Epidemiological Trends of Traumatic Brain and Spinal Cord Injury in Puerto Rico from November 10th, 2006, through May 24th, 2011.

OBJECTIVE: According to the Centers for Disease Control and Prevention (CDC), injury to the central nervous system (CNS) continues to be a leading cause of injury-related morbidity and mortality in the US today. METHODS: A prospective cohort study was performed to determine the incidence of all traumatic CNS injuries. Descriptive variables were presented as frequencies and percentages. Quantitative variables were expressed as means and averages (plus/minus standard deviation); bivariate cross-tabulation and multiple regression analyses were employed to identify risk factors and compare epidemiological patterns of injury related variables. RESULTS: Information from 3,202 patients with confirmed CNS injuries was collected and analyzed. Traumatic brain injuries (TBIs) had occurred in 2,524 of the cases (78.8%). Spine injuries had occurred in 831 cases (25.9%), and 197 cases (6.2%) had suffered spinal cord injuries. Overall, most of the cases were male (75.0%) and with a median age of 40 years. Of the total number of cases, newborns and infants (<= 4 years of age) comprised 7.8% and elderly individuals (>65 years of age), 27.4%. Nearly half of the injuries were due to falls (47.5%), followed by motor vehicle and other transport accidents (35.2%). Loss of consciousness occurred in 61.3% of the traumas. The Glasgow Coma Scale (GCS) was used to categorize TBI severity and showed that the majority of TBIs were mild (70.0%). Over 90% of all cases had been injured either at home (42.8%) or on the street (49.1%). CONCLUSION: These results are evidence that additional collaborative efforts that focus on trauma are needed to increase knowledge, public health awareness, and preventive measures.

A 10-year experience of radiosurgical treatment for cerebral arteriovenous malformations: a perspective from a series with large malformations. Clinical article.

OBJECT: The purpose of this study was to describe a 10-year experience in the use of radiosurgery (RS) for patients with arteriovenous malformations (AVMs) in Puerto Rico. METHODS: This retrospective analysis was performed for all patients with AVMs treated with RS by the senior author (R.H.B.) in Puerto Rico. Between February 1999 and December 2009, a total of 83 patients underwent the procedure. All charts were reviewed for recollection of demographic data, and AVM and treatment characteristics. Clinical and radiographic follow-up information was collected retrospectively. RESULTS: Eighty-three patients were treated and 86 RS procedures for AVMs were performed during a 10-year period. Eight patients were lost to follow-up. The remaining 75 patients included 36 males and 39 females, whose median age was 34.5 years. Hemorrhage was the initial presentation in 40% of patients. Fifty-seven AVMs (73%) were treated previously with endovascular neurosurgery, without success. The median volume of the malformation was 17.7 ml. Nearly 65% of the malformations were considered large (≥ 10 ml) in volume. Forty patients had AVMs with largest diameter ≥ 3.5 cm. The overall obliteration rate was 56.4%, and the median time for obliteration was 29 months. The AVMs ≥ 3.5 cm in diameter had a greater latency period than those < 3.5 cm (31 months vs 46 months, respectively; p = 0.01). In addition, AVM obliteration was inversely associated with its volume, especially in large lesions (p = 0.037). In bivariate analysis, patients achieving obliteration had lower Spetzler-Martin scores compared with patients in whom obliteration was not achieved (p = 0.009). Postradiosurgery hemorrhages were seen in 9 cases. Eleven patients underwent surgery after RS. Major neurological deficits developed in 9 patients, whereas 17 had only minor deficits. The occurrence of neurological deficits was significantly associated with lesions with volume ≥ 10 ml. CONCLUSIONS: Radiosurgery is a reasonable treatment option for AVMs in the majority of cases, in spite of the large, difficult-to-treat malformations.

Stereotactic radiosurgery for intracranial tumors: Puerto Rico experience.

Historically, the treatment for most intracranial pathologies has included medical management, surgery, radiotherapy and recently, stereotactic radiosurgery. Since its introduction, stereotactic radiosurgery has evolved from an investigational concept into a recognized neurosurgical procedure for the management of a wide variety of brain disorders. The goal of this research was to describe the experience in Puerto Rico using this technology and review the efficacy, safety, and role of radiosurgery in the treatment of the most common intracranial tumors treated today. Patients treated from 1999-2009 at Clinicas Las Americas were reviewed and medical literature databases were searched for articles pertaining to stereotactic radiosurgery performed in these intracranial tumor pathologies: meningiomas, gliomas, cerebral metastasis, vestibular schwannomas and pituitary adenomas. Each study was examined to determine the radiosurgical parameters, duration of follow-up review, tumor growth control rate and complications. A total of 50 peer-reviewed studies were examined. Radiosurgery in benign tumors resulted in the control of tumor size in 90% of treated patients. Unfortunately radiosurgery for malignant tumors is not curative, but has been effective in improving survival and quality of life. Although microsurgery remains the primary treatment modality in most cases, stereotactic radiosurgery offers both safe and effective treatment for much intracranial pathologies. Further refinements in the radiosurgical technique will likely lead to improved outcomes and make it a standard of care.

Descriptive profile of surgically-confirmed adult central nervous system tumors in Puerto Rico.

INTRODUCTION: Published studies regarding the incidence of central nervous system (CNS) tumors in Puerto Rico (PR) are exceedingly rare. The general understanding is that the incidence of these tumors in Puerto Rico is similar to the one found in the United States of America (USA). The objective of this study is to describe the specific profile of all the CNS tumors that are surgically intervened in Puerto Rico, through the creation of a database. METHODS: A retrospective analysis of all the surgical procedures from January 1, 2002 to May 31, 2006 for adult CNS tumors in Puerto Rico was performed. Each case was evaluated for demographic information, operative procedure, lesion description and official pathological report. Recurrent lesions were excluded. The information was organized to form a database of all the CNS neoplasms. RESULTS: A total of 1,018 procedures for CNS tumors were performed on 1,005 patients. The incidence rate of surgically intervened CNS tumors in Puerto Rico is 6 per 100,000 people. CNS tumors were more common in women than in men (58% vs. 42%), respectively. The mean age was 52.4 years. The most common histological type found was meningioma WHO I (24%), followed by pituitary adenomas (16%), and glioblastoma multiforme (14%). CONCLUSIONS: Our results reflect a unique histopathological distribution of operated CNS tumors in Puerto Rico. In this series, primary tumors are more common than metastatic tumors. Benign histological tumors were more frequent than more malignant variants. Although this study reflects only the histologically diagnosed tumors, it is headway towards diagnosing the incidence of all CNS tumors in Puerto Rico.

Babinski's signe de l'eventail: a turning point in the history of neurology.

PURPOSE: The Babinski sign is a finding known since the start of the teachings of physical diagnosis by almost all medical students. This reflex is an incredibly helpful phenomenon that enables physicians to distinguish between central and the peripheral nervous system diseases right at the bedside. Yet, most students as well as physicians remain oblivious to the remarkable history behind the Babinski sign and what it means to evolutional history of the modern neurological exam. We intend to study the birth of the "signe de l'eventail" (the fanning sign) and how it transformed medical diagnosis as we practice it today. METHODS: An extensive search was conducted through the Internet to identify historical documents referring to Babinski and other physicians who also observed the phenomenon as early as the 17th and 18th century. We also conducted a search through medical journals that examined the Babinski sign and its history. RESULTS: The Babinski reflex had been observed much earlier than 1896, when Babinski referred to his finding for the first time. The reflex had been reported in the literature as far back as 1784 and afterwards reobserved several times before Babinski. However, it was Babinski who first offered an interpretation of the reflex and suggested that it was related to an organic disruption in the central nervous system. By identifying the sign, Babinski separated himself from Charcot in the sense of creating a new tradition in neurology where the findings in a neurological exam were of far more importance than just a plain history as his mentor had relied upon. CONCLUSIONS: Babinski was not only responsible for suggesting the significance of such sign, but also transformed the role that physical diagnosis plays in modern medicine, where physical examination is key in revealing underlying pathology.

Assessment of the educational experience in the Neurosurgery Residency Program of the University of Puerto Rico Medical Sciences Campus.

OBJECTIVE: In 2003, the American Council of Graduate Medical Education (ACGME) made significant changes in the medical postgraduate training policies, especially the 80 Duty Hours per Week regulation. The Neurological Surgery Department at Mayo Clinic performed a national survey regarding the perceptions of program directors and residents on how compliance with the ACGME requirements has changed neurosurgery training. Using a similar methodology, we analyzed the University of Puerto Rico's Medical Sciences Campus, Neurological Surgery Division's resident and faculty staff perceptions with regard the way its training is currently performed. METHODS: Anonymous questionnaires were distributed among the neurosurgery division's resident and faculty staff at the University of Puerto Rico Medical Sciences Campus. Performance on the American Neurological Surgery Board (ANSB) written examinations was obtained from residents' records. The quantity and types of surgeries performed by residents was retrieved from neurosurgery section computer files. The relevant data was entered into a database and descriptive analysis and frequency distributions were performed. RESULTS: Surveys showed some concerns from both residents and attending physicians on the topics of inpatient and outpatient facilities, research activities, duty hours and the number of residents currently in the program. An upward trend in the residents' ANSB written examination performance was observed over the years. The residents' yearly number and diversity of surgical procedures were adequate. CONCLUSIONS: Considering the results from the surveys, the performance of residents in the Board examination, and their surgical experience, it is concluded that the general perception of the educational experience in neurosurgery is satisfactory but improvements could be made.

Impericia médica en Puerto Rico: 1990-1996 / medical negligence in Puerto Rico: 1990-1996

The purpose of this communication is to present the statistical information of the medical and hospital professional liability situation in Puerto Rico from 1990 to 1996. The Medical Institutional liability is a topic of great relevancy and importance to the people of Puerto Rico and the leaders responsible for establishing policies for the health care services. The Reports on Medical and Hospital Professional Liability from 1991 to the 1996 produced by the Examining Physicians Board were reviewed. The liability claims from 1991 to the 1996 totaled 4054. During the seven years analyzed, 3506 cases were closed against physicians and institutions, a payment was issued in 1272 cases (36.3 percent), for a total compensation of $56,268,053. The risk of a legal claim is greater for the group of Plastic Surgeons and Emergency Medicine. The probability of a plaintiff receiving a compensation payment in a case of medical malpractice is approximately 36 percent, usually receiving a third of the total of the award as suggested by the medical literature. A thoughtful analysis of the current medical liability situation and defensive medicine should be done with the purpose of protecting the fiduciary function of the physicians with respect to the health of their patients, this is the function that guarantees a physician-patient relationship that is healthy, righteous and empathic

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) and extranodal involvement of the orbit

We present the case of a 5-year-old boy who was referred to the Neurosurgical Service of the San Jorge Children's Hospital for evaluation of right eye proptosis. At the age of one year the diagnosis of sinus histiocytosis with massive lymphadenopathy (SHML) had been rendered on a cervical lymph node biopsy. The right orbit mass causing the proptosis was the result of extranodal involvement of the orbital tissue by SHML. The clinical and pathologic features of this entity are discussed

Mielomeningocele en Puerto Rico / Myelomeningocele in Puerto Rico

Los expedientes médicos de 128 niños tratados por su condición de mielomeningocele en el Hospital Pediátrico Universitario del Centro Médico de Puerto Rico durante el período de enero de 1980 a julio de 1985 fueron revisados retrospectivamente. Diferentes parámetros previamente definidos de la primera hospitalización de estos niños fueron analizados en detalle. La edad promedio a la cual se reparó el defecto de mielomeningocele fue de 6.6 días. Analisis estádistico demostró que reparar el defecto de mielomeningocele antes de la primeras 48 horas de vida no disminuye el riesgo de desarrollar infecciones en el sistema nervioso central (ventriculitis). Complicaciones del sanado de la reparación del mielomeningocele (como necrosis de los colgagos de piel, escape de líquido cefalorraquídeo e infección de la herida) estuvieron presentes en el 43.8% de los pacientes que desarrollaron ventriculitis y solo en el 19.0% de los que no desarrollaron infecciones del sistema nervioso central. Esta observación estadísticamente válida (P=0.03) establece que complicaciones del sanado de la reparación del mielomeningocele constituyen el factor de riesgo principal para el desarrollo de ventriculitis. Esta observación constituye una aportación significativa a la literatura médica mundial