Boletin de la Asociacion Medica de Puerto Rico最新文献

Objective: Although many institutions in the United States have incorporated palliative care practices in their emergency departments, very little has occurred in Puerto Rico. Information regarding palliative care training of emergency medicine physicians in Puerto Rico is unclear and most physicians have poor or no access to palliative care services for their patients. This study explores the perceptions and barriers encountered by practicing emergency physicians in providing palliative care in Puerto Rican Emergency Departments.

Methods: A survey was administered to physicians attending the American College of Emergency Physicians Puerto Rico Chapter annual Convention Attending physicians and residents from the University of Puerto Rico School of Medicine validated the survey tool via a "content validity" approach. Participants were asked to respond to Likert scaled statements with options that ranged from "Strongly Agree" to "Strongly Disagree". The statements addressed physician comfort level with provision of palliative care and discussion of end of life issues, as well as barriers encountered by providers such as time constraints, fear of lawsuits, and lack of access to specialists among others.

Results: Of the 85 physicians at the convention 59 provided surveys available for review for a response rate of 70%. Of those surveyed, 35% reported feeling some level of discomfort at providing palliative care in the ED and 39.6% agreed or strongly agreed that their lack of training in palliative care affects their ability to provide this service. In addition, 81% lack access to palliative care specialists/teams in the emergency department. However, 82.8% agreed or strongly agreed that palliative care is an important competence for emergency physicians.

Conclusions: Despite recognizing palliative care as an important competence, emergency physicians in Puerto Rico reported insufficiencies in training, decreased level of comfort, and lack of access to specialists in palliative care. Efforts to enhance physician training and provide palliative care resources must be pursued in order to improve the quality of care given to patients visiting Puerto Rican Emergency departments.

Immune thrombocytopenia (ITP) is a rare autoimmune disorder characterized by low platelet count and skin-mucosal bleeding. In adults it is usually idiopathic and may have a chronic onset, while in children it is usually acute following a viral illness. Dengue has been rarely reported as a cause of ITP. We report a case of a young adult woman that presented with acute ITP following a dengue virus infection.

A 54-year-old woman came to our endocrinology clinics presenting with upper and lower extremity paresthesia, salt cravings, episodes of hypotension, fatigue and a long term history of depression. Physical exam was unremarkable. Cervical and brain MRI ordered by her neurologist three years ago revealed sella and pituitary normal in size, stable very small 3 mm pituitary incidentaloma and mild disc bulging. Basal pituitary hormonal screening showed low cortisol and ACTH levels. Insulin Tolerance Test and Glucagon Stimulation Test confirmed secondary ACTH deficiency with concomitant GH deficiency. In spite of medical counseling the patient refused glucocorticoid replacement. Due to the non-specific symptoms of this condition it remains a challenge to be diagnosed by clinicians. In conclusion: Our case shows that hormonal deficiencies may occur in small tumors less than 6 mm.

There are 1.7 million sepsis-related hospitalizations each year making it the sixth most common cause for hospitalization in the United States. Not only are this hospitalizations common, they are expensive to our medical system with $15.3 billion spent yearly (3) and hospitalizations lasting 75% longer than for other conditions. In 2001, Rivers et al published in the NEJM the results of his study "Early Goal Directed Therapy (EGDT) in The Treatment of Severe Sepsis and Septic Shock". EGDT demonstrated a 16.5% decrease in mortality in septic patients (4). In 2002 the Surviving Sepsis Campaign began as a collaboration between the Society of Critical Care Medicine and European Society of Intensive Care Medicine with goals of reducing worldwide sepsis related mortality by 25% in the next 5 years. Despite the proven benefit of early identification and management, knowledge regarding the topic in Puerto Rico remains scarce. In a study performed in PR by Fernandez et al. in 2006, only an alarming 31.4% of doctors from different specialties correctly identified SIRS criteria. Our goal is to educate physicians about the importance of early identification and treatment of the septic patient. A campaign to increase awareness and improve care is essential and we propose treatment protocols for our Puerto Rican hospitals to help reduce morbidity, mortality, length of stay and costs.

We present a case of a 61 year old man who presented with a 3 week history of easy bruising and ecchymoses in both thighs and right arm without significant trauma. Physical exam was remarkable for oozing gums, diminished second heart sound, a systolic ejection murmur at the aortic position with radiation to carotids, and delayed pulses. Laboratories were remarkable for iron deficiency anemia. Echocardiogram was consistent with severe aortic stenosis. Colonoscopy revealed several arteriovenous malformations throughout the colon. There is an association between severe aortic stenosis and gastrointestinal bleeding. The pathogenesis of Heyde's Syndrome involves iron deficiency anemia due to acquired von Willebrand factor (vWF) deficiency and ultimately gastrointestinal angiodysplasia. Correct diagnosis and management warrants a multidisciplinary approach.

Objective: To determine the use of screening tests for colorectal cancer (CRC) among Gynecologists in Puerto Rico. This study evaluates the screening practices used by Gynecologists in PR to diagnose CRC and adherence to screening guidelines.

Methods: A self-administered anonymous questionnaire was mailed to 440 practicing gynecologists through the College of Physicians and Surgeons of PR. The questionnaire included general and specific questions.

Results: Response rate was 23.2% (102/440). Of this group of gynecologists, 77.5% referred screening patients, while 22.5% did not. The majority (28.4%) use Fecal Occult Blood Test (FOBT) as a first screening test, while 27.5% use Colonoscopy. Screening is started by 49% at age 50. Only 7% stop screening at 75 years and 31% never stop screening. CRC Screening performed by participants were: 35% screen annually, 6% screen 2-3 years, 10% screen every 5 years, 6% screen every 10 years and 6% screen 5-10 years. Data for CRC Screening reveals 7% gynecologists comply with all the guidelines; 49% comply with the recommendations regarding the start screening age and 7% stop screening as per guidelines.

Conclusion: The recommendations are not followed by most of the gynecologists in PR that participated in the study, Further research should be directed towards the reasons for not complying and how to educatethemedical population to achieve adequate screening in the PR female population.

Human development and its physiology depends on a number of complex biochemical body processes, many of which are interactive and codependent. The speed and the degree in which many physiological reactions are completed depend on enzyme activity, which in turn depends on the bioavailability of co-factors and micronutrients such as vitamins and minerals. To achieve a healthy physiological state, organism need that biochemical reactions occur in a controlled and specific way at a particular speed and level or grade fully completed. To achieve this, is required an optimal metabolic balance. Factors such as, a particular genetic composition, inadequate dietary consumption patterns, traumas, diseases, toxins and environmental stress all of these factors rising demands for nutrients in order to obtain optimal metabolic balance. Metabolic correction is a biochemical and physiological concept that explains how improvements in cellular biochemistry of an organism can help the body achieve metabolic and physiological optimization. We summarize the contribution of several pioneers in understanding the role of micronutrients in health management. The concept of metabolic correction is becoming a significant term due to the presence of genetic variants that affect the speed of reactions of enzymes, causing metabolic alterations that enhance or promote the state/development of multiple diseases. Decline in the nutritional value of the food we eat, the increase in demand for certain nutrients caused by normal development, diseases and medications induce, usually, nutrients consumption. These nutritional deficiencies and insufficiencies are causing massive economic costs due to increased morbidity and mortality in our society. In summary, metabolic correction improves the enzymatic function, which favors the physiological normal functions, thus, contributing to improving health and the welfare of the human being. The purpose of this paper is to describe and introduce the concept of optimal metabolic correction as a functional cost-effective mechanism against disease, in addition, to contribute to diseases prevention and regeneration of the body and health.

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.

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.