59 pacientes que siguen el programa. Resultados: A modo de resultado preliminar se entrega la experiencia de 59 casos que siguieron el protocolo del programa. Conclusión: El trabajo con el paciente fisurado, es un trabajo de largo aliento. Como factores de importancia se destacan el largo tiempo de seguimiento, el factor crecimiento y la observación atenta de la evolución en cada caso en particular. Resulta imprescindible el trabajo en equipo multidisciplinario, evaluando en conjunto cada caso, elaborando un claro y estructurado plan de acción con cada paciente, así como evaluar en forma periódica y en conjunto los resultados parciales.

Multiple Sclerosis (MS) is a chronic disease of the central nervous system. It is manifested in the young adult who presents at the beginning alternation between transient neurological dysfunction and normality, followed by a progressive level of disability. MS affects the quality of life in the young adults in their full productive and creative age limiting not only in their personal lives but also affects to the whole society in terms of "dreams and life projects". Besides, this illness also influences the family group who has to assume progressively the help and care for the patient. In healthcare aspect MS implies intensive and progressive resources. In Chile, although we don't have epidemiological studies that indicate which is the MS prevalence it exist a projection that states 14 per 100.000 inhabitants. Considering a population of 16.5 million of inhabitants our expectative of patients with MS is of 2310 cases in our country. The MS immunomodulating injectable disease-modifying therapies are of high cost and were not available in a regular way in the state health care system of Chile (FONASA) that attends the 70% of the population; the other 30% has different prívate health insurances. In 2008 the ministry of health decided to initiate and pilot (exploratory) program which had a great meaning and impact concerning to start offering immunomodulating therapies to relapsing remitting MS, for patients belonging to FONASA system. The pilot program was thought with a double mission, on the one hand to achieve that a very limited group of MS patients belonging to FONASA system (80 cases) from all over the country had access to immunomodulating injectable disease-modifying therapies of high cost in a regular way. The second objective was to obtain clinical and epidemiological information which let us to evalúate the clinical and administrative obstacles generated by the incorporation of this treatment in the public health net. As the effectiveness of this treatment has been very well documented it wasn't considered as an objective in this program. The chosen number of 80 cases to be treated in the first year of the pilot program (June 2008-2009) wasn't related to any study methodology, special sample o literature review conclusions, it was just determined by the relation of máximum amount of the available economical resources assigned at the starting of this initiative. In that moment the dilemma was to wait for more resources or simply to take the opportunity and push forward making progress in the daily hard working routine. Probably the 80 cases represent 10% of the relapsing remitting MS cases, belonging to FONASA system, with classic indication to treat with immunomodulating therapies (non progressive forms with EDSS < 7). The pilot program has been fulfilled successfully for the 80 cases during the first year. At the present (December 2009) there are 110 patients in treatment from Arica to Punta Arenas what means we have advanced in a significant way not only in the patient's treatment but also in the territorial equity access in a long but very centralized country. Taking as reference Santiago the capital of the country, Arica is 2069 kilometers in the northern boundary and Punta Arenas is 3115 kilometers in the south. The first criteria used to choose the patients to be admitted in the program not only answered to effectiveness and safety purposes, proper of any kind of treatment, but also gave an ordered and sensible offer of a place which were presumably insufficient. With this protocol the 100% of the patients who were able to fulfill the inclusión criteria could enter to the program. For this program we made the option for the institutional administration of the injection treatment directly observed having in the mind the objectives of: preventing that it was just the selected beneficiary who received the treatment and monitor the adherence and adverse effects. The administrative modality was determinant in the chosen MS disease-modifying drug. The selected one for this particular stage of this exploratory program was interferon beta (IFNb)-la (Avonex) 30 mg considering similar effectiveness to other drug and administration once weekly. This also let us, in this institutional administration model, to interfere the less possible the patient's life and adequate progressively the national public health net. This program means a significant advance in the access equity to a treatment of high cost. In the 86% of the cases who qualified the month economical income of the family group is less than the amount required to pay a month of treatment so their access to treatment would be impossible through other means. The national reference center has carried out the tasks of selecting and evaluating all the patients for treatment, monitoring their evolution and defining any failure in the treatment. The clinical epide-miological basal data obtained is unprecedented information in our country probably being the most numerous group of patients with MS whose evaluation had been done by the same team and with a rigorous protocol in common. The information considered: general demographic data, clinical data, neurological exams, photographic record of security and diagnosis exams. The sample was evaluated through diverse scales: EDSS, Multiple Sclerosis Functional Composite, Brief Repeatable Battery of Neuropsychological Test in Multiple, Sclerosis, Fatigue Severity Scale, Profile of anxiety and Mood States, and Labor or Productivity Impact. The success in the first year of the exploratory program has allowed us to make progressive arrange-ments to extend the access criteria and decentralization the clinical process. In the second year we have achieved to advance in an increase in the amount of new 100 places for treatment, so that, more than 100% of the original places. The new challenges are now to improve the access in the diagnosis exams MRI and the differential diagnosis of MS. The independent perseverant and positive push and work done by the patients associations has helped and supported the MS pilot program though completely different ways putting in agenda of the communication media and political authorities the MS problem. As a result of this Pilot MS treatment program, patients requests and public health authorities decisions, by the end of 2010, by law "relapsing remitting MS" will be part of the explicit guarantees national program (GES-AUGE) considering unlimited amount of places for treatment, including all the first-line MS disease-modifying drugs, symptomatic treatment, rehabilitation and psychological support.

Introducción El presente documento corresponde al informe del primer año de trabajo operativo del "Programa piloto de tratamiento con inmunomoduladores, para pacientes beneficiarios de Fonasa1, que padecen esclerosis múltiple (EM)", elaborado por el equipo del centro de referencia nacional, para este programa, con sede en el Servicio de Neurología del Complejo Asistencial Barros Luco (CABL) del SSMS2. Dado su origen no incluye antecedentes del proceso de gestión ni toma de decisiones del nivel Minsal3 o Fonasa. Este trabajo, no es ni aspira ser: un ensayo clínico, una guía de práctica clínica, una revisión bibliográfica, ni una puesta al día sobre el tratamiento de la Esclerosis Múltiple (EM), es simplemente el informe anual de un centro de referencia, para una tarea específica, a la autoridad ministerial competente. El informe incluye algunos antecedentes generales y referencias presentadas como "notas al pie", sólo para contextualizar la información presentada4. La EM es una enfermedad crónica del SNC, de origen incierto, inmunológicamente mediada, bien definida en sus características inmunopatogénicas, patológicas, imagenológicas y clínicas. Se expresa en el adulto joven, quien presenta inicialmente alternancia entre disfunción neurológica transitoria y normalidad y cuya progresión determina múltiples efectos discapacitantes. La EM afecta la calidad de vida de adultos jóvenes en plena edad productiva y creativa limitando tanto los "sueños y proyectos de vida" como el desarrollo laboral, social y afectivo. Además trasciende al grupo familiar, cuando deben asumir la asistencia del paciente. En lo sanitario, la EM, genera uso intensivo y progresivo de recursos. Las terapias inmunomoduladores para la EM, que tienen la posibilidad de detener o reducir la evolución de la modalidad recurrente remitente de la EM, no se encontraban disponibles en forma regular en el sector público de salud de nuestro país, por esto el presente programa piloto tiene el gran significado de dar inicio regular a un tratamiento efectivo para esta enfermedad, para los beneficiarios del Fonasa. Programa El objetivo del programa de tratar a un número acotado de pacientes con EM que cumplieran con determinados criterios de indicación de tratamiento, se cumplió con rigurosidad y plenitud. Existen pacientes en tratamiento efectivo desde Arica a Punta Arenas con lo que hemos avanzado significativamente, no sólo en el acceso al tratamiento, sino en la equidad territorial de éste. Los criterios de ingreso además de responder a motivos de eficacia y seguridad propios de cualquier tratamiento, buscaron dar una respuesta ordenada y razonable a una oferta de cupos presumiblemente insuficiente. El 100% de los pacientes que cumplieron los criterios pudieron ingresar al programa. Para este programa se optó en esta primera etapa por la administración institucional directamente observada del tratamiento, con los objetivos de: cautelar que fuese el beneficiario seleccionado quien recibiera el tratamiento, monitorizar la adherencia y los efectos adversos. A su vez esta modalidad de administración fue determinante en la elección del fármaco a emplear, la que recayó, ante similar efectividad entre otros inmunomoduladores, en el interferón beta la, que requiere sólo una dosis de administración semanal. Ello además permitió, interferir lo menos posible con la vida del paciente y adecuar progresivamente a la red de salud. Este programa es un significativo avance en la equidad de acceso a un tratamiento de alto costo. En el 86% de los casos que calificaron, el ingreso económico del grupo familiar equivale a menos del valor necesario para costear un mes de tratamiento, por lo tanto, su acceso era imposible de otra forma. La información clínica-epidemiológica basal obtenida durante un año de trabajo y presentada en este informe, es un insumo inédito en nuestro país, constituyendo probablemente la serie de pacientes más numerosa cuya evaluación ha sido realizada por un mismo equipo y con un riguroso protocolo común5. Durante este primer año de desarrollo de programa piloto ocurrieron dificultades, su detección servirá para correcciones del mismo piloto y de eventuales programas de mayor envergadura. Observamos retardos en la definición clínica e inicio de tratamiento ajenos al centro de referencia del CABL. Esta demora fue generada principalmente por desconocimiento del programa y retrasos en la espera de: evaluación de otros especialistas, acceso a exámenes de seguridad o complementarios e ingreso del paciente a la red pública de salud6. Para el segundo año se propone: mejorar la información sobre el programa a nivel médico7 y de pacientes, ajustes en los criterios de ingreso, cambios en la modalidad de proceso clínico, descentralización del control y administración del fármaco, avanzar en dar una atención integral a los pacientes y evaluar la ausencia de envío de casos de algunos servicios de salud. Para el segundo año, se ha logrado avanzar en un aumento de 100 nuevos cupos para tratamiento, más del 100% de los cupos originales. Los nuevos desafíos son mejorar el acceso a exámenes de diagnóstico (resonancia) y de diagnóstico diferencial de la EM. Por otro lado, es imperativo desarrollar un programa de tratamiento integral que considere: tratamiento sintomático, rehabilitación motora, cognitiva y soporte psicológico8. El perseverante y positivo trabajo de las agrupaciones de pacientes, ha logrado posicionar sinérgicamente con el programa piloto, aunque por caminos completamente independientes, el tema de la EM en los medios, la población y en las autoridades del poder ejecutivo y legislativo. Para este segundo año, si finalmente lográramos el apoyo de una enfermera ad-hoc, nos proponemos realizar reuniones periódicas de información e interacción con los pacientes ingresados al programa, a fin de realizar educación, evaluación y sentar las bases de grupos de autoayuda. El centro de Referencia, ha cumplido un rol de seleccionar y evaluar pacientes para tratamiento, monitorizar su evolución y definir falla de tratamiento. Si se entregan los recursos necesarios existen las capacidades para participar en capacitación de profesionales, prueba y diseño de instrumentos de evaluación clínica y apoyo a pacientes. En un tema con tanto dinamismo en el desarrollo del conocimiento puro y aplicado como es la EM, resulta necesario que exista un ente público con la responsabilidad de identificar, eventualmente probar, monitorizar y ponderar los avances relevantes, para informar a las autoridades del sector público de salud que lo requieran. La demanda cotidiana por dependencias de atención ambulatoria en neurología del CABL copa la disponibilidad actual de oficinas de atención de pacientes (boxes). Por eso, se requiere construir o asignar un módulo que permita acoger la asistencia clínica, la capacitación y reunión de profesionales y pacientes, así como la habilitación pionera en el sector público de dependencias para un programa de hospitalización de día para esta condición.