VA Caribbean Healthcare System

San Juan, Puerto Rico

VA Caribbean Healthcare System

San Juan, Puerto Rico
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Martinez-Gonzalez J.,VA Caribbean Healthcare System | Robles-Arias C.,VA Caribbean Healthcare System | Rodriguez-Cintron W.,VA Caribbean Healthcare System
Puerto Rico Health Sciences Journal | Year: 2017

We herein describe the case of a 65-year-old male patient who presented with Osler’s triad, which is the combination of endocarditis, pneumonia, and meningitis. This report is even more unusual since the pathogen isolated was the invasive and virulent strain of Streptococcus pneumoniae serotype 3. The clinical entity described is also called Austrian syndrome. Even though rare in this antibiotic era, the syndrome remains one of high morbidity and mortality. This particular case is of paramount importance for the clinician reader. First, it documents the clinical features associated with invasive pneumococcal disease and the Austrian syndrome. Second, and equally important, it highlights why following the Surviving Sepsis Campaign guidelines saves lives. For this case, the following steps were taken: 1. As a surrogate for perfusion, early and aggressive fluid resuscitation therapy (guided by lactic acid levels) was instituted; 2. also early in the treatment , broad spectrum antibiotics were administered; 3. to guide antibiotic therapy, microbiological cultures were obtained. The patient subsequently improved and was transferred to the internal medicine ward to complete 4 weeks of antibiotic therapy. © 2017, University of Puerto Rico. All rights reserved.

Kershenobich D.,National Autonomous University of Mexico | Razavi H.A.,Center for Disease Analysis | Sanchez-Avila J.F.,Instituto Nacional Of Ciencias Medicas Y Nutricion Salvador Zubiran | Coelho H.S.,Federal University of Rio de Janeiro | And 8 more authors.
Liver International | Year: 2011

Background and aim: The purpose of the present investigation is to provide an analysis of previous works on the epidemiology of the hepatitis C virus (HCV) infection from six countries throughout Latin America, to forecast the future HCV prevalence trends in Argentina, Brazil, Mexico and Puerto Rico, and to outline deficiencies in available data, highlighting the need for further research. Methods: Data references were identified through indexed journals and non-indexed sources. Overall, 1080 articles were reviewed and 150 were selected based on their relevance to this work. When multiple data sources were available for a key assumption, a systematic process using multi-objective decision analysis (MODA) was used to select the most appropriate sources. When data were missing, analogues were used. Data from other countries with similar risk factors and/or population compositions were used as a proxy to help predict the future trends in prevalence. Results: The review indicates that the dominant genotype is type 1. HCV prevalence in the analysed countries ranges from 1 to 2.3%. The Latin American countries have been very proactive in screening their blood supplies, thus minimizing the risk of transmission through transfusion. This suggests that other risk factors are set to play a major role in continued new infections. The number of diagnosed and treated patients is low, thereby increasing the burden of complications such as liver cirrhosis or hepatocellular carcinoma. The HCV prevalence, according to our modelling is steady or increasing and the number of infected individuals will increase. Conclusions: The results herein reported should provide a foundation for informed planning efforts to tackle hepatitis. © 2011 John Wiley & Sons A/S.

Vera M.,University of Puerto Rico at San Juan | Perez-Pedrogo C.,University of Puerto Rico at San Juan | Huertas S.E.,University of Puerto Rico at San Juan | Reyes-Rabanillo M.L.,VA Caribbean Healthcare System | And 4 more authors.
Psychiatric Services | Year: 2010

Objective: This study examined whether a collaborative care model for depression would improve clinical and functional outcomes for depressed patients with chronic general medical conditions in primary care practices in Puerto Rico. Methods: A total of 179 primary care patients with major depression and chronic general medical conditions were randomly assigned to receive collaborative care or usual care. The collaborative care intervention involved enhanced collaboration among physicians, mental health specialists, and care managers paired with depression-specific treatment guidelines, patient education, and follow-up. In usual care, study personnel informed the patient and provider of the diagnosis and encouraged patients to discuss treatment options with their provider. Depression severity was assessed with the Hopkins Symptom Checklist; social functioning was assessed with the 36-item Short Form. Results: Compared with usual care, collaborative care significantly reduced depressive symptoms and improved social functioning in the six months after randomization. Integration of collaborative care in primary care practices considerably increased depressed patients' use of mental health services. Conclusions: Collaborative care significantly improved clinical symptoms and functional status of depressed patients with coexisting chronic general medical conditions receiving treatment for depression in primary care practices in Puerto Rico. These findings highlight the promise of the collaborative care model for strengthening the relationship between mental health and primary care services in Puerto Rico.

Calvo C.E.,VA Caribbean Healthcare System | Cruz M.,VA Caribbean Healthcare System | Ramos E.,University of Puerto Rico at San Juan
PM and R | Year: 2013

This case report describes the presentation of a 9-year-old boy with a history of hereditary multiple osteochondromatosis who presented to the outpatient setting with progressive difficulty in ambulation. Magnetic resonance imaging of the spine revealed a thoracic spinal tumor, which was surgically removed. After surgery, the boy's ambulation and spasticity/contractures improved. This case is unique because this complication of hereditary multiple osteochondromatosis was identified at an age and in a region that are not typical. From a clinical standpoint, early identification of this complication is important because surgical treatment typically leads to good outcomes. © 2013 American Academy of Physical Medicine and Rehabilitation.

Martin R.J.,University of Puerto Rico at San Juan | Santiago B.,VA Caribbean Healthcare System
Puerto Rico Health Sciences Journal | Year: 2015

Objective: Left ventricular (LV) function parameters have major diagnostic and prognostic importance in heart disease. Measurement of ventricular function with tomographic (SPECT) radionuclide ventriculography (MUGA) decreases camera time, improves contrast resolution, accuracy of interpretation and the overall reliability of the study as compared to planar MUGA. The relationship between these techniques is well established particularly with LV ejection fraction (LVEF), while there is limited data comparing the diastolic function parameters. Our goal was to validate the LV function parameters in our Hispanic population. Methods: Studies from 44 patients, available from 2009-2010, were retrospectively evaluated. Results: LVEF showed a good correlation between the techniques (r = 0.94) with an average difference of 3.8%. In terms of categorizing the results as normal or abnormal, this remained unchanged in 95% of the cases (p = 0.035). For the peak filling rate, there was a moderate correlation between the techniques (r = 0.71), whereas the diagnosis remained unchanged in 89% of cases (p = 0.0004). Time to peak filling values only demonstrated a weak correlation (r = 0.22). Nevertheless, the diagnosis remained the same in 68% of the cases (p = 0.089). Conclusion: Systolic function results in our study were well below the 7-10% difference reported in the literature. Only a weak to moderate correlation was observed with the diastolic function parameters. Comparison with echocardiogram (not available) may be of benefit to evaluate which of these techniques results in more accurate diastolic function parameters. © 2015, University of Puerto Rico. All rights reserved.

Paulo Malave L.,VA Caribbean Healthcare System
Boletín de la Asociación Médica de Puerto Rico | Year: 2010

In this report, we describe a patient with Follicular Lymphoma with central nervous system involvement, rarely reported in indolent lymphomas. Central nervous system involvement in indolent non-Hodgkin's lymphoma is a rare and unexpected complication and should be considered in the differential diagnosis of patients presenting with de-novo neurological signs.

Santiago-Rios K.J.,VA Caribbean Healthcare System
Boletín de la Asociación Médica de Puerto Rico | Year: 2010

Evans syndrome is an autoimmune disorder characterized by the simultaneous or sequential development of autoimmune hemolytic anemia and immune thrombocytopenia. It may be primary (idiopathic, or associated with other diseases. First line therapy is immunosupression. A second line therapy includes danazol and splenectomy. Rituximab was approved by the Federal Drug Administration since 1998 for the treatment of lymphomas. We report a 46-year-old-male Hispanic with Evans syndrome. He presented with severe life threatening autoimmune hemolytic anemia and subsequently developed autoimmune thrombocytopenia. After treatment with steroids and rituximab he remains in remission. This case report supports the use of rituximab in an adult patient with Evans syndrome.

Toro D.H.,VA Caribbean Healthcare System | Amaral-Mojica K.M.,VA Caribbean Healthcare System | Rocha-Rodriguez R.,VA Caribbean Healthcare System | Gutierrez-Nunez J.,VA Caribbean Healthcare System
Infectious Diseases in Clinical Practice | Year: 2011

Background: Clostridium difficile infection (CDI) accounts for significant inhospital mortality. The purpose of this study was to validate a 9-point severity score index (SSI) at the time of diagnosis that could predict severity and mortality in CDI. METHODS:: Patients with positive toxin A/B were screened and enrolled within 48 hours of diagnosis. They were categorized based on SSI into mild, moderate, or severe disease. The Charlson Comorbidity Index (CCI) was calculated, and the patients were divided into the following categories: CCI 0, 1, ≥ 2 or greater. All patients were followed for a period of 90 days. Results: Fifty-four male patients were enrolled (mean age, 76.8 years). Mild, moderate, and severe disease was scored in 63%, 30%, and 7% of the patients, respectively. Low albumin (53.7%) and altered white blood cell count (46.3%) were the most common criteria. Need for intensive care unit care was more frequent with higher SSI (P < 0.05). Mortality rate correlated with disease severity (P = 0.005). The CCI score did not correlate with the severity of CDI; nevertheless, a CCI of 2 or greater had a direct association with overall mortality (P = 0.0001). Discussion:: Severity score index measured at the time of diagnosis is a useful tool to assess severity and predict mortality. A high SSI score suggests the need for intensive care unit care in patients with CDI. Subsequent studies are needed to assess if SSI at the time of diagnosis should be used to determine the level of care and treatment strategies that may modify outcomes in this population. © 2011 by National Foundation for Infectious Diseases.

Hernandez-Rivera H.,VA Caribbean Healthcare System
Boletín de la Asociación Médica de Puerto Rico | Year: 2011

Pulmonary arterial hypertension used to be considered an ultimately fatal disease despite the formerly available therapy. It is a disease characterized by progressive elevation of pulmonary vascular resistance and pulmonary arterial pressure, eventually resulting in right ventricular failure and death. The purpose of this article is to review the basic pathophysiologic processes involved in pulmonary arterial hypertension, to discuss patient presentation, classification, and diagnostic workup. Regarding treatment, all patients with PAH should be considered for standard therapy with anticoagulation, oxygen, and diuretics for management of right heart failure. Calcium channel blockers are only indicated for patients with a positive acute vasoreactivity test. Patients with a negative vasoreactivity test and considered low risk can be treated with oral agents such as endothelin receptor antagonists or PDE-5 inhibitor. Patients at high risk should be treated with prostacyclin analogs. Finally, a brief mention of new and future potential therapeutic strategies is also included.

Roman-Diaz J.,VA Caribbean Healthcare System
Boletín de la Asociación Médica de Puerto Rico | Year: 2010

We report the case of a female patient with an incidental finding at routine mammography evaluation which consisted of a benign spindle cell tumor, namely Breast Myofibroblastoma. It is arranged in fascicles with interspersed broad bands of hyalinized collagen with variable immunohistochemical reactivity to desmin, vimentin, smooth muscle actin and CD 34. It is usually not reactive to cytokeratins and S-100 as seen in the myoepitheliomas. Recurrence of the lesion after excisional surgical procedure is not documented at medical literature. It is important to recognize the benign nature of this neoplasm to prevent extensive mutilating surgical procedures.

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