RESUMEN La evaluación de la marcha en cinta caminadora puede resultar relevante para la toma de decisiones clínicas. No obstante, factores demográficos como la edad y el IMC pueden alterar la interpretación de los resultados. Nuestro objetivo fue obtener variables espacio- temporales, energéticas y costo de transporte durante la velocidad autoseleccionada en cinta caminadora para una muestra representativa de adultos uruguayos (n=28) y evaluar si diferentes rangos de edades e IMC pueden ser factores a tener en cuenta en pruebas clínicas donde se consideren dichas variables. Participaron 17 hombres y 11 mujeres (39,3 ± 14,8 años, 75,9 ± 12,5 kg, 1,74 ± 0,09 m, IMC 25,2 ± 4,06). Se realizó una reconstrucción 3D del movimiento en forma sincronizada con el consumo energético. Se obtuvieron valores de referencia y luego de agrupar los participantes según su IMC y rango de edad se compararon los datos mediante test de t (p≤0.05). Los resultados revelaron discrepancias significativas en las medidas espacio-temporales y energéticas de los adultos uruguayos al caminar en cinta con respecto a la literatura. La marcha difiere entre adultos jóvenes y de mediana edad en su velocidad autoseleccionada (p=0,03), longitud de zancada (p=0,01), trabajo mecánico externo (<0,001) y recuperación de energía mecánica (0,009), destacando la importancia de considerar la edad en evaluaciones clínicas. El IMC no influyó significativamente en estas variables. Estos hallazgos subrayan la necesidad de ajustar las interpretaciones de las pruebas clínicas de la marcha sobre cinta caminadora en adultos uruguayos de mediana edad (45 a 65 años).

RESUMO A avaliação da marcha na esteira pode ser relevante para a tomada de decisões clínicas. No entanto, fatores demográficos como idade e IMC podem alterar a interpretação dos resultados. Nosso objetivo foi obter variáveis espaço-temporais, energéticas e custo de transporte durante a velocidade de caminhada autoselecionada na esteira para uma amostra representativa de adultos uruguaios (n = 28) e avaliar se diferentes faixas etárias e IMC podem ser fatores a serem considerados em testes clínicos que envolvam essas variáveis. Dezessete homens e onze mulheres participaram (39,3 ± 14,8 anos, 75,9 ± 12,5 kg, 1,74 ± 0,09 m, IMC 25,2 ± 4,06). Foi realizada uma reconstrução tridimensional do movimento sincronizada com o consumo de energia. Foram obtidos valores de referência e os dados foram comparados usando testes t (p≤0,05), após agrupar os participantes por IMC e faixa etária. Os resultados revelaram discrepâncias significativas nas medidas espaço-temporais e energéticas dos adultos uruguaios ao caminhar na esteira, em comparação com a literatura. A marcha diferiu entre adultos jovens e de meia-idade em sua velocidade autoselecionada (p=0,03), comprimento da passada (p=0,01), trabalho mecânico externo (<0,001) e recuperação de energia mecânica (0,009), destacando a importância de considerar a idade em avaliações clínicas. O IMC não influenciou significativamente essas variáveis. Esses achados destacam a necessidade de ajustar as interpretações dos testes clínicos de marcha na esteira em adultos uruguaios de meia- idade (45 a 65 anos).

ABSTRACT Treadmill gait assessment can be relevant for clinical decision-making. However, demographic factors such as age and BMI may alter result interpretation. Our aim was to obtain spatiotemporal, energetic, and cost of transport variables during self-selected treadmill walking speed for a representative sample of Uruguayan adults (n=28) and to assess if different age ranges and BMI could be factors to consider in clinical tests involving these variables. Seventeen men and eleven women participated (39.3 ± 14.8 years, 75.9 ± 12.5 kg, 1.74 ± 0.09 m, BMI 25.2 ± 4.06). A synchronized 3D motion reconstruction was performed with energy consumption. Reference values were obtained and data were compared using t-tests (p≤0.05), after grouping participants by BMI and age range. Results revealed significant discrepancies in spatiotemporal and energetic measures of Uruguayan adults walking on the treadmill, compared to the literature. Gait differed between young and middle-aged adults in their self-selected speed (p=0.03), stride length (p=0.01), external mechanical work (p<0.001), and mechanical energy recovery (0.009), emphasizing the importance of considering age in clinical evaluations. BMI did not significantly influence these variables. These findings underscore the need to adjust interpretations of treadmill gait clinical tests in middle-aged Uruguayan adults (45 to 65 years).

Abstract This narrative review addresses the historical and legal evolution of advance directives globally and locally since their emergence. It starts from the principle of autonomy in modern bioethics and its relationship with the patient’s vulnerability, as well as the consideration of death by health professionals. It highlights the essential role of the advance directives document as a valuable tool in the physician-patient-family relationship, being fundamental to understanding the patient’s perspective. The document is defined considering the medical literature and its application is discussed, stressing the importance of not waiting until advanced clinical deterioration for its implementation. The review also examines national and international legislation, as well as current medical knowledge, with the aim of facilitating consensual decisions among all parties involved in patient care.

Resumen Esta revisión narrativa aborda la evolución histórica y legal de las voluntades anticipadas a nivel global y local desde su surgimiento. Parte del principio de autonomía en la bioética moderna y su relación con la vulnerabilidad del paciente, así como la consideración de la muerte por parte de los profesionales de la salud. Destaca el papel esencial del documento de voluntades anticipadas como una herramienta valiosa en la relación médico-paciente-familia, siendo fundamental para comprender la perspectiva del paciente. Se define el documento considerando la literatura médica y se discute su aplicación, subrayando la importancia de no esperar hasta un deterioro clínico avanzado para su implementación. La revisión también examina la legislación nacional e internacional, así como el conocimiento médico actual, con el objetivo de facilitar decisiones consensuadas entre todas las partes involucradas en el cuidado del paciente.

Abstract: End-of-life care management presents significant ethical challenges, especially in complex clinical cases such as that of a patient with severe head trauma and multiple complications. Ethical decision-making involves considering the rights, dignity, and preferences of the patient and his or her family, as well as quality of life and relief from suffering. The objective of this research is to design and implement a comprehensive methodology to provide a care plan that respects the dignity and improves the quality of life of patients at the end of life, aligned with their wishes and those of their family. The approach used was the Comprehensive Methodology of Clinical-Ethical Analysis (CMECA), which included a continuous evaluation, pain and symptom management, supportive care, limitations of medical interventions, and preparation for the end of life, with the active participation of the family from a palliative care approach. The resolution of the case was achieved through a shared decision between the parents and the medical team, proceeding with a gradual disconnection of life support. The importance and relevance of the Comprehensive Methodology of Ethical-Clinical Analysis (CMECA) is highlighted, due to its comprehensive approach focused on the patient and in accordance with medical ethics. This method stands out for considering legal and ethical aspects, empathy, and respect for human dignity at all times.

Resumen: La gestión de cuidados al final de la vida presenta desafíos éticos significativos, especialmente en casos clínicos complejos como el de un paciente con severo trauma craneoencefálico y múltiples complicaciones. La toma de decisiones éticas involucra considerar los derechos, la dignidad y las preferencias del paciente y su familia, así como la calidad de vida y el alivio del sufrimiento. El objetivo de esta investigación es diseñar e implementar una metodología integral para brindar un plan de cuidado que respete la dignidad y mejore la calidad de vida de pacientes al final de la vida, alineado con sus deseos y los de su familia. El enfoque utilizado fue la Metodología Integral de Análisis Ético-Clínico (MIAEC), en el que se incluyó una evaluación continua, manejo del dolor y síntomas, cuidados de soporte, limitaciones de intervenciones médicas y preparación para el final de la vida, con la participación activa de la familia desde un enfoque de cuidados paliativos. La resolución del caso se logró a través de una decisión compartida entre los padres y el equipo médico, procediendo con una desconexión paulatina del soporte vital. Se resalta la importancia y pertinencia de la Metodología Integral de Análisis Ético-Clínico (MIAEC) por su enfoque integral centrado en el paciente y en conformidad con la ética médica. Este método se destaca por considerar aspectos legales y éticos, la empatía, y el respeto por la dignidad humana en todo momento.

Resumo: La gestão de cuidados ao final da vida apresenta desafios éticos significativos, especialmente em casos clínicos complexos como o de um paciente com severo trauma cranioencefálico e múltiplas complicações. A tomada de decisões éticas envolve considerar os direitos, a dignidade e as preferências do paciente e de sua família, assim como a qualidade de vida e o alívio do sofrimento. O objetivo desta investigação é desenhar e implementar uma metodologia integral para oferecer um plano de cuidado que respeite a dignidade e melhore a qualidade de vida de pacientes ao final da vida, alinhado com seus desejos e os de sua família. O enfoque utilizado foi a Metodologia Integral de Análise Ético-Clínica (MIAEC), na qual incluiu-se uma avaliação contínua, manejo da dor e de sintomas, cuidados de suporte, limitação de intervenções médicas e preparação para o final da vida, com a participação ativa da família desde um enfoque de cuidados paliativos. Alcançou-se a resolução do caso através de uma decisão compartilhada entre os pais e a equipe médica, procedendo-se uma desconexão paulatina do suporte vital. Ressalta-se a importância e pertinência da Metodologia Integral de Análise Ético-Clínica (MIAEC) por seu enfoque integral centrado no paciente e em conformidade com a ética médica. Este método se destaca por considerar aspectos legais e éticos, a empatia e o respeito pela dignidade humana em todos os momentos.

The guidelines in this series provide evidence-based practical guidance for the diagnosis, treatment and follow-up of persons with inflammatory joint diseases. The purpose of these guidelines is to aid in shared decision-making between patient and physician, aiming to support high-quality clinical care. These guidelines have been prepared using the AGREE II instrument and based on adoption and, where appropriate, adaptation of international guidelines.

Abstract Introduction: This study examines the technological revolution in the realm of connected medical devices, which are redefining the monitoring, diagnosis, and treatment of diseases. It analyzes how the integration of advanced technologies is driving personalized and remote healthcare. Objectives: To evaluate the advancements in connected medical devices and their impact on improving disease monitoring and diagnosis. The study investigates how these technologies are changing the dynamics of healthcare delivery and identifies the associated challenges and opportunities. Methodology: A qualitative approach is used, linking research questions with theories and outcomes. The study is based on analyses of wearable devices and implantable systems, combining literature review with expert interviews and data analysis. This methodological approach allows for a deep understanding of the interaction between technology and medical practice. Results: The findings show that connected medical devices offer significant advantages in terms of precision and efficiency, enabling real-time monitoring and better clinical decision-making. Technical, ethical, and regulatory challenges are identified, but innovative solutions to overcome them are also highlighted. Conclusions: The research underscores the importance of a qualitative approach in studying connected medical devices. The results emphasize the need for a robust methodological framework to evaluate both technological advancements and associated challenges. This study contributes to understanding how connected medical devices are transforming healthcare, highlighting the necessity of integrated and multidisciplinary approaches to maximize benefits and minimize risks.

Resúmen Introducción: Este estudio examina la revolución tecnológica en el ámbito de los dispositivos médicos conectados, que están redefiniendo el monitoreo, diagnóstico y tratamiento de enfermedades. Se analiza cómo la integración de tecnologías avanzadas está impulsando la atención médica personalizada y a distancia. Objetivos: Evaluar los avances en dispositivos médicos conectados y su impacto en la mejora del monitoreo y diagnóstico de enfermedades. Se investiga cómo estas tecnologías están cambiando la dinámica de la atención médica y cuáles son los desafíos y oportunidades asociados. Metodología: Se utiliza un enfoque cualitativo, vinculando preguntas de investigación con teorías y resultados. El estudio se basa en análisis de dispositivos wearables y sistemas implantables, combinando la revisión de literatura con entrevistas a expertos y análisis de datos. Este enfoque metodológico permite una comprensión profunda de la interacción entre la tecnología y la práctica médica. Resultados: Los hallazgos muestran que los dispositivos médicos conectados ofrecen significativas ventajas en términos de precisión y eficiencia, permitiendo un seguimiento en tiempo real y una mejor toma de decisiones clínicas. Se identifican retos técnicos, éticos y regulatorios, pero también se destacan soluciones innovadoras para superarlos. Conclusiones: La investigación subraya la importancia de un enfoque cualitativo en el estudio de los dispositivos médicos conectados. Los resultados enfatizan la necesidad de un marco metodológico robusto para evaluar tanto los avances tecnológicos como los desafíos asociados. Este estudio contribuye a la comprensión de cómo los dispositivos médicos conectados están transformando la atención médica, enfatizando la necesidad de abordajes integrados y multidisciplinarios para maximizar sus beneficios y minimizar los riesgos.

Abstract Introduction Artificial Intelligence (AI) technologies have made it possible to analyze large databases and subsequently apply this knowledge to solve practical clinical problems. Objectives Compare the perception of the application of AI in otorhinolaryngology, in Portugal, between the general population and healthcare professionals. Material and Methods A cross-sectional study was carried out using an anonymous, self-completed online questionnaire. The questionnaire analyzed aspects related to the areas of application of AI, namely diagnosis, clinical decision-making, surgical procedures and monitoring of chronic diseases. Of the 770 adult participants (aged 18 years or over), 249 were excluded for submitting questionnaires with incomplete information, with a total of 521 selected. Results Of the participants, 60.8% were female (60.8%), 66.8% were between 26 and 57 years old and 46.4% were healthcare professionals. Women more often preferred a human being to monitor chronic diseases (p = 0.024) and to perform low-life-threatening surgery (p = 0.003). Participants from younger (18-25 years) and older (>67 years) age groups preferred humans to perform clinical assessment of signs and symptoms (p = 0.000), treatment decision-making (p = 0.011) and creation of rehabilitation plans (p = 0.009). Healthcare professionals more often preferred humans to perform treatment monitoring (p = 0.000) or life-threatening surgeries (p = 0.004), compared to the general population. Conclusions This study suggests that there are significant differences in the perception of AI application depending on gender, age, and the general population versus healthcare professionals.

Resumo Introdução As tecnologias de Inteligência Artificial (IA) têm sido capazes de analisar bases de dados de grandes dimensões e posteriormente aplicar esse conhecimento na resolução de problemas clínicos práticos. Objetivos Comparar a perceção da aplicação de AI na otorrinolaringologia, em Portugal, entre a população geral e os profissionais de saúde. Material e Métodos Foi realizado um estudo transversal com recurso a um questionário on-line anónimo e de auto-preenchimento. O questionário analisou aspetos relacionados com as áreas de aplicação da IA, nomeadamente diagnóstico, tomada de decisão clínica, procedimentos cirúrgicos e monitorização de doenças crónicas. Dos 770 participantes adultos (idade igual ou superior a 18 anos), foram excluídos 249 por apresentarem questionários com informações incompletas, sendo selecionados um total de 521. Resultados Dos participantes, 60.8% eram do sexo feminino (60,8%), 66.8% tinham entre 26 e 57 anos e 46.4% eram profissionais de saúde. As mulheres preferiram mais frequentemente um ser humano a realizar a monitorização de doenças crónicas (p = 0.024) e cirurgia com baixo risco de vida (p = 0.003). Os elementos de grupos etários mais jovens (18-25 anos) e mais velhos (>67 anos) preferiram humanos a realizarem a avaliação clínica de sinais e sintomas (p = 0.000), a tomada de decisão terapêutica (p = 0.011) e a criação de planos de reabilitação (p = 0.009). Os profissionais de saúde preferiram mais frequentemente humanos a realizar o seguimento de um tratamento (p = 0.000) ou cirurgias com risco de vida (p = 0.004), em comparação com a população geral. Conclusões Este estudo sugere que existem diferenças significativas na percepção da aplicação de IA, dependendo do sexo, da idade e da população em geral versus profissionais de saúde.

Resumen El embarazo ectópico se considera un problema de salud pública a nivel mundial, se hizo una investigación con el objetivo de establecer los fundamentos acerca del embarazo ectópico y las políticas de salud que se requieren para su mitigación. Esta revisión bibliográfica integrativa incluyó diversos textos, artículos, materiales impresos y digitales relacionados con el embarazo ectópico, consultando además en las bases de datos y directorios: SciELO, LILACS, Latindex, Medline; el proceso se realizó mediante el uso de palabras clave en español, quedando seleccionados 18 artículos publicados entre 1990 y 2023. Desde un enfoque histórico social del embarazo ectópico, se determinó que de la toma de decisiones clínicas oportunas, depende el diagnóstico temprano de esa patología; así como de la identificación de factores de riesgo y la actuación pertinente en consecuencia.

Abstract Ectopic pregnancy is considered a public health problem worldwide. This research aimed to establish the foundations of ectopic pregnancy and the health policies required for its mitigation. This bibliographic review included various texts, articles, printed and digital materials related to ectopic pregnancy, consulting databases and directories such as SciELO, LILACS, Latindex, and Medline; through the use of keywords in Spanish, 18 articles published between 1990 and 2023 were selected. Based on a social-historical approach to ectopic pregnancy, it was determined that timely clinical decision-making depends on the early diagnosis of this pathology, the identification of risk factors, and the relevant action accordingly.

ABSTRACT Purpose The clinical outcomes of kidney transplantation from deceased donors have seen significant improvements with the use of machine perfusion (MP), now a standard practice in transplant centers. However, the use of perfusate biomarkers for assessing organ quality remains a subject of debate. Despite this, some centers incorporate them into their decision-making process for donor kidney acceptance. Recent studies have indicated that lactate dehydrogenase (LDH), glutathione S-transferase, interleukin-18, and neutrophil gelatinase-associated lipocalin (NGAL) could predict post-transplant outcomes. Materials and Methods Between August 2016 and June 2017, 31 deceased-donor after brain death were included and stroke was the main cause of death. Pediatric patients, hypersensitized recipients were excluded. 43 kidneys were subjected to machine perfusion. Perfusate samples were collected just before the transplantation and stored at -80ºC. Kidney transplant recipients have an average age of 52 years, 34,9% female, with a BMI 24,6±3,7. We employed receiver operating characteristic analysis to investigate associations between these perfusate biomarkers and two key clinical outcomes: delayed graft function and primary non-function. Results The incidence of delayed graft function was 23.3% and primary non-function was 14%. A strong association was found between NGAL concentration and DGF (AUC=0.766, 95% CI, P=0.012), and between LDH concentration and PNF (AUC=0.84, 95% CI, P=0.027). Other perfusate biomarkers did not show significant correlations with these clinical outcomes. Conclusion The concentrations of NGAL and LDH during machine perfusion could assist transplant physicians in improving the allocation of donated organs and making challenging decisions regarding organ discarding. Further, larger-scale studies are required. MP, MP , (MP) However debate this decisionmaking decision acceptance LDH, (LDH) Stransferase, Stransferase S transferase, transferase S-transferase interleukin18, interleukin18 interleukin 18, 18 interleukin-18 gelatinaseassociated gelatinase associated (NGAL posttransplant post 201 2017 3 deceaseddonor patients excluded 4 80ºC. 80ºC ºC -80ºC 5 years 349 34 9 34,9 female 24637 24 6 7 24,6±3,7 nonfunction. nonfunction non function. 233 23 23.3 14 14% AUC=0.766, AUC0766 AUC 0 766 (AUC=0.766 95 CI P=0.012, P0012 P P=0.012 012 P=0.012) AUC=0.84, AUC084 84 (AUC=0.84 P=0.027. P0027 P=0.027 . 027 P=0.027) discarding Further largerscale larger scale required (MP (LDH interleukin1 1 interleukin-1 20 34, 2463 2 24,6±3, 23. AUC=0.766 AUC076 76 (AUC=0.76 P001 P=0.01 01 AUC=0.84 AUC08 8 (AUC=0.8 P002 P=0.02 02 interleukin- 246 24,6±3 AUC=0.76 AUC07 (AUC=0.7 P00 P=0.0 AUC=0.8 AUC0 (AUC=0. 24,6± AUC=0.7 P0 P=0. AUC=0. (AUC=0 24,6 P=0 AUC=0 (AUC= 24, P= AUC= (AUC

Resumen La prevención de la enfermedad tromboembólica venosa (ETV) es motivo de continua actualización en función de nueva evidencia que se genera permanentemente. Cada institución debe contar con una estrategia activa de prevención contra la ETV y debe generar normas de tromboprofilaxis (TP) de acuerdo con la realidad local. Durante este proceso de adaptación de una guía a la región debemos siempre tener en cuenta los recursos locales disponibles, el riesgo tromboembólico y hemorrágico propio del paciente, de la enfermedad por la que se encuentra internado (ya sea clínica o quirúrgica) y las consideraciones o preferencias del paciente. La tasa de adherencia a recomendaciones locales de TP es uno de los indicadores de excelencia más importantes evaluados en organismos que califican la calidad de una institución de salud. Las medidas de profilaxis que propongamos para los centros de salud, deben ser individualizadas para cada paciente, tienen que considerar antecedentes personales y familiares del enfermo y utilizar modelos de evaluación de riesgo validados de trombosis y de sangrado. También deben incluir a la población con riesgo de trombosis persistente luego del alta. Lo ideal es tener estadísticas propias de cada nosocomio para la toma de decisiones de cómo implementar una correcta TP. Extrapolar guías de los países desarrollados a nuestro ámbito podría tener un impacto negativo, si no se conoce la propia realidad. En este documento encontraremos herramientas prácticas para las instituciones de salud de la región, que les permita orientarse al momento de confeccionar recomendaciones para una adecuada TP.

Abstract Venous thromboembolism disease (VTE) prevention strategy has to be constantly updated based on new evidence that is generated every year. Each institution must have a formal and active prevention policy against VTE and must develop guidelines or standards for thromboprophylaxis (TP) according to the local reality. During this process of adapting a guideline to the region and the generation of hospital recommendations, we must always consider the available local resources, the thromboembolic and hemorrhagic risk of the patients, even after discharge, and also their considerations and preferences. Adherence to local TP recommendations is one of the most important items evaluated by organizations that measure institutional quality. Individualized prophylaxis should consider personal and family history of VTE, the use of validated risk assessment models or RAMs for thrombosis and bleeding events, as well as the special characteristics of each patient. Ideally, each center’s own statistics should be available for decision-making. Extrapolating guidelines from developed countries could have a negative impact, if we ignore our hospital´s reality. In this document we will find practical tools for health institutions that will allow them to prepare recommendations or guidelines for adequate VTE prophylaxis.

BACKGROUND. The COVID-19 pandemic highlighted the weakness of relying on in-person tuition in higher education. Massive open online courses (MOOCs) have been a successful addition to higher education. In this study, educators had to replace a planned elective in the medical curriculum with an online option during the pandemic. The roles of the competency framework of the Health Professions Council of South Africa (HPCSA) (Leader and Manager, Health Advocate, Professional, Communicator, Collaborator, Scholar, and Healthcare Practitioner) were used to guide its development. This elective emphasised the non-clinical roles of medical practitioners and was offered in 2020 and 2021. OBJECTIVES. To describe the choices of third-year medical students and time spent participating in a modified online elective in 2020 and 2021. METHODS. A descriptive cross-sectional study design was used, involving the participation of 629 medical students. Data were collected and analysed from three primary sources: registration data from LinkedIn Learning, data from the Foundation for Professional Development, and self-reported estimates by students of the average time spent on selected courses. Data included identification of the associated competency acquired. Data analysis was conducted using Python, version 3.10.11. RESULTS. The course choices of 629 students were analysed. In 2020 there were 300 participants and in 2021 there were 329. All the students had one compulsory inclusion in the elective (Management and Leadership Short Course for Undergraduate Healthcare Students). Students in both years reported spending the most average time on courses related to clinical knowledge (Healthcare Practitioner), followed by financial literacy and management (Professional), diversity management (Collaborator), and priority actions to identify and/or respond to (Health Advocate). The most popular courses related to the Leader and Manager role were around decision-making in human resources, problem-solving, and managing healthcare teams. Based on the top 10 LinkedIn Learning course selections of both cohorts, there appeared to be a preference for courses that were consistent with the role of medical professionals in practice. The most popular LinkedIn Learning course was The Six Morning Habits of High Performers. CONCLUSION. Students gravitated toward courses aligned with their role as professional doctors within the HPCSA competency framework. More studies are needed to understand how medical students develop the six non-clinical roles in the HPCSA framework and the effectiveness of MOOCs in a medical curriculum.

ABSTRACT Bioethics plays a fundamental role in resolving dilemmas that may arise in the field of healthcare. One of the most complex issues is the withdrawal of life support in critically ill patients. This is based on a thorough assessment of the patient's prognosis and consideration of their own wishes where possible. Decision making in this area is usually the result of a collaborative process that involves doctors, family members and, sometimes, ethics committees. A clinical case is presented in which the patient was in a delicate health situation due to a serious respiratory illness for which he was kept on life support. After all available therapeutic options had been exhausted, the decision was made to withdraw life support. The withdrawal of life support in critically ill patients is a complex process that involves multiple dimensions.

RESUMEN La bioética desempeña un papel fundamental en la resolución de dilemas que pueden surgir en el ámbito de la atención médica. Uno de los temas más complejos es el retiro del soporte vital en pacientes en estado crítico. Este se basa en una evaluación minuciosa del pronóstico del paciente y en la consideración de sus propios deseos cuando sea posible. La toma de decisiones en este ámbito suele ser el resultado de un proceso colaborativo que involucra a médicos, familiares y, en algunas ocasiones, comités de ética. Se presenta un caso clínico en el que el paciente se encontraba en una situación delicada de salud debido a una enfermedad respiratoria grave por lo que se mantuvo en soporte vital. Después de haberse agotado todas las opciones terapéuticas disponibles, se tomó la decisión de retirar el soporte vital. El retiro del soporte vital en pacientes en estado crítico es un proceso complejo que conlleva múltiples dimensiones.

Thyroid cancer (TC) is the first malignant tumor in endocrine glands, and it is estimated that by 2030 it will be in the top five cancers worldwide. In Chile, TC was recently included as pathology No. 82 with Explicit Health Guarantees, which implies allocating significant public and private resources to the treatment of patients with a cancer that is on the rise. There are groups of young patients with small tumors that present a more aggressive clinical behavior, where decision-making could be advanced. Specifically, a group of patients under 55 years of age with tumors less than 2 cm in size but with regional metastases, that lack indication for radioiodine therapy and could require complementary treatment or present a worse evolution. Clinical and molecular tools to guide appropriate treatment in patients with lymph node metastases are limited and have not been updated. There are tumorigenicity and prognostic factors, such as EpithelialMesenchymal Transition (EMT) and Cancer Stem Cells (CSC) markers that have been incorporated into the study of other tumors and recently in thyroid cancer. Studies linking EMT and CSC with TC currently point to molecular and genetic description, with few reports clinically correlating these findings (particularly in subgroups with particular characteristics of aggressiveness) and proposing them as tumorigenicity and prognosis markers. The description of these biomarkers in the described population could facilitate decision-making regarding follow-up, surgical therapy, and radioiodine therapy.

Resumen El cáncer de tiroides (CT) es el primer tumor maligno en glándulas endocrinas, y se estima que al 2030 estará en el top cinco de cáncer a nivel mundial. En Chile, el CT fue incluido, recientemente, como la patología N° 82 con Garantías Explícitas de Salud, lo que implica destinar importantes recursos públicos y privados al tratamiento de pacientes con un cáncer que va en aumento en el mundo. Existen grupos de pacientes jóvenes con tumores pequeños que presentan un comportamiento clínico más agresivo desde el inicio, donde se podría adelantar la toma de decisiones. Específicamente, destaca un grupo de pacientes menores de 55 años con tumores pequeños menores de 2 cm, pero con metástasis regionales, que quedan fuera de la indicación de radioyodoterapia y podrían requerir tratamiento complementario o presentar peor evolución. Las herramientas clínicas y moleculares para guiar el tratamiento adecuado en pacientes con metástasis linfonodales son limitadas y no han sido actualizadas hasta el momento. Existen factores de tumorigenicidad y pronóstico, tales como los marcadores de Transición Epitelio-Mesenquimal (TEM) y Cáncer Stem Cells (CSC) que se han incorporado al estudio de otros tumores y recientemente en cáncer de tiroides. Actualmente estudios que relacionan TEM y CSC con CT apuntan a la descripción molecular y genética, con escasos reportes que correlacionen, clínicamente, estos hallazgos, (particularmente en subgrupos con características particulares de agresividad) y que los propongan como marcadores de tumorigenicidad y pronóstico. La descripción de estos biomarcadores en la población descrita podría facilitar la toma de decisiones en cuanto a seguimiento, terapia quirúrgica y radioyodoterapia.

Abstract Objective: To determine the reference intervals (RI) for serum levels of IgG, IgM, and IgE in healthy children aged 1–10 years living in central Brazil. Method: A sample of 1743 healthy children was randomly selected from kindergartens and public schools. Reference intervals were defined by non-parametric rank (Clinical Laboratory Standards Institute, USA), bootstrapping, and Horn’s robust methods. Results: By the rank method, the IgG RI was 792–1771 mg/dL for children of both sexes aged 1–10 years. IgM RI were different for gender and age groups, being 45–196 mg/dL and 34–190 mg/dL for boys aged 1–2 years and 3–10 years, respectively. For girls, the IgM RI were 50–212 mg/dL and 39–212 mg/dL, for ages 1–4 and 5–10 years, respectively. The IgE RI for both sexes and ages 1–10 years was 6–1005 mg/dL. The bootstrap method showed RI similar to the rank method but with slightly different confidence intervals. Horn’s robust method determined RI different from those obtained by previous methods. Conclusion: RI for serum concentrations of IgG, IgM, and IgE were established for Brazilian children aged 1–10 years. This definition will be useful for Brazilian physicians, who will have more adequate parameters for their clinical decision-making. Objective (RI 110 1 10 1–1 Brazil Method 174 schools nonparametric non parametric Clinical Institute USA, USA , USA) bootstrapping Horns Horn s methods Results 7921771 792 1771 792–177 mgdL mg dL groups 45196 45 196 45–19 34190 34 190 34–19 12 2 1– 310 3 3–1 respectively girls 50212 50 212 50–21 39212 39 39–21 14 4 510 5 5–1 61005 6 1005 6–100 Conclusion physicians decisionmaking. decisionmaking decision making. making decision-making 11 17 792177 79 177 792–17 4519 19 45–1 3419 34–1 31 3– 5021 21 50–2 3921 39–2 51 5– 6100 100 6–10 79217 7 792–1 451 45– 341 34– 502 50– 392 39– 610 6–1 7921 792– 61 6–

Abstract Background: The patient-doctor relationship promotes shared decision-making and patient-centered care, implying emotional intelligence and good communication, leading to positive health outcomes. Objective: To culturally adapt the Patient-Doctor Depth of Relationship Scale (PDDR) and convergently validate with the Patient Enablement Instrument (PEI) to ascertain the correlation between PDR and enablement. Methods: Cross-cultural adaptation process of the PDDR questionnaire to European Portuguese, through translation, linguistic verification, and reverse translation and also its understandability. Convergent validation with the Patient Enablement Instrument (PEI), after their doctor’s appointment, in a general practice/family medicine health unit. Context information, such as gender, age, living status, educational level, monthly income, Socioeconomic Deprivation Index (SEDI), and clinical appointment with the usual doctor, was also collected. Results: PDDR showed good understandability and acceptance and strong internal consistency (Cronbach’s α=0.785; intraclass correlation coefficient=0.785). A total of 81 patients participated in the study, most of them female (70.4%). There was a significant difference in the PDDR total score depending on whether the appointment had been with the usual doctor (p<0.001). Both a weak positive non-significant correlation between PDDR and SEDI total scores (ρ=0.300; p=0.790) and a moderate significant negative correlation between PDDR total score and PEI (ρ=-0.396; p<0.001) were found. Conclusion: The cross-cultural adaptation of the PDDR questionnaire to European Portuguese was carried out. PDDR proved to be a reasonable measure of the patient-doctor relationship, allowing greater patient enablement when a deeper patient-doctor relationship exists.

Resumo Introdução: A relação médico-doente promove a decisão partilhada, o cuidado centrado no doente e implica o uso de inteligência emocional e de boa comunicação, originando bons resultados em saúde. Objetivo: Realizar a adaptação cultural de Patient-Doctor Depth of Relationship Scale (PDDR) e validação convergente com Patient Enablement Instrument (PEI), verificando a correlação entre a relação médico-doente e a capacitação pela consulta. Métodos: Adaptação cultural de PDDR para português, por tradução, verificação linguística e retro-tradução para inglês. Trabalho observacional transversal correlacional entre PDDR (melhor se total mais alto) e PEI (melhor se total mais baixo), depois da consulta médica numa Unidade de Saúde Familiar (USF). Estudo de resultados também segundo variáveis de contexto sexo, idade, residência individual ou partilhada, escolaridade, rendimento mensal com estes três se construindo o SEDI (como proxi de classe socioeconómica) e se consulta realizada com o médico de família. Resultados: A PDDR demonstrou boa compreensibilidade, aceitabilidade e forte consistência interna (α de Cronbach=0,785; coeficiente de correlação intraclasse=0,785). Participaram 81 doentes no estudo, a maioria mulheres (70,4%). Verificaram-se diferenças significativas na pontuação total de PDDR em função de a consulta ter ou não ocorrido com o médico habitual (p<0,001). Constatou-se correlação positiva fraca não significativa entre valores totais de PDDR e SEDI (ρ=0,300; p=0,790) e negativa moderada significativa entre a pontuação total de PDDR e de PEI (ρ=-0,396; p<0,001). Conclusão: Foi realizada a adaptação cultural e validação do questionário PDDR para português, que provou ser uma medida adequada de profundidade na relação médico-doente, demonstrando que uma forte relação médico-doente capacita mais o doente após a consulta.

ABSTRACT Death processes have been progressively transferred to hospital spaces due to biomedicalization and the use of technologies, generating important challenges for healthcare systems. The COVID-19 pandemic exposed the lack of unified criteria and principles for a dignified death in the hospital. This study corresponds to a narrative review using Higgins & Green's methodological framework as a reference. A systematized search was carried out with the question: What are the elements considered in the decision-making of hospital teams regarding access and use of life support technology and dying processes in adult critically ill patients? The searches conducted during October 2022 in MEDLINE/PubMed, Scopus, Science Direct, CINAHL, Biblioteca Virtual en Salud (BVS), Cochrane Library, and Scielo identified 1499 records for screening, and 148 were retrieved for full-text review. Eighty-four articles were included in the review, identifying seven categories. The evidence shows variability in decision-making associated with the clinical status of the patient, the criteria of the medical professional, added to structural elements of the health system and political-legal aspects. The literature recommends reflexive, dynamic, flexible, and individualized decision-making processes that consider the patient's preferences, clinical judgment, prognosis, and available resources. Communication, advance care planning, interdisciplinary discussions, external consultations, and the involvement of ethical committees are crucial throughout the process.

RESUMEN Los procesos de muerte han sido transferidos progresivamente a los espacios hospitalarios producto de la biomedicalización y el uso de tecnologías, generando importantes desafíos para los sistemas sanitarios. La pandemia por COVID-19 dejo al descubierto la falta de criterios unificados, y de principios para una muerte digna en el hospital. Este estudio corresponde a una revisión narrativa que utiliza como referencia el marco metodológico de Higgins & Green. Se realizó una búsqueda sistematizada con la pregunta: ¿Cuáles son los elementos considerados en la toma de decisiones de equipos hospitalarios respecto al acceso y uso de la tecnología de soporte vital y procesos de muerte en pacientes críticos adultos? Las búsquedas realizadas durante octubre de 2022 en MEDLINE/PubMed, Scopus, Science direct, CINAHL, Biblioteca Virtual en Salud (BVS), Cochrane Library y Scielo, identicaron1.499 registros para screening, 148 fueron recuperados para revisión en texto completo. 84 artículos fueron incluidos en la revisión, identificando siete categorías. La evidencia muestra variabilidad en la toma de decisiones asociada al estado clínico del paciente, al criterio del profesional médico, sumado a elementos estructurales del sistema sanitario y los aspectos político-legales. La literatura recomienda procesos de toma de decisiones reflexivos, dinámicos, flexibles e individualizados que consideren las preferencias del paciente, el juicio clínico, el pronóstico y los recursos disponibles. La comunicación, la planificación anticipada de los cuidados, los debates interdisciplinarios, las consultas externas y la participación de comités éticos son cruciales durante todo el proceso.