Laboy-Ortiz IE, Velez-Maymí S, Hernán Martínez J
… +9 more, Trinidad R, Mangual M, Sanchez A, Gutierrez M, Mansilla P, Rivera C, Palermo C, de Lourdes Miranda M, Brau R
Bol Asoc Med P R
· 2016 · PMID 29193928
Prolactinomas are the most common hormone-secreting pituitary tumors and represents approximately 40% of all pituitary adenomas. Pharmacology therapy with dopamine agonists is the mainstay treatment for prolactinomas. Us...Prolactinomas are the most common hormone-secreting pituitary tumors and represents approximately 40% of all pituitary adenomas. Pharmacology therapy with dopamine agonists is the mainstay treatment for prolactinomas. Usually, patients respond to these drugs with decreased level of the serum prolactin and with time, by tumor shrinkage. Less than 10% of patients with prolactinomas exhibit resistance to the action of dopamine agonists, as defined by the lack of normalization of the serum prolactin levels despite long- term treatment at high doses of these drugs. However secondary resistance to dopamine agonists therapy has also been described in patients who were initially responsive to treatment, either with Cabergoline or Bromocriptine but later develop dopamine agonist resistance, with elevated prolactin levels and sometimes an enlarging tumor volume several years afterwards. We report a case of a male patient with prolactinoma who developed drug resistance 13 months after initial dopamine agonist therapy.
Alvarado M, Ramirez-Vick M, Allende-Vigo M
… +8 more, Mendez-Latalladi W, Agosto M, Gonzalez R, Martinez M, Vega M, Fernandez M, Velez R, Méndez K
Bol Asoc Med P R
· 2016 · PMID 29193927
This is the case of a 38 year-old female patient with an intrauterine pregnancy, in which a previous incidentally identified adrenal mass proved to be a pheochromocytoma during the antenatal period. The patient was start...This is the case of a 38 year-old female patient with an intrauterine pregnancy, in which a previous incidentally identified adrenal mass proved to be a pheochromocytoma during the antenatal period. The patient was started on α-and β-adrenergic blockade to maintain hemodynamic stability, and surgical removal of the lesion was performed during the second trimester without major complications. In view of the rarity of this disorder in pregnancy, it is imperative to have a high index of suspicion for a prompt and dedicated management, since this tumor, if unrecognized, is associated with high fetal and maternal mortality.
INTRODUCTION: A traumatic event to the tibia with more than 14 cm of bone and soft tissue loss represents a challenge to most orthopedic surgeons and is considered a limb-threatening condition. Few solutions are availabl...INTRODUCTION: A traumatic event to the tibia with more than 14 cm of bone and soft tissue loss represents a challenge to most orthopedic surgeons and is considered a limb-threatening condition. Few solutions are available in such clinical situations and among them is the acute shortening and re-lengthening of bone and soft tissue. MATERIALS AND METHODS: Our study presents the management of 7 patients with grade III B open fractures (according to the Gustillo-Anderson classification) of the tibia who underwent resection of all the devitalized tissues, acute limb shortening to close the defect, application of an external fixator, and metaphyseal osteotomy for re-lengthening. The patient outcomes were based on different parameters using the evaluation system established by Paley et al. RESULTS: Results acquired during the study show an average bone loss of 19cm (with a minimum of 14 cm and a maximum of 31.50cm). The average time to full recovery of all patients was 19 months with a minimum of 14 months and a max of 34 months. Patient presented with excellent bony union and none existent or small refractory leg length discrepancy and did not require bone grafts or free flaps. Complications that the patients had were contractures, which required secondary procedures such as Achilles tendon re-lengthening and recurrent infections. DISCUSSION: Overall patients had excellent bone union and were able to perform activities of their daily living. The Ilizarov technique of compression-dis- traction osteogenesis is an elegant treatment option that should be considered in patients suffering such traumatic events providing excellent bony union and good functional outcomes for the patient.
INTRODUCTION: Previous studies have described Klinefelter syndrome as a genetic disorder characterized by at least one extra X chromosome and at least 47 chromosomes. It is the most common sex chromosome aneuploidy among...INTRODUCTION: Previous studies have described Klinefelter syndrome as a genetic disorder characterized by at least one extra X chromosome and at least 47 chromosomes. It is the most common sex chromosome aneuploidy among men. Patients may present with large height, gynecomastia, low testosterone levels, infertility, hypogonadism and diseases usually more common in females such as osteoporosis, breast cancer and auto-immune disorders. Other rare ophthalmic associations have been described, such as diffuse choroidal atrophy, microphtalmia, cataracts, juvenile glaucoma, choroid colobomas and goniodysgenesis. OBJECTIVES: To report on the ocular findings in a Puerto Rican patient with Klinefelter syndrome (XXXXY/XXXY). PATIENTS AND METHODS: A patient with Klinefelter syndrome with revious history of elevated intraocular pressure underwent a comprehensive ocular examination, Humphrey visual fields and Stratus optical coherence tomography (OCT) tests. Patient had inreased intraocular pressure, visual field loss and OCT findings compatible with glaucoma. After laser YAG laser iridotomies, high IOP persisted. Brimonidine 0.2 % drops three times a day drops were prescribed to lower IOP. CONCLUSIONS: A patient with Klinefelter syndrome had poor visual acuity, high intraocular pressure, visual fields and OCT results, all compatible with angle closure glaucoma as part of the syndrome.
Quadriceps muscle injuries are common in athletes and middle age patients. Strains and tears of the distal portion of the muscle is the most common presentation of these injuries. Isolated rectus femoris tears are rare a...Quadriceps muscle injuries are common in athletes and middle age patients. Strains and tears of the distal portion of the muscle is the most common presentation of these injuries. Isolated rectus femoris tears are rare and few reports are published that evaluate outcomes in of nonsurgical treatment of these injuries. This article will described an unusual case of isolated distal rectus femoris tear in a patient with no associated risk factors, who initially presented with extensor mechanism weakness and limping, treated conservatively with range of motion therapy and strengthening.
End Stage Renal Disease patients undergo profound hemodynamic changes during hemodialysis treatments which are now recognized as a marker for increased risk of morbidity and mortality. Development of intradialytic hypote...End Stage Renal Disease patients undergo profound hemodynamic changes during hemodialysis treatments which are now recognized as a marker for increased risk of morbidity and mortality. Development of intradialytic hypotension or hypertension are a common clinical problem in this population with an incidence of up to 20%. We performed a retrospective review of 49 Hispanic patients receiving ambulatory hemodialysis during a period of 6 months to ascertain the development of aforementioned intradialytic events. Clinical data examined the association of these events to mortality and their relationship to antihypertensive medications and cardiomegaly. The prevalence of intradialytic hypotension was 38.78%, hypertension 16.33% individually and both taking place 16.33%. Taken together, the prevalence of these intradialytic events was 71.43% in our Hispanic population. A significant association was found between mortality and Beta blockers (BB)(P=0.044), Calcium channel blockers (CCB) (P=0.023), cardiomegaly (P=0.044), and intradialytic events (P=0.035). Odds ratio of multiple variables dis- closed that dependent variable death decreased in probability with the use of BB by an estimate of 73% and with the use of CCB by 74.8%. On the other hand, odds of developing the dependent variable death increased by 74.5% if the patients developed intradialytic events. Similarly, the odds of developing cardiomegaly in the living group increased by 70%. A logistic regression of multiple variables found that the probability of developing the dependent condition of death increases by almost 2.896 times if intradialytic events are present and that there is a 58.9% inferred causality. It is concluded that intradialytic hyper- tension and hypotension are major risk factors for mortality in dialysis patients. The use of BB and CCB may be protetive to avoid the risk of mortality in these patients.
Methicillin-resistant Staphylococcus aureus (MRSA) is a strain of S. aureus that shows resistance to multiple antibiotics. Up to 30% of S. aureus strains isolated from nosocomial infections are MRSA, and it has become a...Methicillin-resistant Staphylococcus aureus (MRSA) is a strain of S. aureus that shows resistance to multiple antibiotics. Up to 30% of S. aureus strains isolated from nosocomial infections are MRSA, and it has become a growing problem for public health. The cost of MRSA infection is also having a huge impact financially and results in considerable resource utilization. Puerto Rico’s Legislature passed Law # 298 on October 19, 2012 for the control and prevention of MRSA infections in medical installations in Puerto Rico. In order to comply with the law we conducted a pilot study to identify possible setbacks of the implementation of the MRSA decolonization protocol as standard of care therapy in our institution while contributing to the process of quality improvement and patient safety. Nasal swabs were taken at the Pre-admission Department and processed through a PCR-based MRSA detection assay. A protocol of decolonization in patients with positive results was implemented. The study showed that patients without apparent risk factors could be colonized either with MRSA or Methicillin-sensitive S. aureus (MSSA). The time between pre- admission and surgery was less than the indicated for a proper decolonization procedure. Therefore, 50% of the scheduled surgeries could have been postponed in case of positive MRSA or MSSA. In our experience patient’s education was crucial to guarantee compliance and adherence to treatment. In order to decrease risk of wound infection we recommend that both, screening process and decolonization if required, be performed before the preadmission appointment for elective surgery. This study provided a framework for MRSA pre-admission screening and decolonization in our Institution.
Rivera Rosado E, Santaella Sante B, Corderob PM
… +2 more, Rivera JJ, Otero Lopez F
Bol Asoc Med P R
· 2016 · PMID 29193921
Stress fractures and muscle strains are common in marathon runners. Most stress fractures occur in lower extremities and tibia stress fractures comprise almost half. Iliac wing stress fractures are not commonly found in...Stress fractures and muscle strains are common in marathon runners. Most stress fractures occur in lower extremities and tibia stress fractures comprise almost half. Iliac wing stress fractures are not commonly found in runners and are usually related to osteoporosis. There have been 4 previous reports of iliac stress fractures in marathon runners none reported an associated isolated gluteus minimus tendon tears. We will report a case of a female marathon runner with iliac wing stress fracture with associated isolated gluteus minimus tendon tear.
In this case report a patient presents with high-output cardiac failure in the clinical setting of acute leukemia and leukostasis. Case particulars are presented, literature is reviewed and a potential mechanistic explan...In this case report a patient presents with high-output cardiac failure in the clinical setting of acute leukemia and leukostasis. Case particulars are presented, literature is reviewed and a potential mechanistic explanation is proposed to describe presentation and clinical findings.
OBJECTIVES: The aim of this work is to determine the diabetes treatment satisfaction in a group of hospitalized patients with type 2 diabetes. METHODS: observational cross research. Patients over the age of 18 with diagn...OBJECTIVES: The aim of this work is to determine the diabetes treatment satisfaction in a group of hospitalized patients with type 2 diabetes. METHODS: observational cross research. Patients over the age of 18 with diagnosed type 2 diabetes of at least one year until the present study were included. Those presenting pathologies attributed to diabetes were excluded. Patients should have responded to the DTSQ questionnaire upon admission. r Pearson regression, multivariate linear regression and U Mann-Whitney tests were analyzed. RESULTS: A total of 102 patients were included with an average age of 63.1 years. Average value of the DTSQs was 14.5. A significant statistic correlation was observed between the score of the questionnaires and good diabetes control showed by the levels of HbAc1 and fasting blood glucose, among other parameters. Indeed there was no correlation between satisfaction and age and BMI. Women had lower satisfaction score than men. CONCLUSIONS: levels of diabetes treatment satisfaction in the study population correlated well with diabetic status. That is, the lower diabetic compromise, the better satisfaction score. The degree of satisfaction in patients with type 2 diabetes was lower than the observed on patients with the same pathology but from primary levels of health care.
López-Díaz T, Lugo F, Rodríguez JM
… +4 more, Sabao E, Sierra K, Valdés Y, Vera J
Bol Asoc Med P R
· 2016 · PMID 29193918
Dengue is an endemic disease in Puerto Rico, with three to nine thousand suspected dengue cases reported yearly. In PR, physicians are required to maintain medical education courses about dengue in order to recertify the...Dengue is an endemic disease in Puerto Rico, with three to nine thousand suspected dengue cases reported yearly. In PR, physicians are required to maintain medical education courses about dengue in order to recertify their medical licenses. The purpose of this study was to describe characteristics of patients admitted to Bella Vista Hospital with suspected dengue and estimate the compliance with guidelines established by the CDC documented in medical records. A total of 197 medical records of patients admitted with diagnosis of suspected dengue during January 1, 2013 through December 31, 2013 were reviewed. The annual distribution of admitted cases showed a higher incidence during the months of June through September, with August having the higher incidence of all. Combined aches and pains were most commonly reported at admission with a prevalence of 82%. In general there was a low prevalence of severe disease as per definition at presentation (DM, clinical fluid accumulation, hepatomegaly, pregnancy and/or renal insufficiency). Overall, compliance with CDC established guidelines were only partially followed. The guideline that was followed more frequently was a daily CBC, with 95% of patients having this as part of their management. Prevalence of administration of isotonic intravenous fluids was 63%, monitoring of vital signs was 48%), and administration of bolus of intravenous fluid was11%. No fatalities were reported during the period.
Choledochal cysts are cystic dilatation of the common bile duct managed by excision and hepatico-intestinal reconstruction. The gold standard after choledochal cyst excision is reconstruction using the jejunum. With the...Choledochal cysts are cystic dilatation of the common bile duct managed by excision and hepatico-intestinal reconstruction. The gold standard after choledochal cyst excision is reconstruction using the jejunum. With the advent of laparoscopy the pendulum has changed toward hepaticoduodenostomy reconstruction. We review the classification, diagnosis and recent management of choledochal cyst.
Laboy-Ortiz IE, Velez-Maymí S, Hernán Martínez J
… +9 more, Trinidad R, Mangual M, Sanchez A, Gutierrez M, Mansilla P, Rivera C, Palermo C, Lourdes Miranda M, Brau R
Bol Asoc Med P R
· 2016 · PMID 29193914
Prolactinomas are the most common hormone-secreting pituitary tumors and represents approximately 40% of all pituitary adenomas. Pharmacology therapy with dopamine agonists is the mainstay treatment for prolactinomas Usu...Prolactinomas are the most common hormone-secreting pituitary tumors and represents approximately 40% of all pituitary adenomas. Pharmacology therapy with dopamine agonists is the mainstay treatment for prolactinomas Usually, patients respond to these drugs with decreased level of the serum prolactin and with time, by tumor shrinkage. Less than 10% of patients with prolactinomas exhibit resistance to the action of dopamine agonists, as defined by the lack of normalization of the serum prolactin levels despite long- term treatment at high doses of these drugs. However secondary resistance to dopamine agonists therapy has also been described in patients who were initially responsive to treatment, either with Cabergoline or Bromocriptine but later develop dopamine agonist resistance, with elevated prolactin levels and sometimes an enlarging tumor volume several years afterwards. We report a case of a male patient with prolactinoma who developed drug resistance 13 months after initial dopamine agonist therapy.
This case illustrates the unusual presentation of Takotsubo cardiomyopathy in an elderly male patient with characteristic chest pain and dyspnea associated with electrocardiographic changes of biphasic T wave inversions...This case illustrates the unusual presentation of Takotsubo cardiomyopathy in an elderly male patient with characteristic chest pain and dyspnea associated with electrocardiographic changes of biphasic T wave inversions and QT-interval prolongation on anterior segment, mimicking acute coronary syndrome. Takotsubo cardiomyopathy is a transient systolic dysfunction of the apical and/or mid and anterior segments of left ventricle most frequently seen in post- menopausal women, up to 80 to 100% of cases. Often there is a history of a recent (within the previous two months) episode of severe emotional or physical stress associated with the event.
Rivera Rosado E, Hernandez Ortiz E, Lopez Aponte C
… +1 more, Marrero Ortiz PV
Bol Asoc Med P R
· 2016 · PMID 29193912
Fibrous dysplasia is benign developmental disorders of bone where normal lamellar cancellous bone is replaced with immature fibro-osseus tissue resulting in poorly formed trabeculae of immature woven bone. It may affect...Fibrous dysplasia is benign developmental disorders of bone where normal lamellar cancellous bone is replaced with immature fibro-osseus tissue resulting in poorly formed trabeculae of immature woven bone. It may affect one (monostotic) or multiple bones (polyostotic). Polyostotic disease is less common, 20-25% of patients, mostly in children below 10 years old and tends to enlarge beyond bone maturation ration which can cause pain, progressive damage and higher tendency of pathological fractures.(1) We report a case of polyostotic fibrous dysplasia present on bilateral tibia diaphysis. Patient presented with bilateral leg pain on examination and imaging showed bilateral tibia lytic lesion. Management consisted of reaming and intramedullary nailing on bilateral tibia after which patient presented without pain and radiographs showing no evidence of lesion. Tibia x-rays demonstrated exuberant cortical intramedullary bone formation with disappearance of the scalloped osteolytic lesions on the inner wall of tibial cortex. Clinically the patient's symptoms disappeared giving the opportunity to return to contact sports without limitation.
Surgical site infections (SSI) are the most common healthcare-associated infections. Approximately 2-5% of all surgeries develop SSI as a complication. These infections are responsible for significant fatality, morbidity...Surgical site infections (SSI) are the most common healthcare-associated infections. Approximately 2-5% of all surgeries develop SSI as a complication. These infections are responsible for significant fatality, morbidity, and length of hospital stay. The purpose of this study was to describe characteristics of SSI in a community hospital in Puerto Rico. This was cross-sectional study. Between July 2013 and August 2015, 5468 major operative procedures were performed and 31 SSI were reported for an overall SSI incidence rate of 0.57%. A total of 31 cases of SSI were studied. The mean age of patients was 59.4 years, with a range of to 29 to 89 years. The median age was 64 years. The sex distribution showed 22 women (71%) and 9 men (29%). The prevalence rate of diabetes mellitus was 13/31 (42%). In this study 90% of patients with SSI had at least one underlying health condition (diabetes, hypertension, obesity, age > 65 years). Location of surgical site infections were: abdominal 16 (52%), orthopedic 4 (13%), pelvic 7 (22%), stump 3 (10%), and chest tube 1 (3%). A total of 12 different bacterial pathogens were found. A single etiologic agent was identified in 18 patients (53%) and multiple agents were found in 13 patients (47%). Enterococcus faecalis was the most common pathogen (45% of patients) followed by Escherichia coli (39% of patients). The majority of bacteria isolated from cultures were susceptible to B-lactams and aminoglycosides.
Servilla M, Trabanco C, Feliciano W
… +2 more, Bredy RE, Lojo S
Bol Asoc Med P R
· 2016 · PMID 29192750
Fine needle aspiration of thyroid (FNA) is broadly used as the preferred preoperatory test to evaluate thyroid nodules. The clinical importance of this procedure is primarily related the need to exclude Thyroid Cancer. T...Fine needle aspiration of thyroid (FNA) is broadly used as the preferred preoperatory test to evaluate thyroid nodules. The clinical importance of this procedure is primarily related the need to exclude Thyroid Cancer. There are few studies investigating the association between FNA and final pathology in patients with thyroid nodules with surgical indications. There is no evidence from studies in the southern area of Puerto Rico that investigate this association. This was a randomized cross-sectional study, 82 medical records were evaluated. Data were obtained for FNA diagnosis, demographics, body mass index, findings on ultrasound and histopathology results. In this study the sensitivity of FNA was 73.53% and specificity of 100%. The accuracy of the study was 78%. The study reported a prevalence of 83% malignant tumors in the final pathology and 61% in the FNA. The positive predictive value was 100% and negative 43.75%, suggesting that FNA is a good diagnostic test to detect thyroid nodules suspicious for malignancy. FNA of 33 patients was reported with undetermined cytopathology. The measure of agreement and correlation coefficient showed a moderate agreement between both studies with a Kappa value of 0.487, suggesting that the test results of FNA and final pathology are associated. Of the indeterminate nodules, final pathology reported 15 benign and 18 malignant. This study demonstrated that the FNA is reliable in identifying thyroid nodules in patients with surgical indications.