Compliance of guidelines for the diagnosis of mycrocytic anemia at Damas Hospital: pilot study.

Iron deficiency is the most common nutrient deficiency in the world. Serum ferritin measurement is considered the most reliable test for the diagnosis of Iron Deficiency Anemia. At our institution there seems to be non consensus in terms of the diagnostic workup for patients with microcytic anemia or the application of guidelines. The purpose of this investigation was to examine the compliance of guidelines for the diagnosis of microcytic anemia at Damas Hospital performed by admitting physicians when microcytic anemia is encountered; compared to the proposed algorithm by the American Academy of Family Physicians (AAFP). Of the patients included in the study 82% did not underwent ferritin studies, of this 79% did not underwent any other serum laboratories to assess the cause of the anemia. Of the patients who did not underwent any serum laboratories 18 went straight to colonoscopy without further work up. None of the patients who did undergo serum laboratories for anemia was further investigated with colonoscopy. In comparison with AAFP guidelines, none of the patients with microcytic anemia was adequately studied for the cause of disease. None of the guidelines or algorithms proposed establish a difference between what should be done depending on the setting in which a :patient is been studied either inatient or outpatient.

Correlation between body mass index and need for total knee replacement in a group of Latin patients with knee osteoarthritis.

UNLABELLED: Osteoarthritis (OA) of the knee has been linked to obesity. Clinical observations suggested that there is a direct relationship between the degree of obesity and the severity of knee OA in the Latin community. This study associates the risk of requiring total knee replacement (TKR) attributable to being obese on a subset of Latin patients. METHODS: 112 Latin patients ages 21 to 89 years were evaluated by an orthopedic surgeon and enrolled in a pilot case-control study. The charts of these patients were reviewed and sociodemographic data, body mass index (BMI), and initial management, whether it was medical or TKR were reviewed. Patients were segregated according to their BMI in different categories: normal, overweight, obesity class I, obesity class II, and obesity class III. Severity of OA was then compared between the patients in the different BMI classifications. Analyses were further adjusted for age, sex and hometown. RESULTS: 100 subjects were successfully included into the study. Of the non-obese patients, neither underweight nor normal weight patients were managed with TKR, and only 9% of overweight patients were managed with TKR. Overall, 48% of the obese patients were managed with TKR. This included 43% of the obese class 1, 58% of the obese class I, and 33% of the obese class III patients. CONCLUSION: There seems to be a direct relationship between obesity and risk of TKR in the Latin community.

Outcomes associated with conventional management of severe sepsis at Damas Hospital.

UNLABELLED: Severe sepsis and septic shock have become one of the leading causes of medical intensive care unit (MICU) mortality as well as one of the greater consumers of healthcare resources. Several institutions in the United States have reported positive outcomes after following the Severe Sepsis Campaign (SSC) recommendations. Current management of severe sepsis and septic shock at Damas Hospital's MICU follows no specific protocols or recommendations. This study report data regarding outcomes associated with ongoing management of severe sepsis at our institution. METHODS: Historical controls with ICD-9 diagnosis of Severe Sepsis and/or Septic Shock hospitalized between January 2007 and August 2009 were randomly selected. Data regarding survival, length of stay (ICU/ In-hospital), and disease severity was gathered through record review. Measured outcomes as well as sociodemographic data were compared to those reported in the literature. RESULTS: Thirty patients were studied with a mean age of 62 years; 50% male and 50% female. Mean APACHE II score was 21 (40% mortality) with average MICU length of stay of 5.2 days and overall hospital stay of 12.9 days. Overall mortality was 66%. CONCLUSION: There is a high mortality rate associated with conventional management of severely septic patients in Damas Hospital ICU. Studies with similar populations had significantly lower mortality rates based on conventional management of severe sepsis/septic shock. Starting protocoled care of patients with severe sepsis as recommended by the SSC could have a positive impact in the overall mortality at Damas Hospital.

Lowest safe hematocrit level on cardiopulmonary bypass in patients undergoing coronary artery bypass grafting.

UNLABELLED: Coronary artery bypass grafting (CABG) is the most common cardiothoracic surgical procedure performed in the United States. The majority of patients undergoing CABG are placed on cardiopulmonary bypass (CPB) to support the circulation. CPB hemodilutes the patient imposing extremes in the hemostatic system, requiring careful assessment of pre-surgical hematologic values. Recent clinical data suggests that patients who receive blood transfusions while hospitalized for CABG have an increased morbidity and mortality. Women have a greater risk of transfusions than men with CABG and are thus at greater postoperative risk. The purpose of the present study was to determine the lowest safe hematocrit level achievable on CPB during CABG surgery where no transfusion and no post-operative complications were identified. METHODS: Inpatient record review evaluation including socio-demographic data, hematocrit values (pre-pump and on pump), red blood cell transfusion administration and Surgery, postoperative complications. RESULTS: Collected data from 136 first-time, single CABG patients demonstrated 68% had no postoperative complications. Of this non-complicated group 60% were transfused while only 40% were non-transfused. The non-complicated, non-transrusea group nematocrit vaiues averagea 25.1% +/- 2.8 with a minimum of 19%. (P = 0.003). 68% of the patients had no postoperative complication. Transient acute renal insufficiency was the most common complication observed. CONCLUSION: The lowest safe hematocrit level on CABG in non-complicated and non-transfused patients was 19% corresponding to an average of 25.1% +/- 2.8. A preoperative patient profile has been identified where age, weight, height, BSA, BMI, and pre-pump and on pump hematocrit values can aid medical staff about transfusion decision making.

Preoperative clinical and demographic characteristis in Puerto Rico patients referred to inpatient cardiac rehabiliation after cardiac surgery.

UNLABELLED: Patients with coronary artery disease (CAD) or cardiac valve disease who have undergone cardiac surgery are prime candidates for cardiac rehabilitation. Cardiac rehabilitation is a multidisciplinary activity that aims to facilitate physical, psychological and emotional recovery. Multiple studies have evaluated preoperative characteristics of patients who undergo rehabilitation to predict improvement and prolonged length of stay after CAD surgery. This research aimed to establish which preoperative clinical and demographic characteristics are present in Puerto Rico patients that require inpatient rehabilitation after cardiac surgery. METHODOLOGY: Record review evaluating clinical and sociodemographic variables of patients with cardiac surgery and it relationship with or without cardiac rehabilitation referral. A total of 65 records were selected: 17 records referred for inpatient rehabilitation and 48 records of patients who were discharged home. RESULTS: Older patients > 65 y/o, living alone with no caregiver availability, impaired functional status, surgical status (urgent/ emergency surgery), concomitant valve surgery, BMI > 24.9, HgbA1C > 7.0%, female gender, CVA history, COPD history, PVD history, and prior weakness contribute to a functional decline, and are more likely to be associated with a referral to inpatient rehabilitation. CONCLUSION: An identification of these variables before surgery could lead to early intervention by skill nursing facility departmental team. This early intervention can diminish later complications, postoperative and intensive care stay.

Independent association of LDL-C and non HDL-C with acute coronary syndrome in a Hispanic population.

UNLABELLED: There is an identified relationship between increasing plasma cholesterol and the incidence of Acute Coronary Syndrome (ACS). The National Cholesterol Education Program Adult Treatment Panel identified low-density lipoprotein--cholesterol (LDL-C) as the first target of therapy and non high-density lipoprotein cholesterol (Non HDL-C) as the second target. However, in epidemiologic studies non-HDL is a superior predictor of cardiovascular risk compared with LDL-C. We don't know the independent association of non HDL-C and LDL-C in Hispanic population with ACS. METHODS: We evaluated patients with acute coronary syndrome admitted to Damas Hospital CCU, ICU & Telemetry Unit during a five months period and previous criteria of uncontrolled lipid levels. We compared the independent association of uncontrolled lipids levels with subsequent acute coronary syndrome. RESULTS: Of 26 patients with ACS, 58% had independently association with non HDL-C elevation and 42% with LDL-C elevation. Regardless the categorization of the cardiovascular event, 6 of the 8 female patients had predominantly elevated blood levels of LDL as an independent factor. On the other hand, 15 of 18 male patients had Non-HDL elevated blood levels. DISCUSSION: The association of ACS with independent lipid levels of LDL and non-HDL seems to be equivalent in our population. Interestingly there seems to be a female predominance in elevated LDL levels and a male predominance elevated blood levels of Non-HDL associated with cardiovascular events.

Parapharyngeal space tumor: undifferentiated sarcoma of the parotid gland. A case report.

Parapharyngeal space tumors are extremely uncommon. A 43-year-old man presents with a painless upper neck and face mass, airway obstruction and dysphagia. Physical evaluation revealed a firm, non-mobile mass extending from the right auricular region to the mandibular region of the neck. Radical parotidectomy was scheduled and muscle biopsy was done yielding undifferentiated sarcoma of the parotid gland. Parapharyngeal space tumors represent a problem for physicians in making an accurate diagnosis and determining management options available. Extensive knowledge of the anatomical boundaries of the parapharyngeal space, diversity of pathological problems and common clinical manifestations should help avoid delayed diagnosis and improve patient's outcome.

High blood pressure risk factors in a community of students in the south area of Puerto Rico.

INTRODUCTION: The south area of Puerto Rico has a high density of a college student population. This population is exposed to a series of hypertension risk factors, for instance: they are exposed to the stress associated with their studies, they are the target of publicitary promotion of fast foods, alcoholic drinks, smoking, and they share with the rest of the Puertorican population predisposition to diabetes mellitus. We collected data about the risk factors for High Blood Pressure (HBP) to which this specific population was exposed. METHODS: This is an observational-descriptive, cross-sectional study with a data collection period from February to March 2004. SUBJECTS: students of a health science institution of the south area of Puerto Rico (N = 310). Sample availability (155). The Prediagnostic History of Francisco Fragachán (2002), High Blood Pressure Unit, questionaire Universitary Hospital, Central University of Venezuela was utilized. We also performed the questionnaire of Vulnerability Stress Test of Beech and Scheffield (adapted for a Hispanic community). The blood pressure was measured with an electronic calibrated Omrom 4M equipment. Measured anthropometric variables: Weight and height with a calibrated scale; Hip and waist circumference under the anatomical references of Siegell et al. RESULTS: Age Average: 25.4 +/- 3.19. Ninety three percent (93%) of the population had at least one risk factor for HBP. Of our population, 90% consider themselves vulnerable to stress at least in one of the items proposed. 45% of our subjects were overweight and 17% were obese. 94.8% of the study population had an adequate W/H ratio. Mean values for BP: 112/71; Pulse Presure: 41; Mean Blood Presure: 85,4; Heart Rate: 79,5. We found seven subjects with hypertension. CONCLUSION: In our study population the presence of risk factors (modifiable and non-modifiable) in an early stage of life (25.4 +/- 3.19 years) increases the possibility to develop hypertension.

Salt taste threshold and salt good taste sensitivity in a community of students of the southern area of Puerto Rico.

Sodium appetite reflects the importance of sodium homeostasis. The sodium ion is one of the most important risk factors in the development of hypertension. Humans, for various reasons, seem to have a specific preference for salt which is consumed in excess of need and this has been characterized as an important contributor to hypertension. Salt intake is related to the salt taste sensitivity threshold and the salt good taste level. Gustatory sensibility responds to various physiological mechanisms and salt taste is directly modified by cultural and socio-economical factors. We measured the salt taste sensitivity threshold and salt good taste level of a young student population. Air popped popcorn sprayed with different Molar concentrations of salt where given to students to taste and a questionnaire to evaluate diet salt intake preferences. Both salt taste sensitivity threshold and salt good taste level graph patterns are different from each other. Salt taste sensitivity threshold has a bell shape distribution with different molar salt concentrations. The major tendency of the salt umbral sensitivity of our population was the 0.5 M concentration. Salt good taste level has an exponential shape distribution with different molar salt concentrations. The tendency for the good taste level of our population was 3 M. Smoking does not seem to modify the salt taste sensitivity thresholds or the salt good taste level graphs. Also, salt shaker use does not seem to modify salt taste sensitivity thresholds or salt good taste level graphs in our population. Salt taste sensitivity threshold is probably associated to morpho-physiological factors. Salt good taste level is mainly associated with the cultural environment. The majority of subjects have a tendency to prefer foods with higher concentrations of salt increasing the possibility of exposure to the salt intake risk factor.

Temporal arteritis in Puerto Rico Hispanics.

Medical statements from previous epidemiologic studies consider temporal arteritis as extremely rare or absent in Hispanic patients. A probable genetic protective condition was proposed as an explanation for this. We performed a descriptive observational, retrospective, comparable and not randomized study in the southern region of Puerto Rico (Ponce Area). The period for recollection of data was July/2002 to March/2004. We reviewed all the information of the clinical charts of patients diagnosed with temporal arteritis who were seen in the medical offices of one internist and two rheumatologists of the teaching staff of Damas Hospital. The subjects of our study consisted of 11 patients (8 female and 3 male), between the ages of 70 to 90, all of Hispanic origin, with a diagnosis of temporal arteritis. Frequencies and percentages were used to describe the data of the study. Headache was the most common symptom. Other symptoms included the presence of fatigue, malaise, anorexia, scalp tenderness, amaurosis fugax and decreased vision. Laboratory results showed the presence of a mild leukocytosis and anemia in most of the patients. Renal and liver functions were observed to be well-preserved, and serum electrolyte levels were within normal limits. The increase of the ESR and C Reactive Protein values and positive unilateral and bilateral biopsy studies were statistically significant. All of the above characterization of Hispanic population with temporal arteritis cited in our study correlates well with the classic description of the disease in previous epidemiological studies conducted on non-Hispanic subjects. Our study confirmed the presence of temporal arteritis in a Hispanic population. The disease was more prevalent in women than men, with a female to male ratio of 2:6, which is the lowest ratio found for this disease compared to previous epidemiological studies. In our study group, the disease was found in patients over 70 years of age, with a mean age of 75.7. Arterial hypertension was the most commonly associated condition in our patients, probably due to its high prevalence in our community. The clinical characteristics of our patients correlate closely with the previous data from other ethnic groups.