San Juan, Puerto Rico
San Juan, Puerto Rico

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Fernandez Gonzalez F.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2013

The inappropriate antibiotic can lead to serious negative effects on health. This has been the cause of emergence of multidrug resistant bacteria and the need of surveillance of antibiotics in the inpatient setting. An adequate knowledge on which and when prescribing antibiotics is essential to avoid these issues. Because of this problems, guidelines have been developed to educate and control the misuse and abuse of antibiotics and improve clinical outcomes. We evaluated the medical knowledge, medical trends, and the effectiveness of professional interventions among Puerto Rico physicians in promoting prudent antibiotic prescribing. A comparative study was performed using a questionnaire about prudent antibiotic use in common infections seen in Puerto Rico. It was distributed among the major three internal medicine training programs at San Juan, internal medicine physicians and general physicians. General physicians failed to treat adequately asymptomatic bacteriuria, and overall failed in treating other common conditions when compared with residents and internal medicine physicians. One of our questions was related to the treatment of Extended Spectrum Beta Lactamase (ESBL) positive Escherichia coli (E. coli) and more than 50% of the surveyed failed to answer the question correctly. Conditions as viral respiratory tract infections and community acquired pneumonia had the higher correctly answered questions among the groups. Our questionnaire demonstrates that guidelines have to reach the education among the general physician population to decrease the overuse of inadequate antibiotics, and education should be strengthen on those internal medicine physicians that have already completed formal training.


Torres A.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2013

Cervical dysplasia alters the release of cytokines and inflammatory mediators in pregnant woman with cervical dysplasia. This study evaluates a cohort of pregnant patients screened for cervical dysplasia to determine the relationship between cervical dysplasia and preterm labor (PTL). Retrospective chart review of pregnant patients screened for cervical dysplasia at the San Juan City Hospital between October 2006 and December 2010. Patients with low or high-grade squamous intraepithelial lesions (LGSIL or HGSIL, respectively) were evaluated with colposcopy. Primary outcome was the event of PTL and the risk factor evaluated was presence of cervical dysplasia. A total of 2,059 patients were screened for cervical dysplasia and 59 were evaluated with colposcopy due to LGSIL or HGSIL. From those, 29% were negative for intraepithelial lesions and malignancy (NILM), 54% had cervical intraepithelial neoplasia (CIN)-1, 17% where diagnosed as CIN-2/3 where no invasive cervical cancer was identified. In the group of NILM, 24% had PTL compared to 18% in patients who screened negative on initial cytological evaluation. In cases where CIN-1 was confirmed by colposcopy 28% had PTL compared with 40% in patients with CIN-2/3. Other risk factors associated with PTL were not significantly different among the groups. Cervical dysplasia in pregnancy may represent an increase risk for premature labor.


Santiago Casiano M.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2011

We report a case of a young female patient presenting with a high serum beta-HCG levels, amenorrhea, nausea and anemia which mimicked pregnancy followed by upper gastrointestinal bleeding. A gastric tumor was shown on endoscopy. Histopathologic evaluation revealed Primary Gastric Choriocarcinoma (PGC). The patient was treated with three cycles of standard nongestational choriocarcinoma chemotherapy. Tumor persistence was evidenced by CT Scans and high serum beta-HCG levels. The patient died approximately six months after diagnosis. Our case report suggest that PGC is a highly aggressive tumor that is often associated with liver and lungs metastasis without evidence of pelvic organ abnormality and is associated with some hormonal effects, such as amenorrhea, anemia, nausea and vomiting mimicking pregnancy in young adult female


Palermo-Garofalo C.A.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2011

We report a case of 24 year-old-female presenting with bilateral leg heaviness sensation and difficult walking of one-day duration. Over the past three months she developed progressive and frequent tingling sensation on her hands accompanied by headache and increased thirst. Hypokalemia was identified and treated with resolution of symptoms. She was later found to have Graves' disease. After propranolol and radioiodine therapy no further episodes were reported. Thyrotoxic hypokalemic periodic paralysis is an alarming, potentially lethal, and rare complication of hyperthyroidism. The pathogenesis is uncertain. Because the condition is rare, it is frequently overlooked and misdiagnosed on presentation. It is important to recognize these clinical settings in hypokalemic patients in order to promptly start adequate medical therapy and avoid the lethal complications caused by prolonged sustained potassium depletion.


Martinez J.H.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2013

Nontoxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function. Familial forms of goiter in areas not known to feature iodine deficiency are much less common. However, not all individuals in the same iodine deficiency region develop goiter and iodine supplementation does not prevent goiter development in all treated individuals. The etiology of euthyroid goiter is still incompletely understood. It is assumed that the development of goiter depends on various interactions between genetic and environmental factors. We present an overview on the thyroid physiology, which is important for a better understanding of Familial Euthyroid Multinodular Goiter.


Palermo-Garofalo C.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2013

Amiodarone is used in a large number of cardiac conditions. Amiodarone-induced thyroid dysfunction has been reported to affect up to 20% of users. Amiodarone can lead to both amiodarone-induced hypothyroidism (AIH) and less commonly amiodarone-induced thyrotoxicosis (AIT). There are two main forms of AIT. Type 1 AIT, a form of io-dine-induced hyperthyroidism, and type 2, a drug-induced destructive thyroiditis. Type 1 AIT develops on individuals with underlying thyroid disease. Treatment of Type 1 AIT includes the use of antithyroid drugs and discontinuation of amiodarone. Type 2 AIT is commonly self-limiting in nature. In this article wedescribe a patient with Amiodarone-induced thyrotoxicosis discussing its clinical features and medical therapeutic approach.


Guzman L.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2013

Chylous jejunal cysts are extremely rare entities and if not diagnosed promptly may lead to severe complications like bowel obstruction, loss of small bowel and even death. We present the case of a 4 year-old-male referred to our institution with severe abdominal pain, constipation, abdominal distention and radiological findings of large amount of fluid in the lower abdomen with associated bowel obstruction. Operative findings were that of large chylous jejunal cyst causing segmental volvulus. Resection of the involved jejunal segment and cyst along with bowel detorsion was undertaken. Literature review on the subject follows.


Catalano L.N.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2013

evaluation of Nifedipine protocol success defined as postponement of labor for 48 hours. Secondary objective: evaluation of the presence of risk factors in patients that develop preterm labor and delivery outcome. Chart review retrospective study with patients admitted to the Hospital of the Metropolitan Area of San Juan in the period of January 1,2009 to December 31, 2010 with diagnosis of preterm labor. A total of 382 patient's records were evaluated for inclusion and exclusion criteria. 48 met all the requirements to be included in the study. There were 68.8% patients who successfully completed the 48 hours postponement of labor required to administer corticosteroid therapy for fetal lung maturation. Risk factors for preterm labor commonly observed in the study group were urinary tract infection (60.4%), previous preterm labor (43.8%), multiple gestations (12.5%), and preterm premature rupture of membranes (10.4%). The use of Nifedipine therapy in patients with preterm labor between 24-34 weeks of gestational age can be effective in the postponement of labor for 48 hours so that the patient can receive corticosteroid fetal lung maturation therapy. The most common risk factor observed in this group of patients with preterm labor was urinary tract infection.


Dieguez-Santiesteban N.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2012

Intrathoracic ectopic kidney is a rare congenital abnormality with a prevalence estimated as less than one in 10000 and with only thirteen cases reported in the pediatric age group over the past twenty-five years. Herein, we report the uncommon case of a 20 month-old-male exhibiting a left ectopic intrathoracic kidney diagnosed as an incidental finding in image studies. Uncomplicated incidentals diagnosis has demonstrated normal function and development of those kidneys in long-term follow-up with no late bowel herniation.


Hernan Martinez J.,San Juan City Hospital
Boletín de la Asociación Médica de Puerto Rico | Year: 2013

Hashimoto's encephalopathy (HE) is a rarely recognized neurocognitive syndrome that is associated with thyroid autoimmunity. It is more common in women. HE is diagnosed when patients present with nonspecific neurological symptoms associated to elevated titers of antithyroid antibodies and normal or abnormal thyroid function tests. Other neurologic disorders must be ruled out before diagnosis can be established. HE is associated to nonspecific EEG abnormalities as well as elevated cerebrospinal fluid proteins and nonspecific white matter changes. The pathophysiology of HE is unknown but an autoimmune etiology is strongly supported. HE responds to corticosteroids and immunosuppressive therapy, further supporting an autoimmune etiology. A high index of clinical suspicion must be present in order to promptly recognize and treat this disease.

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