Carotid artery restenosis in a Hispanic population.

BACKGROUND AND PURPOSE: Carotid endarterectomy is one of the main surgical procedures used for carotid stenosis and its recurrence. Besides the setting of a randomized controlled trial for asymptomatic and symptomatic carotid artery stenosis, there is little information about the rate of restenosis after carotid endarterectomy in Hispanics. The purpose of this study is to describe the results of carotid endarterectomy on the basis of restenosis in a Hispanic population. METHOD: A retrospective revision of 47 endarterectomies performed on 43 patients by a single surgeon at the VA Caribbean Health Care System and Pavia Hospital, during an eight year period (1990-1998), was conducted. Information about endarterectomies, restenosis and known risk factors for carotid stenosis were obtained from medical records. RESULTS: Of the 43 patients, 31 were male (72%) and 12 female (28%), with a mean age of 67.9 years. Re-operations for recurrent carotid stenosis were performed in 2 patients (4.7%). Restenosis cases were asymptomatic, hence diagnosed through followup ultrasound Duplex studies and confirmed by angiography after 3 and 4 years of the first surgical procedure. The degree of restenosis (70% to 99%) after the initial endarterectomy was 4.3%. The major risk factors found among patients were hypertension (58%), hypercholesterolemia (50%), smoking (46%), and alcohol (34%). CONCLUSIONS: Carotid endarterectomy with primary closure is safe and durable. Repeated surgery using patch grafts in this Hispanic population was also safe. The concordance of risk factors and incidence of carotid stenosis correlated well with other studies.

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 METHODS: An extensive search was conducted through the Internet to identify historical documents referring to Babinski and other physicians who also observed the phenomenon as early as the 17th and 18th century.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.

[Medical negligence in Puerto Rico: 1990-1996]. / Impericia médica en 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%), 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%, 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.

Carotid endarterectomy in Puerto Rico.

The experience of the authors performing carotid endarterectomy in Puerto Rico is reported. The study was stimulated by the recently published results of the Carotid Endarterectomy Cooperative Trial groups in North America and Europe. This series consists of 61 carotid endarterectomies performed on 53 patients. The majority of the patients suffered from hypertension, diabetes mellitus, smoking, and ischemic heart disease. Most of the patients presented with Transient Ischemic Attacks (64%) or Reversible Ischemic Neurologic Deficits (19%). One patient died of a presumptive myocardial infarction and one patient had a post-operative worsening of his neurologic condition. The permanent morbidity and mortality rate was 3.2%.

Experience in the management of myelomeningocele in Puerto Rico.

The medical records of 128 children with myelomeningocele who were treated at the Pediatric University Hospital, Puerto Rico Medical Center, from January, 1980, to July, 1985, were reviewed retrospectively. The medical and surgical management during the first hospitalization of these children was studied in detail for predefined parameters. The average age at the time of myelomeningocele repair was 6.6 days. Statistical analysis showed that repair of the myelomeningocele defect before 48 hours of age did not reduce the occurrence of ventriculitis. The incidence of ventriculitis secondary to the management of the myelomeningocele lesion was 12.5%. Complications after repair of the myelomeningocele (including skin flap necrosis, cerebrospinal fluid leaks, and wound infection) were present in 43.8% of the patients who developed ventriculitis and in 19.0% of those who did not. This observation is statistically significant (p = 0.03) and indicates that complications of healing after myelomeningocele repair represent the most significant risk factor for the development of ventriculitis.

Metamorphopsia and permanent cortical blindness after a posterior fossa tumor.

A case of posterior fossa tumor associated with supratentorial symptoms is presented. The pattern of symptoms that developed after operation follow the description of metamorphospsia. The condition progressed to permanent cortical blindness. Tumoral vasospasm is suggested as a possible etiological mechanism for the clinical picture.

Cerebrospinal fluid ascorbic acid levels in neurological disorders.

The ascorbic acid/dehydroascorbic acid system was analyzed in the cerebrospinal fluid (CSF) of 41 patients with different neurological disorders. The chi-square test of covariance analysis revealed in this sample significant differences in the CSF levels of total ascorbic acid when patients were classified by diagnostic categories. The population analyzed contained a group of 18 patients (back pain/sciatica group) in whom no overt neurological abnormalities were disclosed upon evaluation. Taking the CSF levels of total ascorbic acid and dehydroascorbic acid in these patients as the reference (3.57 +/- 0.87 (SD)/100 ml and 0.53 +/- 0.19 mg/100 ml, respectively), it was found that head-traumatized patients showed a significant reduction in the concentration of total ascorbic acid in the CSF. CSF ascorbic acid levels were also significantly lower in patients with increased intracranial pressure (noninfected hydrocephalus group) and in patients with cerebral tumors. Although the CSF concentration of dehydroascorbic acid did not correspondingly increase over the reference values in these three groups of patients, the tendency existed for dehydroascorbic acid to represent in them a higher percentage of total ascorbic acid. After examining different alternatives, it is concluded that the hypothesis of free radical damage to the central nervous system after certain types of injury (trauma, ischemia, and tumors) may provide a satisfactory explanation of our findings. A rationale for the use of vitamin C in the management of some neurological patients is also derived from this work.