Junio - Septiembre 2012

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COLEGIO DE MÉDICOS-CIRUJANOS DE PUERTO RICO PO BOX 70169 SAN JUAN, PR 00936

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2015 Malaria Outbreak in Puerto Rico: The Importance of Increasing Awareness in the Population p. 7

Lesión cerebral, ¿qué es? p.18

Patellofemoral Pain Syndrome: A Comprehensive Literature Review p. 21

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By image by Ute Frevert; false color by Margaret Shear [CC BY 2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons

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Mensaje del Presidente

A

Víctor Ramos Otero, MD Presidente del Colegio de Médicos Cirujanos

l juramentarse hace casi dos años, la actual directiva del Colegio se esperaba que sus funciones fueran similares a la de todas las directivas anteriores, velar por el bienestar general de los colegiados, colaborar generalmente con el Departamento de Salud en asuntos relacionados con la salud pública, proveer asistencia a la Asamblea Legislativa basada en el peritaje del Colegio y de sus miembros, en asuntos de salud, entre otras tareas rutinarias y usuales. Las condiciones críticas encontradas, sin embargo, llevaron a nuestros cuadros directivos a tener que enfrentar retos insospechados. Pasemos revista de dichos acontecimientos. Primeramente, la crisis fiscal que se ponía de manifiesto a inicios del 2014, o sea el hundimiento del crédito de Puerto Rico a nivel de chatarra, la incapacidad del gobierno de acceder a los mercados de capital, el creciente déficit presupuestario, permeaba todas las facetas de la vida puertorriqueña. Sin embargo, impactó especialmente al sector de la salud. Los hospitales públicos carecieron de los fondos necesarios para operar adecuadamente y para adquirir y modernizar equipos. ASES no contó con los recursos para financiar el seguro de salud para pacientes médico-indigentes y acumuló deudas multimillonarias con aseguradoras y proveedores. Las aseguradoras, por otra parte, iniciaron procesos de cancelaciones masivas de contratos con proveedores, incluyendo a cientos de médicos. La salida de médicos a otras jurisdicciones, siempre un problema, se agravó con la salida récord de 361 médicos en el 2014, y aproximadamente 500 en el 2015. Segundo, el gobierno federal, en parte por presiones presupuestarias de un Congreso conservador, restringiría las ayudas federales a la isla. La asignación en bloque del Affordable Care Act, comúnmente conocido como “Obamacare”, gestionada en el 2010 para cubrir hasta el 2019, ya para principios del

2014 se estimaba que no alcanzarían hasta el 2019 sino que podrían agotarse un año antes, en el 2018. Sin embargo, la dependencia extrema del gobierno estatal en estos fondos, reflejada en la asignación de fondos estatales insuficientes a ASES, llevará a que se adelante la fecha de extinción de los fondos en bloque de Obamacare, ya no para el 2018 sino para el 2017 y, quizás, los últimos días del 2016. Tercero, durante este cuatrienio el asedio para debilitar la práctica de la medicina en diversas especialidades ha sido de proporciones insospechadas y el deterioro económico ha llevado a grupos de personas que no son médicos a intensificar las gestiones para invadir la práctica de la medicina, tanto de oftalmólogos, como fisiatras, obstetras y otros especialistas. Cuarto, las tácticas de las aseguradoras para incrementar sus ganancias a costa de la compensación de los proveedores se ha intensificado dramáticamente, a la vez que también se han incrementado las acciones proteccionistas a favor de las aseguradoras por parte de la Oficina del Comisionado de Seguros. Y quinto, Puerto Rico se ha visto asediado en estos dos años, no solo por las usuales y periódicas epidemias de influenza y dengue, sino por dos enfermedades anteriormente desconocidas para nuestros pacientes, el Chikungunya y, ahora, el virus del Zika. Anticipándose al rápido deterioro de las condiciones económicas que afectan la práctica de la medicina en Puerto Rico, la nueva directiva comenzó a redirigir los recursos del Colegio para enfrentar esos retos insospechados. Por ejemplo, desde sus inicios, el Colegio mantenía una presencia ante la Asamblea Legislativa cuando se discutían proyectos

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directamente relacionados con la salud pública. En este cuatrienio, esa presencia se ha intensificado, no solo por la gran cantidad de iniciativas que inciden en permitir que personas sin un doctorado en medicina ejerzan aspectos de la profesión médica, especialmente oftalmología, obstetricia, fisiatría, entre otros, sino que también para evitar que se aplicara a los médicos el IVU, el IVA y el llamado B2B. De igual forma, aún antes de surgir la posibilidad de que una junta federal asuma el poder decisional que hasta ahora había residido en las autoridades estatales en Puerto Rico, era evidente que muchas de las decisiones que más afectan a nuestros colegiados se toman en Washington, no en San Juan. Por tanto, el Colegio de Médicos ahora está representado en la capital federal por una firma con extensos contactos, tanto en la rama legislativa como la rama ejecutiva, tanto en el lado demócrata como en el lado republicano. El Colegio ha sostenido reuniones con figuras federales claves en Washington y en Nueva York, al igual que en reuniones efectuadas en San Juan. Hemos radicado escritos persuasivos ante diversas agencias federales y hemos levantado conciencia de la necesidad de obtener mejor trato para Puerto Rico en la distribución de fondos para la clase médica y nuestros pacientes. Aunque el gobierno federal aprobó un trato negativo para el 2016, el propuesto trato para el 2017 luce prometedor, gracias al incremento en esfuerzos de cabildeo con la Casa Blanca, el Departamento de Salud y Servicios Humanos (HHS) y los Centers for Medicare and Medicaid Services (CMS), incluyendo nuestros esfuerzos. Con el propósito de reducir los cuantiosos gastos que incurre el Colegio regularmente en hoteles y centros de convenciones para el alquiler de espacios para reuniones muy grandes para la pequeña antigua sede de la organización, comenzamos el proceso para dotar al Colegio de una sede que pueda acomodar reuniones de mucho mayor tamaño y dejar de “pagarle al inglés” por locales para reuniones y seminarios. Se demolió las varias viejas casas interconectadas que usábamos como sede en Villa Nevárez y, en el mismo solar, construiremos una nueva estructura multi-pisos con estacionamiento, salones amplios para reuniones, al igual que las oficinas de la organización. Desafortunadamente, expresiones de ex-oficiales del Colegio dirigidos a lesionar el buen nombre y el crédito de la organización, unido a la severa contracción en el crédito por parte de instituciones financieras locales, han atrasado la obtención del financiamiento de la obra de construcción, préstamo cuyo repago está contemplado en el presupuesto actual del Colegio. 4 | El Bisturí Octubre - Diciembre 2015

En el campo legal, el Colegio tampoco se ha quedado atrás. Por ejemplo, cuando hemos triunfado en el ámbito legislativo, como fue el caso de la Ley 203 de negociación colectiva de los médicos con las aseguradoras. Dicha ley se vió afectada, al ejecutivo reglamentar de tal manera que la hacía inoperante. No hemos tenido reparos en acudir al foro judicial donde logramos invalidar el Reglamento 91 que la Oficina del Comisionado de Seguros ahora tiene que corregir, por orden del tribunal. También fuimos parte del ejército legal que logró que se impugnara exitosamente otro reglamento de la rama ejecutiva que incidía en la Ley 5, sobre las razones por las cuales las aseguradoras podían limitar o negar el pago del servicio prestado en las hospitalizaciones. En menos de dos años hemos obtenido dos triunfos importantes en los tribunales para hacer valer nuestros derechos como clase. Ante la escasez de fondos que sufre el Departamento de Salud, la colaboración del Colegio ha permitido que la Secretaria, nuestra colegiada Ana Ríus, frecuentemente haya podido transmitir información urgente e importante sobre el Chikungunya y el Zika a todos los médicos por conducto de las redes de nuestro Colegio, y el Colegio ha invertido de sus recursos para pagar anuncios en apoyo a los esfuerzos de salud pública del Departamento. La inversión que el Colegio ha realizado para que nuestros médicos estén bien representados ante el gobierno estatal, el gobierno federal y los tribunales, comienza a dar fruto con la posibilidad de mayores fondos federales, mejores condiciones de trabajo y respeto a los derechos del médico por parte del gobierno y las aseguradores ante nuestros triunfos en los tribunales. Si aspiramos a crear las condiciones para evitar que nuestros médicos se sientan obligados a trasladar sus prácticas fuera de Puerto Rico, si queremos defender a cada una de nuestras especialidades de quienes pretendan ejercer la medicina sin la preparación requerida para ser un médico, hay que continuar construyendo un Colegio con la sofisticación y el profesionalismo para enfrentar los retos que amenazan a la clase médica y a nuestros pacientes.

Mensaje de la Editora

R

Ivonne Z. JiménezVelázquez, MD, FACP Presidenta, Junta Editora

eciban un saludo afectuoso de parte de la Junta de Directores del Bisturí, revista científica del Colegio Médico de Puerto Rico. En tiempos de cambio como los que vivimos en nuestra isla y el mundo, es muy importante mantener un foro de expresión científica para médicos, residentes y estudiantes de medicina, donde podamos presentar y discutir tanto casos complejos como temas de interés general y así colaborar con la educación continua de nuestra clase médica. Un ejemplo de estos, son los casos de Malaria que han surgido desde hace algunos meses, donde viajeros han presentado esta enfermedad ya erradicada, en Puerto Rico. Sospecharla de inmediato es imprescindible para lograr un manejo adecuado, evitar complicaciones y salvar vidas. Por otro lado, tenemos en esta revista un tema de mucha relevancia para la salud de nuestra población. El efecto de una dieta saludable en la reducción de enfermedades crónicas, como la hipertensión y la diabetes. Las dietas DASH y Mediterránea han contribuido al alcance de una reducción en complicaciones por estas y otras condiciones que afectan una gran cantidad de personas de todas las edades.

El artículo de lesiones cerebrales cobra relevancia en esta época donde los deportes extremos, los accidentes de tránsito y la alta incidencia de caídas en las personas de la edad dorada, han aumentado grandemente los casos de trauma en las salas de emergencia. El tema de las arritmias, que pueden pasar desapercibidas y convertirse en un asunto de alto riesgo es de gran importancia también para nuestros médicos primarios. Una excelente revisión del tema de manejo de dolor patelo-femoral, contribución del Departamento de Fisiatría, RCM, enriquece estas páginas. Y para terminar, pero no menos importante, presentamos abstractos aceptados para presentación en la Convención de la Sociedad Puertorriqueña de Pediatría, que demuestran la calidad de la investigación que están llevando a cabo los residentes de esta importante especialidad. Les felicitamos tanto a ellos como a sus Mentores y los exhortamos a continuar con esta tarea de excelencia. Nuestro más sincero agradecimiento a todos los autores de estos artículos y trabajos de investigación, y a nuestro excelente grupo de revisores. Esperamos disfruten la lectura de ésta, Su revista.

Tenemos un Editorial con un tema sumamente importante, nuestro rol como líderes, para el cual debemos prepararnos adecuadamente. Es importante mantener nuestros valores y brindar ese modelaje a los que estamos educando para que nos sustituyan a cargo de la salud de nuestro pueblo.

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EDITORIAL

El Rol del Médico como Líder Edwardo Ramos Cortés, MD

En el entrenamiento de nuestra profesión, no se nos educa en cuanto al rol del médico como líder. Pasamos años educándonos y entrenando, y por lo tanto, se asume que se nos ha preparado para ser líderes. En estos momentos estamos observando cambios en la prestación de los servicios de salud en Puerto Rico y los Estados Unidos. Muchas veces nosotros los médicos en general, hemos tenido poca o ninguna injerencia en estos cambios. Entiendo que somos una parte vital para establecer estas nuevas políticas de salud.

4. Transparencia: El líder identifica circunstancias apropiadas que promueven el desarrollo de los objetivos, no las utiliza para beneficio propio, pero las hace disponibles como herramientas de trabajo por el grupo. El rol del médico como líder, es el de proveer propósito, visión, poder, inspirar, involucrar e influenciar a personas para que deseen formar parte del grupo de cambios. La meta es hacer una agenda de trabajo en la que se pueda tener resultados tangibles.

Primero que nada tenemos que definir lo que es un líder. Ser líder es una cualidad humana, y no viene atada a títulos, posiciones o nombramientos administrativos1. Ser líder implica tener herramientas para influenciar a otras personas, encaminándoles hacia un propósito y hacia una dirección con motivación, mientras que a la misma vez, se va logrando el cumplimiento de la misión y el mejoramiento de la organización. La capacidad del líder se puede mejorar con cambios en conducta y actitudes. Un líder es un facilitador.

El médico líder debe preguntar a su grupo de trabajo que sugerencias tienen para un problema en particular. Para lograr esto, se recomienda realizar reuniones periódicas de forma colaborativa entre el equipo de trabajo.

CUALIDADES IMPORTANTES DEL LÍDER:

1. Gewertz BL, Logan DE. The Best Medicine: A physician Guide to Effective Leadership. 2015, Springer Science-Business Media, ISBN 978-14939-2219-2. 2. Mohamad, K. Physician Leadership, The Rx for Healthcare Transformation. 2015, ISBN 978-1-61244-216-7.

1. Integridad: una manera simple de explicar esto es, cumpliendo con lo que hemos prometido, como dice un dicho de nuestros abuelos: “No hay nada más sagrado que la palabra empeñada”.

El propósito al escribir este artículo, es hacer conocer las preocupaciones que he tenido a través de estos últimos años referentes a nuestra profesión y al rol que deberíamos desarrollar como líderes.

REFERENCIAS:

2. Compañerismo: relaciones sólidas, tanto personales como profesionales, facilitan una comunicación abierta para obtener resultados óptimos en el medio ambiente profesional que nos movemos. Para lograr esto, tenemos que ser sensibles a las necesidades de otros; un buen mantra para esto es: “No tenemos que ganar todos los argumentos”. 3. Responsabilidad: El líder entiende que existen áreas de la práctica en la cual no se es todo un experto, y que se aprende de las fortalezas del equipo con el que se está trabajando, uniendo fuerzas para resolver los problemas que se presentan. 6 | El Bisturí Octubre - Diciembre 2015

Edwardo Ramos Cortés, MD Profesor Departamento Medicina Física y Rehabilitación Director Médico, Health South Rehabilitation Hospital, San Juan

2015 Malaria Outbreak in Puerto Rico: The Importance of Increasing Awareness in the Population Carlos E. Correa Luna, MD; Roberto D. Fernández McClin, MD; Francisco J. Díaz Lozada, MD, FACP; Jorge Bertrán Pasarell, MD

Resumen En el verano del 2015, entre julio 20 y 24, fueron identificados y reportados por oficiales del Departamento de Salud, 14 casos nuevos de Malaria en Puerto Rico. El parásito conocido como Plasmodium falciparum fue el causante en todos los casos reportados; especie que predomina actualmente en el mundo. Según los Centros para el Control de Enfermedades (CDC), Puerto Rico se encuentra geográficamente cerca de áreas donde el Plasmodium falciparum está presente y la Malaria es endémica. El movimiento turístico en la zona y la alta prevalencia del mosquito Anopheles, vector del parásito que causa la Malaria, exige que la población y proveedores de servicios de salud estén preparados para prevenir, diagnosticar y tratar la Malaria de forma diligente. La estrategia de atención temprana es importante para evitar y disminuir la morbilidad y/o la mortalidad en las poblaciones frágiles, particularmente niños, mujeres embarazadas y personas inmunocomprometidas. Este artículo describe la situación ocurrida en Puerto Rico con el brote de Malaria del 2015, la presentación clínica, los métodos diagnósticos, y el tratamiento para esta enfermedad. Además, se incluye la educación provista a la comunidad, las medidas preventivas y cómo evitar el contagio. Summary/Abstract In the summer of 2015, from July 20 to 24, 14 new cases of Malaria were identified in Puerto Rico and reported by officials of the Department of Health. The culprit of all imported cases was identified as Plasmodium falciparum, the predominating species of the parasite in the world as per the Centers for Disease Control. Taking this into account, in addition to the geographical proximity to endemic populations, tourism and prevalence of the malaria vector, the Anopheles mosquito, it is important to be prepared to diagnose and treat Malaria diligently in order to decrease morbidity and/or mortality particularly in children, pregnant and immunocompromised patients. We provide information about the latest outbreak of Malaria in Puerto Rico in 2015 along with the suggested preventive measures, clinical presentation, diagnosis and treatment of this disease. We conclude with recommendations for awareness.

INTRODUCTION In 1962, Puerto Rico (US territory) became the first tropical territory in the Americas, and possibly in the world, to receive certification from World Health Organization (WHO) for having eradicated malaria and declared itself free of the disease4. Since that time, there have been reports of 1-5 cases of diagnosed malaria in PR every year. All cases have been from patients traveling to endemic areas of the disease. According to a study from the Division of Epidemiology, Department of Health, between 1970 and 1989 there were recorded in Puerto Rico 173 cases of malaria, all of which were considered imported, not endemic. Most of these cases were returning soldiers of the Vietnam War and the remaining came from Africa, Central America, Haiti and Dominican Republic. In the summer of 2015, most Puerto Ricans were shocked

by the news of 14 new cases of Malaria from July 20 to July 24. As informed by an Officer of the Department of Health, all patients demonstrated the same strain of the parasite, Plasmodium falciparum, and all patients had traveled to Punta Cana, Dominican Republic between June and July. The press news coverage of the event ceased once the cases were confirmed as imported. The reality is that giving the close proximity to endemic populations, travel and the prevalence of the malaria vector (Anopheles mosquito) in our island, we must be prepared and able to diagnose and treat Malaria. Failure to consider malaria in the differential diagnosis of a febrile illness in a patient who has traveled to an area where malaria is endemic can result in significant morbidity or mortality, especially in children, pregnant and immunocompromised patients. Octubre - Diciembre 2015

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PREVENTION Malaria is found where the proper conditions allow parasite survival within the mosquito, usually tropical and subtropical niches. Based on the geographic distribution information provided by the CDC, P falciparum is the predominating species in the world, P ovale is found overlapping geographically with P vivax, with P ovale being mostly found in the Sub-Saharan Africa, and some areas of Asia and Oceania. P vivax is not common in Sub-Saharan Africa but is found in the other areas. P malariae is found in South America, Asia and Africa, but not as much as P falciparum, and P knowlesi is mostly found in southeast Asia.7 Most travelers who develop malaria do so because they do not adhere to an effective chemoprophylactic drug regimen. In addition, many travelers frequently fail to use personal protection measures for mosquito bite prevention. Preventive efforts should be aimed at all forms of Malaria. In addition to P falciparum, other Plasmodium species that cause human malaria include P vivax, P ovale, P malariae, and P knowlesi. These forms of malaria usually cause febrile illness but less commonly result in severe disease and are rarely fatal, although deaths have been reported in the setting of P vivax and P knowlesi infections. In general, most chemoprophylaxis regimens are designed to prevent primary attacks of malaria but may not prevent the later relapses that can occur with P vivax and P ovale. No antimalarial drug is 100% protective and must be combined with the use of personal protective measures, (i.e., insect repellent, long sleeves, long pants, sleeping in a mosquitofree setting or using an insecticide-treated bed net). According to the Center for disease control (CDC) the Dominican Republic continues to be a country with malaria transmission except for the cities of Santiago and Santo Domingo. Currently, multiple cases of malaria from US tourists returning from the Dominican Republic have been reported to the CDC. Transmission reports include the resort areas of popular places like Punta Cana and Puerto Plata, constantly visited by Puerto Rican travelers. Tourists visiting the Dominican Republic are advised to use appropriate preventive measures particularly those traveling outside of Santiago and Santo Domingo, which include pharmacotherapy and avoiding mosquito bites with protective measures, especially during dusk and dawn, also known as the peak biting period.6

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CHEMOPROPHYLAXIS OPTIONS Atovaquone-proguanil 1 tablet/day PO used as prophylaxis in all areas. Begin 1-2d before travel to malarial areas; discontinue 7d after departure from malarial areas. Not recommended for prophylaxis if creatinine clearance < 30 mL/min and should be taken with food or a milky drink. Doxycycline 100-mg/day PO used as prophylaxis in all areas. Begin 1-2d before travel to malarial areas; discontinue 4wk after departure from malarial areas. Contraindicated in children < 8 y/o and in pregnant women. Increased risk of photosensitivity. Mefloquine 250-mg PO once weekly used as prophylaxis in areas with mefloquine-sensitive malaria. Begin 1-2wk before travel to malarial areas; discontinue 4wk after departure from malarial areas. Contraindicated in persons with active or recent history of depression, or generalized anxiety.

CHEMOPROPHYLAXIS OPTIONS Chloroquine Phosphate (for areas with chloroquinesensitive malaria) Hydroxychloroquine sulfate (an alternative to chloroquine) Primaquine 30-mg base/day PO used as prophylaxis for short-duration travel to areas with > 90% P vivax. Begin 1-2d before travel to malarial areas; discontinue 7d after departure from malarial areas. Contraindicated in persons with glucose-6phosphate dehydrogenase (G6PD) deficiency (all persons who take primaquine should have a documented normal G6PD level before starting). Also contraindicated during pregnancy and lactation unless the infant being breastfed has a documented normal G6PD level.

SYMPTOMS Patients with malaria typically become symptomatic a few weeks after infection, although the host’s previous exposure or immunity to malaria affects the symptomatology and incubation period. In addition, each Plasmodium species has a typical incubation period. Importantly, virtually all patients with malaria present with headache. Clinical symptoms also include cough, fatigue, malaise, shaking chills, arthralgia, and myalgia; paroxysm of fever, shaking chills, and sweats (every 48 or 72 h, depending on species). The classic paroxysm begins with a period of shivering and chills, which lasts for approximately 1-2 hours and is followed by a high fever.3 Finally, the patient experiences excessive diaphoresis, and the body temperature of the patient drops to normal or below normal.

Complications of Plasmodium falciparum infection may include impaired consciousness, seizures, severe anemia, renal failure, pulmonary edema or acute respiratory distress syndrome (ARDS), refractory hypotension, and disseminated intravascular coagulation (DIC).1

DIAGNOSIS Diagnosis of malaria is suspected by clinical presentation of the associated symptoms along with a history of travel to a malaria endemic area within the previous year and confirmation is made by microscopic visualization of the parasites on Giemsa-stained blood smears, that should be obtained during febrile episodes.

TREATMENT Uncomplicated Chloroquine-Resistant P. falciparum or Chloroquine-Resistant P. vivax • Atovaquone-Proguanil • Artemether-Lumefantrine • Quinine sulfate plus doxycycline or tetracycline or clindamycin • Mefloquine Uncomplicated Chloroquine-Sensitive P.falciparum or Chloroquine - Sensitive P. vivax, P. ovale, P. malariae, P. knowlesi • Chloroquine Phosphate Complicated malaria (Preferred treatment in United States) • Quinidine gluconate + Doxycycline [Clindamycin if pregnancy] Severe Malaria • Quinidine Gluconate + Artesunate (available from the CDC) Terminal Prophylaxis of Relapsing Malaria: P. vivax or P. ovale • Primaquine Phosphate

activities. Social networking sites provide an immediate and personal way to deliver programs, products and information to individuals or friends within your personal network”2. Even though they are on the right path, their social media advertising do not focus to specific regional concerns. It’s our recommendation that the PR Department of Health in conjunction with all medical entities in the island, focus on how to make chemoprophylactic travel information available and directed to the general public. There is a quote by Dr. Mary Ann Allison, which reads “Accurate information is a key part of motivation”.

REFERENCES:

1. Center for Disease Control and Prevention (CDC). (2012, November 9). Center for Disease Control and Prevention. Retrieved August 12, 2014, from CDC Web site: www.cdc.gov/malaria/diagnosis_treatment/treatment.html 2. Center for Disease Control and Prevention (CDC). (2014, January 13). Center for Disease Control and Prevention. Retrieved August 12, 2014, from CDC Web site: www.cdc.gov/socialmedia/index.html http://www. cdc.gov/dpdx/malaria/gallery.html 3. Griffith, K S Lewis, L S Mali, S & Parise, M E (2007). Treatment of Malaria in the United States: A systematic review. Journal of the American Medical Association, 2264-2277. 4. Miranda Franco, R & Casta Velez, A. (1997). La erradicación de la malaria en Puerto Rico. Pan Am Journal of Public Health, 146-150. World Health Organization (WHO). (2014). Guidelines for the treatment of malaria (3rd ed.). Geneva 27, Switzerland: World Health Organization. 5. Center for Disease Control and Prevention (CDC). (2015, July 27). Center for Disease Control and Prevention. Retrieved September 25, 2015, from CDC Web site: http://www.cdc.gov/malaria/new_info/2015/malariadom_rep_july2015.htm 6. Ed. Hermant Godara, Angela Hirbe, Michael Nassif, Hannah Otepka, and Aron Rosenstock. The Washington Manual of Medical Therapeutics. 7. Lippincott Williams & Wilkins, 2014.”Chapter 14: Treatment of Infectious Diseases.”

(Note: The expressions and recommendations in this article do not necessarily represent the official position of the CDC, WHO, Hospital Auxilio Mutuo or any medical journal that may publish this article. No affiliations with pharmaceuticals or government agencies exist between the authors in this review.)

RECOMMENDATIONS One hundred percent of malaria cases diagnosed in Puerto Rico are imported. Patients and general public remain unaware of rules and guidelines that have to be followed before visiting countries outside the continental USA. An efficient education plan should be implemented, in order to expose the population to these facts. Currently, the social media platform has the greatest power to cover and diffuse information to the public. It has the capacity to reach further in the population if compared to television, radio or printed material. The CDC has started a campaign on social media with guidelines and promotions stating: “Popular social networking sites are being used daily by millions of people and are becoming a part of everyday online

Carlos C. Correa Luna, MD Medical Intern, Auxilio Mutuo Hospital

Roberto D. Fernández McClin, MD, FACP Infectious Diseases Section Chief, Auxilio Mutuo Hospital Francisco J. Díaz Lozada, MD Infectious Diseases Program Director, UPR School of Medicine Jorge Bertrán Pasarell, MD Director Programa Adiestramiento Enfermedades Infecciosas, RCM, UPR Octubre - Diciembre 2015

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Puerto Ricans and Hypertension: Can Our Dietary Habits Make a POSITIVE Difference? Alba D. Rivera-Díaz, MD, LND; Francisco J. Díaz-Lozada, MD, FACP

RESUMEN: La dieta puertorriqueña está compuesta principalmente por hidratos de carbono complejos tales como: arroz, tubérculos, pan y cereales. Legumbres, vegetales, frutas cítricas, aves, carnes y mariscos, también comprenden gran parte de nuestra dieta. Sabemos que puede ser dañino para Ia salud de los puertorriqueños, no solamente por el alto contenido de hidratos de carbono y grasas, también por su manera de cocción y preparación. Este factor ambiental podría estar asociado con el riesgo de algunas enfermedades crónicas, como obesidad, diabetes e hipertensión, las cuales, son altamente prevalecientes en nuestra población. La evaluación de los beneficios de las dietas: Enfoques Alimenticios para Detener la Hipertensión (DASH) y Ia dieta MEDiterránea (MED) propuesto para el manejo de Ia hipertensión es muy importante, con el fin de incorporarlos como parte de los patrones dietéticos de nuestra población en riesgo SUMMARY: The Puerto Rican diet is composed mostly of complex carbohydrates such as rice, tubers, bread, and cereals. Legumes, vegetables, citric fruits, poultry, meats and seafood are also part of our diet. It can be harmful to the health of Puerto Ricans, not only by the high content of carbohydrates and fats, also by its preparation. This environmental factor might be associated with risk for some chronic diseases, such as obesity, diabetes, and hypertension in our population. Evaluation of the benefits of the diets: Dietary Approaches to Stop Hypertension (DASH) and the MEDterranean diet (MED) proposed for the management of hypertension is very important, in order to incorporate them as part of the dietary patterns of our population at risk. Keywords: Diet, Puerto Ricans, Hypertension

INTRODUCTION The Puerto Rican population is genetically heterogeneous and originated from three ancestral populations: European settlers, native Taino Indians, and Western Africans. This nutritionally mixed genetic ancestry of Puerto Ricans provides the intrinsic variability of complex geneenvironment interactions in disease susceptibility and severityl. The Puerto Rican population has a tendency toward elevated blood pressure (BP), heart disease, diabetes, cancer, arthritis, gastrointestinal disorders, and obesity. Conditions, such as, diabetes, obesity and cardiovascular diseases are most likely due to interaction of genetic, environmental and social risk factors. Ethnic background might modify some of these risk factors and may also be associated with health disparities among Puerto Ricans. It is probable that the high prevalence rates of these diseases are not due to genetic variation alone, but to the combined effects of genetic variation interacting with environmental 12 | El Bisturí Octubre - Diciembre 2015

and social factors’. The health-related behaviors may be inadequate, including very low levels of physical activity and poor dietary habits, which are likely contributing factors to their high prevalence of obesity, hypertension, and diabetes. Therefore, identifying environmental factors such as lifestyle and dietary patterns, that contribute to the health disparities in Puerto Ricans, and a review of the dietary regimens proposed to manage disease risk factors is needed for the development of effective strategies to prevent the development of disease and subsequent complications in this vulnerable population.

DIETARY PATTERNS IN PUERTO RICO The dietary intake patterns of Puerto Ricans are unique, as well as their social, cultural, and environmental exposures that may contribute to higher cardiovascular disease (CVD) risk, most specifically hypertension. Dietary patterns are generally high in calories, carbohydrates, fats, and sodium.

These include high quantities of complex carbohydrates such as breads, cereals, soda crackers, and rice. When available, “viandas” (starchy vegetables) such as, plantains, green bananas, potatoes, sweet potatoes, breadfruit and yucca (cassava), are also included in the Puerto Rican dishes. Lettuce with tomato is frequently included as a side salad. Legumes such as beans and chickpeas are often part of their diet. Meat group includes chicken, pork and its products, turkey, beef, and seafood, all of which are high in protein but have varying levels of fat and cholesterol. Fish is included, but in smaller quantities than other meats. Almost 70% of the food consumed in the island of Puerto Rico is imported from the United States. Because of this, the Puerto Rican diet, particularly the diet of younger generations, has become very americanized3. Favorite foods include pizza, hot dogs, canned spaghetti, cold cereal, and canned soups, which increase the risk for hypertension, due to their high amount of sodium. Fast food restaurants are often preferred.

modification together with medical treatment. It has been reported in the literature that diet influences the arterial BP6. Significant effects of diet on BP have been reported from large nutritional interventions, particularly with the DASH and the MED.

HISTORICAL BACKGROUND OF DASH The National Institute of Health (NIH) conceptualized the DASH diet as part of the DASH trials in the mid 90’s. These trials were looking for a complete nutritional profile that could influence the BP. DASH diet is a lifelong approach to healthy eating that is designed to help treat or prevent high BP. This diet emphasizes that certain other dietary modifications are as important as decreasing salt intake in the control of hypertension and encourages reducing the sodium in diet and eating a variety of foods rich in nutrients that help decrease BP, such as potassium, calcium and magnesium7.

Puerto Ricans had the highest hypertension-related death rate among all Hispanic subpopulations in 2002, with an incidence of 154.0 per 100,000 individuals compared with non-Hispanic whites6. Hypertension is a modifiable disease that can lead to stroke, myocardial infarction, congestive heart failure, sudden cardiac death, peripheral vascular disease, and renal insufficiency. Untreated hypertension elevates risk for mortality and morbidity from diseases of the heart and stroke, the first and fifth leading causes of death.

The DASH eating plan, as established by Mayo Clinic requires: to consume daily 6-8 servings of grains, 4-5 servings of vegetables, 4-5 servings of fruits, 2-3 servings of fat-free or low-fat dairy products, 6 or fewer lean meats, poultry, and fish, and 2-3 servings of fats and oil, together with 4-5 servings of nuts, seeds, and legumes per week. These foods are included in Puerto Rican’s culture, which make it easier to include them as part of their dietary pattern. By following the DASH plan diet, individuals can achieve a daily nutrient goal in the following specification: total fat, 48 hours to PICU. AG determination, a rapid and inexpensive clinical tool, on admission to PICU may become a useful predictive marker in this population. In a future study, we will compare AG to validated ICU severity scores, such as PRISM III.

REFERENCES *mean (SD), # n(%), $median (IQR), ≠n=17 patients received mechanical ventilation. MV = mechanical ventilation.

$median (IQR), # n(%),, ≠n=95 patients received mechanical ventilation,AG = anion gap. MV = mechanical ventilation.

1. Allen, M., Lactate and acid base as a hemodynamic monitor and markers of cellular perfusion. Pediatric Critical Care Med, 2011. 12(4 Suppl): p. S43-9. 2. Badrick, T. and P.E. Hickman, The anion gap. A reappraisal. Am J Clin Pathol, 1992. 98(2): p. 249-52. 3. Hiren J. Mehta, et al. The association between initial anion gap and outcomes in medical intensive care unit patients. J Crit Care.: S08839441(12)00114-1 10.1016/j.jcrc.2012.04.003

PREVALENCE AND CLINICAL OUTCOME OF BRAIN ARTERIOVENOUS MALFORMATIONS IN CHILDREN ADMITTED TO THE PEDIATRIC INTENSIVE CARE UNIT

Milton Miranda, MD1; Hector Rojas2, BS; Hector Oliveras2, MD; Anabel Puig2, PhD; Ricardo Garcia2, MD 1-Dept. of Pediatrics, San Juan City Hospital, San Juan, Puerto Rico, 2- UPR-School of Medicine, Dept. of Pediatrics-Critical Care Medicine Section

INTRODUCTION

Figure 2. Patients with High AG spent more time on mechanical ventilation support.

Figure 3. Mortality rate is higher in patients with High AG.

A brain arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, bypassing the capillary system It occurs in 0.1% of the generalized population between the ages of 10 and 40 years (1). Clinical presentations are intracranial hemorrhage, (most common presentation in children) seizures, headaches and focal neurologic deficit (3-5). It lacks the reducing effect of capillaries on the blood flow. Extremely fragile connections between high-pressure arteries and lowpressure veins can be observed. AVM can cause sporadic congenital developmental vascular lesions. Pathogenesis is not well understood. Angiography is the gold standard for the diagnosis of AVMs. There is no evidence about the prevalence of AMV and its management in the pediatric Hispanic population. This study was designed to evaluate the prevalence of AVM in the pediatric population in patients admitted to the Pediatric Intensive Care Unit at the University Pediatric Hospital of Puerto Rico.

METHODS This study is a retrospective cross-sectional that evaluates the prevalence of AVM and its clinical outcome in Octubre - Diciembre 2015

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patients admitted to the Pediatric Intensive Care Unit (PICU) at the University Pediatric Hospital for a 5 years period: January 1, 2008-December 31, 2012. Patients with diagnosis of traumatic brain injury, past medical history of coagulopathies and/or chronic hypertension and history of brain tumor at admission were excluded. Data were expressed as medians and percentiles.

RESULTS: Table 1: Patients Characteristics

During study period, a total of 2,450 patients were admitted to the Pediatric Intensive Care Unit, where we found a prevalence of patients diagnosed with AVM of 1.4% (35 patients). Most of the patients diagnosed were females (63%, n=22) and 46% were at the age range of 6-12 years old. The average PICU length of stay was 3 ± 9.8 (1,10) days. Mortality rate was 14.3%, with a mean Pediatric Mortality Score 2 (PIM 2) of 6.7 ± 25 (1.3, 28.5). A 45% of patients required mechanical ventilation support during their PICU stay, with a median Mechanical Ventilation Days of 0 ± 7.8 (0, 2.5) days.

CONCLUSION

Graph 1: AVM Mortality Rate in PICU All deaths occurred within the first 24 hours of admission to PICU.

Graph 2: Age Distribution

The purpose of this study was identify the prevalence of pediatric AVM’s in the pediatric population. It is important to further investigate why females (2:1) were more affected by this condition than males. Our study is the first one to characterize this patient population in Puerto Rico. There was a high prevalence (1.4%) as compared to the reported in the general population in the United States. This study will help develop further studies to categorize AVM’s using the Spetzler-Martin grading system to correctly diagnose and treat this population based on a standardized system.

MALNUTRITION AND ITS IMPACT ON THE CLINICAL COURSE AFTER CARDIAC SURGERY IN PEDIATRIC PATIENTS Janice Gómez-Garay; José E. Lugo-Bernier, MD; Anabel Puig-Ramos, PhD, Francisco Rodríguez; Enrique Cruz; Emili Rosado Hospital Pediátrico Universitario - Centro Médico, San Juan, Puerto Rico

INTRODUCTION:

Chart 1: AVM Prevalence of 1.4%

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Congenital Heart Disease (CHD) is the most common human developmental anomaly in pediatric patients with a reported prevalence of between 4 and 10 per 1000 live births. Neonates and young children with CHD have long been recognized to be at risk for poor growth and failure to thrive. World Health Organization (WHO) has established growth standards to facilitate comparative nutritional assessment and the grade of childhood malnutrition. Malnutrition can be classified as acute, chronic or mixed type. The classifications depend on anthropometric measurements such as weight for age, length for age and body mass index. Studies have shown that pediatric patients with CHD have a high incidence of both acute and chronic malnutrition in infants and chronic malnutrition in toddlers. Evidence demonstrates that the ability to recover after surgery is highly dependent on adequate nutrition in children. Acute malnutrition usually occurs during the course of an illness. Wasting is the main characteristic of

acute malnutrition that occurs as a result of recent rapid weight loss or a failure to gain weight within a relatively short period of time. Chronic malnutrition occurs over time, unlike acute malnutrition. It mostly affects children and when chronic malnutrition is sustained over a long period of time, it leads to failure of linear growth. There is no evidence in literature that compares the prevalence of acute and chronic malnutrition in critically ill children with congenital heart disease and its impact on clinical outcomes. The aim of this study is to determine the effect of both acute and chronic malnutrition on the clinical outcome of children with congenital heart disease who underwent cardiac surgery.

METHODS We conducted a retrospective cohort study and collected data from 200 consecutive patients (0-21 years) admitted to the Pediatric Intensive Care Units from the University Pediatric Hospital (UPH) and San Jorge Children’s Hospital (SJCH) for one year (November 2009-November 2010). Patients less than 48 hours of stay were excluded from the study. Demographic data, anthropometric measurements, clinical diagnosis, PICU length of hospital stay (LOS), use and duration (days) of mechanical ventilation support, use of ionotropics and clinical outcome were collected from patients medical records. The collection data sheet was designed in an Excel spreadsheet that will be encrypted and password protected, where only the PI and Co-PI investigators will have access to the password. The collection data sheet does not include the record number of patients to avoid that during statistical data management arises a possible link with the identity of the patient. To determine acute malnutrition the following criteria was used: WFH SD score less than 2 or WFH less than 5th percentile. To determine chronic malnutrition the following criteria was used: HFA SD score less than 2 or HFA less than 5th percentile.

Figure 1. Patients Nutritional Status at PCICU

Figure 2. Nutritional status at admission has no effect on PCICU length of stay. Data were expressed as medians ± interquartile range. (Kruskal-Wallis test: 2.5, p = 0.28)

Figure 3. Nutritional status at admission has no effect on days on mechanical ventilation support. Data were expressed as medians ± interquartile range. Kruskal-Wallis test: 2.8, p = 0.24

RESULTS Table 1. Patient’s Demographics and Characteristics

CONCLUSIONS:



Of 171 patients evaluated, 53% were males with a median age of 11 months. We observed a prevalence of 16% for acute and 34% for chronic malnutrition at admission to PCICU. Patients with chronic malnutrition had a median age of 6 months, being younger than those with normal nutrition and with acute malnutrition. Most of the patients were Octubre - Diciembre 2015

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categorized with a RACHS Score 1 and 2 (22% and 44% respectively). There was no association between nutritional status at PCICU admission with time spent at the unit and time on mechanical ventilation support after surgery. Nutritional status at admission did not predict mortality: OR = 0.86, p=0.6 (95% CI: 0.47, 1.96). Of 15 deceased patients, 60% (9/15) had normal nutritional status, 7% (1/15) had acute malnutrition and 33% (5/15) had chronic malnutrition. Despite evidence that malnutrition has been shown to impact the physiological stability of critically ill children, we did not observed a correlation between malnutrition and poor clinical outcome and risk of mortality. It is possible that we did not observed an association in the clinical course because we only evaluated the nutritional status at admission to PCICU, and did not measured weight and height of patients at other time points during their stay at PCICU and at discharge from the unit. Moreover, we may not observed a correlation between nutritional status and mortality because most of the patients were categorized with a RACHS-Score of 1 and 2 (66%), which means that those patients were submitted to less complex surgical procedures.

REFERENCES

1. Chronic Malnutrition: Stunting. (n.d.). Retrieved October 5, 2015, from http://www.unicef.org/nutrition/training/2.3/20.htlm 2. Mehta NM, Duggan CP.Nutritional deficiencies during critical illness. Pediatr Clin North Am 2009, 56(5):1143-1160. 3. Pawellek I, Dokoupil K, Koletzko B. Prevalence of malnutrition in paediatric hospital patients. Clin Nutr 2008, 27(1):72-76. 4. Pollack MM, Ruttimann UE,Wiley JS. Nutritional depletions in critically ill children: associations with physiologic instability and increased quantity of care. JPEN J Parenter Enteral Nutr. 1985;9:309–313. 5. Toole, BJ, Toole, LE, Kyle, UG, et al. Perioperative nutritional support and malnutrition in infants and children with congenital heart disease. Congenit Heart Dis. 2014;9:15–25

obstruction. Nowadays long-term intubation has become the most important indication for tracheotomy in children (Kremer et al, 2002). Despite the known advantages, considerable controversy remains regarding the appropriate indications, timing, and results of tracheotomy in pediatrics. Complications related to tracheotomy include: intraoperative and postoperative bleeding, emphysema, air embolism, pneumothorax, mediastinitis, pneumonia, tracheo-esophageal fistula, tracheal stenosis with difficult decannulation, swallowing disorders, granulations and tracheomalacia (Zenk et al, 2009). This study was designed to conduct a comprehensive evaluation of patients undergoing tracheotomy placement during their stay at the Pediatric Intensive Care Unit (PICU).

METHODS Study Design: Retrospective observational cohort study of the evaluation of the medical records of patients admitted to PICU who underwent tracheotomy procedure while at the unit during the years 2006 through 2014. Subjects: Patients (0-21 years) admitted to PICU who underwent tracheotomy placement. Exclusion Criteria: Patients admitted to PICU that already had a tracheotomy. Post-op patients admitted to PICU after a tracheotomy. Variables: Admission Diagnosis, Gender, Age, Health Insurance, PICU Length of Stay (LOS), Mechanical Ventilation Days (MV Days), Timing for Tracheotomy Placement, Use of Inotropes, Outcome. Statistical Analysis: Demographic data were presented as Mean ± SEM and percentages. A Mann-Whitney Test was conducted to evaluate the timing of tracheostomy in patients with or without inotropic agents.

RESULTS Indications for tracheotomy placement in Pediatrics

TRACHEOTOMY PLACEMENT IN PEDIATRICS: INDICATIONS, TIMING AND COMPLICATIONS Adrianna E. Mojica Marquez; Anabel Puig Ramos,PhD; Ricardo Garcia De Jesus, MD Hospital Pediátrico Universitario - Centro Médico, San Juan, Puerto Rico

INTRODUCTION University Pediatric Hospital from January 2006 to December 2014. Three decades ago, tracheotomies were performed in children mostly for the relief of upper airway obstruction, secondary to acute infectious process, such as epiglottitis and laryngotracheobronchitis (Donnelly et al, 1996). Vaccination programs, improvement in artificial airway’s materials and designs, and anesthetic skills have dramatically reduced the number of emergency tracheotomies performed for acute upper airway 32 | El Bisturí Octubre - Diciembre 2015

Age distribution of patients that required tracheotomy

PICU LOS, MV Days and Timing for Tracheotomy placement

3 weeks after admission. There is no such directive in children. In our PICU, tracheotomy placement occurred in patients who had been on mechanical ventilation for approximately one month (32.3 ± 4.3 days). Identifying the need and optimal timing for tracheotomy placement in children is essential in the management of critically ill pediatric patients. In well trained hands, tracheotomy is a safe procedure, and will probably help reduce ventilation days.

REFERENCES

Outcome and Timing for Tracheotomy placement

Patients using inotropes spent more time in MV support and the timing for tracheotomy placement was longer

Kremer B, Botos-Kremer AI, Eckel HE et al. Indications, complications, and surgical techniques for pediatric tracheostomies- an update. J. Pediatr. Surg. 2002; 37: 1556-62. Donelly, Martin J. et al. A twenty year(1971-1990) review of tracheostomies in a major paediatric hospital. International Journal of Pediatric Otorhinolaryngology 1996; 35: 1-9. Zenk, Johannes, et al. Tracheostomy in young patients: indications and longterm outcome. European Archives of Oto-Rhino-Laryngology 2009; 266(5): 705-711

INVASIVE VS. NON INVASIVE MECHANICAL VENTILATION SUPPORT AND ITS IMPACT IN THE CLINICAL OUTCOME OF PEDIATRIC PATIENTS WITH ACUTE RESPIRATORY FAILURE Carlos A. Flores; Samuel Pabón-Rivera, BS; Anabel Puig-Ramos, PhD; Zuleyma E. Toledo-Nieves, BS; Jessica Irizarry-Flores; Jan G. García-Agosto; Gilberto PuigRamos, MD Hospital Pediátrico Universitario - Centro Médico, San Juan, Puerto Rico

BACKGROUND

CONCLUSIONS During the study period (2006 to 2014), 59 patients required tracheotomy placement during their stay in PICU. 71% of patients that required a tracheotomy were males. Overall mortality was 5%, and was not associated with the procedure or its timing. Almost half of the patients that required tracheotomy placement were younger than one year of age, and usually required it for prolonged ventilation. In the adolescent group (>13 years), tracheotomy placement was conducted as early airway management after post traumatic brain injury. Patients that used inotropic agents during their stay in PICU, spent more time in assisted ventilation and required a longer period of time for tracheotomy placement, problably due to the severity of their condition. The National Association of Medical Directors of Respiratory Care recommended that tracheotomy should replace endotracheal intubation in adult patients who still require mechanical ventilation

Respiratory failure is a syndrome in which the respiratory system fails in one or both of its gas exchange functions: carbon dioxide elimination and oxygenation. It is classified: Hypercapnic, Hypoxemic, Acute or Chronic Respiratory Failure. The objective of mechanical ventilation is to decrease PaCO2, increase PaO2 and prevent respiratory muscles fatigue. Noninvasive mechanical ventilation refers to several modalities of respiratory support that do not require an artificial airway. These include Bi-level Positive Airway Pressure (BiPAP) and Continuous Positive Airway Pressure (CPAP). Advantages on NIMV • Keeps the mucosal barrier intact by avoiding trauma to the upper airway, trachea, and main bronchial mucosa. • Reduces lung barotrauma and the risk of nosocomial infections. • It also frequently decreases or eliminates the need for deep sedation, thereby maintaining upper airway and cough reflexes and facilitating secretion clearance. Octubre - Diciembre 2015

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NIMV is increasingly used in pediatric intensive care units (PICU) both for the early stage of respiratory failure and for the post-extubation phase. NIMV indications in children are not well defined unlike in adults, for which NIMV is already regarded as a first-line intervention in several clinical conditions. Objectives of this study was:To determine the prevalence of NIMV, to evaluate clinical outcomes on the use of NIMV vs Invasive MV in patients with Acute Respiratory Failure admitted to PICU.

Prevalence of Mechanical Ventilation Support

PIM2 Score

METHODS Design: A retrospective observational study. Setting: Pediatric Intensive Care Unit at the only tertiary hospital of Puerto Rico from June 2008 – June 2012. Subjects: Inclusion Criteria: Patients between 1 month and 21 years admitted to PICU with Respiratory Failure (Bronchiolitis, Status Asthmaticus, Chronic Lung Disease and Septic Shock). Exclusion Criteria: Patients with BiPAP or CPAP as standard of care prior to admission; patients that were MV dependent. Variables: • Demographics: Sex, Age, Weight • Prevalence on: • Non-invasive Mechanical Ventilation (NIMV) Use • Invasive Mechanical Ventilation (IMV) Use • PICU Length of Stay (LOS) • Mechanical Ventilation Days • NIMV Failure Rate • Mortality Rate Statistical Analysis: Data was expressed as means ± SEM and medians and interquartile ranges. A Mann- Whitney test to evaluate: • NIMV vs MV with PICU Length of Stay, MV Days and Pediatric Index of Mortality 2 (PIM2) Score. • Logistic regressions to evaluate: • Mortality rate vs type of respiratory support and PIM2 Score.

RESULTS Patient Demographics

Pediatric Mortality Index Score in patients with NIMV vs MV. Patients with MV had higher PIM2 Score than patients with NIMV. (MannWhitney Test, p