Torres-Miranda D, Al-Saffar F, Ibrahim S
… +1 more, Font-Diaz S
Bol Asoc Med P R
· 2015 · PMID 26434076
This report describes a 64-years-old male patient that presented to our hospital with a chief complaint of acute worsening of his usual chronic lower back pain, progressive weakness in lower extremities and subjective fe...This report describes a 64-years-old male patient that presented to our hospital with a chief complaint of acute worsening of his usual chronic lower back pain, progressive weakness in lower extremities and subjective fevers at home. Spine CT failed to demonstrate any infectious foci but showed partially visualized lung cavitary lesion and renal pole abnormalities. Blood cultures grew methicillin-sensitive Staphylococcus Aureus (MSSA). Transthoracic echocardiogram (TTE) showed no signs of infective endocarditis (IE). Later, the patient experienced an acute deterioration on clinical status and examination showed development of a new murmur. He also developed new hemiparesis with up-going babinski reflex. A head MRI showed multiple infarcts. MRI spine displayed osteomyelitis at T12-L1. Cerebro-spinal fluid was positive for meningitis. A transesophageal echocardiogram (TEE) was performed demonstrating new severe mitral and mild tricuspid regurgitations with a definitive 1.5 cm mobile vegetation on posterior mitral leaflet. We present is a very interesting case of a rapidly progressive MSSA infection. MSSA meningitis is a rare disease; there are only few reported cases in the literature to date. We describe a case of MSSA bacteremia, of questionable source, that resulted in MSSA endocarditis affecting right and left heart in a patient who did not have a history of intravenous drug use (IVDU) or immunosuppression. The case was complicated by septic emboli to systemic circulation involving the kidneys, vertebral spine (osteomyelitis), lungs and brain with consequent meningitis and stroke. Even when MSSA infections are well known, to our knowledge there are no previous case reports describing such an acute-simultaneous-manifestation of multi-end-organ failure, including meningitis and stroke. These latter are rarely reported, even individually.
Thyroid storm is a rare but potentially catastrophic disease expression of thyrotoxicosis with well-recognized cardiovascular manifestations such as heart failure and atrial fibrillation. Even through some studies have f...Thyroid storm is a rare but potentially catastrophic disease expression of thyrotoxicosis with well-recognized cardiovascular manifestations such as heart failure and atrial fibrillation. Even through some studies have found an increased risk of cardiac thrombus formation and subsequent thromboembolism in these patients, the use of anticoagulation to prevent thromboembolic sequelae of thyrotoxic atrial fibrillation remains unclear. We present a patient presenting with new onset dilated cardiomyopathy and resistant atrial fibrillation with thyroid storm that had a large left atrial appendage clot. Case particulars are discussed and the literature reviewed.
Handlebar hernia is a rare traumatic abdominal wall hernia occurring after blunt trauma. We report a case of an adolescent patient with a traumatic rectus muscle abdominal wall hernia produced by injury with the bicycle...Handlebar hernia is a rare traumatic abdominal wall hernia occurring after blunt trauma. We report a case of an adolescent patient with a traumatic rectus muscle abdominal wall hernia produced by injury with the bicycle handlebar. The skin abrasion caused by the trauma and a swelling reproduced after a Valsalva maneuver suggested the diagnosis. Traumatic wall hernias after blunt trauma should be repaired primarily to avoid complications.
Small cell carcinoma of the uterine cervix is a rare and aggressive extra-pulmonary variant of small cell tumors. This carcinoma of the cervix comprises less than 5% of all cervical carcinomas and is know to be highly un...Small cell carcinoma of the uterine cervix is a rare and aggressive extra-pulmonary variant of small cell tumors. This carcinoma of the cervix comprises less than 5% of all cervical carcinomas and is know to be highly undifferentiated. It is associated with a poor prognosis and characterized by premature distant nodal involvement. The survival rate at all stages ranges from 17% to 67%. We describe the case of a 41 year old female patient with a rare, and aggressive, clinical stage IB1 small cell neuroendocrine carcinoma of the cervix. The goal of this case report is to describe this rare pathology and contribute information to the scant available data.
Paraliticci G, David Rodríguez-Quintana R, Dávila A
… +1 more, Otero-López A
Bol Asoc Med P R
· 2015 · PMID 26035986
Bilateral femur neck fractures in young adult patients are very rare in atraumatic circumstances. We report a young premenopausal female with osteomalacia secondary to vitamin D deficiency and spontaneous bilateral femur...Bilateral femur neck fractures in young adult patients are very rare in atraumatic circumstances. We report a young premenopausal female with osteomalacia secondary to vitamin D deficiency and spontaneous bilateral femur neck fractures. Patients had no reported risk factors for osteomalacia but hypovitaminosis D was noted on laboratory evaluation. Osteomalacia secondary to low serum levels of vitamin D may lead to stress and fragility fractures. Identification and treatment of at risk patients may decrease the incidence of stress fractures and its possible complications.
Figueroa-Jiménez LA, González-Márquez AL, Negrón-García L
… +7 more, Rosas-Soler F, Dones-Rodríguez A, De La Paz-López M, Santiago-Casiano M, Rodríguez-Cruz E, Cáceres-Pérkins W, Béez-Díaz L
Bol Asoc Med P R
· 2015 · PMID 26035985
Splenic artery aneurysms (SAA) are a rare life threatening clinical diagnosis. We present a case of a young Hispanic woman with an aneurysm of the middle branch of the splenic artery and active leakage. The defect was em...Splenic artery aneurysms (SAA) are a rare life threatening clinical diagnosis. We present a case of a young Hispanic woman with an aneurysm of the middle branch of the splenic artery and active leakage. The defect was embolized with complete resolution of the retroperitoneal bleeding. Physicians should be aware of this rare entity especially when female patients presents complainiing of severe epigastric pain with associated hypovolemic shock.
Pietras DA, Lopez FR, Peréz R
… +2 more, López-Candales A, Elwing J
Bol Asoc Med P R
· 2015 · PMID 26035984
Systemic sclerosis (SSc) can cause interstitial lung and pulmonary vascular disease that can induce pulmonary arterial hypertension (PAH). It is well known that severe PAH may reduce left ventricluar preload and decrease...Systemic sclerosis (SSc) can cause interstitial lung and pulmonary vascular disease that can induce pulmonary arterial hypertension (PAH). It is well known that severe PAH may reduce left ventricluar preload and decrease diastolic filling with the potential of reducing forward flow. We present a case in which a patient with SSc and symptomatic PAH required direct pulmonary vasodilator therapy for treatment of elevated pulmonary pressures. On follow-up echocardiogram, while improvement in right ventricular function and reduction in estimated pulmonary pressures were noted; worsening of aortic valve gradients was also found. Cardiac hemodynamics of pulmonary vasodilator therapy is discussed and the literature is reviewed.
González W, Altieri PI, Alvarado E
… +4 more, Banchs HL, Colón E, Escobales N, Crespo M
Bol Asoc Med P R
· 2015 · PMID 26035983
Higher doses and consumption of energy drinks leads to cardiovascular effects and potential consequences. Principal components found in energy drinks such as caffeine, guarana and taurine has been related to dilatation,...Higher doses and consumption of energy drinks leads to cardiovascular effects and potential consequences. Principal components found in energy drinks such as caffeine, guarana and taurine has been related to dilatation, aneurysm formation, dissection and ruptures. There is no evidence showing an integration of these components and its effects in endothelium and aortic walls due to higher levels of pressure during exercises. We report a case of a 44 years male with celiac trunk and branches dissection due to long-term consumption of energy drinks and intense exercise routine. Our proposition relates cell and vessel walls alterations including elasticity in endothelial wall due to higher blood pressure, resistance by intense exercise routine and long-term consumption of energy drinks.
Álvarez J, Castro P, Fernández M
… +3 more, Mcmullen B, Rodríguez C, Vera J
Bol Asoc Med P R
· 2015 · PMID 26035982
UNLABELLED: The purpose of this study was to estimate the degree of association between clinical (Ranson criteria) and radiological variables (Abdominal CT scan) with degree of severity in patients with a diagnosis of ac...UNLABELLED: The purpose of this study was to estimate the degree of association between clinical (Ranson criteria) and radiological variables (Abdominal CT scan) with degree of severity in patients with a diagnosis of acute pancreatitis. METHOD: All patients discharged with the diagnosis of acute pancreatitis from January 1, 2010 through December 31, 2012 in a community hospital were selected (N=174). The following variables were studied: sex; age; weight; height; admission and discharge dates; presence of several chronic conditions; laboratory results included in Ranson criteria; abdominal CT category; outcome, including fatality surgery, and other complications. Analysis included descriptive statistics and Risk-Ratios for complications for different groups of subjects, using clinical and radiological criteria. RESULTS: The incidence rate of complications, including fatality, surgery and organ failure was 36.2%. Factors that showed significant associations with the risk of complication on crude analysis were gallbladder disease with a RR=1.78 ($95% CI: 1.22, 2.60) and abnormal abdominal CT with a RR=1.85 (95% CI: 1.11, 3.07). with multivariate analysis, gallbladder disease, abnormal abdominal CT, and presence of 3 or more Ranson's criteria showed increased risk for complications, but the results did not reach statistical significance. DISCUSSION: The factors that seemed to be associated with increased rate of complications in subjects with acute pancreatitis were gallbladder disease, abnormal abdominal CT, and 3 or more Ranson's criteria. The Results did not show statistical significance probably because of low statistical power of the study.
Vega-Vázquez MA, Gonzalez-Rodriguez L, Santiago-Rodríguez EJ
… +4 more, Garcés-Domínguez A, Shum LM, Tírado-Gómez M, Ramírez-Vick M
Bol Asoc Med P R
· 2015 · PMID 26035981
UNLABELLED: Differentiated thyroid cancer (DTC) can compromise the quality of life of patients. Our purpose is to investigate if the quality of life, in a cohort of patients in Puerto Rico, is affected by the diagnosis a...UNLABELLED: Differentiated thyroid cancer (DTC) can compromise the quality of life of patients. Our purpose is to investigate if the quality of life, in a cohort of patients in Puerto Rico, is affected by the diagnosis and/or treatment modalities received for DTC. METHODS: This is a cross-sectional study of 75 subjects with DTC. A Spanish version of the University of Washington Quality of Life Questionnaire was used, including multiple aspects of physical and social functioning. Descriptive and bivariate analysis between domain scores and variables of interest were performed. RESULTS: 82.7% of the patients reported that their health was the same or better than it was before treatment. The mean composite score obtained was 82.3, reflecting an overall little effect on quality of life. Patients diagnosed with DTC at an age of > or =45 years reported a significantly better score on the pain domain when compared with those diagnosed earlier (p < 0.05). Patient who received >150 mCi of radioiodine had a tendency towards a worse score on the same domain (p = 0.05). CONCLUSIONS: Our cohort reported an overall minimal effect on the quality of life of patients with DTC. Future treatment strategies should include periodic quality of life evaluations, in order to tailor therapy in this growing population.
Chikungunya is a viral illness characterized by severe joint pains, which may persist for months to years. There is no effective treatment for this disease. We treated 56 patients with moderate to severe persistent pains...Chikungunya is a viral illness characterized by severe joint pains, which may persist for months to years. There is no effective treatment for this disease. We treated 56 patients with moderate to severe persistent pains with a single infusion of ascorbic acid ranging from 25-50 grams and hydrogen peroxide (3 cc of a 3% solution) from July to October 2014. Patients were asked about their pain using the Verbal Numerical Rating Scale-11 immediately before and after treatment. The mean Pain Score before and after treatment was 8 and 2 respectively (60%) (p < 0.001); and 5 patients (9%) had a Pain Score of 0. The use of intravenous ascorbic acid and hydrogen peroxide resulted in a statistically significant reduction of pain in patients with moderate to severe pain from the Chikungunya virus immediately after treatment.
UNLABELLED: Deep venous thrombosis and pulmonary embolism can be the first manifestation of cancer. In light of this association screening for cancer has been proposed in patients with primary VTE to identify an undiagno...UNLABELLED: Deep venous thrombosis and pulmonary embolism can be the first manifestation of cancer. In light of this association screening for cancer has been proposed in patients with primary VTE to identify an undiagnosed malignancy. METHOD: Descriptive, retrospective record review that includes 3244 patients from VA San Juan Caribbean system with diagnosis of lung (small and non-small cell), prostate, colon, rectum, liver, stomach, esophagus, pancreas and breast cancer, lymphoma or leukemia from 2005 to 2010 evaluated for primary VTE during five years prior to their malignancy diagnosis. Secondary outcomes evaluated were age and staging at the time of VTE diagnosis. The inclusion criteria were veterans with age 21 years old or more and with diagnosis of the above mentioned malignancies. The exclusion criteria were pregnancy five years to the diagnosis of malignancy, history of coagulopathy or use of anticoagulation at moment of the diagnosis of malignancy. RESULTS: 3244 records were reviewed. From the 2858 that met the inclusion criteria 22 (8%) had history of VTE five years before their malignancy, most of them (14%) with diagnosis of pancreatic malignancy. After we studied VTE by site of malignancy: 7% of pancreatic, 0.8% of prostate, 0.5% of colon, 0.6% of bladder, 0.8% of liver, 0.4% of lung, 1.1% of rectal cancer patients but none with leukemia, stomach, esophagus, breast cancer had VTE. Regarding patients with advanced metastatic cancer at the moment of their diagnosis, only 13% had a prior event of VTE. CONCLUSION: Although at this point there is no clear indication to screen for malignancy in patients presenting primary VTE our results point out an increased number of VTE in patients with subsequent pancreatic cancer. More research is needed before further recommendations on cancer screening in patients with VTE.
Banchs-Viñas H, Rivera N, Banchs-Pieretti H
… +1 more, Altieri P
Bol Asoc Med P R
· 2015 · PMID 26035978
Brugada syndrome is characterized by ST-segment changes in the right precordial ECG leads and a high incidence of sudden death in patients with strutural norm hearts. Life-threatening ventricular arrhythmias are the hall...Brugada syndrome is characterized by ST-segment changes in the right precordial ECG leads and a high incidence of sudden death in patients with strutural norm hearts. Life-threatening ventricular arrhythmias are the hallmark of Brugada syndrome whice incidence and prevalence of BrS in Puerto Rico, to our knowledge, has never been studied and there is only one case report of BrS in Puerto Rico in the literature. We review three cases of BrS in Puerto Rican patients who presented to our institution with syncope reviewing the literature.
Puerto Rico is one of the most prevalent areas covered by Medicare in need of renal replacement therapy for which interventional procedures are performed. A cumulative analysis of this management is reported in patients...Puerto Rico is one of the most prevalent areas covered by Medicare in need of renal replacement therapy for which interventional procedures are performed. A cumulative analysis of this management is reported in patients during the period between June 2007 and August 2010. Experience accumulated with 3755 surgical patients revealed that 58% had intravascular catheters, 28% had arteriovenous fistulas, 15% had arteriovenous grafts, and 2% without vascular access. Procedures performed in these patients were: catheter introduction in 1990 cases (33%), angioplasty in 751 cases (20%), angiography in 450 cases (12%), thrombectomy in 413 cases (11%) and venous mapping in 151 cases (4%). The success rates of these procedures were evaluated by analysis of the Society of Interventional Radiology (SIR) criteria for Lifeline Vascular Access. Using SIR definition of success rate for at least one session that includes "declots", placement of catheters and angioplasty, our results revealed an average of 98.2% overall success rate greater than the standard value KDOQI/SIR (> 85% ). This study has documented for four years the success rate of Vascular Interventional Nephrology Center at Auxilio Mutuo Hospital. In order to maintain this success rate is necessary to further evaluate its effectiveness and, most importantly, the development of an educational program for vascular access in patients with chronic kidney disease prior to placement in dialysis units.
Altieri PI, Marcial JM, Banchs HL
… +3 more, Escobales N, Crespo M, González W
Bol Asoc Med P R
· 2015 · PMID 26035976
Two groups of patients were studied to find out the levels of angiotensin-II and endothelin-I in the coronary and peripheral circulation. Group A consisted of eight patients with diabetes mellitus type 2 and coronary art...Two groups of patients were studied to find out the levels of angiotensin-II and endothelin-I in the coronary and peripheral circulation. Group A consisted of eight patients with diabetes mellitus type 2 and coronary artery disease; and Group B with diabetes mellitus without coronary artery disease. Significant differences were found between Group A and B in the levels of both peptides peripherally and intracoronary. This shows the importance of these peptides in the origin of coronary artery disease and progression of the disease in diabetics with coronary artery disease.
Challenges and changes facing modern medicine make it imperative that physicians acquire knowledge of the legal and regulatory framework of medical practice. Despite the importance of this issue, the curriculum in most m...Challenges and changes facing modern medicine make it imperative that physicians acquire knowledge of the legal and regulatory framework of medical practice. Despite the importance of this issue, the curriculum in most medical schools do not include courses that offer medical students the necessary information about their legal duties to practice medicine. The trend should be to offer such courses in medical schools and medical residency programs.
ST-elevation myocardial infarction (STEMI) is a common presentation in the Emergency Room. Proper treatment requires precision and time saving procedures. Hospitals around the world are currently developing STEMI protoco...ST-elevation myocardial infarction (STEMI) is a common presentation in the Emergency Room. Proper treatment requires precision and time saving procedures. Hospitals around the world are currently developing STEMI protocols to optimize this process since mortality and morbidity increase with time without treatment. These protocols may involve Percutaneous Interventions (PCI), fibrinolytics or both, to optimize outcomes. Protocols utilize different methods and techniques to improve Door-to-Balloon time. It is well established that PCI provides improved mortality with a lower complication rate when compared to fibrinolytic therapy, lack of availability being its biggest obstacle. Only a few PCI capable facilities are available and networking protocols are required to improve STEMI management in Puerto Rico- an area that needs vast improvement. Strategies that seek to reduce the intervention times are being evaluated and implemented throughout the world. We present an approach implemented at a local hospital called "STEMI Code".
Anecdotal reports and some clinical studies suggest that marihuana (Cannabis sativa) is effective in treating a variety of conditions such as glaucoma, migraine, pain, spasticity of multiple sclerosis, anorexia, insomnia...Anecdotal reports and some clinical studies suggest that marihuana (Cannabis sativa) is effective in treating a variety of conditions such as glaucoma, migraine, pain, spasticity of multiple sclerosis, anorexia, insomnia, depression, nausea and vomiting. One of the diseases mostly associated to a beneficial effect from marihuana is cancer. Twenty-one states of the United States including the District of Columbia have approved the use of marihuana for cancer and other medical conditions. In Puerto Rico, public debate on criminal penalty removal and medicalization of marihuana has intensified. It is considered essential for health professionals to have strong scientific evidence on the effectiveness and safety of medications or substances when recommending them for treating illness. This article discusses scientific evidence and information provided by prestigious organizations on the effectiveness and safety of marihuana and its derivatives in cancer patients.