De Izquierda a Derecha: Dr. Luis Perez Toro, Delegado, Dra. Marina Almenas, Delegada y miembro “Reference Committe Public & Health”, Dr. Angel Matos - Reconocimiento por 58 años de asistencia a la Convencion AAFP ininterrumpidamente, Dr. Jorge Meaux, Delegado Alterno AAFP, Presidente AMFPR y Dra. Leslie Hoy, Delegada Alterna. Dra. Marina Almenas, Delegada y pasada Presidenta AMFPR, Dareen Soto, Congresista Electo-Florida y Dr. Jorge Meaux, Presidente AMFPR y Delegado Alterno AAFP.
Feliz Navidad y Próspero Año Nuevo 2017
P.O. Box 11989 San Juan, PR 00922
Academia de Médicos de Familia de Puerto Rico 12/16 CHANGE SERVICE REQUESTED
Non Profit US Postage PAID San Juan P.R. Permit No. 3394
Diciembre de 2016
Academia Médicos de Familia de Puerto Rico Junta de Directores 2016-2017
Dr. Jorge Meaux Pereda Dr. Ariel Cruz Igartúa Dr. Carlos Cestero Dra. Joan Pijem Dra. Rebecca Rodríguez Dra. Marina Almenas Dr. Luis Pérez Toro Dr. Raúl Castellanos Dra. Leslie Hoy Dra. Sonia Ortiz Dra. Karla Berríos Dra. Heileene Torres Dr. Ariel Díaz Dra. Carmen Izquierdo Dr. William J. Ortiz
Presidente Pasado Presidente Presidente Electo Secretaria Tesorera Delegada Delegado Delegado Alterno Delegada Alterna Directora Directora Directora Director Ejecutivo Representante Residencias Representate Estudiantes
MF es la revista oficial de la Academia de Médicos de Familia de Puerto Rico. Prohibida su reproducción total o parcial sin previa autorización escrita de la Academia de Médicos de Familia de Puerto Rico. Nos reservamos el derecho de publicar y editar los artículos recibidos. La veracidad de la información sometida es responsabilidad de sus autores y en ningún momento nos hacemos responsables por lo expresado en los artículos o anuncios publicados, ni de las fotos suministradas para los mismos. No somos responsables de las ofertas en los anuncios, siendo responsabilidad exclusiva de los anunciantes. MF es meramente informativo y en ningún momento su información debe ser utilizada para fines diagnósticos ni terapéuticos.
Junta Editora Dr. Elasin Muñoz Dra. Marina Almenas Dra. Heileene Torres Dr. Carlos Cestero Dra. Sonia Ortiz Dr. Raul Castellanos
Mensajes..................................................................................................................................... 1 Bacterial Species, Susceptibility to Antibiotics and Characteristics of Patients with Surgical Site Infections....................................................................................................... 2 Case Report: Reversible Renal Failure in Young Female............................................................. 7 Prevalence of Hypothyroidism and Its Association with Diabetes Mellitus in Patients of an Ambulatory Clinic........................................................................................ 11 “Time elapsed between Triage and Evaluation by Physician on ER in Mayagüez Medical Center”.................................................................................................. 15 Rare and Disturbing Complications of Acute Pancreatitis: Pancreatic Panniculitis and Erythema Nodosum.......................................................................................................... 17 Regala un Día de Fondos Unidos de Puerto Rico............................................................................. 19 Comités de Relaciones Públicas y Salud Pública...................................................................... 20 Comité de Estudiantes y Residentes......................................................................................... 25 El proyecto #1 Word for Family Medicine llega “la isla del encanto”..................................... 28 Disseminated Skin lesions on an immunocompromised patient ........................................... 29 When the cause of childhood pneumonia is truly uncommon............................................... 31 Not all etiologies of Congestive Heart Failure are known: Spongiform Cardiomyopathy....... 33 An atypical etiology of Acute Appendicitis: Appendix Carcinoid Tumor................................. 36 Integral intervention addressing concomitant type II diabetes mellitus and depression in a primary care setting.......................................................................................................... 38 Decaying teeth leaves you out of breath.................................................................................. 41 Impact of educational bulletins on the rate of influenza vaccination in the pediatric population...................................................................................................... 43
Mensajes Dr. Jorge Meaux Presidente Saludos cordiales a nuestros lectores muy en especial a los médicos de familia, residentes de los Programas de Medicina de Familia, estudiantes de las cuatro Escuelas de Medicina de Puerto Rico y a la Comunidad Médica de Puerto Rico. Es un placer dirigirme a ustedes con motivo del retorno de nuestra revista, en la edición en formato impreso , la cual ha sido elaborada con mucho esmero para todos ustedes , espero la disfruten. La actual Junta de Directores de la Academia de Médicos de Familia de Puerto Rico, la cual me honro en presidir empezó en funciones en el mes de abril del presente año, 2016. A través de los diferentes Comités organizados para tales fines, hemos estado trabajando activamente para cumplir con el Plan de Trabajo propuesto. Muchas de esas actividades ustedes podrán constatar en esta publicación. Aprovecho esta oportunidad para desearles, a nombre de nuestra Academia y en el mío propio, una Feliz Navidad, un Próspero Año Nuevo y sobre todo mucha salud para todos ustedes y sus familiares. Estén pendientes al próximo número de nuestra revista que será una edición especial con motivo de la celebración de los Sesenta Años de la fundación de nuestra Academia.
Dr. Elasin Muñoz
Dra. Marina Almenas
Dra. Heileene Torres
Dr. Carlos Cestero
Dra. Sonia Ortiz
Dr. Raul Castellanos
Junta Editora Culminando un año de grandes logros, no podía faltar el comenzar nuevamente la publicación de la Revista de la Academia de Médicos de Familia de PR. y que mejor forma que publicando los Trabajos de Investigación de nuestros Programas de Residencias de Medicina de Familia. Además de todas las actividades que hemos realizado durante este año gracias a nuestra Junta y los diferentes Comités de la Academia y el apoyo de otras Entidades. Nuestra revista digital se estará publicando trimestralmente y algunas ediciones como ésta, en formato impreso. Por esto también les invitamos a que visiten nuestra página web: www.amfpr.org. En esta edición agradecemos todo el trabajo y esfuerzo de los Comités y Entidades con las cuales hemos hecho alianzas de trabajo. Nuestra próxima publicación será una edición especial celebrando los 60 años de nuestra Academia durante el mes de abril 2017. Feliz Navidad y Muchas bendiciones en el 2017 a toda la Clase Médica y al Público en General, les desea la Junta Editora. Dra. Marina Almenas, Dr. Eliasin Muñoz, Dra. Heilenne Torres, Dr. Carlos Cestero, Dra. Sonia Ortiz, Dr. Raúl Castellanos. Medicina de Familia Diciembre 2016-1
Bacterial Species, Susceptibility to Antibiotics and Characteristics of Patients with Surgical Site Infections Author: Inés Serrano, MD PGY3, Jorge Vera, MD, DABFM
Abstract: 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.
Resumen: Las infecciones del sitio quirúrgico son las infecciones nosocomiales más comunes. Aproximadamente el 2-5% de todas las cirugías desarrollan infecciones del sitio quirúrgico. Estas infecciones son responsables de una cantidad significativa de la letalidad, morbilidad, y la duración de la estancia hospitalaria. El objetivo de este estudio fue des2-Medicina de Familia Diciembre 2016
cribir las características de las infecciones del sitio quirúrgico en un hospital comunitario en Puerto Rico. Este fue un estudio transversal. Entre julio del 2013 y Agosto 5468 cirugías mayores fueron realizadas, y 31 infecciones del sitio quirúrgico fueron reportadas, con una tasa de incidencia de 0.57%. La edad media de los pacientes con infecciones del sitio quirurgico fue de 59.4 años, con una amplitud entre 29 a 89 años. La mediana de edad fue 64 años. La distribución de sexo presentó 22 mujeres (71%) y 9 hombres (29%). La prevalencia de diabetes mellitus fue 13/31 (42%). En este estudio 90% de los pacientes con infecciones del sitio quirúrgico tenían al menos una condición subyacente (diabetes, hipertensión, obesidad, edad> 65 años). La localización de las infecciones del sitio quirúrgico fueron: abdomen 16 (52%), ortopédico 4 (13%), pelvis 7 (22%), muñón 3 (10%), tórax 1 (3%). Se encontró un total de 12 agentes patógenos bacterianos diferentes. Un solo agente etiológico se identificó en 18 pacientes (53%) y más de una bacteria se encontró en 13 pacientes (47%). Enterococcus faecalis fue el patógeno más común (45% de los pacientes) seguido de Escherichia coli (39% de los pacientes). La mayoría de las bacterias fueron susceptibles a B-lactámicos y aminoglucósidos.
Introduction Surgical site infections (SSI) are the most common healthcare-associated infections(1, 2). The risk of SSI is low; approximately 2-5% of all surgeries develop SSI as a complication. These infections continue to be a big economic burden, even though there is an improvement of infection control practices and surveillance programs(3). SSI’s are associated with increased fatality, morbidity, length of hospital stay, and additional expenses cost up to 10 billion annually. Studies show that SSI’s increase length stays a mean 7.3 post-operative days and increase cost for an average of $3,512 in extra fees(4-6). SSI is defined as an infection that occurs within
30 days after a surgery or 90 days when an implant is left in place on a deep incisional surgical site. The diagnosis of SSI includes clinical and laboratory findings. It is important that surveillance programs use standardized definitions of SSI. SSIâ€™s are classified as either incisional surgical infections or organ space surgical site infections(4). Pathogen sources include endogenous (patient flora and distant focus of infection) and exogenous (surgical personnel, operating room physical environment and surgical equipment(7). Risk factors for surgical site infections include: immunosuppression, obesity, diabetes mellitus, hypertension, advanced age, cigarette smoking, and malnutrition(4,6,8,9). The type of surgery is also associated with different rates of SSI. Abdominal surgeries have the highest rates, especially large bowel surgeries. According to data from International Nosocomial Infection Control Consortium (INICC) the most common isolated pathogens in surgical site infections have not changed in the last years. Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp. and Escherichia coli are the most commonly isolated pathogens using culture base methods(4,5). Puerto Rico lacks epidemiologic studies about surgical site infections. It is unknown if risk factors and pathogens described in other studies are the same in this island. The purpose of this study was to describe characteristics of surgical site infections in a community hospital in Puerto Rico. These characteristics include demographic variables of subjects, surgical sites, most common pathogens and antimicrobial susceptibility of these pathogens.
Method This was cross-sectional study. Authorization for the study was obtained from the Institutional Review Board (IRB) at Ponce Health Science University (#150910-JV) and the Administration of Bella Vista Hospital. The investigators identified all medical records of patients who had diagnosis of SSI from July 1, 2013 through August 31, 2015. A total of 31 cases satisfied these inclusion criteria. The records were reviewed by the investigators. Variables that were obtained were: age, sex, weight, height, presence of diabetes, hypertension, smoking status, type of surgery, culture and sensitivity information. Data analysis was done with Epiinfo 7ÂŽ. Analysis included descriptive statistics (means, medians, standard deviation and frequency distribution).
Results 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%. The medical records of all these cases were included in this study. The mean age of patients was 59.4 years, with a SD = 16.1 and range from to 29 to 89 years. The median age was 64 years. Figure 1 shows the distribution by Age Groups. [fig 1] The sex distribution showed 22 women (71 %) and 9 men (29%). Using measurements of weight and height, Body Mass Index (BMI) was calculated for each subject, and subjects were classified in groups according to their BMI. The prevalence rate of obesity was 15/31 (48%). The prevalence of diabetes mellitus was 13/31 (42%). Hypertensive patients represented 23/31 (74%) of the subjects studied. In this study 90% of patients with SSI had at least one underlying condition (diabetes, hypertension, obesity, age > 65 years). None of the subjects reported to be smokers. Location of surgical site infections were: abdominal 16 (52%), orthopedic 4 (13%), pelvic 7 (22%), stump 3 (10%), and chest tube 1 (3%). Bacterial pathogens were isolated from these 31 individuals. 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%); two bacteria were isolated in 8 patients 23%, three bacteria were isolated in 3 patients 9%, four bacteria in 4 patients (12%), and five bacteria in 1 patient (3%). Enterococcus faecalis was the most common pathogen, found in 14 patients (45%). Escherichia coli was isolated in 12 patients (39%) followed by Klebsiella pneumoniae in 7 patients (23%). Table 1 shows the prevalence rate of all bacteria that were isolated from the cultures. The susceptibility patterns to antimicrobial agents of these 12 bacteria are summarized in Table 2.
Discussion The rates of SSI depend on multiple factors that could be patient-related or environmental. There are well known patient-related factors associated with surgical site infections like immunosuppression, obesity, diabetes mellitus, hypertension, advanced age, cigarette smoking, and malnutrition (2,6,9). This study included data about diabetes mellitus, hypertension, obesity, cigarette smoking, Medicina de Familia Diciembre 2016-3
Table 1 PREVALENCE RATE OF BACTERIA ISOLATED FROM SURGICAL WOUNDS Bacteria
4-Medicina de Familia Diciembre 2016
Table 2 Percentage of Bacteria Susceptible to Antimicrobial Agents Antibiotics Bacteria
and types of surgery. It showed a high prevalence of all these factors; this may suggest an association between them and the occurrence of SSI, but a definite conclusion cannot be made because the study did not include a control group. Surgical site infection rates differ depending of different factors: size of hospital, patient population, and surgeon’s experience and surveillance systems in place. The US Center for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) 2006-2008 reported an overall SSI rate of 2.0% (10). The INICC (20052010), reported an overall SSI rate of 2.9% (11). The cases included in this study represented an overall SSI incidence rate of 0.57% from all surgical procedures performed in Bella Vista Hospital. This SSIs incidence rate is lower compared with those reported by CDC-NHSN and INICC. Possible explanations for these lower rates may include more available resources and enforceable regulations concerning the implementation of infection control programs in Puerto Rico compared with other countries. The lower incidence rate found when these data is compared with those in the USA may be due to reporting patterns of the condition. According to the data the location of the sur-
gery is associated with the rate of surgical site infection. Abdominal and colonic surgeries have the highest rates (2,6,9). In this study conclusions about associations between surgical sites and SSI cannot be made because there is no control group for comparison. Epidemiologic data about the distribution of pathogens isolated in cultures of SSI’s has not changed in the last years. Staphylococcus aureus, coagulase negative staphylococci, and enterococcus are the most common pathogens among epidemiologic studies (4,12). Pathogens isolated in this study differ from other epidemiologic studies. Enterococcus faecalis was the most common bacterium isolated from cultures of SSI’s in this research project. Enterococcus faecalis was followed by Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus in that order. Staphylococcus coagulase negative is a frequently reported cause of infection in surgical wounds but in this study it was not found. The susceptibility patterns of these 12 bacteria to several antimicrobial agents were studied. Enterococcus faecalis was 100% susceptible to B-lactams and aminoglycosides, but resistant to quinolone in 50%. Escherichia coli was resistant Medicina de Familia Diciembre 2016-5
to quinolones in 50%. Staphylococcus aureus was present only in 13%. Oxacillin resistance was documented in 50% of Staphylococcus aureus. The methicillin-resistant staphylococci were resistant to all B lactams, including penicillin, cephalosporins, combinations with B-lactamse inhibitors, and carbapenems. These bacteria showed 100% susceptibility to vancomycin. Antimicrobial susceptibility can be used to tailor empiric antibiotic treatment of surgical site infections in this community hospital. This study had some limitations. It is possible that cases were under reported in the hospital if some patient with SSI were treated in other health care facilities. This could explain the low rate of SSI’s and the low number of cases identified. If this were true, it could introduce a selection bias and affect the characteristics of the population under study. Although this study included data about the prevalence of different surgical sites, comorbid conditions and age distribution, the association between these variables and the risk of SSI could not be studied because of the lack of a control group. Therefore, further studies should be done to continue studying what appears to be a different profile of bacterial organisms, susceptibility patterns and characteristics of subjects with SSI in Puerto Rico, compared with other countries.
References 1.Procedure-associated module SSI, Centers for Disease Control and Prevention, January 2016 http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf 2.Deverick J Anderson, Daniel J Sexton, MD Epidemiology of surgical site infection in adults uptodate, Sep 03, 2015 3.Portillo-Gallo JH, Miranda-Novales MG, Rosenthal VD, Sánchez M, Ayala-Gaytan JJ, Ortiz-Juárez VR, Aguilera-Almazán F, Iglesias-Miramontes G,Vázquez-Olivas Mdel R, Sánchez-Chávez A, Angulo-Espinoza Y, Zamudio-Lugo I, Surgical site infection rates in four Mexican cities: findings of the International Nosocomial Infection Control Consortium (INICC), Journal of Infection and Public Health. 2014 Nov-Dec:7(6):465-71. 4. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR., Guideline for prevention of surgical site infection, 1999, infection control and hospital
6-Medicina de Familia Diciembre 2016
epidemiology 1999; 20(4): 250-278 5. Berríos-Torres, MD Surgical Site Infection (SSI) Toolkit Activity C: ELC Prevention Collaboratives Division of Healthcare Quality Promotion Centers for Disease Control and Prevention, http://www.cdc.gov/HAI/pdfs/toolkits/SSI_toolkit021710SIBT_revised.pdf 6. Harrington P, Prevention of surgical site infection. Nursing Standard.2014, 28(48): 50-58. 7. Ronald Lee Nichols, Preventing Surgical Site Infections: A Surgeon’s Perspective emerging infectious disease Centers for Disease Control and Prevention 2001, 7(2) 8. Martin Kiernan, Reducing the risk of surgical site infection, Nursing Times 2012, 108 ( 27):1214 9. Ilker Uçkay, Stephan Harbarth, Robin Peter, Daniel Lew, Pierre Hoffmeyer, Didier Pittet Preventing surgical site infections, Expert Review of Anti-infective Therapy 2010; 8(6): 657-670 10. Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen-Bridson K, Morrell G, Dudeck MA, Pollock DA, Horan TC. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, . American Journal of Infeccion Control, 2009-12-01, 37 (10):783-805. 11.Rosenthal VD, Richtmann R, Singh S, Apisarnthanarak A, Kübler A, Viet-Hung N, RamírezWong FM, Portillo-Gallo JH, Toscani J, Gikas A, Dueñas L, El-Kholy A, Ghazal S, Fisher D, Mitrev Z, Gamar-Elanbya MO, Kanj SS, Arreza-Galapia Y, Leblebicioglu H, Hlinková S, Memon BA, Guanche-Garcell H, Gurskis V,Alvarez-Moreno C, Barkat A, Mejía N, Rojas-Bonilla M, Ristic G, Raka L. Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005-2010. Infection Control and Hospital Epidemiology. 2013 Jun;34(6):597-604. 12.Giacometti O, Cirioni A, Schimizzi M, Del Prete F, Barchiesi M, D’Errico E, Petrell G, Scalise, Epidemiology and Microbiology of Surgical Wound Infections, Journal of Clinical Microbiololgy. 2000, 38(2):918-922 About the authors: Inés Serrano, MD PGY3, Jorge Vera, MD, DABFM; Family Medicine Department, Bella Vista Hospital, Mayaguez Puerto Rico.
Case Report: Reversible Renal Failure in Young Female Authors: Eliasin MuĂąoz, MD, DABFM Enrique Lefevre, MD Jean Savio Estel, MD, PGY-3 Rosa Manrique, MD, PGY-3 Katiuska Gonzalez, MD, PGY-3
Abstract This is the case of a 29 years old female patient with history of polycystic ovarian syndrome, knee pain, taking OCPs and analgesics, who presented to the ER due to a dull RUQ pain of 3 days, following a flu-like syndrome treated symptomatically at another ER. The physical examination was positive for a BMI of 39.6 kg/m2; dry oral mucosa; RUQ pain with positive Murphy sign; and a non-erythematous tender right knee swelling. The ER laboratory and studies revealed an unremarkable CBC; BUN: 44mg/dl, creatinine: 5.27mg/ dl (eGFR: 11.65ml/min) (in the chemistry); the urinalysis was positive for hematuria, proteinuria and epithelial cell casts. The abdominal CT scan demonstrated mild gallbladder wall thickening with questionable cholelithiasis. The patient was admitted due to: Renal failure, Gallbladder disease, flu-like syndrome. The orders were to keep NPO, aggressive IV hydration, labs and imaging studies with consultation to the nephrologist. We decided to share this case due to the atypical initial presentation, the unusual progression of the case and the challenges associated with the management due the inherent limits of our setting in comparison to available literature. We hope this case will bring awareness to the judicious use of a class of medications usually considered safe in the younger population.
Backgound Acute renal failure (ARF) is an abrupt and usually reversible decline in the glomerular filtration rate (GFR). This results in an elevation of serum blood urea nitrogen (BUN), creatinine, and other metabolic waste products that are normally excreted by the kidney. The term acute kidney injury (AKI), rather than ARF, is increasingly used by the nephrology community to refer to the acute loss of
kidney function. AKI has multiple possible etiologies. Acute kidney failure almost always occurs in connection with another medical condition or event. Conditions that can increase the risk of acute kidney failure include: advanced age, diabetes, high blood pressure, heart failure, decompensation of chronic kidney diseases and liver diseases. Among hospitalized patients, AKI is most commonly due to acute tubular necrosis (ATN) from ischemia, nephrotoxic exposure, or sepsis. Other frequent causes of AKI among either ambulatory or hospitalized patients include volume depletion, urinary obstruction, rapidly progressive glomerulonephritis, and acute interstitial nephritis. AKI is generally detected by an increase in the serum creatinine and/or a decrease in urine output. The magnitude of the increase in creatinine and/or decrease in urine output that is required to establish a diagnosis of AKI has been the focus of multiple expert consensus groups. The purpose of establishing a precise definition of AKI is to allow better interpretation of epidemiologic and clinical studies and to identify potential therapies.
Case Report This is a clinical case about a 29 years old female Hispanic patient who presented to the emergency department due to a right upper quadrant pain of 3 days of evolution. The patient described a dull pain, 10/10, without radiation, of sudden onset after eating Chinese food, accompanied by nausea, poor appetite and decreased urination. The patient also reported a flu-like syndrome with persistent nasal congestion and dry cough that started 3 weeks ago for which she was treated at a different emergency department with combination of parenteral ketorolac, antitussive and ibuprofen 4 days ago. Patient was also taking naproxen for 2 months due to right knee pain. In her past medical history, the patient had polycystic ovarian syndrome with obesity and was being treated with oral contraceptive pills and analgesics. The patient also reported a previous diagnostic of gallbladder disease since last year. Patient Medicina de Familia Diciembre 2016-7
was nulliparous in a monogamous relationship. Patient had no previous surgical history or hospitalization. The patient had no known drug allergy. Her current medications included: Ibuprofen, naproxen and Provera. The patient reported that the previous year was marked by a period of smoking, binge drinking and marijuana use. The family history was positive for rheumatoid arthritis, hypothyroidism in one of her siblings; obesity and diabetes mellitus. Her maternal grandmother was being treated due to kidney disease secondary to diabetes. The physical examination showed a female patient with BP:130/59 HR: 72 b/min RR: 19/min Temp: 360 C, Weight: 230 lbs and Height: 163 cm(BMI: 39.6 kg/m2 ). She had dry oral mucosa; her abdomen was globous with bowel sounds
8-Medicina de Familia Diciembre 2016
present and a right upper quadrant pain with positive Murphy sign but, no costovertebral angle tenderness at percussion. The patient also presented a non-erythematous tender right knee swelling without ankle or pedal edema The initial cardiac and pulmonary examination did not reveal any gross abnormalities. Patient started with bibasilar crackles after IV hydration. At this point, the differential diagnosis included: Gallbladder diseases, acute gastroenteritis and flu-like syndrome. The initial laboratory and studies available revealed an unremarkable CBC; the chemistry was positive for Blood urea nitrogen: 44 mg/dL, creatinine: 5.27 mg/dL with an estimated glomerular filtration rate of 11.65 mL/min. The urinalysis showed: blood in urine with elevated numbers of RBC, WBC, epithelial cells, hyaline casts and gran-
opsy confirmed the final diagnosis as: acute interstitial Nephritis, allergic type. The patient responded well to treatment and was discharge with a restored kidney function.
• Mild interstitial inflammatory cell infiltrate, predominantly mononuclear leukocytes, admixed with rare eosinophils. Mild interstitial fibrosis and tubular atrophy. Mild to moderate arteriosclerosis. ular casts with more than 600 mg/dL of protein. The abdominal CT scan was remarkable for mild wall gallbladder wall thickening with questionable cholelithiasis. The patient was admitted with the following diagnoses: Renal failure; Gallbladder disease; Flu like syndrome, obesity class 2. The admission orders were to keep the patient NPO and to provide pain management, aggressive IV hydration. Additional laboratory and imaging studies were ordered to investigate the initial diagnoses: antiglomerular BM Ab, urine eosinophils, lupus panel, 2D-echocardiograpy, etc. Consultation with the nephrologist was done. At the beginning of the hospitalization, the patient’s kidney function continued to deteriorate despite aggressive IV hydration and discontinuation of any potential nephrotoxic drugs. The nephrologist decided that the patient would benefit from a session of hemodialysis. Prior to starting the patient on intravenous steroids, a renal biopsy was done by the interventional radiologist. The kidney function started to improve after the session of hemodialysis. Once, the patient was started on intravenous steroids, hemodialysis was no longer necessary. Clinically, the patient reported feeling better, the BUN and Creatinine levels were consistently improving. The report of the renal bi-
Acute interstitial nephritis (AIN) is a renal lesion that causes a decline in creatinine clearance and is characterized by an inflammatory infiltrate in the kidney interstitium. It is most often induced by drug therapy. AIN is also caused by autoimmune disorders or other systemic disease, a variety of infections remote to the kidney, and tubulointerstitial nephritis with uveitis (TINU) syndrome. In initial reports, the vast majority of cases of AIN resulted from exposure to beta-lactam antibiotics, particularly methicillin. More recently, drugs other than antibiotics as well as infections and other underlying conditions have been recognized as clinically significant causes. The distribution of causes of AIN has been reported as follows: Drugs (70-75%), mostly antibiotics; Infections (4-10%); Tubulointerstitial nephritis and uveitis (TINU) syndrome (5-10%); Systemic disease including sarcoidosis, Sjögren’s syndrome, systemic lupus erythematosus (SLE), and others in 10 to 20 percent of cases. In this case, any infectious etiology was ruled out since the different cultures were being reported as negative. Due to the delay in the special laboratory test results, like: lupus panel and Antiglomerular BM Ab, the final diagnosis was obtained, by biopsy report, before being able to rule out any auto-immune etiology, which came out negative, eventually. In NSAID-induced AIN, affected patients typically present with hematuria, pyuria, white cell casts, proteinuria, and an acute rise in the plasma creatinine concentration. The full picture of an allergic reaction (fever, rash, eosinophilia, and eosinophiluria) is typically absent, but one or more of these findings may be present. Spontaneous Medicina de Familia Diciembre 2016-9
recovery generally occurs within weeks to a few months after therapy is discontinued. All NSAIDS should be terminated in patients suspected of having NSAID-induced AIN.
Conclusion Nonsteroidal anti-inflammatory drugs (NSAIDs) may cause AIN with an interstitial infiltrate composed primarily of T lymphocytes, with the nephrotic syndrome due to minimal change disease or membranous nephropathy. The renal biopsy, in the current case, did not show any minimal change disease and the podocytes were preserved. As opposed to most cases of NSAID-induced acute interstitial nephritis, this case was about a young patient with prior chronic exposition to NSAIDs. There is no clear evidence in the literature of cases to indicate that allergic-type acute interstitial nephritis can be dose related. According to the available literature, there is no definitive evidence that corticosteroid therapy is beneficial in the setting of NSAIDs-induced AIN. Corticosteroid therapy may be considered in patients whose renal failure persists more than one to two weeks after the NSAID has been discontinued. Immunosuppressive therapy has also been employed to treat AIN that persists despite discontinuation of the offending agent. However, the benefits of therapy are inconclusive since the available data are conflicting and there are no randomized, controlled trials. In the setting of this case, the patient’s health plan had to be taken into consideration before any ambulatory follow-up could be considered. The risk of complications due to lack of continuity of care was very high. The clinical response to steroids was prompt and the patient was able to be discharge with a normal kidney function.
References 1. Rossert JA, Fischer EA. Acute interstitial nephritis. In: Comprehensive Clinical Nephrology, 2, Johnson RJ, Feehally J. (Eds), Elsevier Limited, Philadelphia 2003. Vol 1, p.769. 2. Neilson EG. Pathogenesis and therapy of interstitial nephritis. Kidney Int 1989; 35:1257. 3. Ten RM, Torres VE, Milliner DS, et al. Acute in-
10-Medicina de Familia Diciembre 2016
terstitial nephritis: immunologic and clinical aspects. Mayo Clin Proc 1988; 63:921. 4. Michel DM, Kelly CJ. Acute interstitial nephritis. J Am Soc Nephrol 1998; 9:506. 5. Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001; 60:804. 6. Schwarz A, Krause PH, Kunzendorf U, et al. The outcome of acute interstitial nephritis: risk factors for the transition from acute to chronic interstitial nephritis. Clin Nephrol 2000; 54:179. 7. Baker RJ, Pusey CD. The changing profile of acute tubulointerstitial nephritis. Nephrol Dial Transplant 2004; 19:8. 8. Kodner CM, Kudrimoti A. Diagnosis and management of acute interstitial nephritis. Am Fam Physician 2003; 67:2527. 9. Praga M, González E. Acute interstitial nephritis. Kidney Int 2010; 77:956. 10. Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990; 5:94. 11. Muriithi AK, Leung N, Valeri AM, et al. Biopsy-proven acute interstitial nephritis, 1993-2011: a case series. Am J Kidney Dis 2014; 64:558. 12. Nolan CM, Abernathy RS. Nephropathy associated with methicillin therapy. Prevalence and determinants in patients with staphylococcal bacteremia. Arch Intern Med 1977; 137:997. 13. Galpin JE, Shinaberger JH, Stanley TM, et al. Acute interstitial nephritis due to methicillin. Am J Med 1978; 65:756. 14. Esteve JB, Launay-Vacher V, Brocheriou I, et al. COX-2 inhibitors and acute interstitial nephritis: case report and review of the literature. Clin Nephrol 2005; 63:385. 15. Hoppes T, Prikis M, Segal A. Four cases of nafcillin-associated acute interstitial nephritis in one institution. Nat Clin Pract Nephrol 2007; 3:456. 16. Wang YC, Lin YF, Chao TK, et al. Acute interstitial nephritis with prominent eosinophil infiltration. Clin Nephrol 2009; 71:187. About the authors: Eliasin Muñoz, MD, DABFM Enrique Lefevre, MD Jean Savio Estel, MD, PGY-3 Rosa Manrique, MD, PGY-3 Katiuska Gonzalez, MD, PGY-3 Mayaguez Medical Center, Family Medicine Residency.
Prevalence of Hypothyroidism and Its Association with Diabetes Mellitus in Patients of an Ambulatory Clinic Mariela Bernal, MD, Eddy Escobar, MD, Carmen E. Rodríguez González, MD, DABFM
Abstract Hypothyroidism is the most common thyroid disorder in the adult population. Studies have found a higher prevalence of overt hypothyroidism in type 2 diabetic population than in the general population, but the relationship between subclinical hypothyroidism and diabetes mellitus 2 is still controversial. The aim of this study is to estimate the prevalence rate of hypothyroidism in the adult population receiving services in an ambulatory clinic and to determine if there is an association between hypothyroidism and diabetes mellitus. From the database of all adult patients who attended the outpatient clinic at Family Medicine Center Policlínica Bella Vista in Mayagüez, P.R. during 2014, a random sample of 200 subjects was obtained and the medical records were reviewed. The prevalence rate of diabetes mellitus in this group was 22% and the prevalence rate of hypothyroidism was 17%. The prevalence rate of hypothyroidism in diabetic patients was 10/44 (22.7%). The prevalence rate of hypothyroidism in non-diabetic patients was 24/156 (15.4%). The prevalence ratio was 1.48 (95% CI: 0.77, 2.85; X2 = 1.31, p = 0.25). The results of this cross-sectional study showed a non-statistically significant tendency for a higher prevalence of hypothyroidism in diabetic patients, which suggest that screening for hypothyroidism among patients with diabetes should be considered. More studies with more patients are necessary to investigate the association between thyroid dysfunction and diabetic patients.
Resumen El hipotiroidismo es el desorden más común entre los problemas tiroideos en la población adulta. Estudios han encontrado una prevalencia mayor de hipotiroidismo clínico en la población de pacientes con diabetes tipo 2 que en la población general, pero la relación entre hipotiroidismo sub-clínico y diabetes tipo 2 es todavía controversial. El propósi-
to de este estudio fue estimar la prevalencia de hipotiroidismo en una población adulta que recibe servicios en una clínica ambulatoria y determinar si hay una asociación entre hipotiroidismo y diabetes mellitus. Se seleccionó una muestra aleatoria de 200 sujetos de la base de datos de todos los pacientes adultos que asistieron la clínica ambulatoria del Centro de Medicina de Familia de la Policlínica Bella Vista en Mayagüez, P.R. en el 2014, y los expedientes fueron revisados. La tasa de prevalencia de diabetes mellitus en este grupo fue 22% y la tasa de prevalencia de hipotiroidismo fue 17%. La tasa de prevalencia de hipotiroidismo en los pacientes diabéticos fue 10/44 (22.7%). La tasa de prevalencia de hipotiroidismo en los no-diabéticos fue 24/156 (15.4%). La razón de prevalencias fue 1.48 (IC 95%: 0.77, 2.85; X2 = 1.31, p = 0.25). Los resultados de este estudio transversal demostraron una tendencia estadísticamente no significativa hacia una prevalencia mayor de hipotiroidismo en pacientes diabéticos, lo cual sugiere que el tamizaje para hipotiroidismo en pacientes con diabetes debiera considerarse. Estudios con muestras mayores de pacientes son necesarios para investigar mejor la asociación entre hipotiroidismo y diabetes.
Introduction Hypothyroidism is the most common thyroid disorder in the adult population. It results when the thyroid gland fails to produce enough hormones. It may be caused by many factors including autoimmune disease such as Hashimoto’s thyroiditis, thyroid surgery, radiation to head and neck, and medications. Less often it may result from a pituitary disorder, iodine deficiency, pregnancy, or it may also be congenital(1). Hypothyroidism may be either subclinical or overt. Subclinical hypothyroidism is characterized by a serum TSH above the upper reference limit with a normal free thyroxine (T4). An elevated TSH (usually above 10 mIU/L) in combination with a decreased free T4 characterizes overt hypothyroidism. Serum thyrotropin (TSH) is the single best screening test for primary thyroid dysfunction Medicina de Familia Diciembre 2016-11
for the vast majority of patients(2). Symptoms of hypothyroidism include fatigue, loss of energy, weight gain, cold intolerance, dry skin, hair loss, depression, constipation, menstrual disturbances, and impaired fertility(3). Data collected from the National Health and Nutrition Examination Survey suggest that about one in 300 persons in the United States have hypothyroidism. The prevalence increases with age, and is higher in females than in males(4). Nearly 4.6 percent of the U.S. population age 12 and older has hypothyroidism(5). Thyroid dysfunction is associated with a variety of metabolic disturbances such as hypercholesterolemia, obesity, insulin resistance, and cardiovascular disease(3). Hypothyroidism and diabetes mellitus appear to be linked. A recent meta-analysis of all available data in 10,920 patients with diabetes mellitus showed a mean frequency of thyroid disease of 11%(6). Hypothyroidism is characterized by impaired glucose absorption from the gastrointestinal tract and delayed peripheral glucose assimilation and gluconeogenesis, decreased or normal hepatic glucose output and decreased peripheral tissue glucose disposal(6). Insulin resistance present in hypothyroidism may increase cardiovascular risk, especially when it is associated with other risk factors such as hyperlipidemia and hypertension(6). Numerous epidemiological studies have found a higher prevalence of overt hypothyroidism in type 2 diabetic population than in the general population, but the relationship between subclinical hypothyroidism and diabetes mellitus 2 is still controversial(7). The utility of routine screening for thyroid dysfunction in diabetic patients has been questioned by some authors. There is a lack of definitive guidance on the screening of thyroid dysfunction in patients with type 2 diabetes(8). The American Diabetes Association recommends an annual evaluation of TSH in all patients with type 1 diabetes, in those with dyslipidemia, and in women aged over 50 years, similar to that recommended by the American Association of Physicians(8). The American Association of Clinical Endocrinologists recommends screening for thyroid function in all adults over 35 years, with monitoring every 5 years or sooner if there is a high index of suspicion(8). The United States Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in asymptomatic adults(4). 12-Medicina de Familia Diciembre 2016
The aim of this study is to estimate the prevalence rate of hypothyroidism in the adult population receiving services in an ambulatory clinic and to determine if there is an association between hypothyroidism and diabetes mellitus. The findings of this study will help physicians to define early detection strategies for hypothyroidism and whether these strategies should be focused on diabetic patients. Unrecognized hypothyroidism in diabetic patients may adversely affect the metabolic control and add more risk to an already predisposing scenario for cardiovascular diseases(9).
Method This is an observational cross-sectional study. Authorization was obtained from the Institutional Review Board at Ponce Health Sciences University (IRB #150810-CR) and the administrators of Policlínica Bella Vista in Mayagüez. From the database of all adult patients (21 years and older) who attended the outpatient clinic at Family Medicine Center Policlínica Bella Vista in Mayagüez, P.R. during 2014, a random sample of 200 subjects was obtained. All of these records were reviewed by the investigators. The sample size was calculated using the statistical software Epiinfo® by the CDC. This sample size was appropriate to detect a prevalence ratio of hypothyroidism = 2.0 in the exposed group (diabetes mellitus), with values for alpha = 0.05 and beta = 0.20, and using preliminary estimates of the prevalence of exposure (diabetes mellitus) = 0.33 and outcome (hypothyroidism) = 0.20. The following variables were extracted from the records: age; sex; positive past medical history of conditions (hypothyroidism, diabetes mellitus, hyperlipidemia, cardiovascular disease, arterial hypertension); Body Mass Index (BMI) during last visit; last value of TSH, FPG, HbA1C, LDL when available, and treatment with thyroid replacement. The data was collected in a computerized spreadsheet and analyzed using Epiinfo®. Data analysis included descriptive statistics; means, standard deviations and frequency distributions. The prevalence rate of hypothyroidism was estimated for the study sample and compared between diabetic and non-diabetic patients. Prevalence ratios were calculated with their respective 95% Confidence Intervals.
Results The distribution by sex showed that 128 (64%) were female and 72 (36%) were male. The mean
age was 50.6 years with a standard deviation of 16.6 years. The median age was 52 years and the range was from 21 to 93 years. Figure 1 shows the distribution by age groups. The mean BMI was 28.9 kg/m2 with a standard deviation of 7.1 kg/m2. The median BMI was 27.0 kg/m2 and the range was from 16 to 58 kg/m2. Figure 2 shows the distribution by BMI groups. This figure shows that 70.5% of the subjects were overweight or obese. Table 1 shows the prevalence rates of different medical conditions in the study group. The prevalence rate of diabetes mellitus in this group was 22% and the prevalence rate of hypothyroidism was 17%. The prevalence rate of hypothyroidism in diabetic patients was 10/44 (22.7%). The prevalence rate of hypothyroidism in non-diabetic patients was 24/156 (15.4%). The prevalence ratio was 1.48 (95% CI: 0.77, 2.85; X2 = 1.31, p = 0.25). Results of TSH, FPG, HbA1C, and LDL were not included in the analysis because there were not enough available data in the medical records.
Discussion Epidemiological studies regarding the prevalence of thyroid dysfunction in Puerto Rico are very scanty. Although screening for thyroid dysfunction by primary care providers seems to be a common practice, screening guidelines are still controversial. The prevalence rate of hypothyroidism in this study was 17%, which is much higher than the 4.6 % estimated in the U.S population(5). The higher prevalence of hypothyroidism the population of Puerto Rican patients in an outpatient clinic warrants further investigation. Medicina de Familia Diciembre 2016-13
This study included data of different chronic conditions. Hypertension (37.5%) and hyperlipidemia (26.5%) were the most prevalent morbidities on this study group. Among the subjects under study, 70.5% were overweight or obese. Not only in Puerto Rico but worldwide the prevalence of obesity has been increasing during the last decades. Obesity is a serious health problem in Puerto Rico. The data collected by the Behavioral Risk Factor Surveillance System (BRFSS) showed that in the year 2012 the prevalence of overweight and obesity was 66.2 percent(10). More than 15 percent of Puerto Rico’s population has diabetes according to the data provided on the year 2012 on the survey done by the BRFSS (10). In this study the prevalence rate of diabetes mellitus was 22%, which is nearly 1.5 times greater than the prevalence in the general population. This is expected in a population of patients who receive medical services in an outpatient clinic. The prevalence rate of hypothyroidism in diabetic patients was 1.5 times higher than the prevalence rate of hypothyroidism in non-diabetic patients but these findings are not statistically significant, because the sample size had statistical power only to detect a prevalence ratio of 2.0 or higher. In conclusion, the results of this cross-sectional study showed a tendency for a higher prevalence of hypothyroidism in diabetic patients, which suggests that screening for hypothyroidism among patients with diabetes should be considered. More studies with more patients are necessary to investigate the association between thyroid dysfunction and diabetic patients. Regular screening for thyroid dysfunction in diabetic patients could allow adequate treatment and subsequent decrease of metabolic derangements and cardiovascular risk.
References 1. Hypothyroidism (Underactive Thyroid). Mayo Clinic. Nov. 10, 2015. http://www.mayoclinic. org/diseased-conditions/hypothyroidism/symptoms-causes/dxc-20155382 2. Garber JR, Cobin RH, Gharib H, et al. Clinical Practice Guidelines for Hypothyroidism in adults: Cosponsored By the American Association of Clin-
14-Medicina de Familia Diciembre 2016
ical Endocrinologists and the American Thyroid Association. Endocrine Practice. 2012; 18 (6): 988-1028. 3. Orlander PR. Hypothyroidism Clinical Presentation. 12/19/15. http://emedicine.medscape.com/ article/122393-clinical 4. Gaitonde DY, Rowley KD, Sweeney LB, et al. Hypothyroidism: An Updat FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access. FREE PREVIEW. Purchase online access to read the full version of this article. e. American Family Physician. 2012; 86 (3): 244-251. 5. Golden SH, Robinson KA, Saldanha I, Anton B, Ladenson PW. Prevalence and Incidence of Endocrine and Metabolic Disorders in the United States: a Comprehensive Review. Journal of Clinical Endocrinology & Metabolism. 2009; 94(6):1853–1878. 6. Duntas LH, Orgiazzi J, Brabant G. The Interface Between Thyroid and Diabetes Mellitus. Clinical Endocrinology. 2011; 75(1):1-9. 7. Han C, He X, Xia X, et al. Subclinical Hypothyroidism and Type 2 Diabetes: A Systematic Review and Meta-Analysis. PLoS One. 2015; 10(8): e0135233. 8. Tamez H, Martínez E, Quintanilla DL, et al. The rate of primary hypothyroidism in diabetic patients is greater than in the non-diabetic population. An observational study. Clinic Medicine. 2012; 138(11): 475–477. 9. Palma C et al. Prevalence of thyroid dysfunction in patients with diabetes mellitus. Diabetology & Metabolic Syndrome. 2013, 5:58: 1-5. 10. Ríus A, Sánchez E. Summary of General Health in Puerto Rico. 2014. http://www.salud.gov.pr/ Estadisticas-Registros-y-Publicaciones/Publicaciones/Resumen_General_Situacion_de_la_Salud_20042013_Update_tablas_Fina l_21marzo. pdf. About the authors: Mariela Bernal, MD, Eddy Escobar, MD, Carmen E. Rodríguez González, MD, DABFM, Bella Vista Hospital Family Medicine Residency Program.
“Time elapsed between Triage and Evaluation by Physician on ER in Mayagüez Medical Center” Authors: Javier Lugo De Jesús, MD, DABFM; Brenda Orta, MD; Mario Ramos Bello, MD; Elieser Gonzalez, MD; Jean Savio Estel, MD; Shirley Lojo, MD; Raixa Rivas,MD
Project Description The success of any emergency department is closely related to the effectiveness of the basic principle of triage which is the sorting of patients according to the urgency of their need for care. As it was proven during the different world wars, the appropriate triage and prompt medical evaluation based on the severity of a patient can be the difference between life and death. The Institute of Medicine (IOM) published the landmark report, “The Future of Emergency Care in the United States,” and described the worsening crisis of crowding that occurs daily in most emergency departments across the nation. According to the Center for Disease Control and Prevention report, in 2008 there were 123.8 million visits to U.S. emergency departments and only 18% of patients were seen within 15 minutes, leaving the majority of patients in the waiting room. In view of the national data and feedback received from patients of the Family Medicine Center, the Family Medicine Residency Program decided to study the triage process of the Emergency Department of Mayaguez Medical Center, which the sponsoring Institution. The main components of the study are: a review of the current recommendations and guidelines by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA); data collection from and review of the records of patients who visited the emergency room during the first week of September 2015; and the development of recommendations to improve the efficiency and efficacy of the triage of Mayaguez Medical Center Emergency Department.
Objective/Purpose To evaluate the effectiveness and the efficacy of the current Emergency Department Triage system of the sponsoring institution: “Mayagüez Medical Center”, in order to develop recommendations for quality improvement.
Method During the 2015 calendar year the emergency department received more than 25000 visits where each patient is categorized using a color coded system: green, yellow and red representing nonurgent, urgent and emergent, respectively. Considering the high volume of patients and the limited resources, the study is a descriptive cross-section of all Emergency Department (ED) visits received between the 1st to the 7th of September 2015. The records were identified by the team of investigators. The variables collected were: sex, age, color of paper (designed previously by ED), admission rate, waiting time for medical evaluation. The exclusion criteria were patients transferred to other facilities and patients that were less than 19 years of age during the ER visits. The data were analyzed using Microsoft Excel 2010.
Presenter’s Role In Research Project The study design, protocol, literature review, data collection, statistical analysis, discussion, and recommendations were developed by the team of investigators, which includes a family medicine attending, a family medicine physician expert in research and family medicine residents of all levels.
Results The study included a total of 347 patients. The sex distribution showed 186(54%) Female and 161(46.0%) Male. Age groups were classified by decades of life from the third decade (19-30 years old) to the eighth and above (71 years and oldMedicina de Familia Diciembre 2016-15
er). The calculated mean age was 57.2 years, 184 (53.0%) patients were 50 years old or older in terms of the distribution by age. When considering the category of patients during triage: 49 patients (14.0%) were classified as emergent (red), 61 patients (18.0%) as urgent, and 237 patients (68.0%) were classified as nonurgent. The overall rate of admission was 126 (36.0%) in the population studied. A total of 39 out of 49 (79.5%) patients triaged as red level (emergent) were admitted. Within the other groups, the admission rates were 35 out of 61 patients (57.4%) and 52 out of 237 patients (21.9%) in the urgent and non-urgent levels, respectively. A total of 18 patients (37 %) of the emergent group were evaluated within the 15 minutes timeframe. In the urgent group 24 patients (40%) were evaluated in the 30 minutes stipulated by the literature. A total of 151 patients (63%) of the non-urgent group were evaluated within 60 minutes of triage.
Discussion Despite the limitations of this study related mostly to the time constraint and small sample size, it appears that that in the ED of Mayagüez Medical Center, the percentage of emergent patients seen within 15 minutes was 37%, roughly twice the rate of the national data. However, this can still be improved to better the quality of the service provided to patients, since less than 50% of patients are seen in the ideal time for emergent case.
16-Medicina de Familia Diciembre 2016
Other recommendations are: to extend the study to include a longer period of time; to perform study of cost-analysis to evaluate the financial impact of the overcrowding of the ED and the effect of long patient stay in the ED.
References • American College of Emergency Physicians (2010). ACEP policy statements: Triage scale standardization. Dallas , TX : American College of Emergency Physicians. Retrieved June 1,2001. • Barthell EN, Coonan K, Finnel J ,Pollock D(2004). Disparate systems, disparate data: integration,interfaces 6and standars in emergency medicine information technology. Acad Emerg Med. 11(11):1142- 1148. • Baumann MR, Strout TD (2007). Triage of geriatric patients in the ED: validity and survical with the Emergency Severity Index. Ann Emerg Med. 49: 234-240. • Bernstein SL, Verghese V, Leung W, Lunney AT, Perez I(2003) . Development and validation of new index to measure emergency department crowding. Acad Emerg Med. 10 (9):938-942. About the authors: Javier Lugo De Jesús, MD, DABFM; Brenda Orta, MD; Mario Ramos Bello, MD; Elieser Gonzalez, MD; Jean Savio Estel, MD; Shirley Lojo, MD; Raixa Rivas,MD.
Rare and Disturbing Complications of Acute Pancreatitis: Pancreatic Panniculitis and Erythema Nodosum Authors: Glorilee Delgado Flores, MD, MPH; Pilar Vásquez Hinojosa, MD; Ivonne Robles Cartagena, MD; América Robles Cartagena, MD; Katia Mercado, MD, DABFM; José Silva, MD, FACS; Rafael Vicens, MD
Introduction: Pancreatic panniculitis is an uncommon condition that can occur in association with pancreatic disease. Most of the cases reported to date were associated with acute or chronic pancreatitis and pancreas cancer. Its pathogenesis is still not well understood but the release of pancreatic enzymes in the setting of pancreatic injury may play an important role, leading to fat necrosis in subcutaneous tissue and elsewhere.
Case Description: Patient History A 32 year old Female Patient with no systemic illness arrived to ER due to nausea, vomits, diffuse abdominal pain, fever, chills, and malaise since 2 days of evolution.
Physical Examination On Physical Examination, the patient was found to have multiple, ill defined, tender, warmth, edematous and erythematous subcutaneous nodules, 2-3 cm in diameter, with a spontaneous brown oily drainage in some of them. During abdominal examination, distended abdomen, positive bowel sounds, diffuse abdominal tenderness, rebound and guarding were found.
Clinical Course Blood exams showed microcytic hypochromic anemia that required several blood transfusions, significantly elevated levels of amylase and lipase and leukocytosis. Patient mentioned an episode of Streptococcal Pharyngitis in 2011. Patient also refers several previous hospitalizations in the past
year due to Acute Pancreatitis with development of Pancreatic Pseudocysts and Pancreatic Abscess that required cholecystectomy and a surgery creating a connection between pancreas and small bowel. The patient also refers development of 2 ventral hernias that required herniorrhaphy with placement of stents. The patient developed a complication to the above mentioned surgery, an abdominal infection that required the removal of the stents. At the present Emergency Department visit, A CT Scan was performed and showed subcutaneous abscess and anterior abdominal wall inflammatory changes, suggestive of abdominal wall cellulitis. This patient received an antibiotic named Tygecycline for several days. At day number 3, the patient started again with nausea, vomits, fever, chills and a new complaint of epigastric abdominal pain. On physical examination, the patient was found with persistent subcutaneous nodules with brown oily drainage in some of them, positive bowel sounds, epigastric tenderness, rebound and guarding. Abdominal sonogram was performed and showed pancreatic inflammation. Abdominal CT-Scan and MRCP were performed and findings of swollen pancreas with densification in peripancreatic fat were found, suggestive of acute pancreatitis. Patient received abdominal surgery to take a biopsy of the subcutaneous nodules and remove the draining secretions of the nodules. A fragment of subcutaneous tissue and deep dermis from the patient’s subcutaneous nodules was histopathologic examined. It showed the presence of a lymphoplasmacytic infiltrate in lobular septae as well as in the periphery of the lobules. Degeneration of the subcutaneous adipose tissue with deposits of amorphous basophilic material was seen. A focus with CD 68 positive macrophages was also identified. A Prussian blue stain reveals some hemosiderin deposits. The presence of Thickened septae with fibrosis in combination with the perivascular inflammatory infiltrate in the upper parts of dermis favored erythema nodosum as a possible diagnosis. Findings of subMedicina de Familia Diciembre 2016-17
cutaneous tissue necrosis with some basophilic degeneration of the adipose cells also favored pancreatic panniculitis as a possible diagnosis as well. The patient started to receive corticosteroids. The patient developed a persistent disease, several relapses with development of abdominal
ulceration that required several hospitalizations.
Figure A. Subcutaneous Nodules in abdomen.
Figure B. Subcutaneous nodules draining secretions.
Figure C. Subcutaneous nodules in abdomen.
Figure D. Subcutaneous nodules in abdomen.
Figure E. Early adipose tissue necrosis
Figure F. Basophilic degeneration of adipose cells.
18-Medicina de Familia Diciembre 2016
Discussion: Pancreatic Panniculitis is a very rare entity and Continued on page 35
Regala un Día de Fondos Unidos de Puerto Rico La Academia de Médicos de Familia de Puerto Rico se ha caracterizado por la educación a la Clase Médica y su labor comunitaria, es por ello que la Junta Directiva y los miembros del Comité de Relaciones Publicas decidieron ser parte de la iniciativa: “Regala un Dia” de Fondos Unidos de PR., institución a la cual por muchos años hemos apoyado y reconocido por su misión. El sábado 10 de septiembre de 2016 nos dirigimos hacia el Barrio Pájaro de Bayamón, PR., donde ubica el Centro el Remanso, el siguiente equipo: Dr. Jorge Meaux – Presidente, Dra. Marina Almenas, Pres. Comité Rel. Publicas, Dr. Ariel Cruz Igartua, Pasado Presidente, Dra. Joan Pijen – Secretaria, entre otros colaboradores, junto a familiares, esposos, hijos y amigos. Nuestra labor consistió en hacer un vivero de plantas medicinales y comestibles del cual podrán disfrutar los participantes que asisten al Centro El Remanso. Los miembros de la AMFPR y otros
voluntarios que fueron parte de esta misión se enrollaron las mangas y comenzaron a sembrar (sembraron su granito de arena). Ya se está viendo el fruto según nos indica la Hermana Rivera, directora del lugar. El Centro de Actividades y Servicios Múltiples El Remanso brinda servicios a personas de 60 años o más, que física y mentalmente sean capaces de convivir en grupo. En el Centro se ofrecen servicios de: nutrición, salud básica, transportación, recreación, manualidades, consejería e información. Su propósito principal es contribuir a mejorar la calidad de vida de los participantes, sin importar su credo, raza, religión y nivel social. Queremos agradecer a Fondos Unidos de PR., la Sra. Norca Santos y Gildi Díaz Coordinadoras de esta actividad, al Hogar El Remanso y Las Hermanas Dominicas por habernos recibido con ese amor y cariño. También al grupo de trabajo que colaboro para que pudiésemos lograr nuestra Misión en “Regala Un Día – 2016”.
Medicina de Familia Diciembre 2016-19
Comité de Relaciones Públicas y Salud Pública Dra. Marina Almenas Presidenta Comité Relaciones Públicas y Salud Pública La AMFPR está en su año # 59 de su fundación, años a través de los cuales ha tenido como meta la formación de médicos de excelencia, no solo en su aspecto académico por el cual siempre se ha distinguido, sino también en la formación de médicos comprometidos con el servicio comunitario como bien nuestra especialidad se destaca. Es por esto que a través del Comité de Relaciones Públicas y Salud Pública trabajamos para realizar actividades que vayan dirigidas a nuestras comunidades con el fin de educar y llevar prevención a nuestros pacientes y la comunidad en general a través de la participación y comunicación social en Medicina Familiar y Comunitaria, con la participación de nuestros miembros, estudiantes (FMIG) y programas de residencia de medicina de familia. La Academia de Médicos de Familia de PR y su Comité de Relaciones Públicas, Dra. Marina Almenas, Dr. Jorge Meaux, Dra. Heileene Torres, Dr. Ariel Cruz Igartua y Dr. Raúl Castellanos; organizaron una muy lucida actividad celebrando el Mes de Octubre: Mes de la Medicina de Familia. El evento se llevó a cabo el 14 de octubre de 2016 en el Parque Luis Muñoz Marín. Durante la actividad participaron diferentes entidades que brindaron los servicios ofrecidos ese día, entre ellos: Asociación del Corazón, Asociación de Alzheimer, Asociación Contra el Cáncer, Vocees, MMM, Merck, Manatí Medical Center y Mayagüez Medical Center. Always C.P.R. quienes hicieron una presentación para que los presentes aprendieran lo básico del CPR. (Resucitación Cardio Respiratoria). Además los Metro Pavías ofrecieron clínicas de glucosa, hipertensión arterial y oximetría entre otros. Contamos también con Iniciativa Comunitaria realizando pruebas de HIV, gracias al Dr. Vargas Vidot y Naishka Guzmán. Además Walgreens dijo presente con 5 mesas de vacunación para todos nuestros participantes. Fue un día bien activo donde no solo tuvimos clínicas e información, sino también un Programa en Tarima que puso desde temprano en forma a todos los participantes, gracias a las clases de ca20-Medicina de Familia Diciembre 2016
listenia, ofrecidas por el Sr. Leopoldo ¨Pito¨ Ramos del Municipio de San Juan. También queremos agradecer el apoyo de la Sra. Marta Goytia y Sr. Edwin Arlequín quienes nos orientaron y colaboraron para que la actividad se pudiera llevar a cabo en el Parque Luis Muñoz Marín, recién remodelado para el disfrute de todos. Además al Dr. Ariel Díaz, nuestro director ejecutivo y nuestra secretaria Antonia Rodríguez (Toñita) y Tamara Rivera. Nuestra actividad además de promocionar Octubre como Mes de los Especialistas en Medicina de Familia, tenía como finalidad el que nuestros estudiantes de las Escuelas de Medicina de PR. y los Residentes de Nuestros Programas de Especialidad en Medicina de familia participaran en actividades de Labor Comunitaria, ofreciendo charlas y orientando a nuestra población sobre diferentes aspectos de educación y prevención; creando de esta forma médicos comprometidos con la salud de nuestro país. Agradecemos a la Escuela de Medicina San Juan Bautista y su FMIG (Michelle Márquez), Vivian Ortiz, UCC y sus integrantes del Grupo de Interés de Medicina de Familia encabezados por Viviana Meléndez, William Ortiz. También a los Directores de los Programas de Residencia de MF de Mayagüez Medical Center, Dr. Eliasin Muñoz, Manatí Medical Center Dra. Vielka Cintrón y Recinto de Ciencias Médicas, Katia Mercado y a nuestra Presidenta del Comité de Estudiantes y Residentes de la AMFPR la Dra. Carmen Izquierdo. Contamos con una muy buena asistencia del público en general al Parque Luis Muñoz Marín, participantes del Programa de Edad Avanzada, Abuelos Adoptivos, Retirados en Acción del Municipio de San Juan, Egidas y público en general. Tenemos que agradecer el entusiasmo de nuestra maestra de ceremonia, Saudí Rivera quien condujo nuestro Programa de Tarima de forma excelente. Queremos agradecer a los participantes por su entusiasmo y participación de nuestras charlas, además dieron su arte de canto incluso cantaron Feliz Cumpleaños a la Dra. Almenas. Fue un día inolvidable, queremos agradecer a todos los colaboradores, organizadores y auspiciadores por su esfuerzo y entrega incondicional para que esta actividad fuera un éxito. Volveremos el próximo año en Octubre 2017 con otra magna actividad: Mes de la Medicina de Familia.
Feria de Salud: X Tu Salud Familiar Octubre 14, 2016 en el Parque Luis Muñoz Marín
Medicina de Familia Diciembre 2016-21
22-Medicina de Familia Diciembre 2016
Medicina de Familia Diciembre 2016-23
OPS – OMS 55 Consejo Directivo 68 Sesión del Comité Regional de la OMS para Las Américas 26 al 30 Septiembre 2016 Sede PAHO, Washington, DC. ¡Adiós al Sarampión y la Rubéola! Eliminación del sarampión y la rubeola en las Américas 1960 al 2016 Varios Temas Presentados: Actualización sobre el Virus del Zika en la Región de las Americas Los objetivos de Desarrollo del Milenio y las Metas de Salud Estrategias y Plan de Acción Regionales sobre la Nutrición en la Salud Lanzamiento del Libro de la OPS Las dimensiones económicas de las Enfermedades No Transmisibles en América Latina y el Caribe, prioridades en el control de las enfermedades
Otros asuntos discutidos durante sesión fueron:
Estrategia y Plan de Acción sobre Salud Plan de Acción sobre la Salud de los Adolescentes y los Jovenes Plan de Acción para la Prevención y Control de las Enfermedades No Transmisibles Plan de Acción para Reducir el Consumo nocivo de alcohol y el Plan de Acción sobre el Consumo de Sustancias Psicoactivas y la Salud Pública.
Dra. Carissa Etienne, Directora Oficina Sanitaria Panamericana y Dra. Marina Almenas, Pres. Comite Rel. Publicas - AMFPR
24-Medicina de Familia Diciembre 2016
Dra. Marina Almenas, Dra. Mirta Roses y Dr. Raul Castellanos
Comité de Estudiantes y Residentes Dra. Carmen Izquierdo, Presidente Comité de Estudiantes y Residentes Nuestra labor como Comité ha sido sumamente exitoso. Desde el año pasado se estuvo trabajando arduamente para lograr el objetivo de tener 4 representantes estudiantiles y 4 representantes de residentes de cada institución respectiva en Puerto Rico. Ese objetivo fue logrado para abril del 2016. Desde entonces hemos trabajado en unificar a los grupos de interés de medicina de familia y los residentes a través de la Isla. Esta colaboración se ha
logrado a través de la participación de múltiples actividades que verán plasmadas en la próxima página. Como parte de nuestra misión buscamos inspirar a los estudiantes de medicina a elegir nuestra especialidad como profesión. Hacemos esto visitando a las escuelas de medicina y ofreciendo conferencias sobre nuestra profesión y las oportunidades laborales. También hemos ido divulgando la misión de la AMFPR a través de las residencias, con la intención de inculcar el compromiso que sentimos ante el gran reto de querer mejorar el sistema de salud primaria en Puerto Rico. Después de todo, existo hoy ante ustedes con un llamado de servicio público delegado por mi abuelo, Dr. Luis Izquierdo Mora, que dice: “se sirve sirviendo, y el que no sirve; no sirve.”
22.04.2016: Primer Simposio para Estudiantes y Residentes: Herramientas para futuros médicos de familia.
Foto superior izquierda: representantes del grupo de interés de Universidad Central del Caribe (UCC). Foto superior derecha: residentes durante el simposio. Foto inferior izquierda: residentes de medicina de familia de tercer nivel de Recinto de Ciencias Médicas (RCM). Foto inferior derecha: representantes Mayagüez Medical Center (MMC). Foto extrema derecha inferior: recipientes del premio de estudiante del año (a Adriana Emanuelli) y de residente de año (a Carmen Izquierdo, MD) respectivamente. Medicina de Familia Diciembre 2016-25
07.2016: Convención Nacional Para Estudiantes y Residentes del AAFP Foto superior izquierda: delegados estudiantiles son William Ortiz y Vivian Ortiz, como delegada alterna y delegados de residentes son Carmen Izquierdo, y Jean Savio, como alterno respectivamente.
15.10.2016: Midterm Update For Prevention Statergies. Foto superior izquierda: Debora Reyes (MD), Carmen Izquierdo (MD), Miguel Rivera (MD). Foto superior derecha: Carolina Sierra (Vice-presidenta del FMIG UCC, Giselle M. Torres (Presidenta del FMIG de UCC), Carmen Izquierdo (MD), Ashley Susjé (estudiante UCC). . Foto inferior izquierda: residentes RCM Eduardo Valdés (MD), Vanessa Sarquis (MD), Lorimar Ortiz (MD), y César Rodriguez (MD).
26-Medicina de Familia Diciembre 2016
14.10.2016: Feria X Tu Salud Familiar Foto superior izquierda: participantes de Residencia de Medicina de Familia RCM con el tema de ETS/HIV. Foto superior derecha: participantes del FMIG RCM con el tema de Zika. Fotos inferior izquierda: participantes de FMIG de UCC y SJB con el tema de nutrición. Fotos inferior derecha participantes de Residencia de Medicina de Familia de Manatí y Mayagüez Medical Center con el tema de cernimiento de síndrome metabólico.
Medicina de Familia Diciembre 2016-27
El proyecto #1 Word for Family Medicine llega “la isla del encanto” Authors: Dr. Kyle Hoedebecke, Dra. Maria ColonGonzález, Odemaris Narváez del Pilar El proyecto comenzó con una pregunta simple: “¿Cuál es la mejor parte de ser un médico de familia?” A pesar que esta interrogante no es nueva, la verdad es que aún existen dificultades y retos en el reconocimiento de la identidad de esta especialidad, incluso entre la comunidad médica. La importancia y el valor de la práctica familiar son cruciales para aumentar la confianza depositada por la población general en los médicos de familia. En los últimos años, ha aumentado el apoyo internacional por la MFyC alrededor del mundo como en Puerto Rico. Campañas como la nuestra, en las redes sociales, han servido de gran importancia. Empezando con Polaris – El Movimiento de Médicos Jóvenes de Familia en Norte América que pertenece a Wonca – se contagió rápidamente y se convirtió en un fenómeno viral a través de asociaciones similares en el resto del mundo. (Actualmente hemos recibido más que 15,000 respuestas en 80 países y 6 continentes.)
28-Medicina de Familia Diciembre 2016
Se realizó una simple pregunta a través de las redes sociales (Facebook y Twitter): “En una palabra, ¿cuál es la mejor parte de la MFyC?” Es una pregunta fácil, pero a la vez difícil poder describir el conjunto de actividades, acciones, sensaciones, emociones, y pasiones – entre los sentimientos que despierta esta especialidad. Hubo muchísima participación por parte de los médicos de MFyC y de los estudiantes de medicina del Grupo de Interés de Medicina de Familia del Recinto de Ciencias Médicas (FMIG-RCM). Como era de esperar, surgieron muchas palabras. Después, se juntaron todas las respuestas y se crearon – en el estilo que se llama “nubes de palabras” o “wordles” – imágenes representativas de cada región o país en su propio idioma. Las palabras están presentadas en la imagen de la querida bandera puertorriqueña – algo que demuestra el orgullo y sentimiento de la isla y su gente. La meta del proyecto es abogar por la importancia de la MFyC a nivel mundial para que nuestra especialidad pueda volar bien alto como la bandera puertorriqueña por “la isla del encanto”.
Disseminated Skin lesions on an immunocompromised patient Authors: Jose Javier GuzmĂĄn; Ileana Violeta Barrientos; Marielys Otero Maldonado
Abstract: Herpes Zoster or Shingles results from reactivation of endogenous latent Varizella-Zoster Virus (VZV) within the sensory ganglia. It is an acute vesicular cutaneous infection typically presenting in dermatomal distribution. Non-contiguous multidermatomal herpes zoster is very rare in both immunocompetent and immunocompromised patients, with an incidence of less than 0.1% of cases. We herein report a case of a 56 year old male that presented with extensive painful vesicular cutaneous lesions on his trunk, arms, armpits, legs, head and groin of 4 days of progression consistent with non-contiguous bilateral HZV infection (ICD10 diagnostic code B.02.7) that also developed a superimposed fungal and bacterial infection. The patient had been treated for Granulomatosis with Polyangiitis (GPA) with methylprednisolone for the last two years. He was successfully treated with antiviral therapy for 21 days. These patients, especially immunocompromised ones, are at risk of serious life threatening complications like encephalitis. Therefore, for the purpose of rapid diagnosis and initiation of appropriate therapy clinicians should be aware of these more atypical presentations of VZV infection.
Case Description: A 56 year old male with past medical history of type 2 Diabetes Mellitus, Asthma, Hypertension, and Hypothyroidism; was diagnosed with Granulomatosis with Polyangiitis in October 2013. At that time, he was started on Cyclophosphamide for four months until the condition was stabilized and was currently on immunosuppressive therapy with methylprednisolone 16mg daily. The patient presented to the Emergency Department due to a painful rash that started 4 days before. He stated that the rash started with a burning sensation on the right armpit, afterwards he noticed an eruption of vesicles that spread to the chest, back, groin and extremities associated with pruritus, redness,
warmth and tenderness of affected areas of the skin. The patient denied any fever, chills, hemoptysis, cough, dysuria or hematuria. On examination, the patient was hemodynamically stable and in no distress. He presented with painful vesicular lesions on the anterior and posterior thorax, neck, abdomen, both arms and right armpit in different stages and some of them crusted. Also noticed were multiple ring enhancing lesions associated to vesicular groups on the right armpit, right upper back, left lower back, lower abdomen and right forearm. He was admitted with a diagnosis of Disseminated Herpes Zoster (ICD10 diagnostic code B.02.7) with a superimposed bacterial and fungal skin infection. The patient was placed on airborne isolation and was evaluated by the Infectious Diseases specialist who started the patient on Acyclovir 700 mg IV every 8h for the HZV infection, cefazolin 500mg IV every 8h to cover the skin organism causing cellulitis and fluconazole 200mg orally daily for the superimposed Tinea Corporis. On the 4th day of therapy some improvement was observed. The patient referred less pain, and less itchiness. Renal function was monitored closely during hospitalization to avoid any kidney injury secondary to antiviral therapy and other adverse effects given the patientâ€™s underlying disease. Steroid therapy was tapered down to prevent further spreading and complications of infection. The patient was monitored daily for any visual loss, hearing loss, fever, hematuria or cough that could suggest complications. The patient was successfully treated with acyclovir for 14 days IV and switched to acyclovir PO for 7 more days to complete 21 days, Cefazolin for 10 days and then switched to PO Cephalexin to complete 14 days and fluconazole for 14 days.
Discussion: Dissemination of Herpes Zoster is defined as more than 20 vesicles outside primary and adjacent dermatomes(1). Noncontiguous multidermatomal herpes zoster is very rare in both immunocompetent and immunocompromised individuals. Medicina de Familia Diciembre 2016-29
Most of the reported cases have been limited to 2 noncontiguous dermatomes. This unique presentation has been referred to as Herpes Zoster duplex unilateralis or bilateralis, depending on whether one or both halves of the body is involved(2). In Herpes Zoster Duplex Bilateralis (HZDB) it may occur in the same (symmetric) or in different dermatomes (asymmetric)(3). Our patient developed Herpes Zoster in 7 disparate dermatomes. In our patient, advanced age, diabetes mellitus, hypertension, Granulomatosis with Polyangiitis, and the use of Cyclophosphamide and methylprednisolone could have contributed to dissemination of HZ. Immunosuppressive therapy has been implicated as a risk factor for developing infections and varicella-zoster reactivation(4). Patients with dissemination of HZ are at increased risk for other organ involvement, particularly lungs, liver, and brain(5). Other complications include corneal ulceration, bacterial superinfection, and postherpetic neuralgia (PHN)(5). Therefore, identification and early treatment are important to decrease morbidity and mortality. The principal goals of the treatment of HZ are reduction of pain in immunocompetent patients and cessation of viral replication in immunocompromised patients. The efficacy of antiviral therapy in patients with HZ has been demonstrated by multiple randomized controlled clinical trials(6). Acyclovir (800 mg 5 times daily for 7–10 days), famciclovir (500 mg 3 times daily for 7 days is the approved dosage in United States while 250 mg 3 times daily is approved in some other countries), and Valacyclovir (1000 mg 3 times daily for 7 days) have been approved by the US Food and Drug Administration(6). Shingles vaccine has been used since 2006. Zostavax® is the only shingles vaccine currently approved for use in the United States. This vaccine reduces the risk of developing shingles by 51% and PHN by 67%(7). The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of all persons aged >60 years with 1 dose of zoster vaccine. Zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing post-herpetic neuralgia, or to treat ongoing PHN. In the case of persons on immunosuppressive therapy, including
30-Medicina de Familia Diciembre 2016
high-dose corticosteroids (>20 mg/day of prednisone or equivalent) lasting two or more weeks, Zoster vaccination should be deferred for at least 1 month after discontinuation of such therapy(7). Disseminated zoster is a potentially serious infection that can have an atypical presentation. A high index of suspicion is needed to make the diagnosis promptly and to initiate IV Acyclovir to decrease mortality and morbidity. The treatment of HZ should occur in conjunction with appropriate education and support from the health care provider.
References McCrary M. L., Severson J., Tyring S. K. Varicella zoster virus. Journal of the American Academy of Dermatology. 1999; 41(1):1–14. doi: 10.1016/ s0190-9622(99)70398-1. Takayama M, Takayama N, Hachimori K, Minamitami M. Restriction endonuclease analysis of viral DNA from a patient with bilateral herpes zoster lesions. J Infect Dis. 1988;157: 392. Yoo KH, Park JH, Song KY. Herpes Zoster Duplex bilateralis in a patient with breast cancer. Cancer Res Treat. 2009; 41(1):50–52. Eric Gomez; Ivan Chernez. Disseminated Cutaneous Herpes Zoster in an Immunocompetent Elderly Patient. Infect Dis Rep. 2014 Aug 13; 6(3): 5513. Brown T. J., McCrary M., Tyring S. K. Varicella-Zoster virus (Herpes 3) Journal of the American Academy of Dermatology. 2002;47:972–997. Dworkin, RH; Johnson, RW; Breuer, J et al Recommendations for the Management of Herpes Zoster. Clin Infect Dis. (2007) 44 (Supplement 1): S1-S26.doi: 10.1086/510206. http://www.cdc.gov/mmwr/pre vie w/ mmwrhtml/rr5705a1.htm About the authors: Manatí Medical Center: Jose Javier Guzmán, Family Medicine Residency Program, PGY1; Ileana Violeta Barrientos,Department of Internal Medicine/ Infectology; Marielys Otero Maldonado, Department of Internal Medicine/Infectology Manatí Medical Center, Carretera No.2 Int. 688 Urb. Atenas Manatí, PR 00674
When the cause of childhood pneumonia is truly uncommon Authors: Myrna Z. Bosques, M.D.; Carlos Acevedo, M.D.; Juan Ortega, MD; Aracelis Nieves, MD.
Introduction The thymus is a T-cell producing lymphoid organ in the anterior mediastinum that plays a role in the development of the immune system (1). It is relatively large in infancy, reaching a maximal weight in adolescence between the ages of 12 and 19 years, and gradually involuting with age with progressive fatty replacement (1, 2). The thymus is seen as a triangular sail (Thymic sail sign) frequently towards the right of the mediastinum in about 5% of children. It has no mass effect on vascular structures or airway and has a homogeneous appearance on CT scan (3).
Case presentation A 6 year old female with past medical history of asthma and right (2013) and left (2014) sided pneumonias, came to our Emergency Room complaining of shortness of breath, productive cough and wheezing since 5 days ago already treated with albuterol, atrovent and prednisone without improvement. The mother refers she had fever at home. On physical examination the patient looks acutely ill. Lung examination showed bilateral wheezing and rhonchi. No extremity cyanosis. No fever. On previous admissions the patient received treatment with respiratory therapies (albuterol, atrovent and dexamethasone) and prednisone. No fever was documented during previous hospitalizations. White blood cells were elevated with negative blood cultures in each hospitalization. The patient started to have a pneumonic process on May 2013 on the right side. On the second hospitalization 3 months later, the patient presented with a chest radiograph that showed haziness around the cardiac margin on the left side, “cannot exclude pneumonia”. Adiagnosis of recurrent pneumonia is made. Nine months later the patient is admitted with left sided pneumonia for the second time. Diagnosis of persistent pneumonia is made. A chest
CT scan is requested and showed soft tissue densities along the anterosuperior mediastinum towards the left, which may account for the radiographic abnormalities, the triangular shaped soft tissue density favoring normal thymic tissue. The lungs show asymmetric aeration of the left sided displacement of the heart due to hypoplasia of the lung. No consolidations, masses, interstitial lung disease or emphysema are noted. No distinct pleural disease noted. No significant bronchial wall thickening or endobronchial obstruction noted. During admission several chest x-ray’s described left sided perihilar infiltrates and/or residual thymic tissue. Water’s view was within normal limits. Upper Gastrointestinal series was negative for gastroesophageal reflux.
Discussion Our patient has a history of asthma and multiple hospitalizations over the past year with a diagnosis of recurrent pneumonia and persistent left sided pneumonia. Multiple chest radiographies showed residual thymic tissue versus pneumonia. The thymic sail sign is most common on the right side (3). In our patient, the persistent location of the thymus in the left side resulted in repeated misdiagnoses of pneumonia. The use of steroids and albuterol increased the WBC count. These increases apparently led the physician into making a misdiagnosis of sepsis and pneumonia. True thymic tumors such as thymoma and thymolipoma are very rare in childhood, but it is quite common to encounter thymic infiltration by leukemia or lymphoma (2). The abnormal thymus is characterized by an irregular or lobular margin, heterogeneous echogenicity, coarse echotexture, and calcifications but in this case the structures were normal in appearance. Under uncertain circumstances, computed tomography (CT) and magnetic resonance (MR) imaging are frequently considered the best modalities for solving dilemmas encountered at chest radiography (3). Familiarity with the embryology and anatomy of the thymus is essential to avoid unnecessary imaging and/or administration of medications Medicina de Familia Diciembre 2016-31
(antibiotics in our case), invasive procedures and hospitalizations. The radiologist and primary doctor play a major role in differentiating normal thymic variants, ectopic thymic tissue and non-neoplastic conditions to avoid misinterpretations.
Conclusion Currently, the patient has visited the emergency room for bronchial asthma exacerbations, but has not hospitalized since the persistent infiltrates and/ or thymic residual tissue were mistaken as pneumonia. The Pneumologist took the decision to not do a biopsy or bronchoscopy since the residual thymic tissue was homogenous in appearance and no signs of malignancy or masses were described in the chest CT scan. The CT scan of the chest showed a mediastinum shifting to the left side due to asymmetric volume loss and hypoplasia that may have contributed to the persistent radiographic abnormalities. The location of the thymic shadow is unusual in the left side, but we need to keep it in mind as a mimicker of pneumonia. If there is no clear diagnosis an MRI would be the next step to get a good structural
differentiation of the chest organs. This study was approved by the PHSU IRB (Protocol number 160218-CA on 2/24/2016)
Reference Nishino M, Ashiku SK, Kocher ON et-al. The thymus: a comprehensive review. Radiographics. 2006;26 (2): 335-48. Moore AV, Korobkin M, Olanow W et-al. Agerelated changes in the thymus gland: CT-pathologic correlation. AJR Am J Roentgenol. 1983;141 (2): 241-6. Kim OH1, Kim WS, Kim MJ, Jung JY, Suh JH. US in the diagnosis of pediatric chest diseases. Radiographics. 2000 May-Jun; 20(3):653-71. About the authors: Myrna Z. Bosques, M.D., Family Medicine Residency Program, PGY2; Carlos Acevedo, M.D., Department of Pediatric Medicine; Juan Ortega, MD, Department of Radiology and Imaging; Aracelis Nieves, MD., Family Medicine Department. Manatí Medical Center, Carretera No.2 Int. 668 Urb. Atenas Manatí, PR 00674
Mayagüez Medical Center 787-652-9200 Manatí Medical Center 787-621-3700 32-Medicina de Familia Diciembre 2016
Not all etiologies of Congestive Heart Failure are known: Spongiform Cardiomyopathy Authors: Glorilee Delgado Flores, MD, MPH; Pilar Vásquez Hinojosa, MD; Ivonne Robles Cartagena, MD; América Robles Cartagena, MD; Katia Mercado, MD, DABFM; David Storer, MD, FACP, FA CC
Introduction: Non-compaction of the left ventricle (LVNC) also known as Spongiform Cardiomyopathy is a rare disorder. The European Society of Cardiology Working group on Myocardial and Pericardial Diseases classified LVNC as an unclassified cardiomyopathy. Ventricular non-compaction (VNC) is believed to arise from the arrested endomyocardial development during embryogenesis. It is characterized by distinctive “spongy” morphological appearance of the ventricle.
Case description: Patient History A 45 year old male patient with PMH of Diabetes Mellitus Type II and Hyperlipidemia arrived to our institution with symptoms of oppressive and substernal chest pain during rest and exertion, shortness of breath, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea and lower extremities edema that started 2 weeks ago.
Physical Examination Findings during physical examination included jugular venous distention, S3 gallop, tricuspid regurgitation and mitral regurgitation, crackles bilateral at lung bases and lower extremities pitting edema.
Clinical Course An EKG was performed which showed atrial fibrillation and atrial flutter. Due to all of these signs and symptoms of Unstable Angina and Congestive Heart Failure, a cardiac catheterization was performed. Findings of increased left ventricular cavity size, mitral regurgitation, tricuspid regurgitation, ejection fraction of 39%, severe global
hypokinetic dysfunction in the left ventricle and non-compaction of the left ventricle muscle were evidenced during the study. The left main, left anterior descending left circumflex and right coronary arteries were free of any significant disease. Those cardiac catheterization findings raise the initial clinical suspicion of a cardiomyopathy and an echocardiogram was performed with the purpose of confirming the diagnosis. The Echocardiogram was remarkable for atrial flutter, atrial fibrillation, increased left ventricular cavity size, decreased left ventricular wall thickness, decreased left ventricular systolic function, decreased right ventricular systolic function, moderately increased right atrial size, moderately increased left atrial size, thickened mitral valve, mitral valve regurgitation, tricuspid valve regurgitation, presence of multiple trabeculation particularly in the apex and midventricular segments of the inferior and lateral wall of the left ventricle, multiple deep intertrabecular recesses communicating with the left ventricular cavity and a 2 layered structure of the endomyocardium with an increased noncompacted to compacted ratio creating a spongiform appearance. Based on all of the above mentioned findings, Spongiform Cardiomyopathy was diagnosed in this patient.
Discussion: Spongiform Cardiomyopathy is a rare disorder. Among the cardiomyopathies, a group of diseases of the myocardium that cause poor myocardial function, spongiform cardiomyopathy is very uncommon and due to its recent establishment as a diagnosis and little awareness of this medical condition, it is not fully understood how common this condition is. LVNC may occur in isolation or in association with congenital heart disease. Three major clinical manifestations of LVNC are congestive cardiac failure, arrhythmias (atrial arrhythmias, ventricular tachycardia and sudden cardiac arrest) and thromboembolic events. Spongiform Cardiomyopathy is associated with a sporadic or autosomal dominant inheritance. The diagnosis of this disease is based on typical echocardiographic findings such as: an altered myocardial wall with Medicina de Familia Diciembre 2016-33
prominent trabeculae and deep intertrabecular recesses resulting in thickened myocardium with two layers consisting of compacted and non-compacted myocardium, continuity between the left ventricular cavity and the deep intratrabecular recesses, which are filled with blood from the ventricular cavity without evidence of communication to the epicardial coronary artery system. It has been suggested that LVNC may be due to intrauterine arrest of compaction of the loose interwoven meshwork that makes up the fetal myocardial primordium. Data on treatment of LVNC is limited, and there is no specific therapy for LVNC. Patients with arrhythmias may need implantable pacemakers or cardioverter-defibrillator. Finally, heart transplantation is indicated, in accordance with current guidelines. Further studies are required to investigate about etiology, incidence or prevalence, and the exact medical therapy and management for Spongiform Cardiomyopathy. Patients with LVNC carry a uniformly poor prognosis with high mortality of up to 60% within 5 years of diagnosis.
Conclusion: Non-compaction of the left ventricle (LVNC) also known as Spongiform Cardiomyopathy is a rare disorder. LVNC can be diagnosed by 2D and color Doppler echocardiography. Standard medical therapy for management of CCF and arrhythmias, anticoagulants for prevention of systemic thromboembolic events. Patients with LVNC carry a uniformly poor prognosis with high mortality of up to 60% within 5 years of diagnosis. Patients with LVNC should receive implantable cardioverter-defibrillator (ICD) therapy according to standard indications for primary and secondary prevention of sudden cardiac arrest. About the authors: Glorilee Delgado Flores, MD, MPH, UPR Medical Sciences Campus, Family Medicine Residency; Pilar VĂĄsquez Hinojosa, MD, Auxilio Mutuo Hospital, San Juan, PR; Ivonne Robles Cartagena, MD, Auxilio Mutuo Hospital, San Juan, PR; AmĂŠrica Robles Cartagena, MD, Auxilio Mutuo Hospital, San Juan, PR; Katia Mercado, MD, DABFM, UPR Medical Sciences Campus, Family Medicine Residency; David Storer, MD, FACP, FACC, Auxilio Mutuo Hospital, San Juan, PR.
Figure A. Left Ventricle Ejection Fraction: 40%
Figure C. Non compaction of the left ventricle
Figure B. Non compaction of the left ventricle 34-Medicina de Familia Diciembre 2016
Pancreatic Panniculitis Continued from page 18 uncommon disorder with unknown exact prevalence or incidence. Acute or chronic pancreatitis and pancreatic pseudocysts are the most common pancreatic diseases associated with pancreatic panniculitis. The pathogenesis of pancreatic panniculitis is still unknown, but the release of pancreatic enzymes such as amylase, lipase, phosphorylase and trypsin, may be involved. The latter increase the permeability of the microcirculation within lymphatic vessels, allowing other enzymes to enter into fat lobules. Lipase or Amylase hydrolyze neutral fat resulting in glycerol and free fatty acids accumulation leading to fat necrosis and inflammation. The diagnosis of pancreatic panniculitis is suggested by the presence of pancreatic disease and histopathological findings. The main histopathologic feature is a mostly lobular panniculitis with intense necrosis of adipocytes. These necrotic adipocytes with no nuclei and finely granular and basophilic material in the cytoplasm because of calcification are known as ghost adipocytes. In older lesions, fat necrosis and calcified ghost adipocytes are less evident. This liquefactive necrosis of adipocytes will clinically manifest as spontaneous discharge of oily brown material. The treatment of pancreatic panniculitis is directed at the underlying pancreatic disease. When there is involvement of subcutaneous fat other than the lower extremities, such as abdomen, persistent disease, frequent relapses, or ulceration develops. Erythema nodosum occurs most often in young women and typically presents as crops of painful nodules. Histopathologic examination reveals a septal panniculitis with a primarily lymphocytic or mixed inflammatory infiltrate and thickened septa.
Figure E1. Inflammation of subcutaneous adipose tissue.
Erythema nodosum usually lasts a few weeks and resolves spontaneously, but may recur. Streptococcal pharyngitis is the most common identifiable cause.
Conclusion: • Pancreatic panniculitis is a rare complication in the setting of pancreatic disease, in which fat necrosis takes place in the subcutaneous tissue and elsewhere. • Rarely can it manifest in patients with subclinical pancreatic disease or with no pancreatic disease with high serum levels of pancreatic lipase of unknown origin. • It has a distinct clinical picture of erythematous tender subcutaneous nodules that spontaneously ulcerate to discharge thick oily material. The usual sites are the distal parts of the lower extremities but involvement of areas such as breasts, buttocks, thighs, and abdomen are described. • When there is involvement of subcutaneous fat other than the lower extremities, persistent disease, frequent relapses, or ulceration. About the authors: Glorilee Delgado Flores, MD, MPH, UPR Medical Sciences Campus, Family Medicine Residency; Pilar Vásquez Hinojosa, MD, Auxilio Mutuo Hospital, San Juan, PR; Ivonne Robles Cartagena, MD Auxilio Mutuo Hospital, San Juan, PR; América Robles Cartagena, MD, Auxilio Mutuo Hospital, San Juan, PR; Katia Mercado, MD, DABFM, UPR Medical Sciences Campus, Family Medicine Residency; José Silva, MD, FACS Auxilio Mutuo Hospital, San Juan, PR; Rafael Vicens, MD Auxilio Mutuo Hospital, San Juan, PR.
Figure F1. Inflammation of subcutaneous adipose tissue. Medicina de Familia Diciembre 2016-35
An atypical etiology of Acute Appendicitis: Appendix Carcinoid Tumor Authors: Glorilee Delgado Flores, MD, MPH; MarĂa Correa Rivas, MD, FCAP; Katia Mercado Castro, MD, DABFM.
Introduction: Carcinoid tumor of the appendix is one of the most common single presentations of this type of tumor and is thereby the most common type of primary malignant lesions of the appendix. The ileum is the second common site of presentation. The carcinoid tumors of the appendix are often asymptomatic and found by chance during appendectomy or other abdominal operations.
Case description Patient History A 33 year old Hispanic male patient with no previous medical history arrived to our institution with periumbilical pain with radiation to RLQ abdominal pain of 1 day of evolution. Patient refers nausea, several episodes of vomits, fever but denies any chills, flank pain, melena, hematochezia, palpitations, skin changes, dizziness, chest pain or headache.
Physical Examination At physical exam with acutely ill appearance, in acute distress, positive bowel sounds, RLQ tenderness, rebound tenderness and involuntary guarding, Mcâ€™Burney point tenderness and Rovsign sign positive.
Clinical Course Abdominal and pelvis CT scan reveals findings suggestive of acute appendicitis with perforation. During the procedure of laparoscopic appendectomy, gangrene, perforated appendix was found and was obtained for biopsy. The appendix biopsy result reveals a 1.3 cm proximal half of the appendix well differentiated neuroendocrine tumor (carcinoid tumor), grade 2 (intermediate grade) with pathologic staging of T1bNo, Ki67 positive in more than 3% but less than 20%, involves the muscularis propia and extent to subserosal tissue 36-Medicina de Familia Diciembre 2016
with perineural invasion. Due to appendix biopsy results, this patient received a right hemicolectomy with ileo-transverse anastomosis to removes the draining lymph nodes of the appendix and any residual disease that might remain at the base of the appendix.
Pathology Report Gross examination of the vermiform appendix confirmed a perforated gangrenous appendicitis. The cut surface revealed ill-defined layers of the wall and a yellow tumoral mass that measured 1.3 x 1 cm, located on the proximal half of the appendix, extending close to the proximal margin of resection. Tumor involved the muscularis propria and appeared to extend into the subserosal tissue at less than 0.1 cm. Microscopy disclosed a well differentiated neuroendocrine tumor of intermediate grade, and a proliferation index (Ki67) of 3-20 %. Chromogranin and synaptophysin immunostains confirmed neuroendocrine differentiation (see figure B and C). Tumor extended to the subserosal tissue without involvement of the visceral peritoneum and involved the proximal margin of resection. Perineural invasion was seen. One lymph node was found negative for metastasis.
Discussion: Cancers of the appendix are very rare. Most of them are found accidentally on appendectomies performed for appendicitis. They are found in about 1% of appendectomy specimens and according to a report published by the National Cancer Institute using the Surveillance, Epidemiology, and End Results database account for only about 0.4% of intestinal neoplasms. Carcinoid tumors are the most common, comprising over 50% of appendiceal neoplasms. The majority of primary cancers of the appendix occur in 55â€“65 years of age. Carcinoid tumors were made up of enterochromaffin cells, a type of neuroendocrine cells within the lamina propria and submucosa. These cells produce and contain approximately 90% of the serotonin in our bodies. When the tumor is located at the base of the appendix, it can occlude the lumen and
give the patient similar signs and symptoms of appendicitis. In these patients, the diagnosis of carcinoid cancer is typically made by pathology after an appendectomy has been performed. The North American Neuroendocrine Tumor Society and European Neuroendocrine Tumor Society suggest hemicolectomy for all tumors between 1 and 2 cm higher proliferative rate (grade 2). After 3 and 12 months post resection, a medical evaluation, chromogranin testing and CT imaging are needed and beyond one year post resection, the medical evaluation will be every 6-12 months for a period of 7 years. Awareness of Appendiceal carcinoid tumor as etiology factor of acute appendicitis must be raised among Physicians for adequate detection and intervention.
• Although appendiceal carcinoid tumor has an excellent overall prognosis. • The North American Neuroendocrine Tumor Society and European Neuroendocrine Tumor Society suggest hemicolectomy for all tumors between 1 and 2 cm higher proliferative rate (grade 2). About the authors: Glorilee Delgado Flores, MD, MPH, UPR Medical Sciences Campus, Family Medicine Residency, San Juan, PR; María Correa Rivas, MD, FCAP, UPR Medical Sciences Campus, Pathology Department; Katia Mercado Castro, MD, DABFM UPR Medical Sciences Campus, Family Medicine Residency, San Juan, PR.
Conclusion: • In summary, appendiceal carcinoid tumor occurs most often as acute appendicitis. • Appendiceal carcinoid tumor lacks specific clinical features and its clinical presentation may not differ from that of acute appendicitis. • In most cases, it is found incidentally during appendectomies and its diagnosis is rarely suspected before histological examination. Figure B. well differentiated neuroendocrine tumor of intermediate grade, and a proliferation index (Ki67) of 3-20 %. Chromogranin, 20x.
Figure A. Nests of tumor cells with focal necrosis
Figure C. well differentiated neuroendocrine tumor of intermediate grade, and a proliferation index (Ki67) of 3-20%. Synaptophysin, 20x
Medicina de Familia Diciembre 2016-37
Integral intervention addressing concomitant type II diabetes mellitus and depression in a primary care setting Authors: Félix M Marti Rivera, MD PGY-3; Fares Yasin, MD, PGY-3; Yanira Maldonado Allende, BHE; Diana Núñez Padín, PsyD; María de los Ángeles De Jesús, PhD; Martha L. Villarreal Morales, PhD; Yadira Reyes, MD;
Background Several studies have scrutinized the association of diabetes mellitus (DM) with depression and the bidirectional nature of this relationship considering that depression may occur as a consequence of having diabetes, but may also be a risk factor for the onset of type 2 DM(1,2). Depression is associated with poor adherence to DM self-care resulting in worse overall clinical outcomes(2). In Puerto Rico the prevalence of both diseases is significantly higher compared with the continental United States of America, and other developed and underdeveloped countries. According to the CDC’s behavioral risk factor surveillance system, in 2014 Puerto Rico ranked first for overall diabetes prevalence (14.2%) and first on prevalence of major depression and any depression (4.5% and 14.7% respectively) among all US states and territories(3). In particular, the municipality of Barceloneta has the second highest adjusted prevalence of DM for the island (15.3%)(4).
Objectives This study aims to evaluate the impact of a multidisciplinary educational intervention in the outcome of diabetic and depressed patients in a primary care setting. The secondary objective is to describe the sociodemographic and clinical characteristics associated with diabetic patients having depression in our community.
Methodology Study Population The subjects were recruited among the Diabetic type II population of Atlantic Medical Center (AMC), Barceloneta, Puerto Rico from both sexes 38-Medicina de Familia Diciembre 2016
and aged between 21 and 85 years. Patients with known severe mental illness (psychosis, dementia, and learning difficulties) and patients with advanced diabetes complications and/or having a terminal illness were excluded. The protocol was considered by the PHSU IRB (Protocol number 141124-YR on 12/17/2014) and a consent form was signed by the patients at the beginning of the study.
Study Design A two-stage design study was performed by the Manatí Medical Center Family Medicine Senior Residents working at the AMC. The AMC is a primary health center grantee, which provides primary care to a large underserved population and serves as the Residents’ outpatient clinic practice. In Stage 1, a cross-sectional study was used to assess the sociodemographic and clinical characteristics associated with type II diabetic patients in our community. For this, the levels of Glycosylated hemoglobin (HbA1c) were measured and the PHQ-9 depression inventory and a questionnaire to evaluate the patient’s psych-socio-economic status and support system were used. The data gathered was also used to establish the patient’s baseline status for the next phase. In Stage 2, an integrated intervention providing education and guideline-based treatment recommendations and monitoring adherence and clinical status was done during 6 months by a multidisciplinary team. This team was integrated by the Residents, primary care physician, clinical psychologist, social worker and health educator. Additionally, the patients identified with moderate or severe depression (PHQ-9 score ≥ 10) were referred for psychological evaluation and therapy by the AMC´s Behavioral Medicine Department. The psychologist in charge decided the course of action depending on the individual needs of the patient. After this period the HbA1c levels and PHQ-9 score were measured once more and the potential impact of depression management on the HbA1c levels of diabetic pa-
tients was evaluated. The primary outcome of this phase was the HbA1c levels. PHQ-9 scores and psych-socio-economic status and support system questionnaire scores were secondary outcomes.
Results From all Diabetic type II patients at AMC (n= 531), only 331 could be reached initially, 223 of whom met the inclusion criteria and only 152 agreed to participate and started the first phase of the study. At baseline, the mean age was 62.8 (±12.26), mean HbA1C was 7.97 (±1.7), mean BMI was 30.2 (±7.0), and 66.9% were female. There were 52.7% with minimum depression, 28.7% had mild depression and 18.42% had moderate to severe depression. The most common comorbidity among the patients was Hypertension (81.4%) and 48.3% had at least 1 comorbidity. Only 4.1% of the patients had no formal education, 44.1% only had elementary education while 34.5% had high-school education and 17.2% had college experience. Most of the patients (77.9%) had Medicare or Medicaid. When asked how well they understood their condition, and the status of their economic and support system, 49.7% did not understand what DM was and although 91% of the patients claimed to know how to take their medications, 73.8% did not have the means to pay their prescriptions when the insurance did not cover them. Only 40.78% (n=62) of the patients completed the study; however the group which dropped out and the one which completed it did not differ statistically on baseline measures (p>0.05). The main reasons given by the patients for dropping out were transportation (36.6%), lack of interest (23.3%) and conflict with their work schedules (23.3%). At baseline these patients were stratified according to the PHQ-9 severity index as follows: 12.9% (n=8) scored 0; 32.2% (n= 20) minimal depression, 35.4% (n=22) mild depression; 11.3% (n=7) moderate depression; 6.5% (n=4) moderately severe depression and 1.6% (n=1) severe depression. This group was involved for 6 months in weekly educational and motivational group activities about nutrition, hygiene, physical activity, control of emotions, and depression management. Those patients with moderate depression or worse (PHQ-9 ≥10) received in addition individual psychotherapy. Among those who completed the study there was a slight but not statistically significant decrease in the final Hba1c (mean difference -0.12; 95% CI, -0.42-0.18, p=0.424). However, there was a statis-
tically significant lower PHQ-9 score at the end of the study period (mean difference -0.89; 95% CI, -1.58- -0.19, p=0.01). There is a positive correlation between Final PHQ-9 and Final HbA1C, r=0.32, (95% CI: 0.08 to 0.53), p=0.01. The group of patients who received individual psychotherapy (PHQ-9 ≥10) had a greater and statistically significant change in PHQ9 score than those who did not receive it (mean difference 3.14; 95% CI, 1.564.71, p=0.0002).
Discussion Our study’s main limitation was the high dropout rate during the first phase of the study. Although there were no statistically significant differences on baseline measures it confirmed the need for tailoring the interventions content and modes of delivery to the needs of our community. Almost 60% of those who dropped out had conflicting schedule or lack of transportation. On the other hand, the response of the patients that stayed in the study was positive with 80% of them having one or no missed sessions. While the group who received individual psychotherapy (PHQ-9 ≥10) had a greater reduction of HbA1c% (0.25% in average), the overall HbA1c% reduction observed at the end of the intervention was 0.12%. Nonetheless, these changes are not statistically significant. A possible explanation for this might be the final sample size which reduced the power and precision of the study. The effect of educational and behavioral actions should be considered, together with the use of antidiabetic medication, as part of a holistic approach in the management of diabetic patients. According to systematic reviews and meta-analysis evaluating the reduction of HbA1c in patients starting on oral anti diabetic drugs (OAD) for the first time, the reduction reached a mean of 1.5% in HbA1c in 4-6 months, the benefit being higher at this point but afterwards, as in the case of our patients whom are already on antidiabetic medications, the reduction seems to be modest(5). Different classes of medications offer different decreases in HbA1c, for example GLP-1 receptor agonists tend to decrease the HbA1c 0.5% to 1.0% in average while the DPP-4 inhibitors offers an even lower benefit in reduction from 0.5% to 0.8%(5). Our results suggest the usefulness of the integrated care management intervention in improving symptoms of depression in the patients. And most importantly a correlation between depresMedicina de Familia Diciembre 2016-39
sion scores and HbA1c levels were obtained in our population at the end of the study. According to the American Diabetes Association diabetic patients, particularly those with poor adherence, should be routinely screened for depression(6) yet, many DM patients with type 2 diabetes are not managed adequately. Improved management of both conditions may have an important impact on patient functional status and mortality(2,7).
Conclusion In conclusion, this study suggests that the integrated management of comorbid depression and diabetes may significantly increase quality of life. Moreover, our results should stimulate adequate investigational and corrective strategies to consistently improve outcomes for these patients in primary care settings. Larger population samples and alternative approaches should be addressed in further studies.
Reference Leone T, Coast E, Narayanan S, Aikins AG, Diabetes and depression comorbidity and socioeconomic status in low and middle income countries (LMICs): a mapping of the evidence, 2012, Globalization and Health, 8 (39): 1-10. Mezuk, B., Eaton, W.W., Albercht, S., & Golden, S.H. (2008). Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care, 31(12), 2383-2390. Gonzalez O, McKnight-Eily LM, Edwards VJ, Croft JB, Current depression among adults-United States 2006-2008, 2010, Morbidity and Mortality Weekly Review, 59 (38): 1229-1235.
40-Medicina de Familia Diciembre 2016
Departamento de Salud. (2015). Resumen General de la Salud en Puerto Rico. San Juan, Puerto Rico. [Internet]. Cited 2016 march 25. Available from www.salud.gov.pr. Sherifali, D; Nerenberg, K; Pullenayegum, E eta al. The Effect of Oral Antidiabetic Agents on A1C Levels: A systematic review and metaanalysis. Diabetes Care August 2010 vol. 33 no. 8 1859-1864. American Diabetes Association. Clinical practice recommendations. Diabetes Care. 2010;33(Suppl 1):S1–S100 Bogner, H.R, Morales, K.H, de Vries, H.F et al. Integrated Management of Type 2 Diabetes Mellitus and Depression Treatment to Improve Medication Adherence: A Randomized Controlled Trial. Ann Fam Med January/February 2012 vol. 10 no. 1 15-22 About the authors: Félix M Marti Rivera, MD PGY-3, Residency Program of Family Medicine, Manatí Medical Center; Fares Yasin, MD, PGY-3, Residency Program of Family Medicine, Manatí Medical Center; Yanira Maldonado Allende, BHE, Patient Education Program, Atlantic Medical Center, Barceloneta; Diana Núñez Padín, PsyD, Behavioral Medicine Department, Atlantic Medical Center, Barceloneta, María de los Ángeles De Jesús, PhD, Family Medicine Department, Manatí Medical Center, Manatí; Martha L. Villarreal Morales, PhD, Department of Medical Education, Manatí Medical Center; Yadira Reyes, MD, Family Medicine Department, Manatí Medical Center.
Decaying teeth leaves you out of breath Authors: Yuniet C Moya; Marielys Otero Maldonado; Jorge Jiménez
Introduction Diabetes mellitus is a chronic disease resulting from a relative or absolute deficiency of insulin which affects the metabolism of carbohydrates, proteins and fats. The oral cavity is constantly exposed to saliva which has antibacterial activities among others. Diminished salivation is frequently associated with diabetes especially in patients with poor glycemic control. In addition, people with diabetes may also be more prone to infections, including dental abscesses that results from progressive dental caries(1,2). Physical and biological risk factors for dental caries includes inadequate salivary flow and composition, high numbers of caries-producing bacteria, insufficient fluoride exposure, gingival recession, immunological factors, the need for special health care and genetic factors(1). Anaerobic bacteria and species of Streptococcus like S. anginosus, S. mitis and S. milleri are part of the normal flora of the oropharynx; as such they can be aspirated and cause a variety of thoracic infections. These include pneumonia, lung abscesses, empyema and mediastinitis. These infections are often difficult to treat and may require interventional procedures if the pleural space is involved(2). This case is about a 67 years old male with past medical history of diabetes mellitus and poor oral hygiene with multiple dental caries and abscesses that developed a right pleural effusion. A throracentesis was performed and Gram positive cocci and anaerobic bacteria were cultivated compatible with a diagnosis of right lung empyema.
Case description Case of a 67 year old male who was brought to the Emergency Room complaining of several days history of right side costal pain, 10/10 in intensity, constant with radiation to the right hemi thorax associated with shortness of breath, fever, chills, fatigue and diaphoresis of several days of evolution. The symptoms were getting worse with
time. Vitals signs showed low grade fever (37.7ºC), blood pressure 161/76 mm/Hg, pulse 126 beets/ min and respiratory rate 28 respirations/ min. Past medical history was positive for Diabetes Mellitus, Hypertension, Dyslipidemia, obstructive sleep apnea and obesity (113 kg, 68” for a BMI of 37.9). Toxic habits were denied. On physical examination the patient looked acutely ill. Lung auscultation revealed bilateral ronchi, right side rales and decreased breath sounds. Lower extremities showed mild bilateral edema without cyanosis, ulcerations or skin lesions. Oral hygiene was appalling, multiple chronic and acute dental abscesses were observed. Initial empiric treatments were levofloxacin 500 mg IV X 1 dose, furosemide 20 mg IV X 1 dose. Among our differential diagnose based on initial evaluation were acute coronary syndrome, pulmonary infectious process and malignancy. After laboratory results came out, acute coronary syndrome was ruled out due to negative cardiac enzymes and an electrocardiogram that did not reflect signs of ischemia. The diagnosis of a pulmonary infectious process was strongly suspected due to the patient’s clinical features, leukocytosis with a white blood cell count of 14.9 x 103ul, Lactate plasma of 16.5 mmol/L and the findings of chest x ray that reveal right side pleural effusion. A computerized tomography of the chest showed extensive opacification of the right lung, identified as a loculated fluid pocket of approximately 12 cm x 8 cm at the right lung base and segmental and sub segmental atelectatic changes. Multiple mediastinal lymph nodes, measuring less than 1.5cm were seen, suggesting either an inflammatory and/ or a malignant process. Aspiration of pleural fluid showed a markedly elevated lactate dehydrogenase of 2008 u/l, low glucose of 3 mg/ dl, albumin 2.3 g/dl total protein of 5.0 g/dl and uric acid of 4.2 g/dl compatible with an infectious process. Cytology was negative for malignancy. The diagnosis of pleural empyema was made and antibiotic therapy was started empirically based on the only infectious focus that we found; poor oral hygiene with multiples tooth decay and chronic dental abscesses. Piperacillin/ tazobactam Medicina de Familia Diciembre 2016-41
4.5 g/8h, Clindamycin 900 mg/48h and Vancomycin 1600 mg loading dose then 1400 mg every 24 hours were started. The patient responded very well to therapy with improvement of his clinical findings. After 5 days of the pleural effusion fluid culture revealed anaerobic bacteria and streptococci which confirmed the origin of the infection. The patient improvement was impressive and he was sent home after 10 days with piperacillin/ tazobactam to complete 6 weeks. Follow up with his primary care physician was strongly recommended as well as a dental evaluation.
Case Discussion The altered immunity in diabetic patients, including changes in the respiratory epithelium and ciliary motility, make them more susceptible to pulmonary infections. These infections are characterized by a longer duration, more frequent complications and increased mortality. Uncontrolled glycemia is the cause of alterations in host defenses and consequently, increased susceptibility to infections(1,2). Community-acquired pneumonia is caused in 10%-20% of cases by anaerobic organisms aspirated from the colonized pharynx and by hematogenous spread. The upper airway infection lasts 24 to 48 hours even in healthy individuals; however healthy individuals are resistant to anaerobic bacteria. In diabetic patients the rate of colonization by anaerobic bacteria is increased as well as the adherence of bacteria to the upper airway epithelium(2). For the nearly 30 million Americans who have diabetes, many may be surprised to learn about this unexpected complication. Research shows that there is an increased prevalence of gum di-
42-Medicina de Familia Diciembre 2016
sease among those with diabetes. According to the American dental association, patients with chronic conditions like diabetes mellitus require dental prophylactic cleanings every 6 months and every three months if periodontal disease is present(3). Family physicians should be aware of the many complications that a poor oral hygiene can cause in ours patients, especially those with chronic conditions. Education is an important tool to prevent complications like the one in this case and should be part of all encounters. It is highly advisable to recommended regular visits to the dentist. Case like this is preventable with good communication and proper orientation of our patients.
References Bascones, M. A; Arias, H.S; Criado, C. A et al. Periodontal disease and diabetes. Adv Exp Med Biol. (2012);771:76-87. Ljubic, S; Balachandran, A; Pavlic, I. R et al. Pulmonary infections in diabetes mellitus. Diabet Cr. (2004); 33-4:115-124 Lalla E; Kunzel C; Burkett S; et al. Identification of unrecognized diabetes and pre-diabetes in a dental setting. J Dent Res. (2011) Jul;90(7):85560. About the authors: Yuniet C Moya, Family Medicine Residency Program, PGY1; Marielys Otero Maldonado, Department of Internal Medicine/Infectology; Jorge JimĂŠnez, Department of Internal Medicine, ManatĂ Medical Center, P.O Box 1142, ManatĂ, PR 00674.
Impact of educational bulletins on the rate of influenza vaccination in the pediatric population Authors: Angel Pacheco, MD pediatrician attending; Astrid González, MD FM attending; Edna Landero, PGY3; Delvis Secin, MD PGY2; Martha Díaz, PGY 2; Valeria Baldivieso, PGY 1; Ruth Barosy PGY 1.
Project Description Influenza is an acute respiratory illness caused by the influenza A or B virus. This illness occurs in outbreaks worldwide every year, mainly during the winter season. Seasonal influenza results in significant cost, morbidity and mortality. The consequences of influenza infection in children are missed school days as well as work days, unplanned trips to the pediatrician’s office, medication use, and hospitalization. Influenza vaccination is the most effective way of preventing infection by the influenza virus. Given this burden, the Advisory Committee on Immunization Practices (ACIP), which advises the Centers for Disease Control and Prevention (CDC), voted in 2006 to expand its recommendations for influenza vaccine to include all children 6 months to 5 years of age. Subsequently, in 2008 and 2010, ACIP further expanded its influenza vaccination recommendations to include all children 6 months through 18 years of age and all individuals 6 months of age and older, respectively. Influenza vaccination rates have increased in children since 2009 and accounted for approximately 60 percent during the 2014-2015 influenza season. Coverage rates for influenza however are still lower than for most other recommended childhood vaccines. Multiple interventions have been employed to increase immunization in the pediatric population, some which include reminder calls, parent/ patient education, physical education, electronic alerts, and memos in electronic medical records. This study was conducted to assess the impact of educational bulletin on the rate of influenza vaccination in pediatric population in Puerto Rico.
Objective/Purpose To assess the impact of an educational bulletin on the rate of influenza vaccination in a pediatrician’s office located in Puerto Rico.
Method The design employed was an intervention study using official data obtained from the national registry of vaccination of Puerto Rico for children. A total of 512 subjects aged 18 months to 21 years who visited the pediatrician’s office during the period of October 1, 2015 to February 1, 2016 participated in the study. The parents these subjects were provided with an information bulletin about influenza during their visits. From the national registry of vaccination of Puerto Rico the status of influenza vaccination for each subject was determined for the 2014-2015 and 2015-2016 influenza seasons. Each subject served as his or her own historical control, comparing the immunization status of the two seasons. The investigators compared the rate of influenza vaccination of the patients that received the educational bulletin in the current season with theirrate of vaccination during the previous season. Analysis was done with McNemar’s chi-square test for paired data.
Presenter’s Role In Research Project A team composed of 5 family medicine residents and 2 attendings (a pediatrician and a family physician), employed study designs, protocol, review of the latest literature, clinical analysis of statistical results, discussion, and manuscript compilation to determine the effect of the intervention on a parents’ decision to immunize their children against the influenza virus.
Results Of the 512 participants, 47.07% were female and 52.34% male.The mean age was 6.7 years. A Medicina de Familia Diciembre 2016-43
total of 46 participants (8.98%) received an influenza vaccination in 2014-2015 influenza season compared to the 70 participants (13.67%) who received influenza vaccination during the 2015-2016 influenzaseason. The OR for immunization during the second season compared with the first season was 2.41 (95% CI: 1.34, 4.53). The difference was statistically significant (McNemar’s X2 = 9.12; p = 0.003).
Discussion This study indicates that the educational bulletin had a positive impact on influenza immunizations in a pediatrician’s office. This is a relatively simple strategy that, if widely used, could have a major impact on the health of children in Puerto Rico and even worldwide. The effectiveness of this strategy should be investigated for children with different health insurance plans, economic status and pre-existing chronic conditions. We also recommend the assessment of other kinds of strategies like phone calls, e- mail reminders, and text messages. Given the difficult economic situation of the healthcare system in Puerto Rico, the implementation of strategies to increase the rate of vaccination against influenza would be beneficial in reducing the healthcare costs related to influenza infections. Additionally, the benefit of universal vaccination of children not only would significantly reduce serious morbidity in this age group, but would also have the potential to dampen epidemics and reduce the risk of exposure to the vi-
44-Medicina de Familia Diciembre 2016
rus among vulnerable elderly and infant contact.
References • Glezen WP. Clinical practice. Prevention and treatment of seasonal influenza. N Engl J Med. 2008;359(24):2579. • Committee on Infectious Diseases, American Academy of Pediatrics. Recommendations for Prevention and Control of Influenza in Children, 2015-2016. Pediatrics. 2015;136(4):792. • Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices(ACIP). MMWR Recomm Rep. 2004;53(RR-6):1-40. • Fiore AE, Shay DK, Broder K, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices. • Fiore AE, Uyeki TM, Broder K, et al. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Recomm Rep. 2010;59(RR-8):1-62. • Block SL. Role of Influenza Vaccine For Healthy Children in the US. Pediatric drug 2004; Vol. 6 (4), pp. 199-209. About the authors: Angel Pacheco, MD pediatrician attending; Astrid González, MD FM attending; Edna Landero, MD PGY3; Delvis Secin, PGY2; Martha Diaz, MD PGY2; Valeria Baldivieso, MD PGY 1; Ruth Barosy MD PGY 1.
La Academia de Médicos de Familia de Puerto Rico los invita a participar en
el Certamen de Carteles: Para Estudiantes
“ Por tuSalud Convocatoria a estudiantes del Sistema Educativo de Puerto Rico Público y Privado en las siguientes categorías:
Primer - Sexto Séptimo - Noveno Décimo - Duodécimo Educación Especial PRIMER PREMIO
200 2 1150
TERCER PREMIO PRIMER GRAN PREMIO
Fecha límite para entrega de dibujos:
Viernes, 13 de enero de 2017
Reglas Básicas: • El Cartel debe expresar tu idea del lema de este certamen: ¿Por qué las Vacunas son importantes para la Salud? • El medio de expresión será el dibujo en tempera, acrílico, lápiz, marcador sobre cartulina, cartón de ilustración, papel de construcción o canvas. El tamaño de la pieza no debe exceder de 22" x 28". • Cada trabajo vendrá acompañado de un papel tamaño carta • Hoja de Registro oﬁcial del certamen • Un párrafo explicando porque las vacunas son importantes para la salud. • Los ganadores y los detalles de premiación serán notiﬁcados durante el mes de enero 2017. • La Actividad de Premiación se llevará a cabo en el Museo de Arte de Puerto Rico. • Debe ser enviado por correo ó entregado físicamente antes de la fecha límite. Dirección Postal: P.O. Box 11989 San Juan, Puerto Rico 00969 Dirección Física: Calle José Julia Acosta #9 Guaynabo Pueblo, Puerto Rico • Para más información: Academia de Médicos de Familia de Puerto Rico (787) 790-4735 firstname.lastname@example.org Academia de Médicos de Familia de Puerto Rico Fecha límite para entrega de dibujos: Viernes, 13 de enero de 2017
¡Infórmate y Participa!
Published on Dec 15, 2016
Published on Dec 15, 2016
MF es la revista oficial de la Academia de Médicos de Familia de Puerto Rico. Prohibida su reproducción total o parcial sin previa autoriz...