Boletin de la Asociacion Medica de Puerto Rico最新文献

Surgical site infections (SSI) are the most common healthcare-associatedinfections. Approximately 2-5% of all surgeries develop SSI as a complication.These infections are responsible for significant fatality, morbidity, andlength of hospital stay. The purpose of this study was to describe characteristicsof SSI in a community hospital in Puerto Rico. This was cross-sectionalstudy. Between July 2013 and August 2015, 5468 major operativeprocedures were performed and 31 SSI were reported for an overall SSIincidence rate of 0.57%. A total of 31 cases of SSI were studied. The meanage of patients was 59.4 years, with a range of to 29 to 89 years. The medianage 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 thisstudy 90% of patients with SSI had at least one underlying health condition(diabetes, hypertension, obesity, age > 65 years). Location of surgicalsite infections were: abdominal 16 (52%), orthopedic 4 (13%), pelvic 7(22%), stump 3 (10%), and chest tube 1 (3%). A total of 12 different bacterialpathogens were found. A single etiologic agent was identified in 18 patients(53%) and multiple agents were found in 13 patients (47%). Enterococcusfaecalis was the most common pathogen (45% of patients) followedby Escherichia coli (39% of patients). The majority of bacteria isolated fromcultures were susceptible to B-lactams and aminoglycosides.

Prolactinomas are the most common hormone-secreting pituitary tumorsand represents approximately 40% of all pituitary adenomas. Pharmacologytherapy with dopamine agonists is the mainstay treatment for prolactinomasUsually, patients respond to these drugs with decreased level of the serumprolactin and with time, by tumor shrinkage. Less than 10% of patientswith prolactinomas exhibit resistance to the action of dopamine agonists, asdefined by the lack of normalization of the serum prolactin levels despite long-term treatment at high doses of these drugs. However secondary resistanceto dopamine agonists therapy has also been described in patients who wereinitially responsive to treatment, either with Cabergoline or Bromocriptinebut later develop dopamine agonist resistance, with elevated prolactin levelsand sometimes an enlarging tumor volume several years afterwards. Wereport a case of a male patient with prolactinoma who developed drug resistance13 months after initial dopamine agonist therapy.

Choledochal cysts are cystic dilatation of the common bile duct managed byexcision and hepatico-intestinal reconstruction. The gold standard after choledochalcyst excision is reconstruction using the jejunum. With the advent oflaparoscopy the pendulum has changed toward hepaticoduodenostomy reconstruction.We review the classification, diagnosis and recent management ofcholedochal cyst.

Eighty year old male patient with heart failure preserved ejection fraction (EF),Obstructive sleep apnea, peripherovascular disease admitted with increasingshortness of breath and found with pulmonary emboli. Baseline 2D-echo-cardiogramperformed demonstrated preserved ejection fraction and a rightthrombus in transit. Anticoagulation with weight based-low molecularweight heparin was given for six days. Follow-up echo performed demonstratedcomplete dissolution of right heart thrombi. Since there was complete dis-solution of thrombi seen on right atrium, anticoagulation with Rivaroxabanwas given instead.

Emergency physicians are many times the first-line practitioners to encountercirculatory emergencies. Amongst these many diseases we face, of importanceare acute myocardial infarction, ischemic cerebrovascular accidents and pulmonaryembolism. Familiarity with fibrinolytic agents and regimens, as well as indicationsand contraindications, are crucial to the emergency department physician.Fibrinolytic therapy has been shown to be beneficial and can serve as a bridge todefinite treatment, while lowering the risk of morbidity and mortality. Unfortunatelyfibrinolytic therapy is underused and often administered later than optimum.The aim of fibrinolytics is to dissolve blood clots that can cause serious and potentiallylife-threatening damage if not removed in a timely manner. The mechanism ofthis benefit relates to maximizing tissue salvage by early restoration of blood flowand thereby enhancing both early and long-term survival. Older thrombi haveextensive fibrin polymerization making them more resistant to thrombolysis;hence, the importance of early administration of fibrinolytic therapy.

Isolated ACTH deficiency (IAD) is a rare entity characterized by secondaryadrenal insufficiency with low levels of serum cortisol, decreasedproduction of ACTH, adequate secretion of other pituitary hormonesand normal pituitary structure on radioimaging. The prevalence ofIAD as a cause of secondary adrenal insufficiency has not been determined.Impairment of growth hormone (GH) secretion has beennoted in 20 to 30% of patients with IAD which is normalized after glucocorticoidreplacement. We report the case of a 50 years-old femalewith symptoms and laboratory results suggestive of adrenal insufficiency.Insulin tolerance test confirmed ACTH and growth hormonedeficiency. The rest of the anterior pituitary hormones were normal. Apituitary MRI was unremarkable. Glucocorticoid replacement therapystarted and eight months afterwards glucagon stimulation test revealedpersistent ACTH deficiency but nor-mal growth hormone secretion. IAD can present with nonspecific symptomsand could be potentially fatal in an acute stressful period. Promptrecognition is essential to decrease morbidity and mortality.

The Centers for Disease Control and Prevention (CDC) estimate thatnearly 500,000 surgical site infections (SSIs) occur annually.[3] SSIs remaina substantial cause of morbidity and mortality among hospitalized patients.For this reason, we developed a quality assessment study with aperioperative antibiotic protocol that included antibiotic type, weight dependentdose, and intraoperative re-dosing regime for the proper administration of prophylaxis antibioticsprior to orthopedic surgery. We restricted our study to knee replacementand hip replacement surgeries. All records from September 2014 to June2015 were taken into consideration (78 cases). Before February 2015(protocol implementation date), only 33% or 13 of 39 cases were correctlydosed. After protocol establishment: 44 % or 17 of 39 cases were correctlydosed. Although our p-value suggests no statistical significance, there wasan increasing trend of adequate antibiotic administration. In conclusion,we need to educate more our nursing staff and implement monthly auditsof our cases to improve our mistakes and ensure that this aspect of practicewill remain in the forefront of perioperative orthopedic surgery care.

Introduction: A traumatic event to the tibia with more than 14 cm of bone andsoft 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 ofbone and soft tissue.

Materials and methods: Our study presents the management of 7 patientswith grade III B open fractures (according to the Gustillo-Andersonclassification) of the tibia who underwent resectionof 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 basedon 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 timeto full recovery of all patients was 19 months with a minimum of 14 monthsand a max of 34 months. Patient presented with excellent bony union andnone existent or small refractory leg length discrepancy and did not requirebone grafts or free flaps. Complications that the patients had were contractures,which required secondary procedures such as Achilles tendon re-lengtheningand 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 consideredin patients suffering such traumatic events providing excellent bony unionand good functional outcomes for the patient.

Fine needle aspiration of thyroid (FNA) is broadly used as the preferredpreoperatory test to evaluate thyroid nodules. The clinical importance ofthis procedure is primarily related the need to exclude Thyroid Cancer.There are few studies investigating the association between FNA and finalpathology in patients with thyroid nodules with surgical indications.There is no evidence from studies in the southern area of Puerto Rico thatinvestigate this association. This was a randomized cross-sectional study, 82medical records were evaluated. Data were obtained for FNA diagnosis,demographics, body mass index, findings on ultrasound and histopathologyresults. In this study the sensitivity of FNA was 73.53% and specificity of100%. The accuracy of the study was 78%. The study reported a prevalenceof 83% malignant tumors in the final pathology and 61% in the FNA. Thepositive predictive value was 100% and negative 43.75%, suggesting thatFNA is a good diagnostic test to detect thyroid nodules suspicious formalignancy. FNA of 33 patients was reported with undetermined cytopathology.The measure of agreement and correlation coefficient showed amoderate 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 18malignant. This study demonstrated that the FNA is reliable in identifyingthyroid nodules in patients with surgical indications.

FPrecursor T- or B-cell non-Hodgkin lymphoblastic lymphomas representonly a small fraction of pediatric cancer cases. Due to its rarity, the diagnosis oflymphoblastic lymphoma (LBL) in a pediatric patient is challenging, particularlyif its manifestation is solely cutaneous. We describe the case of an infant with primary cutaneous B-cell LBL whowas initially diagnosed by a primary care physician with an infectious etiologyand consequently treated with topical and oral antibiotics. Subcutaneous noduleslocated on the head or neck of infants should raise suspicion for lymphomaand biopsy should be performed in order to rule out malignancy. A promptdiagnosis is imperative when considering the aggressive nature of LBLs. Expeditedtherapy has been known to help cease systemic involvement of primarycutaneous B-cell LBLs and encourage a more favorable outcome.