• Epidemic cholera in Latin America, 1991-1993: implications of case definitions used for public health surveillance Artículos

    Koo, Denise; Traverso, Héctor; Libel, Marlo; Drasbek, Christopher; Tauxe, Robert; Brandling-Bennett, David

    Abstract in Spanish:

    En este informe se presentan las diversas definiciones de casos de cólera usadas en los países de América Latina que se han visto afectados por la epidemia; se da el número de casos de cólera y de las defunciones por la enfermedad (según datos notificados a la OPS por los países latinoamericanos en 1993), y se describen algunas tendencias regionales de la incidencia de cólera. La información relacionada con la forma en que se definieron los casos de la enfermedad se obtuvo por medio de un cuestionario administrado por la OPS en octubre de 1993. En total, 948 429 casos de cólera fueron notificados a la OPS entre enero de 1991 y diciembre de 1993 por los países latinoamericanos afectados por la epidemia y las incidencias anuales más altas se registraron en el Perú (1991 y 1992) y Guatemala (1993). La tasa de letalidad para todo el trienio, y también para 1993, fue de 0,8%. La incidencia de cólera mostró una tendencia descendente general en la mayor parte de los países sudamericanos pero aumentó en casi todos los países de Centroamérica. Se observó gran variabilidad en las definiciones aplicadas para notificar casos de cólera, casos de cólera hospitalizados y defunciones atribuibles al cólera. Esta variabilidad dificulta cualquier comparación global entre países (y hasta estimar la carga de morbilidad y evaluar la calidad de la atención sobre la base de las tasas de letalidad), y aun las tendencias notificadas dentro de un mismo país deben evaluarse con cuidado. Es muy probable que en un futuro la situación se complique por la llegada de la cepa Vibrio cholerae 0139 a América Latina, situación que genera la necesidad de distinguir entre ella y la cepa 01, que es la predominante. Para efectos de simplificación y para lograr la amplia aceptación y extensa divulgación de la información sobre los casos, se recomiendan las siguientes definiciones: caso confirmado de cólera 01: infección por V. cholerae 01 toxígeno, confirmada por métodos de laboratorio, en cualquier persona con diarrea. Caso confirmado de cólera 0139: infección confirmada por V. cholerae 0139 toxígeno, confirmada por un laboratorio, en cualquier persona con diarrea. Caso clínico de cólera: diarrea acuosa de carácter agudo en una persona mayor de 5 años que busca tratamiento. Defunción atribuible al cólera: defunción durante la semana inmediatamente posterior al comienzo de la diarrea en una persona con cólera confirmado o diagnosticado según la definición clínica. Paciente hospitalizado con cólera: persona con cólera confirmado o diagnosticado según la definición clínica que pasa un mínimo de 12 horas en un centro de atención para el tratamiento de la enfermedad.

    Abstract in English:

    This report presents the various cholera case definitions used by the affected countries of Latin America, shows the numbers of cholera cases and deaths attributable to cholera (as reported by Latin American countries to PAHO through 1993), and describes some regional trends in cholera incidence. The information about how cholera cases were defined was obtained from an October 1993 PAHO questionnaire. In all, 948 429 cholera cases were reported to PAHO by affected Latin American countries from January 1991 through December 1993, the highest annual incidences being registered in Peru (1991 and 1992) and Guatemala (1993). The case-fatality rate over the three-year period, and also in 1993, was 0.8%. A general downward trend in the incidence of cholera was observed in most South American countries, while the incidence increased in most Central American countries. A good deal of variation was noted in the definitions used for reporting cholera cases, hospitalized cholera cases, and cholera-attributable deaths. Because of these variations, broad intercountry comparisons (including disease burden calculations and care quality assessments based on case-fatality rates) are difficult to make, and even reported trends within a single country need to be evaluated with care. The situation is likely to be complicated in the future by the arrival of V. cholerae 0139 in Latin America, creating a need to distinguish between it and the prevailing 01 strain. For purposes of simplicity, wide acceptance, and broad dissemination of case data, the following definitions are recommended: Confirmed case of 01 cholera: laboratory-confirmed infection with toxigenic V. cholerae 01 in any person who has diarrhea. Confirmed case of 0139 cholera: laboratory-confirmed infection with toxigenic V. cholerae 0139 in any person who has diarrhea. Clinical case of cholera: acute watery diarrhea in a person over 5 years old who is seeking treatment. Death attributable to cholera: death within one week of the onset of diarrhea in a person with confirmed or clinically defined cholera. Hospitalized patient with cholera: a person who has confirmed or clinically defined cholera and who remains at least 12 hours in a health care facility for treatment of the disease.
  • Violence and health in Colombia Artículos

    Franco Agudelo, Saúl

    Abstract in Spanish:

    La violencia en Colombia parece incontenible. A las masacres y asesinatos colectivos, de una crueldad desconcertante, se suman los secuestros y desapariciones, el maltrato de niños y ancianos y las violaciones de adolescentes. Cada día, sin tregua, los colombianos son espectadores o víctimas de atracos callejeros y de discriminación racial, sexual y socioeconómica. Sin quererlo, se convierten en agentes de agresiones en el transporte urbano, el hogar, la escuela y el trabajo. Colombia tiene las tasas de mortalidad por homicidio más altas del mundo. Independientemente de la enorme sobrecarga institucional que impone a los servicios de salud y medicina legal, la violencia constituye actualmente en Colombia el principal problema de salud pública. Para hacerle frente, el sector de la salud debe elaborar políticas y financiar acciones; crear nuevos procesos de formación de personal, poner en marcha procesos de educación pública, y dedicar mayor esfuerzo y creatividad al campo de la investigación, que hasta ahora ha dado respuestas importantes pero aún insuficientes. Al reflexionar sobre la violencia, que es la sustitución de toda argumentación por la fuerza, es necesario ubicarla en el contexto de la vida y la salud. No se pretende solo racionalizarla, y menos aún sustituir la acción por la palabra o por las reflexiones, sino tratar de comprenderla a fondo con el objeto de buscarle alternativas. En el presente artículo se analiza, con esta finalidad, el tema de la violencia en Colombia, principalmente desde el punto de vista de su efecto en la salud de los colombianos y de sus implicaciones para el sector sanitario. El autor expone sus puntos de vista con plena conciencia de su subjetividad y limitaciones.

    Abstract in English:

    In Colombia, violence seems uncontrollable. Along with massacres and group killings of astonishing cruelty, there are also kidnappings and disappearances, abuse of children and the elderly, and rape of young adolescents. Every day, without respite, Colombians are witnesses or victims of street cri mes as well as racial, sexual, and socioeconomic discrimination. Unwillingly, they become agents of aggression in public transport, at home, at school, and at work. Colombia has the highest rates of mortality from homicide in the world. Apart from the enormous institutional burden that violence imposes on the health services and forensic medicine, it now constitutes the principal public health problem in the country. To confront it, the health sector must develop policies and finance actions, develop innovative ways to train personnel, implement public education processes, and devote more effort and greater creativity to research, which up to now has provided some, but not enough, important answers. Violence, which is the substitution of force for any type of dialogue, must be conidered within the context of life and health. This it not merely an attempt to rationalize violence, much less to substitute words or reflection for action, but rather an attempt to understand it in depth in order to search for alternatives. With that goal, this article analyzes the subject of violence in Colombia, principally from the perspective of its effect on the health of the citizens and its implications for the health sector. The author fully recognizes the subjectivity and limitations of the views he expresses herein.
  • Duration of maternal breast-feeding in the Dominican Republic Articles

    Bautista, Leonelo E.

    Abstract in Spanish:

    En el presente estudio se reanalizaron los datos de la Encuesta Nacional de Salud de la República Dominicana, realizada en 1991, con el fin de identificar las características sociodemográficas, de la atención médica, del embarazo y el niño que influyen sobre la duración de la lactancia materna total (DLMT). Se estudió una muestra de 1 984 parejas madre-hijo representativa de la población nacional. De los hijos de cada madre, solo se incluyó al último niño nacido vivo, que era amamantado y menor de 3 años de edad en el momento de la encuesta. Los datos sobre la DLMT y los factores estudiados se recabaron entrevistando a las madres (incluidos la edad, tipo de residencia, paridad, nivel socioeconómico, educación, empleo y deseo de procrear de la madre, tipo de parto y lugar en que se produjo, tipo de trabajador de la salud que lo atendió, sexo y peso al nacer del hijo, tiempo transcurrido entre el parto y el inicio de la lactancia materna, y edad del niño al cesar la lactancia y en el momento de realizarse la encuesta). El riesgo de haber sido destetado a distintas edades se calculó por el método de la tabla de vida y el efecto independiente de cada variable de interés se estimó por medio de un modelo de regresión de Cox. La duración mediana de la lactancia materna total fue 7 meses y la tasa relativa de destete (TRD) fue más alta en los niños ablactados (TRD = 8,56; IC95%: 4,25-17,20), los de madres universitarias (TRD = 1,48; IC95%: 1,24-1,77), los que comenzaron a mamar tardíamente (TRD = 1,25; IC95%: 1,11-1,40), los que nacieron en instituciones públicas (TRD = 1,62; IC95%: 1,24-2,11) y privadas (TRD = 2,19; IC95%: 1,65-2,91), y en los de madres primíparas de nivel socioeconómico bajo (TRD = 1,80; IC95%: 1,45-2,24). Los programas de lactancia materna del país deben prestar especial atención a las madres con educación universitaria, a las que dan a luz en hospitales privados y a las primíparas de nivel socioeconómico bajo, ya que estas mujeres tienden a amamantar a sus hijos durante períodos relativamente cortos. Dentro de las estrategias de los programas de promoción de la lactancia materna habría que subrayar la importancia que reviste el retraso de la ablactación, pues este parece ser el factor que mayor impacto ejerce en la duración de la lactancia materna.

    Abstract in English:

    The study reported here explored the influence of maternal, health care, pregnancy, and child-related factors upon the duration of total breast-feeding (DTBF) in the Dominican Republic. The data for the study, which included 1984 mother-child pairs representative of the Dominican population, came from the National Health Survey of 1991. The child in each of the mother-child pairs was the mother's last-born child who had been breast-fed and was less than 3 years of age at the time of the survey. Interviews with the mothers were used to collect information about the duration of breast-feeding and the factors studied (including maternal age, urban/rural residence, parity, mother's socioeconomic status, maternal education, maternal employment, mother's desire for pregnancy, type of delivery, place of delivery, the type of health worker attending the delivery, the child's sex, the child's birth weight, the time elapsed between delivery and initiation of breast-feeding, the child's age at complete weaning, and the child's age at the time of the survey). The child's risk of complete weaning at different ages was calculated using the life table method, and the independent effect of each of the study variables was estimated using Cox's regression model. The median DTBF was 7 months. The risk that a child would be completely weaned (the relative rate of complete weaning, or RRCW) was found to be higher among children who received foods other than breast milk and water while still breast-feeding (RRCW = 8.56; 95% CI = 4.25-17.20), whose mothers had some university education (RRCW = 1.48; 95% CI = 1.24-1.77), who began breast-feeding a day or more after delivery (RRCW = 1.25; 95% CI = 1.11-1.40), who were born in either public health institutions (RRCW = 1.62; 95% CI = 1.24-2.11) or private health institutions (RRCW = 2.19; 95% CI = 1.65-2.91), and who were the first-born of mothers with low socioeconomic status (RRCW = 1.80; 95% CI = 1.45-2.24). According to the study results, the country's breast-feeding programs should give special attention to mothers with university educations, those giving birth in private health facilities, and those with low socioeconomic status giving birth to their first child, since these groups tended to breast-feed their children for relatively short periods of time. Also, breast-feeding promotion strategies should stress the importance of delaying the introduction of foods other than breast milk into the child's diet, as this appears to be the one factor having the greatest adverse effect on the duration of breast-feeding.
  • Opinions about Hansen's disease among the members of patients' social network in Recife

    Feliciano, Katia V. de O.; Kovacs, Maria Helena

    Abstract in Portuguese:

    O presente artigo descreve um estudo realizado no Recife, Brasil, entre novembro de 1993 e julho de 1994, com a finalidade de explorar as opiniões dos membros da rede social (por exemplo, familiares, amigos e vizinhos) de portadores de hanseníase na avaliação, interpretação e manejo das manifestações corporais da doença na trajetória que levou ao diagnóstico. A amostra constou de 93 membros da rede social, com idade entre 20 e 70 anos, que apoiaram o curso de ação de 83 pacientes diagnosticados no período do estudo. A análise buscou detectar variáveis capazes de discriminar os membros da rede de apoio dos pacientes de hanseníase classificados como casos (presença de incapacidades ou lesões precursoras de incapacidades) ou controles. O estudo evidenciou a escassez de informações sobre a transmissão da hanseníase e revelou um quadro transicional onde se confrontam expectativa de cura e uma visão estigmatizante das conseqüências da doença. Apenas uma quarta parte dos sujeitos do estudo suspeitou, antes do diagnóstico, que o paciente era portador de hanseníase, o que sugere baixa percepção do risco representado pela doença e reforça a concepção da invisibilidade das suas manifestações corporais. Os resultados mostram um perfil de percepção e manejo da hanseníase que pode facilitar a propagação da doença e a instalação ou agravamento das suas conseqüências físicas e sociais.

    Abstract in English:

    This article describes a study done in Recife, Brazil, between November 1993 and July 1994 to explore the opinions of the members of the social network (for example, family members, friends, and neighbors) of carriers of Hansen's disease regarding their estimation, interpretation, and management of physical manifestations of the disease in the time leading up to diagnosis. The sample consisted of 93 members of the social network, ranging in age between 20 and 70 years, who supported the course of action of 83 patients diagnosed in the study period. The analysis sought to detect differing capacities among the members of the patients' social network to discriminate between persons classified as cases (presence of disabilities or precursor lesions) or controls. The study found a lack of information about transmission of Hansen's disease and revealed a transitional phase in which there was expectation of cure along with a stigmatizing view of the consequences of the disease. Only one-quarter of the study subjects suspected prior to diagnosis that the patient had Hansen's disease, which suggests low perception of the risk represented by the disease and reinforces the idea that its physical manifestations can be invisible. The results reveal a profile of perception and management of Hansen's disease that favors its propagation and the development or worsening of its physical and social consequences.
  • Auditory evoked potentials in children at neonatal risk for hypoacusis Artículos

    Garza Morales, Saúl; Poblano, Adrián; Robledo Galván, Alicia; Fernández Carrocera, Luis Alberto

    Abstract in Spanish:

    Los potenciales provocados auditivos del tallo cerebral (PPATC) son un método sencillo y no invasor de evaluación de la función auditiva, que se utiliza ampliamente en niños para detectar tempranamente hipoacusia. Entre abril de 1992 y mayo de 1994, se estudiaron 400 niños mexicanos que presentaban, al menos, un factor de riesgo neonatal de hipoacusia. La media de la edad de los niños estudiados fue 6,6 meses y la media de la edad gestacional al nacer, 35,1 semanas. El 51% de ellos fueron tratados con amikacina. Se registraron 1 427 factores de riesgo (3,5 por niño), entre los que predominaron la exposición a ototóxicos, la hiperbilirrubinemia y el peso al nacer menor de 1 500 g. En 27% se encontraron alteraciones auditivas de tipo periférico y en 13%, ausencia de respuesta a estímulos auditivos. El bajo peso y la menor edad gestacional al nacer, la concentración máxima de bilirrubina en el suero, la presencia de sepsis, la hemorragia subependimaria o intraventricular, la ventilación mecánica y la exposición a ototóxicos se asociaron significativamente con la presencia de hipoacusia grave o profunda.

    Abstract in English:

    Auditory evoked potentials of the brain stem (AEPBS) provide a simple, noninvasive method of evaluating hearing function and have been widely used for early detection of hypoacusis in children. Between April 1992 and May 1994, a study was done of 400 Mexican children who presented at least one neonatal risk factor for hearing impairment. The average age of the children studied was 6.6 months and their average gestational age at birth was 35.1 weeks. Just over half of them (51%) had been treated with amikacin. The study found 1 427 risk factors (3.5 per child), the most common ones being exposure to ototoxic substances, hyperbilirubinemia, and birthweight of less that 1 500 g. In 27% of the children, peripheral auditory changes were found, and 13% did not respond to auditory stimuli. Low birthweight and young gestational age at birth, high serum concentration of bilirubin, sepsis, subependymal or intraventricular hemorrhage, mechanical ventilation, and exposure to ototoxic substances were significantly associated with the presence of severe or profound hypoacusis.
  • Cirrhosis of the liver in Brazil: mortality and productive years of life lost prematurely Articles

    Lessa, Ines

    Abstract in Portuguese:

    Este é um estudo descritivo, efetuado com base em dados oficiais sobre mortalidade por cirrose hepática para o ano de 1989. Os seus objetivos são: a) descrever a mortalidade por cirrose hepática em adultos brasileiros; b) estimar os anos produtivos de vida perdidos (APVP) precocemente (entre 20 e 59 anos) e c) determinar possiveis diferenças regionais na mortalidade e nos anos produtivos de vida perdidos. Os dados brutos foram ajustados por idade e sexo, tomando como padrão a população brasileira para o ano de 1980. Os APVP basearam-se na fórmula de Romeder e McWhinnie para anos potenciais de vida perdidos, modificados pela autora para anos produtivos de vida perdidos. As taxas brutas de mortalidade foram mais elevadas no Sudeste e Norte, e em todas as regiões predominou no sexo masculino, com razões homem/mulher para o país de 4,5 e variações regionais dos coeficientes de mortalidade para o sexo masculino de 14,37 (Centro-Oeste) a 35,86/100 000 (Sudeste), e para o sexo feminino de 3,49 (Centro-Oeste) a 8,5/100 000 (Norte). As curvas etárias de mortalidade para os homens, exceto os da região Norte, mostram tendência ao declinio ou estabilização a partir dos 60 anos. Para os homens do Norte, a curva é continuamente ascendente, atingindo 86,37/100 000 habitantes a partir dos 70 anos. As mulheres também apresentam curvas ascendentes, muito expressivas no Norte e Nordeste. As taxas ajustados por idade mostram uma redução para as mulheres do Sudeste, mantendo-se mais elevada no Norte. A mortalidade proporcional por cirrose hepática em relação ao aparelho digestivo chegou aos 48,7% para os homens e 24,1% para as mulheres. Dos 138 860 APVP por cirrose hepática em 1989, 83,2% foram no sexo masculino, mas as médias de APVP para o país, em torno de 15,5 anos, foram semelhantes para os sexos. Todavia, as médias de APVP para homens e mulheres do Norte e mulheres do Centro-Oste foram muito mais elevadas do que nas demais regiões. Os dados sugerem que a cirrose hepática entre os homens de todas as regiões, exceto os da região Norte, é possivelmente determinada pelo alcoolismo, enquanto entre homens nortistas existem fortes evidências da co-existencia de cirrose hepática de etiologia viral (vírus B e C da hepatite). Para as mulheres, as evidências apontam também para o predomínio da cirrose de etiologia viral.

    Abstract in English:

    This descriptive study was done using official data on mortality from cirrhosis of the liver for the year 1989. Its objectives are: (a) to describe mortality from cirrhosis of the liver in Brazilian adults; (b) to estimate the productive years of life lost (PYLL) prematurely (between 20 and 59 years of age) from this cause; and (c) to show any regional differences in cirrhosis mortality or PYLL. The raw data were adjusted by age and sex, using the 1980 population of Brazil as the standard. Calculation of PYLL was based on the formula of Romeder and McWhinnie for years of potential life lost, modified by the author to express productive years of life lost. The crude death rates from cirrhosis were higher in the Southeast and North, and in all regions they were higher in males, the countrywide male/female ratio being 4.5. Cirrhosis mortality among males ranged from a low of 14.37 deaths per 100 000 in the Center-West to a high of 35.86 per 100 000 in the Southeast; for females the rates ranged from 3.49 deaths per 100 000 in the Center-West to 8.5 deaths per 100 000 in the North. The cirrhosis mortality curves by age for men showed a leveling off or decline after age 60, except in the North where the curve continued to rise. Like this latter curve, the cirrhosis mortality curves for women also kept rising progressively with increasing age, most markedly in the North and Northeast. Overall, mortality from cirrhosis of the liver accounted for 48.7% of the deaths from digestive system disorders among men and for 24.1% of such deaths among women. Of the 138 860 PYLL from cirrhosis of the liver in 1989, 83.2% were lost by males; but the average loss per person dying of cirrhosis nationwide, around 15.5 years, was similar for both sexes. Regionally, the average PYLL per affected person was higher for men and women in the North and for women in the Center-West than it was in the other regions. The data suggest that cirrhosis of the liver among men in all the regions, except the North, is probably attributable largely to alcoholism. Among males from the North, there is strong evidence that cirrhosis with a viral etiology (hepatitis B and C viruses) is also important. For women, the evidence suggests that cirrhosis of viral etiology predominates.
  • Evaluation of beta-cypermethrin for control of Triatoma infestans Artículos

    Zerba, Eduardo Nicolás; Wallace, Guillermo; Picollo, María Inés; Casabé, Norma; Licastro, Susana de; Wood, Edgardo; Hurvitz, Abel; Andrés, Américo

    Abstract in Spanish:

    En este estudio se evaluó en el laboratorio y en el campo el efecto insecticida sobre Triatoma infestans, vector de la enfermedad de Chagas, del nuevo piretroide ß-cipermetrina, y se comparó con el de la deltametrina. La comparación de las dosis letales 50 (DL50) de ambos piretroides indicó que la ß-cipermetrina es más efectiva en ninfas y la deltametrina, en adultos. La evaluación de la concentración letal 50 (CL50) de las dos formulaciones floables de ambos insecticidas depositados sobre distintos soportes mostró que su efectividad en vidrio es similar. En cerámica, la deltametrina es ligeramente más efectiva. Los dos insecticidas floables se evaluaron en 100 viviendas infestadas de la provincia de Santiago del Estero, Argentina. La deltametrina floable se aplicó a una concentración superficial de 25 mg/m² y la ß-cipermetrina, de 50 mg/m². Las concentraciones superficiales reales de ambos productos se analizaron por medio de papeles de filtro colocados en paredes y techos. El análisis por cromatografía de gases mostró buena coincidencia con las concentraciones previstas. Asimismo, se realizaron evaluaciones entomológicas 60, 90, 180 y 365 días después de los tratamientos. Solo en la última evaluación se encontró 10% de infestación en peridomicilios de viviendas tratadas con ß-cipermetrina y 7% en las viviendas tratadas con deltametrina (6% en el peridomicilio y 1% en el domicilio). Los resultados indican que la efectividad de la ß-cipermetrina para controlar a T. infestans cuando se aplica a una concentración de 50 mg/m² es similar a la de la deltametrina cuando esta se administra a una concentración de 25 mg/m².

    Abstract in English:

    This study assessed the insecticidal effect in the laboratory and in the field of the new pyrethroid ß-cypermethrin against Triatoma infestans, the vector of Chagas' disease, and compared it with that of deltamethrin. Comparison of the 50% lethal dosis (LD50) of both pyrethroids showed that ß-cypermethrin is more effective against the nymphs and that deltamethrin is more effective against the adults. Evaluation of the 50% lethal concentration (LC50) of the flowable formulations of both insecticides, placed on different surfaces, showed that their effectiveness on glass is similar, while on a ceramic surface deltamethrin is slightly more effective. The flowable formulations of the two insecticides were tested in 100 infested homes in the province of Santiago del Estero, Argentina. Deltamethrin was applied at a surface concentration of 25 mg/m² and ß-cypermethrin at 50 mg/m². The real surface concentrations of these products were analyzed from filter paper samples placed on walls and ceilings. Gas chromatography revealed good agreement with the target concentrations. In addition, entomological assessments were carried out 60, 90, 180, and 365 days after the treatments. Infestations were found only during the last assessment: in the peridomiciliary area of 10% of the houses treated with ß-cypermethrin and in 7% of the houses treated with deltamethrin (6% in the peridomiciliary area and 1% inside the house). The results indicate that ß-cypermethrin's effectiveness in controlling T. infestans when applied at a concentration of 50 mg/m² is similar to that of deltamethrin applied at a concentration of 25 mg/m².
  • Do not resuscitate orders for pediatric patients: the role of a clinical ethics committee in a developing country Artículos

    Beca, Juan Pablo; Guerrero, José Luis

    Abstract in Spanish:

    En la actualidad, no existe información publicada sobre las órdenes formales de "no resucitar" a los pacientes pediátricos en los países en desarrollo, aunque se ha debatido a fondo cómo determinar quién debe intervenir en estas decisiones. En este artículo se presenta la experiencia del Comité de Ética Clínica del Hospital Calvo MacKenna de Santiago, un hospital pediátrico público de Chile. El Comité estaba integrado por cuatro miembros permanentes, todos ellos médicos, y por otros profesionales, como clérigos, enfermeras, el jefe de la sección de pacientes del hospital y el médico que atendía al paciente. Los médicos presentaban casos al Comité voluntariamente, pero las recomendaciones de este no debían cumplirse por obligación. De 1990 a 1993, el Comité recomendó órdenes de no resucitar a 16 de los 34 pacientes evaluados. Se hizo un análisis retrospectivo de los registros hospitalarios de esos 16 pacientes, para recabar información sobre su edad, el diagnóstico emitido, las recomendaciones concretas del Comité y el desenlace del caso. Se observó que, además de la orden de no resucitar, el Comité solía recomendar medidas concretas para ayudar a los padres del niño y al personal que lo atendía. La media de la edad de los pacientes fue de 2 años y 2 meses. Casi todos ellos padecían múltiples enfermedades crónicas. En todos los casos, las recomendaciones del Comité (adoptadas por consenso) fueron cumplidas por el médico con el consentimiento de los padres del paciente. Once de los 16 pacientes para los que se dieron órdenes de no resucitar fallecieron en el transcurso del estudio. Los cinco restantes siguieron vivos a pesar de tener insuficiencia respiratoria, lesiones neurológicas graves o insuficiencia hepática. En general, las recomendaciones del Comité parecieron ser útiles, ofrecieron sólidos argumentos para tomar la decisión de no resucitar y sugirieron otras medidas de apoyo a los pacientes, sus familias y los profesionales que los atendían. Este resultado respalda la idea de que los comités de ética clínica pueden prestar un apoyo valioso y ofrecer una oportunidad para tomar mejores decisiones en los hospitales públicos de los países en desarrollo.

    Abstract in English:

    No published information is currently available about formal "do not resuscitate" (DNR) orders for pediatric patients in developing countries, even though there has been extensive discussion of how to determine who should be involved in such decisions. This article reports the experience of the Clinical Ethics Committee of the Calvo MacKenna Hospital in Santiago, which is a pediatric public hospital in Chile. The Committee consisted of four permanent members, all physicians, and other members including clergymen, nurses, the head of the hospital's patient unit, and the attending physician. Physicians submitted cases to the Committee on a voluntary basis, and the Committee's recommendations were not binding. During the 1990-1993 study period, the Committee recommended issuing DNR orders for 16 of the 34 patients it evaluated. The hospital records of these 16 patients were retrospectively reviewed for information about the patient's age and diagnosis, the Committee's specific recommendations, and the outcome of the case. It was found that the Committee typically recommended specific measures to help the child's parents and attending staff in addition to the DNR orders. The average patient age was 2 years, 2 months. Nearly all of the patients had chronic and multiple pathologies. In all cases the Committee's recommendations (taken by consensus) were followed by the attending physician with the consent of the patient's parents. Eleven of the 16 patients for whom DNR orders were issued died during the study period. The five others remained alive despite respiratory insufficiency, severe neurologic damage, or hepatic failure. In general, the Committee's recommendations appeared useful, providing strong arguments for DNR decisions and suggesting further support measures for patients, their families, and the attending professionals. This finding reinforces the idea that clinical ethics committees can provide both valuable support and an opportunity to arrive at better decisions in the public hospitals of developing countries.
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Organización Panamericana de la Salud Washington - Washington - United States
E-mail: contacto_rpsp@paho.org