O principio da justiça e a saúde no Chile

Equality in access to health care, efficiency in interventions designed to promote, preserve and recuperate health, and the efficient use of available health care resources are the central objectives of the Health Care System Reform in Chile, based on the principle of justice. This article deals with the theme of justice in health, starting from the traditional definition, continuing to that of healthcare, and culminating in what bioethics interprets today as justice, and whether this principle is verified or not under Plan AUGE, as the Political Constitution of Chile establishes the right to health care as a basic right recognized for all citizens.La equidad en el acceso a la atención de salud, eficacia en las intervenciones destinadas a promover, preservar y recuperar la salud, y eficiencia en el uso de los recursos disponibles son los objetivos centrales de la Reforma del Sistema de Salud en Chile, basados en el principio de justicia. Este artículo trata el tema de la justicia en salud desde la definición tradicional, pasando por la de salud, para culminar en lo que la bioética entiende hoy por justicia, y si este principio se verifica o es vulnerado dentro del Plan AUGE, toda vez que la Constitución Política de Chile establece el derecho a la salud como un derecho básico reconocido para todos los ciudadanos.Eqüidade no acesso à atenção de saúde, eficácia nas intervenções destinadas a promover, preservar e recuperar a saúde e eficiência no uso dos recursos disponíveis, são os objetivos centrais da Reforma do Sistema de Saúde no Chile, baseados no principio da justiça. Este artigo trata o tema da justiça em saúde a partir da definição tradicional, passando pela de saúde, para culminar no que a bioética entende hoje por justiça e se este principio se verifica ou é vulnerado dentro do Plano AUGE, toda vez que a Constituição Política do Chile estabelecer o direito à saúde como um direito básico reconhecido para todos os cidadãos

Evolución de las políticas sociales en Chile 1964-1980

Incluye BibliografíaAnaliza las politicas sociales de Chile en los ultimos 15 anos, los cambios significativos en los modelos y estilos de desarrollo, el rol del Estado, y las prioridades asignadas en las politicas publicas del sector educacion, salud y vivienda

ROTACIÓN DE SUBSECRETARIOS EN CHILE: UNA EXPLORACIÓN DE LA SEGUNDA LÍNEA GUBERNAMENTAL, 1990-2014

This article analyzes the rotation and the survival of undersecretaries in Chile during the governments of the Concertación (1990-2010) and the government of Sebastián Piñera (2010-2014). During the last decade cabinets as an object of study have earned centrality among scholars who study the presidential functioning and those who study political elites. In this context, this paper analyzes an object of study that has been overlooked: the undersecretaries, the second government line. Descriptively it examines the rotation of all undersecretaries of the period and with survival analysis, specifically proportional hazards models, the influence of institutional factors and critical events (shocks) as a kind of ministerial dependency, low presidential approval, corruption scandals are evaluated, among others, in relation with the permanence of the undersecretaries in office. The findings of this article allow a thought about factors that are part and influence the political system and emerge as predictors of risk/survival in the undersecretariats. This makes this work an original contribution to the generation of knowledge about the role that undersecretaries have played within the government apparatus.Este artículo analiza la rotación y supervivencia de los subsecretarios en Chile durante los gobiernos de la Concertación (1990-2010) y el gobierno de Sebastián Piñera (2010-2014). Durante la última década los gabinetes como objeto de estudio han ganado centralidad entre los académicos que estudian el funcionamiento presidencial y aquellos que estudian las élites políticas. En este contexto, el presente trabajo analiza un objeto de estudio que ha sido ignorado: los subsecretarios, la segunda línea gubernamental. Se examina de forma descriptiva la rotación de todos los subsecretarios del período y con análisis de supervivencia, específicamente modelos de riesgos proporcionales, se evalúa la influencia de factores institucionales y eventos críticos (shocks), como tipo de dependencia ministerial, baja aprobación presidencial, escándalos de corrupción, entre otros, sobre la permanencia de los subsecretarios en sus cargos. Los hallazgos de este artículo permiten reflexionar sobre factores que son parte e influyen en el sistema político y emergen como predictores de riesgo/supervivencia en las subsecretarías. Esto hace que este trabajo sea una contribución original a la generación de conocimiento sobre el rol que han jugado los subsecretarios dentr

Cluster-randomized, crossover trial of head positioning in acute stroke

The role of supine positioning after acute stroke in improving cerebral blood flow and the countervailing risk of aspiration pneumonia have led to variation in head positioning in clinical practice. We wanted to determine whether outcomes in patients with acute ischemic stroke could be improved by positioning the patient to be lying flat (i.e., fully supine with the back horizontal and the face upwards) during treatment to increase cerebral perfusion. METHODS In a pragmatic, cluster-randomized, crossover trial conducted in nine countries, we assigned 11,093 patients with acute stroke (85% of the strokes were ischemic) to receive care in either a lying-flat position or a sitting-up position with the head elevated to at least 30 degrees, according to the randomization assignment of the hospital to which they were admitted; the designated position was initiated soon after hospital admission and was maintained for 24 hours. The primary outcome was degree of disability at 90 days, as assessed with the use of the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability and a score of 6 indicating death). RESULTS The median interval between the onset of stroke symptoms and the initiation of the assigned position was 14 hours (interquartile range, 5 to 35). Patients in the lying-flat group were less likely than patients in the sitting-up group to maintain the position for 24 hours (87% vs. 95%, P\u3c0.001). In a proportional-odds model, there was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale between patients in the lying-flat group and patients in the sitting-up group (unadjusted odds ratio for a difference in the distribution of scores on the modified Rankin scale in the lying-flat group, 1.01; 95% confidence interval, 0.92 to 1.10; P = 0.84). Mortality within 90 days was 7.3% among the patients in the lying-flat group and 7.4% among the patients in the sitting-up group (P = 0.83). There were no significant betweengroup differences in the rates of serious adverse events, including pneumonia. CONCLUSIONS Disability outcomes after acute stroke did not differ significantly between patients assigned to a lying-flat position for 24 hours and patients assigned to a sitting-up position with the head elevated to at least 30 degrees for 24 hours

Parámetros funcionales y su relación con la velocidad de marcha en adultos mayores chilenos residentes en la comunidad

Introduction: Gait speed is a test to measure functional capacity in older adults. Nevertheless, the factors influencing this variable are not well described in South American populations.Objective: To determine the relationship between usual and maximal walking speed and functional parameters among Chilean community-dwelling older adults.Materials and methods: An observational, descriptive and cross-sectional study including 69 older adults was conducted. The usual and maximal gait speeds were associated with body composition (body mass index), upper limbs muscle strength (arm curl-ups), lower limbs muscle strength (30 seconds sit-to-stand test), global function (Barthel index), ankle flexibility (range of motion), dynamic balance (timed Up & Go test) and aerobic capacity (2 minutes walking test).Results: The ankle flexibility, lower limbs strength and aerobic capacity influenced the maximal speed (R2=0.65; p <0.001), while the usual speed was influenced by upper limbs and lower limbs strength and by the aerobic capacity (R2= 0.51; p <0.001).Conclusion: The usual and maximal gait speeds are mostly influenced by the lower limbs muscle strength plus aerobic capacity.Introducción. La velocidad de marcha es una prueba para medir la capacidad funcional en adultos mayores. Sin embargo, los factores que influyen en esta variable han sido poco descritos en la población sudamericana.Objetivo. Determinar la relación existente entre la velocidad de marcha usual y máxima, y los parámetros de funcionalidad en chilenos adultos mayores de la comunidad.Material y métodos. Este estudio cuantitativo, observacional y descriptivo, de corte transversal, incluyó 69 adultos mayores. La velocidad de marcha normal y la máxima se asociaron con la composición corporal (índice de masa corporal), la fuerza de las extremidades superiores (pruebas de flexiones de brazos) e inferiores (pararse y sentarse en 30 segundos), la funcionalidad general (índice de Barthel), la flexibilidad de los tobillos (rango de movimiento), el equilibrio estático y dinámico (timed Up & Go test) y la capacidad aeróbica (test de marcha en dos minutos).Resultados. La flexibilidad de los tobillos, la fuerza de las extremidades inferiores y la capacidad aeróbica, influyeron sobre la velocidad de marcha máxima (R2=0,65; p<0,001). La marcha normal se vio influida por la fuerza de las extremidades superiores e inferiores, y la capacidad aeróbica (R2=0,51; p<0,001).Conclusión. La velocidad de marcha, tanto normal como máxima, está influenciada principalmente por la fuerza de las extremidades inferiores y la capacidad aeróbica

Validation of the simplified modified Rankin scale for stroke trials: Experience from the ENCHANTED alteplase-dose arm

Background and aims The structured, simplified modified Rankin scale questionnaire (smRSq) may increase reliability over the interrogative approach to scoring the modified Rankin scale (mRS) in acute stroke research and practice. During the conduct of the alteplase-dose arm of the international ENhanced Control of Hypertension ANd Thrombolysis StrokE stuDy (ENCHANTED), we had an opportunity to compare each of these approaches to outcome measurement. Methods Baseline demographic data were recorded together with the National Institutes of Health Stroke Scale (NIHSS). Follow-up measures obtained at 90 days included mRS, smRSq, and the 5-Dimension European Quality of life scale (EQ-5D). Agreements between smRSq and mRS were assessed with the Kappa statistic. Multiple logistic regression was used to identify baseline predictors of Day 90 smRSq and mRS scores. Treatment effects, based on Day 90 smRSq/mRS scores, were tested in logistic and ordinal logistic regression models. Results SmRSq and mRS scores had good agreement (weighted Kappa 0.79, 95% confidence interval (CI) 0.78–0.81), while variables of age, atrial fibrillation, diabetes mellitus, pre-morbid mRS (1 vs. 0), baseline NIHSS scores, and imaging signs of cerebral ischemia, similarly predicted their scores. Odds ratios for death or disability, and ordinal shift, 90-day mRS scores using smRSq were 1.05 (95% CI 0.91–1.20; one-sided P = 0.23 for non-inferiority) and 0.98 (95% CI 0.87–1.11; P = 0.02 for non-inferiority), similar to those using mRS. Conclusions This study demonstrates the utility of the smRSq in a large, ethnically diverse clinical trial population. Scoring of the smRSq shows adequate agreement with the standard mRS, thus confirming it is a reliable, valid, and useful alternative measure of functional status after acute ischemic stroke. Clinical Trial registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT01422616

Ethnicity and Other Determinants of Quality of Functional Outcome in Acute Ischemic Stroke: The ENCHANTED Trial

Background and Purpose- Patient-centered outcomes are important. We aimed to determine predictors of health-related quality of life (HRQoL) and develop utility-weighted modified Rankin Scale (mRS) scores in thrombolyzed acute ischemic stroke patients from both arms of ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study). Methods- ENCHANTED was an international quasi-factorial clinical trial of different doses of intravenous alteplase and intensities of blood pressure control in acute ischemic stroke patients, with outcomes on the 5-Dimensional European Quality of Life Scale and mRS assessed at 90 days post-randomization. Logistic regression models were used to identify baseline predictors of poor HRQoL (≤mean 5-Dimensional European Quality of Life Scale utility scores). Ordinary least squares regression derived utility-weighted mRS scores. Results- In 4016 acute ischemic stroke patients with complete 5-Dimensional European Quality of Life Scale and mRS data, independent predictors of poor HRQoL were older age (odds ratio, 1.19 [95% CI, 1.12-1.27], per 10-year increase), non-Asian ethnicity (1.91 [1.61-2.27]), greater stroke severity on the National Institutes of Health Stroke Scale (1.11 [1.09-1.12]), diabetes mellitus (1.41 [1.18-1.69]), premorbid disability (mRS score 1 versus 0; 1.62 [1.33-1.97]), large vessel atheromatous pathogenesis (1.32 [1.12-1.54]), and proxy respondent (2.35 [2.01-2.74]). Sensitivity analyses indicate the ethnicity influence on HRQoL was driven by the high proportion of Chinese (62.9% of Asian) participants with better HRQoL compared with non-Chinese or other Asian groups. Derived utility values across mRS scores 0 to 5 were 0.977, 0.885, 0.748, 0.576, 0.194, and -0.174, respectively. Correlations between mRS and 5-Dimensional European Quality of Life Scale scores were stronger in Asians. Conclusions- HRQoL is worse after thrombolyzed acute ischemic stroke in the elderly, non-Asians, with greater initial severity, diabetes mellitus, premorbid disability, due to large vessel atheroma, and proxy assessment. The broader significance of better HRQoL in Asians is tempered by Chinese participants dominating analyses. From utility-weighted mRS scores indicating the greatest steps in mRS scores are between 5 and 3, treatments to avoid major disability provide the greatest benefits for patients. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01422616

Early Blood Pressure Lowering Does Not Reduce Growth of Intraventricular Hemorrhage following Acute Intracerebral Hemorrhage:Results of the INTERACT Studies

Background: Intraventricular hemorrhage (IVH) extension is common following acute intracerebral hemorrhage (ICH) and is associated with poor prognosis. Aim: To determine whether intensive blood pressure (BP)-lowering therapy reduces IVH growth. Methods: Pooled analyses of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials (INTERACT1 and INTERACT2) computed tomography (CT) substudies; multicenter, open, controlled, randomized trials of patients with acute spontaneous ICH and elevated systolic BP, randomly assigned to intensive (Results: There was no significant difference in adjusted mean IVH growth following intensive (n = 228) compared to guideline-recommended (n = 228) BP treatment (1.6 versus 2.2 ml, respectively; p = 0.56). Adjusted mean IVH growth was nonsignificantly greater in patients with a mean achieved systolic BP ≥160 mm Hg over 24 h (3.94 ml; p trend = 0.26). Conclusions: Early intensive BP-lowering treatment had no clear effect on IVH in acute ICH