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Introducción: El cuidador familiar cuestiona su capacidad para cuidar cuando la persona que cuida sufre una descompensación aguda de la enfermedad crónica y requiere hospitalización en una unidad de pacientes críticos. En esta situación, se hace fundamental determinar la autoeficacia o capacidad del cuidador para organizar y ejecutar un cuidado que sea eficaz y que permita prevenir conductas riesgosas, tanto para su salud como para la de su familiar. Objetivo: Conocer la percepción de autoeeficacia del cuidador familiar de la persona en estado crítico por descompensación de su enfermedad crónica, que se encuentra en las Unidades de Paciente Crítico del Hospital Dr. Guillermo Grant Benavente de Concepción, y relacionarla con sus características biopsicosociales y con los indicadores de morbilidad de la persona hospitalizada. Metodología: Estudio cuantitativo, correlacional y de corte transeccional. Se aplicó la Escala de Autoeficacia para el Cuidado, la Escala de Autoestima y un cuestionario semiestructurado a 97 cuidadores familiares. Resultados: La autoeficacia fue mayor en los cuidadores hombres y se obtuvo una relación estadísticamente significativa con edad, nivel de estudios, autoestima, conocimiento del tratamiento y duración de la enfermedad. Conclusiones: Se observó cómo algunas características biopsicosociales del cuidador e indicadores de morbilidad de la persona en estado crítico se relacionan con su percepción de autoeeficacia e influyen en su decisión de adoptar una conducta promotora de salud frente a su autocuidado y el de su familiar.

Introduction: The familial caregivers question their capacity to care when patients suffer acute decompensations due to their chronic illnesses and require hospitalization in critical patients units. In these situations, it is fundamental to determine the caregiver self-efficacy in organizing and providing care which is effective and allows the prevention of risk-posing behaviors, both from the patients as well as from the patients' families. Objective: To explore the self-efficacy perception of familial caregivers towards the persons in critical status admitted to Critical Patient Units of the ''Dr. Guillermo Grant Benavente de Concepción'' hospital, as well as the related associations with bio-psycho-social characteristics and morbidity indicators. Methodology: This is a quantitative, correlational and trans-sectional study. A Care Self-Efficacy scale, a Self-Esteem scale, and a semi-structured questionnaire were conducted with 97 familial caregivers. Results: Self-Efficacy was higher among male caregivers, and statistically significant relations with age, level of studies, self-esteem, knowledge of the treatment, and illness duration were found. Conclusions: It was observed that some bio-psycho-social characteristics of the caregiver, as well as some morbidity indicators of the person in critical status, were associated to the caregivers' perception of their self-efficacy, and to the patients' strength to adopting health-promoting conducts towards themselves and their families.

Introdução: O cuidador familiar questiona a sua capacidade para cuidar quando o paciente sofre uma descompensação aguda da doença crónica e requer hospitalização em una unidade de pacientes críticos. Nesta situação, faz-se fundamental determinar a auto eficácia ou capacidade do cuidador para organizar e executar um cuidado que seja eficaz e que permita prevenir condutas arriscadas, tanto para sua saúde como a de seu familiar. Objetivo: Conhecer a percepção de auto eficácia do cuidador familiar com o paciente em estado crítico por descompensação de sua patologia crónica, que se encontra nas Unidades de Paciente Crítico do Hospital Dr. Guillermo Grant Benavente de Concepción, e relacioná-la com suas caraterísticas biopsicossociais e com os indicadores de mobilidade da pessoa hospitalizada. Metodologia: Estudo quantitativo, correlacional e de corte transeccionado. Aplicou-se a Escala de Auto eficácia para o Cuidado, a Escala de Autoestima e um questionário semiestruturado a 97 cuidadores familiares. Resultados: A auto eficácia foi maior nos cuidadores homens e obteve-se uma relação estatisticamente significativa com idade, nível de estudos, autoestima, conhecimento do tratamento e duração da doença. Conclusões: Observou-se como algumas caraterísticas biopsicossociais do cuidador e indicadores de mobilidade da pessoa em estado crítico, relacionam-se com sua percepção de auto eficácia e influenciam em sua decisão de adoptar uma conduta promotora de saúde perante a seu autocuidado e de seu familiar.

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RESUMEN ANTECEDENTES: la hemorragia posparto, secundaria o tardía, es un tema que requiere estudiarse aún más; quizá no ha despertado el interés suficiente por su baja asociación con la mortalidad materna, pero sí alta morbilidad que puede determinar múltiples complicaciones y necesidad de hospitalización. OBJETIVO: con base en la evidencia científica disponible profundizar en el conocimiento de las diferentes condiciones que forman parte del concepto hemorragia posparto secundaria. METODOLOGÍA: estudio retrospectivo mediante la búsqueda de artículos originales y revisiones sistemáticas en: PubMed, EMBASE, ScienceDirect y Biblioteca Cochrane. Para todos los sitios se utilizaron las palabras clave: "secondary postpartum hemorrhage", "delayed postpartum hemorrhage". Se seleccionaron los artículos de mayor nivel de evidencia. CONCLUSIONES: a diferencia de lo que ocurre en la hemorragia posparto primaria, la hemorragia posparto tardía rara vez amenaza la vida de la mujer sin por ello dejar de afectarla seriamente, cuando así sucede suele deberse a padecimientos poco frecuentes y conocidos. En estos últimos es prioritario el diagnóstico temprano junto con el tratamiento multidisciplinario.

ABSTRACT BACKGROUND: Secondary or late postpartum hemorrhage is a disease poorly represented in the literature and research studies; probably due to low association with maternal mortality, but high morbidity it implies that can determine a number of complications as well as increased hospital admissions. OBJECTIVE: To deepen the knowledge of the different entities that are part of postpartum hemorrhage secondary concept based on the available scientific evidence. METHODOLOGY: Was a search for original articles and systematic reviews published in the databases: PubMed, EMBASE, Cochrane Library and ScienceDirect. Included in the different search engines, keywords: "secondary postpartum hemorrhage", "delayed postpartum hemorrhage". Greater level of evidence selected and collected information from 52 documents CONCLUSIONS: Unlike what happens in primary postpartum hemorrhage, postpartum hemorrhage late rarely life threatening women but sometimes it can seriously compromise when this occurs often due to rare diseases and little known. In the latter, early diagnosis is a priority with a multidisciplinary approach.

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El presente estudio exploratorio tiene como objetivo analizar la implementación de dos proyectos de SENADIS para la inclusión laboral de personas con discapacidad (CCR Integral y Proyecto Piloto de Profesionales de Apoyo) en base al relato de Terapeutas Ocupacionales que ejecutaron dichos proyectos en los municipios de Conchalí, Huechuraba, Independencia, La Pintana y Peñalolén entre los años 2011- 2013, contribuyendo a la generación de conocimiento en lo que respecta a políticas públicas de inclusión laboral para personas con discapacidad. Este estudio es de tipo cualitativo y está diseñado en base a la Teoría Fundamentada. La recolección de datos se realizó a través del diseño de una entrevista semi estructurada a las Terapeutas Ocupacionales ejecutoras y a los encargados de dichos proyectos en SENADIS. Las entrevistas abarcaron desde aspectos operativos de la ejecución de los proyectos, hasta refexiones personales en torno a la experiencia. Se identifcan como aspectos signifcativos las siguientes categorías: proceso de implementación de los proyectos en los Municipios, constitución del cargo de las Terapeutas Ocupacionales, equipo de trabajo, factores que facilitaron la implementación de los proyectos, factores que difcultaron la implementación de los proyectos y refexión de las Terapeutas Ocupacionales acerca de la experiencia. La presente investigación se centra en conocer el proceso de implementación de políticas públicas de inclusión laboral a nivel municipal, a partir de la experiencia de Terapeutas Ocupacionales ejecutoras de los proyectos ejecutados.

The aim of this exploratory study is to analyze the execution of two projects proposed by SENADIS for work inclusion, based on the Occupational Therapists report who participated in the execution of both projects in the local councils of: Conchalí, Huechuraba, Independencia, La Pintana and Peñalolén between 2011 and 2013, promoting the knowledge generation related to public policies of work inclusion. This qualitative study is based on Founded Theory. The data recollection was done through semi structured interviews to the Occupational Therapists and two SENADIS professionals in charge of both projects. The interviews included operative aspects like the execution of both projects and also personal thoughts about the experience. The next categories were considered meaningful for the study: The interviewed, execution process of both projects in local councils, Occupational Therapist’s position in both projects, work team, factors that collaborated in the execution, factors that interrupted the execution and personal thoughts about the experience. This study is to recognize the execution process of public policies in work inclusion, generating discussions from the Occupational Therapists experience that executed both projects.

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In 2011 the Chilean National Health Fund (FONASA) commissioned a study to assess the costs of the 120 most relevant hospital care services with an established fee, in a large sample of public hospitals. We herein report the cost evaluation results of such study, considering the financial condition of those hospitals in the year of the study. Based on the premise that the expenses derived from the provision of institutional and appraised hospital services should be identical to the billing of hospitals to FONASA, the prices are undervalued, since they cover only 56% of billing, generating a gap between expenses and invoicing. This gap shows an important limitation of tariffs, since their prices do not cover the real costs. However not all hospitals behave in the same way. While the provision of services of some hospitals is even higher than their billing, most hospitals do not completely justify their invoicing. These assumptions would imply that, generally speaking, hospital debts are justified by the costs incurred. However, hospitals have heterogeneous financial situations that need to be analyzed carefully. In particular, nothing can be said about their relative efficiency if cost estimations are not adjusted by the complexity of patients attended and comparison groups are not defined.

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In 2011 the Chilean National Health Fund (FONASA) commissioned a study to assess the costs of the 120 most relevant hospital care services with an established fee, in a large sample of public hospitals. We herein report the cost evaluation results of such study, considering the financial condition of those hospitals in the year of the study. Based on the premise that the expenses derived from the provision of institutional and appraised hospital services should be identical to the billing of hospitals to FONASA, the prices are undervalued, since they cover only 56% of billing, generating a gap between expenses and invoicing. This gap shows an important limitation of tariffs, since their prices do not cover the real costs. However not all hospitals behave in the same way. While the provision of services of some hospitals is even higher than their billing, most hospitals do not completely justify their invoicing. These assumptions would imply that, generally speaking, hospital debts are justified by the costs incurred. However, hospitals have heterogeneous financial situations that need to be analyzed carefully. In particular, nothing can be said about their relative efficiency if cost estimations are not adjusted by the complexity of patients attended and comparison groups are not defined.

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El gasto de bolsillo en salud de los hogares del Gran Santiago medido por el INE el año 1997 y el año 2007 ha aumentado en un 8 por ciento. A su vez, ha diminuido la brecha de la proporción de gasto en salud de los quintiles 4-5 respecto a 1-2-3 a causa de la disminución de dicha proporción en el estrato más acomodado, con estancamiento en los más pobres. Entre estos últimos no se observa una reducción del gasto de bolsillo en salud como proporción del gasto total del hogar. De acuerdo estos datos las políticas de control, de esta forma regresiva de financiamiento de la salud, no han logrado tener un impacto significativo.

The out of pocket expenditures in health of the households of the Great Santiago measured by the INE the year 1997 and the year 2007 has increased in 8 percent. In turn, there is diminish the gap of the proportion of expenditure in health of the quintiles 4-5 with regard to 1-2-3 because of the decrease of the above mentioned proportion in the most well-off stratum, with stagnation in the poorest. Between the above mentioned is not observed a reduction of the out of pocket expenditure in health as proportion of the total expense of the households. In agreement this information the policies of control, of this regressive form of financing of the health, they have not managed to have a significant impact.

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En este trabajo se desarrolla una metodología de evaluación de Servicios de Salud en búsqueda de explicaciones a la deuda. Pretende abrir ámbitos de explicación, a través del estudio de perfiles de riesgos de personas atendidas a nivel hospitalario en cada Servicio de Salud y la construcción de índices de eficiencia relativa. El trabajo tiene un carácter ilustrativo y pretende resaltar la metodología. De los ocho Servicios de Salud con deuda considerados, cinco presentan gastos esperados de sus pacientes superiores al promedio y son los únicos cinco, del grupo de 17 Servicios de Salud considerados, en esta situación. Esto implica que, en general, los Servicios de salud con deuda muestran gastos esperados superiores que los Servicios de Salud sin deuda. A su vez, 5 Servicios de Salud con deuda justifican sus gastos observados y se desempeñan de manera relativamente eficiente. Sin embargo, tres de ellos arrojan como resultados un indicador que muestra ineficiencia relativa. La metodología se muestra robusta a la hora de comparar Servicios de Salud, dado que permite homogeneizar su producción, al ajustar por riesgos de la población atendida a nivel hospitalario. No obstante, para ser más precisos ella puede ser mejorada en varios aspectos que se señalan.

The present study aims at developing a methodology to explain deficits in different Chilean Health Authorities in Chile. It intends to make comparable the Health Authorities by studying the diverse risk and hence casemix of the different Health Authorities, this resulting in different degrees of efficiency. The present study case is used illustratively being the centre of the research the proposed methodology. The results show that al least 5 of the more indebted HA are those with highest observed expenditures and functioning with relatively good degrees of efficiency in comparison to the rest of them. Despite the concrete results of the illustrative exercise, it is the robustness of the method to compare different Health Authorities the main result of the study. This robustness lies on the possibility of comparing Health Authorities and their populations, adjusting them by their risks and casemix.

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El financiamiento de los hospitales públicos requiere de unos incentivos adecuados para conseguir una mayor eficiencia en el uso de los recursos. El sistema de pago actual muestra insuficiencias para acotarlas tasas de crecimiento de los costos de los prestadores de atención de salud, requiere una nueva regulación y presenta riesgos de desequilibrar el financiamiento. En el artículo se propone desarrollar un modelo de competencia por comparación o “yardstick competition”, que genere incentivos al mejoramiento de la eficiencia en el tiempo basado en lo que los hospitales son, o su estructura y en lo que hacen o su casuística, medida con GRDs. El modelo provee incentivos a los hospitales para asignar mejor recursos en un contexto de un mecanismo más global, de asignación poblacional que se apliquen a los Servicios de Salud a los cuales pertenecen.

Public hospital financing requires appropriate incentives in order to improve efficiency in resources allocation. The payment mechanisms currently in place present serious defi- ciencies in the provision of health as regards cost containment; they also require a new regulation as they represent a risk of financial imbalance. We present a model of competition based on comparison, or yardstick competition intended improve efficiency in the model is based on hospital current structure and activities, measured through DRGs. As a result, the model provides incentives for a better allocation of resources within the hospital, in a wider context related to population based resource allocation to the Health Authorities, of which hospitals are a part.

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Background: Problem based learning, integrating basic science with clinical problems, is one of the most recommended forms of teaching for medical schools. Aim: To compare a problem based learning program for physics with traditional teaching methods. Material and methods: In the physics course, first year medical students were separated in groups with traditional learning and problem based teaching. Both groups were subjected to the same knowledge and qualitative evaluations. Results: At the end of the course, cognitive performance in both groups was similar (60.8 and 61.3 percent among traditional teaching and problem based learning groups respectively). However, students assigned to the problem based learning group evaluated significantly better the teaching methodology and process. Conclusions: Physics education, using problem based learning, obtains the same cognitive results but a higher degree of satisfaction than traditional teaching among students

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To assess the feasibility of a distance medical education program prepared in a written format, 90 physicians aged 25 to 29 years old and with 1 to 4 years of medical practice, working mostly in rural locations, participed in the program. The sending of 10 ussues with medical topics was programmed. The topics were selected according to the results of an survey done among physicians of the region. Each issue contained an evaluation that had to be returned to the authors. Eigthy two physicians completed the program and 59 returned the evaluations. The mean obtained score in the cognitive evaluation was 80ñ6 points (range 68 to 97 points) of a scale from 0 to 100. The qualitative survey revealed a high degree of approval of the issue's format, contents and evaluation system. The favorable effect on patients' management and on the detection and control of chronic diseases was emphasized. This distance medical education program had a good receipt and compliance among physicians and contributed to continuing medical training

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Se han utilizado diferentes sustancias para obtener pleurodesis. Todas ellas tienen el inconveniente de producir dolor y fiebre o de no poder ser usadas mientras persista la fuga de aire a través de drenaje pleural. A fin de superar estos problemas para lograr la pleurodesis se ha utilizado el sellamiento pleural con fibrina obtenida a partir de fibrinógeno el cual es activado por trombina bovina. Con el propósito de evaluar este procedimiento, seleccionamos 7 pacientes ( 6 con neumotórax y 1 con derrame pleural), los cuales no pudieron ser controlados con el tratamiento habitual. A través del tubo pleural se inyectó un compuesto rico en fibrinógeno obtenido a partir de plasma humano, seguido por un volumen equivalente (25 ml)de una solución de trombina bovina (800 U). El drenaje pleural fue pinzado por 15 min y conectado nuevamente a trampa de agua y aspiración (-10 cm H2O). En los 7 pacientes la pleurodesis fue exitosay el drenaje pleural pudo ser retirado al cabo de 1 a 6 días. El procedimiento fue bien tolerado y los pacientes no presentaron dolor ni fiebre. No hubo mortalidad ni otras complicaciones derivadas del procedimiento. Se concluye que el sellamiento con fibrina es una forma eficiente, factible, rápida e indolora para producir pleurodesis

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