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1 B L E T Í N Asociación Médica DE PUERTO RICO AÑO 103 NÚMERO 2 ABRIL A JUNIO Fernandez Juncos Ave. Santurce, PR Return Service Requested PRESORT STANDARD U.S. POSTAGE PAID SAN JUAN, PR PERMIT No. 3007

2 ipro Continuous Glucose Monitoring (CGM) can help you discover glycemic excursions not revealed by self-monitoring of blood glucose (SMBG) alone The American Diabetes Association recommends that patients with diabetes using multiple insulin injections perform SMBG three or more times daily 1 ipro CGM provides up to 12 glucose values per hour and up to 288 values per day, 2 a rate unrealistic for patients to achieve with SMBG alone Get the insights you need to make informed treatment decisions Continuous Glucose Monitoring aided identification of unrecognized hypoglycemia in patients with type 1 diabetes 3 Continuous Glucose Monitoring assisted in determining insulin therapy modifications 3 Indications for Use ipro CGM is intended to continuously record interstitial glucose levels in persons with diabetes mellitus This information is intended to supplement, not replace, blood glucose information obtained using standard home glucose monitoring devices Please see Important Safety Information on adjacent page or request a copy of the ipro CGM user guides from your Medtronic sales representative. For more information, please contact Medtronic at

3 Raúl G. Castellanos Bran, MD Natalio Izquierdo Encarnación, MD Rolance G. Chavier Roper, MD Pedro J. Zayas Santos, MD Ilsa Figueroa, MD Hilda Ocasio Maldonado, MD Raúl A. Yordán Rivera, MD Jaime M. Díaz Hernández, MD Arturo Arché Matta, MD Juan Rodríguez Del Valle, MD Gonzalo González Liboy, MD Ricardo Marrero Santiago, MD Rafael Fernández Feliberti, MD José L. Romany Rodríguez, MD Dra. Mildred R. Arché, MD Julio de la Cruz Rosado, MD Rubén Rivera Carrión, MD Luis Izquierdo Mora, MD Melvin Bonilla Félix, MD Carlos González Oppenheimer, MD Eduardo Santiago Delpin, MD Francisco Joglar Pesquera, MD Yocasta Brugal, MD JUNTA DE DIRECTORES JUNTA DE EDITORES Humberto Lugo Vicente, MD Presidente Presidente Presidente Electo Presidente Saliente Tesorero Secretaria Vicepresidenta AMPR Vicepresidente AMPR Vicepresidente AMPR Presidente Cámara de Delegados Vicepresidente Cámara de Delegados Delegado AMA Delegado AMA Delegado Alterno AMA Delegado Alterno AMA Presidente Distrito Central Presidente Distrito Este Presidente Distrito Sur Asociación Médica de Puerto Rico OFICINAS ADMINISTRATIVAS SUBSCRIPCIONES Y ANUNCIOS Asociación Médica de Puerto Rico PO Box 9387 SANTURCE, Puerto Rico Tel Fax: ANUNCIOS EN BOLETIN, WEBSITE y NEWSLETTER Tel.: (787) Web Site: Juan Aranda Ramírez, MD Francisco J. Muñiz Vázquez, MD Walter Frontera, MD Mario. R. García Palmieri, MD Natalio Izquierdo Encarnación, MD José Ginel Rodríguez, MD El Boletín se distribuye a los médicos y estudiantes de medicina de Puerto Rico y se publica en versión digital en Todo anuncio que se publique en el Boletín de la Asociación Médica de Puerto Rico deberá cumplir con las normas establecidas por la Asociación Médica de Puerto Rico y la Asociación Médica Americana. La Asociación Médica de Puerto Rico no se hace responsable por los productos o servicios anunciados. La publicación de los mismos no necesariamente implica el endoso de la Asociación Médica de Puerto Rico. Todo anuncio para ser publicado debe reunir las normas establecidas por la publicación. Todo material debe entregarse listo para la imprenta y con sesenta días de anterioridad a su publicación. La AMPR no se hará responsable por material y/o artículos que no cumplan con estos requisitos. Todo artículo recibido y/o publicado está sujeto a las normas y reglamentos de la Asociación Médica de Puerto Rico. Ningún artículo que haya sido previamente publicado será aceptado para esta publicación. La Asociación Médica de Puerto Rico no se hace responsable por las opiniones expresadas o puntos de vista vertidos por los autores, a menos que esta opinión esté claramente expresada y/o definida den tro del contexto del artículo. Todos los derechos reservados. El Boletín está totalmente protegido por la ley de derechos del autor y ninguna persona o entidad puede reproducir total o parcialmente el material que aparezca publicado sin el permiso escrito de los autores. 4 Mensaje del Presidente de la Asociación Médica. ORIGINAL ARTICLES / ARTICULOS ORIGINALES 6 PREOPERATIVE CLINICAL AND DEMOGRAPHIC CHARACTERISTIS IN PUERTO RICO PATIENTS RE- FERRED TO INPATIENT CARDIAC REHABILIATION AFTER CARDIAC SURGERY Jorge Pérez Lopez MD, Jesús Negrón MD, Ernesto Soltero MD, Rafael Oms MD, Miguel Magraner MD, Rafael Bredy MD 17 CORRELATION BETWEEN BODY MASS INDEX AND NEED FOR TOTAL KNEE REPLACEMENT IN A GROUP OF LATIN PATIENTS WITH KNEE OSTEOARTHRITIS Daniel Rivera MD, Juan Ortiz MD, Carlos Colón MD, Juan Colón MS, Miguel Magraner MD, Rafael Bredy MD 23 TESTING 300 PATIENTS FOR ALPHA-1 ANTITRYP- SIN DEFICIENCY IN CAGUAS, PUERTO RICO Ramonita Correa PhD, Jorge Pérez MD, Yocasta Brugal MD, José Terrasa MD, José Pérez Gumá MD, Arnulfo Santana MD, Edwin Colón MS, Gisela Puig MS 25 LOWEST SAFE HEMATOCRIT LEVEL ON CARDIO- PULMONARY BYPASS IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING Anna DiMarco MD, Héctor Vélez MD, Ernesto Soltero MD, Miguel Magraner MD, Rafael Bredy MD 31 INDEPENDENT ASSOCIATION OF LDL-C AND NON HDL-C WITH ACUTE CORONARY SYNDROME IN A HISPANIC POPULATION Rafael Trinidad MD, José Gómez MD, José García Mateo MD, Miguel Magraner MD, Rafael Bredy MD 35 OUTCOMES ASSOCIATED WITH CONVENTIONAL MANAGEMENT OF SEVERE SEPSIS AT DAMAS HOS- PITAL Vera Rosado MD, Lisandra Pérez MD, Héctor Guerra MD, Ricardo Hernández MD, Miguel Magraner MD, Rafael Bredy MD CASE REPORTS / REPORTE DE CASOS 41 TETANUS IS STILL PRESENT IN THE 21ST CEN- TURY: Case Report and Review of Literature Mariely Otero-Maldonado MD, Marisel Bosques-Rosado MD, Ruth Soto-Malavé MD, Brenda Deliz-Roldán MD, Jorge Bertrán-Pasarell MD, Pedro Vargas Otero MD 48 SUBACUTE THYROIDITIS AND DYSERYTHRO- POESIS AFTER INFLUENZA VACCINATION SUGGES- TING IMMUNE DYSREGULATION B LETÍN Asociación Médica DE PUERTO RICO CONTENIDO Jose Hernán Martinez MD, Eric Corder MD, Maria Uzcategui MD, Martha Garcia MD, Samuel Sostre MD, Armando Garcia MD 55 POSTERIOR REVERSIBLE LEUKOENCEPHALO- PATHY SYNDROME IN HYPERTENSIVE CRISIS COM- PLICATED WITH SEIZURE Sandra N. Maldonado-Rivera MD, Glorydela Valle-Marín MD, Mónica Santiago-Casiano MD, Edinson Camargo MD, Coromoto Palermo MD, Trevor Grant MD, José Hernán Martínez MD 60 INFLAMMATORY MYOFIBROBLASTIC TUMOR OF THE LIVER IN AN ELDERLY WOMAN FOLLOWING A SECOND LIVER BIOPSY: A Case Report Ana Beauchamp MD, Adolfo Villanueva MD, Walter Feliciano MD, Álvaro Reymunde MD 65 PROFUSE VAGINAL BLEEDING IN AN ADOLES- CENT WITH A CERVICAL MYOMA: A Case Report Lynell Pérez Colon MD, Veronica Colon MD, Joaquín Laboy Torres MD, Waleska Arias MD 67 THYROTOXIC HYPOKALEMIC PERIODIC PARALY- SIS IS A RARE BUT POTENTIALLY FATAL EMERGEN- CY: Case Report and Literature Review Jeisa Y. Gómez-Torres MD, Wilfredo E. Bravo-Llerena MD, Luis M. Reyes-Ortiz MD, Rodrigo J. Valderrábano-Wagner MD, Víctor Mariano-Mejías MD, Héctor Brunet-Rodríguez MD, Juan C. Lemos- Ramírez MD 75 Instrucciones para autores 76 Solicitud de ingreso 77 UNUSUAL PRESENTATION OF PRIMARY GASTRIC CHORIOCARCINOMA IN A 24-YEAR-OLD FEMALE PA- TIENT Mónica Santiago Casiano MD, Liza M. Paulo Malavé MD, Eduardo Fahme MD, Sandra N. Maldonado Rivera MD, Omayra González MD, William Cáceres Perkins MD, José Hernán Martínez MD 80 Boletin 103:2, CME Questions & answers Catalogado en Cumulative Index e Index Medicus Listed in Cumulative Index and Index Medicus No. ISSN Registrado en Latindex -Sistema Regional de Información en Línea para Revistas Científicas de América Latina, el Caribe, España y Portugal BOLETÍN - Asociación Médica de Puerto Rico Ave. Fernández Juncos Núm P.O.Box SANTURCE, Puerto Rico Tel.: (787) Fax: (787) Web site: Web site para el paciente: Diseño Gráfico e Ilustración digital de cubierta realizados por Juan Carlos Laborde en el Departamento de Informática de la AMPR

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6 Original Article/Artículos Originales PREOPERATIVE CLINICAL AND DEMOGRAPHIC CHARACTERISTIS IN PUERTO RICO PATIENTS REFERRED TO INPATIENT CARDIAC REHABILIATION AFTER CARDIAC SURGERY Jorge Pérez Lopez MD*, Jesús Negrón MD**, Ernesto Soltero MD, Rafael Oms MD***, Miguel Magraner MD**, Rafael Bredy MD From the *Physical Medicine and Rehabilitation Department, Baylor School of Medicine, Houston, Texas, **Internal Medicine Department, Department of Cardiothoracic Surgery, ***Physical Medicine and Rehabilitation Department, and Research Department of Hospital Damas and Ponce School of Medicine, Ponce, Puerto Rico. Address reprints requests to: Jorge Pérez MD - Programa de Educación Médica, Edificio Parra 2225,Suite 407, Ponce By Pass, Ponce, Ponce, PR, Presented at Damas Hospital Annual Scientific Meeting. Ponce, Puerto Rico, 2010 INTRODUCTION Patients with coronary artery disease (CAD) or cardiac valve disease who have undergone cardiac surgery are prime candidates for cardiac rehabilitation (CR). Cardiac rehabilitation is a multidisciplinary activity that aims to facilitate physical, psychological and emotional recovery. Inpatient CR serves as a bridge between hospital discharge after cardiac surgery and independent home living. A hospital length of stay (LOS) of seven days or less after a cardiac surgery may not be sufficient for patients who remain with some impairment to recover and be functionally adequate to incorporate into society, therefore, inpatient rehabilitation units offers an alternative to delayed discharge. Kong et al showed that there was a substantial functional improvement in inpatient rehabilitation after open-heart surgery (1). There is substantial functional improvement in inpatient rehabilitation after open-heart procedures (1). The most substantial evidence-based benefits of cardiac rehabilitation include improvement in exercise tolerance, symptoms and reduction in mortality (2). Referral for CR is a class I indication (useful and effective) in most clinical practice guidelines and despite all of this, the CR services are vastly underutilized (3). Recent studies determine that there is a low national utilization rates of CR after a myocardial infarction and coronary artery bypass graft (CABG) surgery among Medicare beneficiaries and also found in the meta-analyses that there is a 15% to 28% reductions in all cause mortality and 26% to 31% reductions in cardiac mortality (4). While there is clinical evidence that accelerated discharge programs are safe for elderly and high-risk patients (5-7), there is always a group of patients that need to undergo inpatient rehabilitation to help them incorporate into society and decrease the postoperative complications. ABSTRACT 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. Index words: preoperative, clinical, demography, Puerto Rico, inpatient, cardiac, surgery, rehabilitation Home based and supervised center based cardiac rehabilitation programs have no different outcomes in mortality of low to moderate risk patients, although the center based programs had the most favorable change (8). Another study showed similarly effective in the short term and total work capacity and health related quality of life between inpatient CR and home CR in low risk older patients (9). Multiple studies have evaluated preoperative characteristics to predict improvement and prolonged length of stay (LOS) after CABG surgery. Most of these studies have concluded that age, gender, body mass index (BMI), chronic obstructive pulmonary disease (COPD), peripheral vascular surgery (PVD), low ejection fraction, emergency surgery, diabetes mellitus, cerebrovascular disease (CVD) and renal function are associated with more postoperative functional impairment (10-13). Advanced chronological age is associated with advanced diseased states and with risk factors that can be identified preoperatively and help to decreased hospital mortality for elderly patients undergoing CABG surgery (14), making them more likely to need inpatient CR. Other investigators have used the models developed for predicting the risk of mortality and morbidity after cardiac surgery and correlated them with prolonged LOS (13-15). Some studies have found that social risk factors, like living alone or patients with small social networks, are predictors of prolonged LOS and elevated risk for mortality (16-18). Other studies found that preoperative weight loss >10% in 6 months or a BMI < 21.0 are independently related to adverse outcomes (19) and that preoperative hemoglobin less than 10 g/dl appear as an independent risk factor for mortality in CABG surgical patients (20). In relation to gender, women were found to have significantly lower functional status after CABG than men, higher hospital readmission rates and worsening depressive symptoms (21), and Herlitz et al found that female sex is an independent predictor for inferior quality of life after CABG (22). We questioned which preoperative clinical and demographic characteristics are present in patients in Puerto Rico that required inpatient rehabilitation after cardiac surgery. The objectives of this study were to: (a) identify Puerto Rico patients that had cardiac surgery and review their preoperative demographic characteristics and co morbidities, (b) examine whether they were referred to an inpatient CR or discharged home and, (c) compare the preoperative characteristics of patients referred to an inpatient CR vs. those that where discharged home. An additional objective was to correlate whether prolonged length of stay in surgical intensive care units (SICU) was associated with patients needing inpatient rehabilitation. METHODS All patients who underwent CABG surgery with or without cardiac valve procedure at Damas Hospital in Ponce, Puerto Rico, between January 2007 and December 2009, were identified using a computer database. After receiving Institutional Review Board approval from Ponce School of Medicine, we implemented a descriptive cross-sectional study to review preoperative clinical and demographic characteristics, functional status and comorbidities. In the study, variables were described as follow: -Age: a numerical variable being the cut off point 65 years old (< than 65 or > 65 years old). Elderly patients are at high risk of physical deconditioning after prolonged hospitalizations. -Gender: a categorical variable; either male or female. Female gender is associated with more postoperative functional impairment when compare with men (20). Herlitz and coworkers identified female sex as an independent predictor for inferior quality of life after CABG (23). -Body Mass Index (BMI): a numerical variable; being the cut off point > 24.9 kg/m2 (normal weight from overweight and obese). -Diabetes Mellitus with Hemoglobin A1C (HbA1C): a numerical variable; being the cut off point 6.5%. -Cerebrovascular accident: a categorical variable;either yes or no. -Chronic Obstructive Pulmonary Disease (COPD): a categorical variable; either yes or no. -Peripheral Vascular Disease (PVD): a categorical variable; either yes or no. -Ejection Fraction (EF): a numerical variable; being the cut off point 45%. -Living alone: a categorical variable; either yes or no. Living alone is an independent risk factor for prognosis after myocardial infarction. The recurrent cardiac event rate at 6 months was 15.8% in the group living alone versus 8.8% in the group not living alone (17). -Caregiver availability: a categorical variable; either yes or no. -Status of surgery (elective/urgent/emergency): a categorical variable; either elective or urgent/emergency surgery. -Preoperative Hemoglobin: a numerical variable; being the cut off point < 10 mg/dl as defined by the World Health Organization (WHO) as a severe anemia in cardiac patients undergoing CABG surgery (10). -Functional Status: a categorical variable; either totally independent or partially/totally dependent. -Smoker: a categorical variable; either a yes or no (including in yes, the current smoker or previous smoker). -Prior CABG surgery: a categorical variable; either a yes or no answer. -Manual muscle testing: a categorical variable; being either 5/5 full strength or deficiency in any muscle of any extremity defined as weakness. -Valve surgery, defined as a categorical variable; being either yes or no. The categorical variables were expressed with percentages and the numerical variables were expressed with average, standard deviation (SD), maximum (Vmax) and minimum (Vmin) numbers. Odds ratios (OR) were calculated by using a 2x2 table for each variable. Odds ratios were calculated to assess the independent association of the variables in the study. A p < 0.05 was considered statistically significant. 6 Asociación Médica de Puerto Rico Asociación Médica de Puerto Rico 7 RESULTS From January 2007 through December 2009 a total of 439 patients underwent CABG surgery at Damas Hospital. Of those 439 patients, a total of 21 patients were

7 referred to skill nurse facilities (SNF), being 4.8% in those 3 years. 69 randomized records were selected for study. Of those 69, four records were not found, resulting in a sample of 65 records for review. The 65 records were divided in seventeen records referred for inpatient rehabilitation and 48 records of patients discharged home. The mean age of the cardiac rehabilitation patients was 68.4 years with 53% females. The control group had a mean age of and 41.70% were females (see Figure 1). Numerical variables of the rehabilitation and control groups are depicted in Table 1 and 2. Categorical variables of the rehabilitation and control groups are included in Table 3. Table 4 display the odds ration for each studied variable. The overall length of stay, postoperative and intensive care unit length of stay of both the rehabilitation and control group can be found in Tables 4, 5 and 6. Figure 1. Patient s distribution. DISCUSSION In the present study, we found certain characteristics that are more likely to be present in patients referred to inpatient rehabilitation. Among these characteristics, age higher than 65, no caregiver availability, a cardiac valve procedure concomitantly with CABG surgery, any previous weakness or paralysis in any extremity, functional status either partially dependent or totally dependent, and status of surgery either urgent or emergency were the ones that gave the most probability to be referred to inpatient rehabilitation. A manual muscle testing of less than 5/5 in any extremity prior to the CABG surgery was the most important predictor for the need of inpatient rehabilitation in our study. Patients with age greater than 65 had a 4.96 higher probability than younger patients to be referred to inpatient rehabilitation. In comparison with the study of Anderson J. et al, they found that the odds of a patient higher than 65 years old was 9.4 times more likely to be transferred to cardiac rehabilitation than patients younger than 55. The most likely reason for this is that individuals with age of 65 or higher tend to have more comorbidities and significantly higher cardiovascular risk (5). On the other hand, Brown TM et al (12), found that older patients, non-st segment elevation myocardial infarction and the presence of most comorbidities were associated with decreased odds ratio of cardiac rehabilitation referral. The probability of poorly controlled diabetics with a HgbA1C >7% was higher for referral to inpatient rehabilitation with an odds ratio of Patients with an ejection fraction of <45% had an odds ratio of 1.03, which was not significant in our study. In the study of Anderson J. et al (4), they used NYHA functional class and the class 3 was not related for referral and even class 4 had an odds ratio of 1.3, not strongly associated with referral. Female gender is associated with more postoperative functional impairment when compared with men as Koch et al (20), demonstrated. In our study, females had a higher need for inpatient cardiac rehabilitation referral, with an odds ratio of Women, particularly elderly women, are less likely to be referred for cardiac rehabilitation and, when referred, are less likely to attend as stated by Wenger (24). In the study of Brown et al (12), individuals referred to cardiac rehabilitation were more likely to be male. Patients with comorbidities like COPD and PVD gave a probability of being referred to inpatient rehabilitation of 1.17 and 1.33 respectively. These values are similar to those reported by Anderson (5). In our study, comorbidities like COPD, PVD or diabetes were not found to be strong predictors for referral to inpatient rehabilitation after cardiac surgery. Meanwhile, smoking, either past or current, had a less probability of being referred to inpatient rehabilitation with an odds ratio of A BMI higher than 24.9 kg/m2 was not significant in our study. 8 Asociación Médica de Puerto Rico Variables Age BMI (kg/m2) HgbA1C (%) Ejection Fraction (%) Pre-op Hemoglobin (mg/dl) unknown unknown unknown unknown unknown unknown unknown Average 6.98 SD Vmax Vmin Table 1. Numerical variables of the rehabilitation group. Variables Age BMI (kg/m2) HgbA1C (%) Ejection Fraction (%) Pre-op Hemoglobin (mg/dl) unknown unknown V arikab unknown unknown Average Standard deviation Vmax Vmin Continue... Studies suggest that adequate social support is essential for functional recovery and maintenance of health and at the same time for incorporation to the community. Living alone is an independent risk factor for prognosis after myocardial infarction (5). The recurrent cardiac event rate at six months was 15.8% in the group living alone versus 8.8% in the group not living alone as demonstrated by Case et al (17). Patients living alone had a probability 2.65 times more likely of being referred to inpatient rehabilitation. In this variable, Anderson J. et al (5), found a probability of 1.7 times higher for referral. When compared with no caregiver availability, in our study there was a times of being referred to inpatient rehabilitation versus 3.9 times reported by Anderson (5). In both studies, the absence of a caregiver after surgery had a higher probability of referral to inpatient rehabilitation than living alone. We hypothesize that patients living alone that have a caregiver after cardiac surgery incorporate to society more easily. A preoperative assessment of social support is very important to determine the needs for referral to inpatient cardiac rehabilitation. In our study, the surgery status, whether urgent or emergency, was an important factor for inpatient cardiac rehabilitation referral with an odds ratio of 6. This is most likely due to the fact that elective surgery is planned and the patient is more stable, but urgent/emergency procedures are usually after recent acute myocardial infarction or decompensated heart failure and the patients are usually more compromised and benefit the most from a cardiac rehabilitation program. To our knowledge, no other study in the literature has evaluated this important factor for referral to inpatient rehabilitation. Further studies are needed to confirm the results of our work. The fact that a patient was having problems for performing activities of daily living (functional status) prior to the cardiac surgery was an important factor. Patients who were partially or totally dependent had a times more probability of being referred to an inpatient rehabilitation facility. Anderson found that functional status was a predictor for prolonged length of stay in hospital greater than seven days and not for transfer to a rehabilitation facility (5). Tools like the Functional Independence Measure (FIM) score, which is a standardized instrument used as an assessment scale designed to measure uniformly changes in the degree of disability, are highly recommended to study in more detail whether functional status serves as a preoperative characteristics for referral of inpatient rehabilitation.

8 Variables Age BMI (kg/m2) HgbA1C (%) Ejection Fraction (%) Pre-op Hemoglobin (mg/dl) unknown unknown V arikab unknown unknown Average Standard deviation Vmax Vmin Table 2. Numerical variables of the control group. Variables Gender CVA COPD PVD Living Alone Rehab Group Male: 8 (47%) Female: 9 (53%) Control Group Male: 28 (58.30%) Female: 20 (41.70%) Variables Caregiver availability Smoker Yes: 13 (76.50%) No: 4 (23.50%) Control Group Yes: 47 (98%) Yes: 3 (17.60%) No: 14 (82.40%) Yes: 0 (0%) No: 48 (100%) Status of surgery Elective: 11 (64.70%) Urgent: 6 (35.30%) Emergency: 0 (0%) Elective: 44 (91.70%) No: 1 (2%) Urgent: 3 (6.30%) Emergency: 1 (2%) Yes: 4 (23.50%) No: 13 (76.50%) Yes: 10 (20.80%) No: 38 (79.20%) Functional Status TI: 13 (76.50%) PD: 4 (23.50%) TD: 0 (0%) TI: 47 (98%) Yes: 4 (23.50%) No: 13 (76.50%) Yes: 9 (18.70%) No: 39 (81.30%) Smoker Yes: 5 (29.40%) No: 12 (70.60%) Yes: 27 (56.30%) PD: 1 (2%) No: 21 (43.70%) TD: 0 (0%) Yes: 4 (23.50%) No: 13 (76.50%) Yes: 5 (10.40%) No: 43 (89.60%) We would like to encourage further research involving the FIM scores as a variable for predicting the need of inpatient rehabilitation after cardiac surgery. Preoperative characteristics like CVA, hemoglobin <10 mg/dl and previous CABG surgery were not able to be assessed in our study due to lack of sample. There was an odds ratio of 1.7 in CVA for rehabilitation group. Anderson et al found that this and other co morbidities where associated with transfer to a rehabilitation unit (5). Manual muscle testing is a subjective measure, which is score from 0 to 5, where 0 is no contractile activity and 5 is when the patient can hold the position against maximum resistance. In our study, the grades of muscle testing were written in the record by either the internal medicine doctor, physiatrist and/or residents doctors. Since is a subjective test, we decided to divide the patients in two groups, either the ones with no deficiency or weakness (having 5/5 in all extremities) or the ones that had some weakness in some extremity before the surgery. We found that this was the greatest risk factor, giving a times more probability to being referred for inpatient rehabilitation if there was some weakness prior to the cardiac surgery. Our data suggest that a weakness prior to the surgery will contribute to functional limitation, which at the same time limit or prolong the cardiac rehabilitation. These patients might benefit the most of inpatient rehabilitation program, where they can improve exercise tolerance, be as independent as possible and at the same time improve any functional disability. Valve surgery in conjunction with CABG surgery is sometimes necessary in these patients. Our data suggest a 4.92 times more probability of being referred to inpatient rehabilitation when there is concomitant valve surgery. Similar to our study, Anderson observed a 1.9 odds ratio in these patients (5). At the end, when both groups were compared with the overall LOS, postoperative and SICU stay, the rehabilitation group had a more prolonged length of stay and more hours in SICU before being transferred to SNF when compared with the control group. This might be explained by secondary complications during hospitalizations that could contribute to de-conditioning syndrome. Our study is limited by the fact that this was a retrospective study, and all the information was acquired by record review and by a small sample size. In summary, our study showed that older patients, living alone with no caregiver availability, impaired functional Variables Prior CABG surgery No: 17 (100%) Manual Muscle Testing Less than 5/5 in some extremity: 8 (47%) Control Group Yes: 0 (0%) 5/5 in all extremities: 47 (98%) No: 48 (100%) Less than 5/5 in some extremity: 1 (2%) status, surgical status (urgent/emergency surgery), concomitant valve surgery and prior weakness contribute to a functional decline, and these patients are more likely to be referred to inpatient cardiac rehabilitation. Additionally, based on our results, both the LOS in the hospital and the SICU time were found to be prolonged in patients that were referred to inpatient rehabilitation. The ability to predict which patients might need inpatient rehabilitation prior to surgery could give health care professionals time for education, program planning and facilitate referral to improve patient care. Facilities like SNF, offer an important alternative for patients who need to continue acute care even after the hospitalization. Understanding factors that are associated with referral to inpatient rehabilitation after cardiac surgery will give health care providers the ability to develop appropriate policies and optimize resource utilization. Preoperative characteristics could help physicians to start patient education, program planning and referral to inpatient rehabilitation as needed for improvement of patient care. Participation in CR is associated with reductions in mortality and recurrent myocardial infarction. Participation in CR is dependent on physician referral. Numerous barriers for referral have been studied, which include cost, lack of insurance coverage, time consuming and lack of referral from the health care. Valve Surgery No: 14 (82.40%) Yes: 2 (4.10%) No: 46 (95.90%) Table 3. Categorical variables of the rehabilitation and control groups. Variables Odds Ratio Age > BMI > HgbA1C >6.5% 0.94 HgbA1C >7.0% 1.29 Ejection Fraction <45% 1.03 Pre-op hemoglobin <10 mg/dl unable to assess Gender (being a female) 1.57 CVA unable to assess COPD 1.17 PVD 1.33 Living alone 2.65 No caregiver availability Status of surgery (urgent/emergency) 6 Functional status (PD or TD) Smoker (past or current) 0.32 Prior CABG surgery unable to assess Manual Muscle Testing (Less than 5/5) Valve Surgery 4.92 Table 4 display odds ratio for each variable professionals. Failure to refer patients to CR represents one of the most easily overcome barriers REFERENCES 1. Kong K.H., Kevorkian C.G. and Rossi C.D. (1996) Functional outcomes of patients on a rehabilitation unit after open heart surgery Journal of Cardiopulmonary Rehabilitation, 16 (6): (1) 2. Herman C., Karolak W., Yip A.M., Buth K.J., Hassan A. and Legare J.F. (2009) Predicting prolonged intensive care unit length of stay in patients undergoing coronary artery bypass surgery: development LOS (days) LOS after Surgery SICU (hours) (days) Average Standard deviation Vmax Vmin Table 5. Rehabilitation group length of stay, length of stay after surgery and surgical intensive care unit: of an entirely preoperative scorecard Interactive Cardiovascular and Thoracic Surgery, 9: Welke K.F., Stevens J.P., Schults W.C., Nelson E.C., Beggs V.L. and Nugent W.C. (2003) Patient characteristics can predict improvement in functional health after elective coronary artery bypass grafting The Annals of Thoracic Surgery, 75: Suaya J., Shepard D., Normand S.L., Ades P., Prottas J. and Stason W. (2007) Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery Circulation, 116: (4) 5. Anderson J.A., Petersen N.J., Kistner C., Soltero E. and Willson P. (2006) Determining predictors of delayed recovery and the need for transitional cardiac rehabilitation after cardiac surgery Journal of the American Academy of Nurse Practitioners, 18: Peterson E.D., Coombs L.P., Ferguson T.B., Shroyer A.L., De- Long E.R., Grover F.L.and Edwards F.H. (2002) Hospital variability in length of stay after coronary artery bypass surgery: results from the society of thoracic surgeon s national cardiac database The Annals of Thoracic Surgery, 74: Asociación Médica de Puerto Rico 11

9 LOS LOS SICU (days) after (hours) surgery (days) Average Standard Deviation Vmax Vmin Table 6. Control group length of stay, length of stay after surgery and surgical intensive care unit: 7. Weintraub W.S., Jones E.L., Craver J., Guyton R. and Cohen C. (1989) Determinants of prolonged length of hospital stay after coronary bypass surgery Circulation, 80: Sansone G.R., Alba A. and Frengley J.D. (2002) Analysis of FIM instrument scores for patients admitted to an inpatient cardiac rehabilitation program Archives of Physical Medicine and Rehabilitation, 83: Jolly K., Taylor R., Lip G. and Stevens A. (2006) Home based cardiac rehabilitation compared with centre based rehabilitation and usual care: A systematic review and meta analysis International Journal of Cardiology, 111: Lazar H., Fitzgerald C., Gross S., Heeren T., Aldea G. and Shemin R. (1995) Determinants of length of stay after coronary artery bypass graft surgery Circulation, 92: Bell M.L., Grunwald G.K., Baltz J.H., McDonald G.O., Bell M.R., Grover F.L. and Shroyer L.W. (2008) Does preoperative hemoglobin independently predict short term outcomes after coronary artery bypass graft surgery The Annals of Thoracic Surgery, 86: Brown T., Hernandez A., Bittner V., Cannon C., Ellrodt G., Liang L., Peterson E., Pina I., Safford M. and Fonarow G. (2009) Predictors of cardiac rehabilitation referral in coronary artery disease patients: Findings from the American Heart Association s get with the guidelines program Journal of the American College of Cardiology, 54: Lazar H.L., Fitzgerald C.A., Ahmad T., Bao Y., Colton T., Shapira O.M. and Shemin R.J. (2001) Early discharge after coronary artery bypass graft surgery: Are patients really going home earlier? The Journal of Thoracic and Cardiovascular Surgery, 121: Higgins T., Estefanous F., Loop F., Beck G., Blum J. and Paranandi L. (1992) Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients JAMA, 267: Tu J., Jaglal S. and Naylor C.D. (1995) Multicenter validation of a risk index for mortality, intensive care unit stay, and overall hospital length of stay after cardiac surgery Circulation, 91: Brummett B., Barefoot J., Siegler I., Clapp-Channing N., Lytle B., Bosworth H., Williams R. and Mark D. (2001) Characteristics of socially isolated patients with coronary artery disease who are at elevated risk for mortality American Psychosomatic Society, 63: Case R., Moss A., Case N., McDermott M. and Eberly S. (1992) Living alone after myocardial infarction: impact on prognosis JAMA, 267: Johnston G., Gross J.R., Malmgren J.A. and Spertus J.A. (2004) Health status and social risk correlates of extended length of stay following coronary artery bypass surgery The Annals of Thoracic Surgery, 77: Horneffer P.J., Gardner T.J., Manolio T.A., Hoff S.T., Rykiel M.F., Pearson T.A., Gott V.L., Baumgartner W.A., Borkon A.M., Watkins L. and Reitz B.A. (1987) The effects of age on outcome after coronary bypass surgery Circulation, 76:v6-v Koch C.G., Khandwala F., Cywinski J.B., Ishwaran H., Estefanous F.G., Loop F.D. and Blackstone E.H. (2004) Health related quality of life after coronary artery bypass grafting: A gender analysis using the Duke activity status index The Journal of Thoracic and Cardiovascular Surgery, 128: Van Venrooij L., de Vos R., Borgmeijer-Hoelen M., Haaring C. and de Mol B. (2008) Preoperative unintended weight loss and low body mass index in relation to complications and length of stay after cardiac surgery The American Journal of Clinical Nutrition, 87: Marchionni N., Fattirolli F., Fumagalli S., Oldrige N., Del Lungo F., Morosi L., Burgisser C. and Masotti G. (2003) Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial Circulation, 107: Herlitz J., Wiklund I., Caidahl K., Karlson B., Sjoland H. and Hartford M. (1999) Determinants of an impaired quality of life five years after coronary artery bypass surgery Heart, 81: Wenger N.K. (2008) Current status of cardiac rehabilitation Journal of the American College of Cardiology, 51 (16): Asociación Médica de Puerto Rico RESUMEN Pacientes con cirugía por enfermedad coronariana o por enfermedad valvular son candidatos ideales para rehabilitación cardíaca. La rehabilitación cardíaca es una actividad multidisciplinaria que busca facilitar la recuperación física, psicológica y emocional del paciente. Múltiples estudios han evaluado las características preoperatorias de los pacientes que van a rehabilitación cardíaca para predecir mejoría y duración de la hospitalización post quirúrgica. Nosotros nos preguntamos cuáles son las características clínicas y sociodemográficas preoperatorias de los pacientes que requieren rehabilitación después de cirugía cardíaca. Metodología: Revisión de expedientes evaluando características clínicas y sociodemográficas de pacientes con cirugía cardíaca y su relación con el referido o no a rehabilitación cardíaca. Se evaluaron 65 expedientes distribuidos 17 al grupo de rehabilitación cardíaca intrahospitalaria y 48 al grupo que fue Educación Médica Continua Mantengase informado visitando periódicamente nuestro website letter dado de alta sin rehabilitación cardíaca. Resultados: Las características preoperatorias que se relacionaron con referido postquirúrgico a rehabilitación cardíaca intrahospitalaria fueron: edad > 65 años, vivir solo sin cuidados disponible, estado funcional alterado, cirugía de urgencia o emergencia, cirugía valvular concomitante, índice de masa corporal > 24.9, Hgb A1C > 7%, género femenino, historial de accidente cerebrovascular, historial de enfermedad obstructiva cronica pulmonar, e historia de enfermedad vascular periférica. Conclusión: Una identificación previa de estas variables podría orientar a una intervención temprana por el departamento de destreza de enfermería. Esta intervención temprana podría disminuir complicaciones ulteriores y disminuir la estadía en el hospital, la estadía postoperatoria y la duración del paciente en la unidad de cuidados intensivo. La Asociación Médica distribuye por el primer boletín semanal de información médica, el cual es enviado a médicos de Puerto Rico, si usted aún no lo recibe, verifique en su bandeja de spam o junk- o suscríbase gratuitamente en nuestro website en el link eletter Unidos y Comunicados Somos Más Eficientes

10 samurai s budo MARTES, MIERCOLES Y JUEVES - 6:00 A 7:30 PM 1305 FERNANDEZ JUNCOS AVE. - SAN JUAN - PUERTO RICO COSTO DE CADA CLASE POR PERSONA $ 5 INFORMES: (787) Todo el aprendizaje en un solo sistema: MOKUSHO (MEDITACION) KUJI-IN & KIKKUO ESPADA SAMURAI: KENJUTSU & IAIDO COMBATE SIN ARMAS: KARATE KEMPO SEGUN EL CODIGO TRADICIONAL DEL BUDO JAPONES Caduet es una pastilla * para mi presión arterial alta... y para mi colesterol elevado. Caduet combina dos medicamentos comprobados en una sola pastilla: Norvasc (besilato de amlodipina) para la presión arterial alta y Lipitor (atorvastatina cálcica) para reducir el colesterol elevado. "Caduet hace más fácil manejar mis dos condiciones. Caduet es una pastilla que, conjuntamente con la dieta y el ejercicio, reduce efectivamente tanto la presión arterial alta como el colesterol elevado. Caduet viene en una variedad de dosis de manera que su médico puede elegir la dosis adecuada para usted. Pregunte a su médico sobre Caduet. Caduet. Dos medicamentos, una pastilla. Aprenda más en *Caduet puede usarse solo o en combinación con otros medicamentos antihipertensivos. Por favor vea el resumen sobre información al paciente en la siguiente página. INFORMACION IMPORTANTE: Caduet es un medicamento para venta con receta que combina 2 medicamentos, Norvasc y Lipitor. Norvasc se usa para tratar la presión arterial alta (hipertensión), el dolor de pecho (angina) o las arterias cardiacas bloqueadas (enfermedad de las arterias coronarias). Lipitor se usa, junto con la dieta y el ejercicio, para reducir el colesterol elevado. Se usa también para reducir el riesgo de ataques cardiacos y derrames en personas con factores múltiples de riesgo de enfermedad cardiaca, como historial familiar, presión arterial alta, edad, HDL-C bajo o fumar. Caduet no es para todo el mundo. No es para personas con problemas del hígado ni para mujeres que lactan, que están embarazadas o que puedan quedar embarazadas. Si usa Caduet, infórmele a su médico si siente algún dolor o debilidad muscular nuevos. Esto podría ser señal de efectos secundarios musculares poco comunes, pero graves. Informe a su médico sobre todas las medicinas que usa para ayudar a evitar interacciones graves de fármacos. El médico debe ordenarle exámenes de sangre para verificar su función hepática antes del tratamiento y durante el mismo y podría ajustar la dosis. Si tiene algún problema cardiaco, asegúrese de informárselo a su médico. Los efectos secundarios más comunes son edema, dolor de cabeza y mareo. Éstos tienden a ser leves y, a menudo, desaparecen. Caduet es una entre varias opciones para tratar la presión arterial alta y el colesterol elevado, además de la dieta y el ejercicio, que usted y su médico pueden considerar. Le exhortamos a notificar a la Administración de Drogas y Alimentos (FDA) sobre los efectos secundarios negativos de los medicamentos con receta. Visite o llame FDA Pfizer Inc. Todos los derechos reservados. CTU00211PR

11 DATOS IMPORTANTES PARA DISMINUIR LA PRESIÓN ARTERIAL ALTA Y EL COLESTEROL ELEVADO. La presión arterial alta y el colesterol elevado son más que simples números. Son factores de riesgo que no deben ignorarse. Si su médico le informó que tiene la presión arterial alta y el colesterol elevado, usted puede estar expuesto a un riesgo mayor de sufrir un ataque cardiaco o un accidente cerebrovascular. Sin embargo, la buena noticia es que usted puede tomar los pasos necesarios para disminuir su presión arterial y su colesterol. Con la ayuda de su médico y medicamentos como CADUET, conjuntamente con dieta y ejercicio, usted podría estar en vías de disminuir su presión arterial y su colesterol. Está listo para comenzar una alimentación adecuada y ejercitarse un poco más? Hable con su médico y visite la página en Internet de la Sociedad Americana del Corazón, PARA QUIÉN ES CADUET? Quién puede tomar CADUET: Los adultos que necesitan disminuir su presión arterial alta Y que no pueden reducir suficientemente su colesterol con dieta y ejercicio Quién NO debería tomar CADUET: Mujeres que están embarazadas o piensan que puede estarlo o tiene planes de quedar embarazadas. CADUET puede perjudicar a su bebé por nacer. Si queda embarazada, deje de tomar CADUET y llame de inmediato a su médico. Mujeres que están lactando. CADUET puede pasar a la leche materna y perjudicar a su bebé. Personas que tienen problemas del hígado. Personas alérgicas a algún ingrediente de CADUET. ANTES DE TOMAR CADUET Háblele a su médico: Acerca de todos los medicamentos que está tomando, incluso medicamentos con y sin receta, las vitaminas y los suplementos herbáceos. Si ha sufrido enfermedades cardiacas Si ha tenido dolor o debilidad muscular Si toma más de dos bebidas alcohólicas al día Si tiene diabetes o problemas de los riñones Si ha tenido problemas de la tiroides INFORMACIÓN SOBRE CADUET CADUET es un medicamento con receta que combina Norvasc (besilato de amlodipina) para tratar la presión arterial alta y Lipitor (atorvastatina cálcica) que se usa para disminuir el colesterol elevado, en una pastilla. CADUET, conjuntamente con dieta y ejercicio, trata tanto la presión arterial alta (hipertensión) como el colesterol elevado. CADUET puede disminuir el riesgo de un ataque cardiaco o accidente cerebrovascular en pacientes con factores de riesgo de enfermedades cardiacas como: historial familiar de enfermedades cardiacas, presión arterial alta, HDL-C bajo, diabetes, fumar o ser mayor de 55 años. CTU00211PR (CAD-oo-et) POSIBLES EFECTOS SECUNDARIOS DE CADUET Efectos secundarios graves en un número pequeño de personas: Problemas musculares que pueden conducir a problemas renales, incluso insuficiencia renal. Usted tiene una mayor probabilidad de tener problemas musculares si está tomando otros medicamentos junto con CADUET. Problemas hepáticos. Su médico puede hacerle análisis de sangre para verificar la función del hígado antes de comenzar a tomar CADUET y mientras lo está tomando. Los síntomas de problemas musculares y hepáticos incluyen: Debilidad, sensibilidad o dolor que ocurre sin una buena razón, especialmente si también tiene fiebre o se siente más cansado que de costumbre Náuseas, vómitos, dolor estomacal Orina de color marrón o de tonalidad oscura Se siente más cansado que de costumbre La piel o la parte blanca de los ojos se torna amarilla Dolor de pecho. A veces el dolor de pecho no desaparece o empeora o puede sufrir un ataque cardiaco. Si esto sucede, llame al médico o vaya de inmediato a la sala de emergencia. Los efectos secundarios más comunes de CADUET incluyen: dolor de cabeza cansancio dolor estomacal gases estreñimiento mareos somnolencia extrema náuseas erupción diarrea hinchazón de las piernas o los tobillos (edema) sensación de calor en la cara (ruborización) latidos irregulares del corazón (arritmias) latidos bien rápidos del corazón (palpitaciones) dolor en los músculos y en las articulaciones Hable con su médico o con su farmacéutico sobre los efectos secundarios que le molestan o que no desaparecen. Hay otros efectos secundarios de CADUET. Pida una lista completa a su médico o a su farmacéutico. CÓMO TOMAR CADUET Qué hacer: Tome CADUET una vez al día, exactamente como le indique el médico. Intente ingerir alimentos saludable para el corazón mientras toma CADUET. Tome CADUET todos los días a cualquier hora del día, con o sin alimentos. Si olvida una dosis, tómela tan pronto se acuerde. Pero si han transcurrido más de 12 horas desde que olvidó la dosis, espere. Tome la próxima dosis a la hora establecida. Qué no hacer: No parta las tabletas de CADUET antes de tomarlas. No deje de tomar nitroglicerina si la toma para el dolor de pecho (angina). No cambie o deje de tomar su dosis sin hablar antes con su médico. No comience a tomar medicamentos nuevos o deje de tomar cualquier medicamento que esté tomando sin antes hablar con su médico. NECESITA MAYOR INFORMACIÓN? Pregúntele a su médico, proveedor de servicios de salud o farmacéutico. Este documento es sólo un resumen de la información más relevante. Vaya a CADUET está incluido en el programa de ahorros en medicamentos con receta Together RX Access, Para información adicional llame al o visite Rx únicamente Fabricado por Pfizer Ireland Pharmaceuticals, Dublin, Irlanda Distriubido por Pfizer Labs, División de Pfizer, Inc. Nueva York, NY Pfizer, Inc. Todos los derechos reservados. Impreso en los Estados Unidos de Norteamérica. CTIF Rev. 1, ABSTRACT 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 I, 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. Index words: body, mass, index, total, knee, latin, osteoarthritis INTRODUCTION Osteoarthritis (OA) is the most common joint disease and one of the most prevalent symptomatic health condition in older individuals. OA can affect any synovial joint, but most commonly occurs in the hand, foot, knee, spine, and hip joints (1). Knee OA is the most common form of arthritis (2). Symptomatic knee OA affects more than 10% of adults in the United States (3). Osteoarthritis of weight bearing joints has consistently been linked to obesity, defined as a body mass index (BMI) greater than 30 kg/m2. Within these weight-bearing joints, obesity is most strongly linked to OA of the knee (4). Obesity has drawn interest in recent studies because of its modifiable status and its association with OA (4-11). It has been hypothesized that obesity may lead to OA through increased joint pressure, accumulated microtrauma, and disruption of normal chondrocyte metabolism (12). Obesity has doubled and reached epidemic proportions in the United States over the last 30 years (13). Recent data shows that 30% or over 60 million adults, 20 years of age and older are classified as obese (BMI > 30 kg/ m2) (14). Another 35% of adults are overweight (BMI = kg/m2) (13). Men and women from all ethnic, socioeconomic, and age groups are affected. There has been little research, if any, for the implications of BMI on OA in the Latin community. CORRELATION BETWEEN BODY MASS INDEX AND NEED FOR TOTAL KNEE REPLACEMENT IN A GROUP OF LATIN PATIENTS WITH KNEE OSTEOARTHRITIS Daniel Rivera MD*, Juan Ortiz MD*, Carlos Colón MD***, Juan Colón MS, Miguel Magraner MD**, Rafael Bredy MD* From the *Transitional Residency Program, **Internal Medicine Residency Program, ***Surgery Department, Hospital Damas, and the Ponce School of Medicine, Ponce, Puerto Rico. Presented at the 58th Damas Hospital Annual Scientific Meeting. Ponce, Puerto Rico, 2009 Address reprints request to: Daniel Rivera MD - Programa de Educación Médica, Edificio Parra 2225, Suite 407, Ponce By Pass, Ponce, Ponce, PR, If a direct relationship between the BMI and the severity of knee OA is established, the reduction of obesity, being a modifiable risk factor, could be used as a goal to decrease the severity of the disease and potentially prevent the need of total knee replacement (TKR) in Latin patients with knee OA. This would underscore a need for greater use of clinical and public health interventions, especially those that address weight loss and self-management, to reduce the impact of having knee OA. We wonder what is the relationship between the BMI and need for TKR in a group of Latin patients with knee OA. We propose that there is a direct relationship between the degree of obesity and the severity of knee OA. Our study objectives were: 1) Identify a group of Latin patients with knee OA. 2) Identify in all of these patients the ones that underwent TKR and the ones who did not. 3) Identify the BMI of these patients. 4) Identify the risk of requiring TKR attributable to being obese on these patients. Asociación Médica de Puerto Rico 17

12 METHODS The study consisted of a retrospective, chart review type case-control study. Sociodemographic and clinical data from the medical charts of patients being evaluated for knee OA during 2008 were compiled into a standardized form. The form included sociodemographic variables like ethnicity, age, gender and hometown, and clinical information such as weight, height, BMI and initial recommended management. Patients with the already mentioned secondary causes of arthritis were excluded to avoid potential confounding factors, other than BMI status, playing a role in the severity of the knee OA. There were two kinds of management recommendation: Medical (any means of treatment other than TKR) and TKR (patients native tibio-femoral joint is replaced with a prosthetic joint). RESULTS We reviewed 112 charts with the following distribution: 100 subjects included and 12 subjects excluded. The reason for exclusion were as follow: seven due to history of direct trauma to the affected knee; 1 due to Systemic Lupus Erythematosus; 1 due to Gout and 3 due to Rheumatoid Arthritis. Results are systematically depicted in Tables 1 to 5. Gender Age group Female Male Grand Total Grand Total Table 1: Gender distribution according to age group Management Risk TKR Medical Total Exposed (Obesity Class I, Obesity Class II, Obesity Class III) Nonexposed (Underweight, Normal weight, Overweight) Total Our universe was any patient with diagnosis of knee OA. As a pilot study, the sample was set arbitrarily to 112 patients. Knee OA diagnosed patients evaluated within 2008 were identified by CPT code through the electronic billing computer program and out of those patients 112 charts were randomly pulled out from the medical record shelves. The patients were evaluated by an orthopedic surgeon in Damas Hospital-Ponce, PR during 2008 with age of 21 to 89 years, female and male, Latin for ethnicity (Latin: defined as any person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) (15). The Inclusion criteria was a patient with diagnosis of knee OA and the exclusion criteria was knee OA not due to secondary causes such as congenital disorders of joints, Inflammatory diseases such as Lyme disease, Systemic Lupus Erythematosus, Gout, Rheumatoid arthritis, septic arthritis, direct trauma to the affected knee, Marfan s syndrome, Alkaptonuria, Hemochromatosis or Wilson s disease. The time period of intervention and outcomes was January to December 2008 and the time period of data collection was February to March Trying to identify the risk of requiring TKR attributable to being overweight, these patients were divided into two groups: individuals initially recommended to undergo TKR surgery and individuals recommended to undergo conservative management. Then, depending on the BMI, patients were placed into the following categories: underweight, normal, overweight, obesity class I, obesity class II, and obesity class III. Initial management recommendation, whether medical or surgical, was then analyzed and compared between the patients of each of the BMI subgroups. Analyses were further adjusted for age, gender and hometown. A 2x2 table was then used to calculate the odds ratio for undergoing surgical management in obese and non-obese patients. For purposes of comparison, obese patients were considered as the exposed group, while patients that were underweight, normal or overweight were considered as the unexposed group. The Body Mass Index (BMI) was a measure of a person s body mass calculated as weight in kilograms divided by the square of the height in meters reported in kg/m2 under the following classification: Underweight kg/m2, Normal kg/m2, Overweight kg/m2, Obesity class I kg/m2, Obesity class II kg/m2, Obesity class III kg/m2. DISCUSSION In the present study, obesity was associated with an increased risk of TKR recommendation as initial management. According to this study it can be inferred that Latin patients seem to have a similar effect of body mass on the severity of knee OA, as other studied populations (16-20). Overall in this study, medical management markedly dominated as the preferred initial management recommendation. None of the patients with normal or below normal weight had TKR as the management chosen. Only obese subgroups had significant number of patients that were recommended TKR. However, the only BMI classification that had higher surgical versus medical management was the Obesity Class II subgroup. There may be several reasons that were not taken into consideration in this study that might account for these findings; for example, additional comorbidities in obese patients might render them poorer candidates for surgery (21). Also, judging by the demographic data collected in this study, there seems to be a predilection to consider surgery in the 60 to 79 age group. This might mean that, even if a patient is severely obese, if the patient is younger than 60 years of age, TKR might not be considered as the initial management, probably to avoid numerous future revisions (22-23). If the patient is older than 80 years of age, TKR might also not be considered as the initial management, probably due to increased surgical risks in elderly individuals (23-25). One of the possible strategies to avoid this problem is instead of relying on the initial management recommendation to infer the severity of the OA, knee radiographs of each patient can be evaluated and through a standardized OA grading system, like the Kellgren/Lawrence grading system, the severity of the OA can be established beforehand. With this in mind, efforts to further investigate and report the reason for recommending medical over surgical management in patients with severe knee OA can then follow. Even though this study clearly supports the idea of obesity playing a role in the severity of knee OA in Latin individuals, the study clearly has its limitations, yet it opens the doors for future studies regarding this matter. REFERENCES 1. Flugsrud G., Nordsletten L., Espehaug B.. Risk factors for total hip replacement due to primary osteoarthritis. Arthritis Rheumatism 2002; 46(3): Gender BMI Classification Female Male Grand Total Underweight Normal Weight Overweight Obesity Class I Obesity Class II Obesity Class III Grand Total Table 2: Gender distribution according to BMI classification Management Age Medical TKR Grand Total Grand Total Table 3: Management according to age group Management BMI Classification Medica TKR Grand Total Underweight Normal Weight Overweight Obesity Class I Obesity Class II Obesity Class III Grand Total Table 4: Management as a percentage according to BMI classification Odds Ratio (OR) = (23 X 49) / (25 X 3) = 1127 / 75 = Table 5: 2 X 2 Table: of Obese vs. Non-obese 2. Pearson-Ceol J., Literature review on the effects of obesity on knee osteoarthritis. Orthop Nurs Sep-Oct;26(5): Review. 3. Dillon C., Rasch E., Gu Q., Hirsch R., Prevalence of knee osteoarthritis in the United States: arthritis data from the Third National Health and Nutrition Examination Survey J Rheumatol Nov;33(11): Felson D., Chaisson C.. Understanding the relationship between body weight and osteoarthritis. Baillieres Clin Rheumatol 1997(11) Buckwalter J., Saltzman C., Brown T. The impact of osteoarthritis: implications for research. Number 2004(427S)S6 S Coggon D., Reading I., Croft P. Knee osteoarthritis and obesity. Int J Obesity 2001(25) Karlson E., Mandl L., Aweh G.. Total hip replacement due to osteoarthritis: the importance of age, obesity, and other modifiable risk factors. Am J Med 2003(114) Manek N., Hart D., Spector T. The association of body mass index and osteoarthritis of the knee jointarthritis Rheumatism 2003(48) Marks R., Allegrante J. Body mass indices in patients with disabling hip osteoarthritis. Arthritis Res 2002(4) Sowers M. Epidemiology of risk factors for osteoarthritis: systemic factors. Curr Opin Rheumatol 2001(13) Wendelboe A., Hegmann K., Biggs J. Relationships between body mass indices and surgical replacements of knee and hip joints. Am J Prev Med (4): Buchholz AL, Niesen MC, Gausden EB, Sterken DG, Hetzel SJ, Baum SZ, Squire MW, Kaplan LD. Metabolic activity of osteoarthritic knees correlates with BMI. Knee Sep CDC.gov [homepage on the Internet]. Atlanta: Centers for Disease Control and Prevention [updated 16 Dec 2004; cited 25 Jan 2006]. Prevalence of Overweight and Obesity Among Adults: United States, Available from: products/pubs/pubd/hestats/obese/obse99.htm 14. CDC.gov [homepage on the Internet]. Atlanta: Centers for Disease Control and Prevention; [updated 15 Feb 2005; cited 21 Jan 2006]. Obesity Still a Major Problem, New Data Show. Available from: 15. United States of America Office of Management and Budget, Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Federal Register Notice. October 30, Bliddal H., Christensen R., The treatment and prevention of knee osteoarthritis: a tool for clinical decision-making. Expert Opin Pharmacother Aug;10(11): Reijman M., Pols H., Bergink A., Hazes JM, Belo J., Lievense A., Bierma-Zeinstra S., Body mass index associated with onset and progression of osteoarthritis of the knee but not of the hip: the Rotterdam Study. Ann Rheum Dis Feb;66(2): Marks R., Obesity profiles with knee osteoarthritis: correlation with pain, disability, disease progression. Obesity (Silver Spring) Jul;15(7): Asociación Médica de Puerto Rico Asociación Médica de Puerto Rico 19

13 18. Changulani M., Kalairajah Y., Peel T., Field R., The relationship between obesity and the age at which hip and knee replacement is undertaken. J Bone Joint Surg Br Mar;90(3): Lohmander L., Gerhardsson de Verdier M., Rollof J., Nilsson P., Engström G., Incidence of severe knee and hip osteoarthritis in relation to different measures of body mass: a population-based prospective cohort study. Ann Rheum Dis Apr;68(4): Guh D., Zhang W., Bansback N., Amarsi Z., Birmingham C., Anis A., The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health Mar 25;9: Windsor R., Scuderi G., Moran M., Insall, J., Mechanism of failure of the femoral and tibial components in total knee arthroplasty. Clin. Orthop Nov; 248: Mancuso C., Ranawat C., Esdalle J., Johanson N., Charlson M., Indications for total hip and total knee arthroplasties. Results of orthopaedic surveys. J Arthroplasty Jan; 11(1): Goldman L., Cardiac risks and complications of non cardiac surgery. Ann Intern Med Apr; 98: Fleisher LA., ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: Executive Summary. J Am Coll Cardiol Oct 23; 50(17): RESUMEN La osteoartritis (OA) de la rodilla se asocia con obesidad. Observaciones clínicas sugieren que hay una relación directa entre el grado de obesidad y la severidad de la OA de rodilla en hispanos. En este estudio asociamos el riesgo de requerir remplazo total de la rodilla (RTR) atribuible a estar obeso en un grupo de pacientes latinos. Métodos: 112 pacientes evaluados por un cirujano ortopédico durante el 2008 fueron incluidos en el estudio piloto de casos y controles. Records médicos fueron revisados y datos sociodemográficos, índice de masa corporal (IMC) y manejo inicial médico o RTR fueron recolectados. Los pacientes fueron segregados de acuerdo a su IMC entre las siguientes categorías: normal, sobrepeso, obesidad clase I, obesidad clase II y obesidad clase III. La severidad de la OA fue comparada entre los pacientes de los diferentes subgrupos de IMC. Los análisis fueron ajustados luego por edad, sexo y lugar de origen. Resultados: De los 112 records revisados, 100 sujetos fueron incluidos en el estudio. Entre los pacientes no-obesos, ni los que tenían peso inferior al normal, ni los que tenían peso normal, fueron manejados con RTR, y 9% de los pacientes sobrepeso fueron manejados con RTR. El 48% de los pacientes obesos fueron manejados con RTR. Esto incluía 43% de los obesos clase I, 58% de los obesos clase II, y el 33% de los obesos clase III. Conclusión: Parece haber una relación directa entre la obesidad y el riesgo de RTR en la comunidad latina. Lisa dejó de fumar con CHANTIX y con apoyo. CHANTIX Hable es una con opción su médico de tratamiento para que ver usted si CHANTIX y su médico es pueden el medicamento considerar. Llame apropiado al CHANTIX para usted. ( ). A mí sinceramente me gustaba fumar, y en realidad jamás pensé que lo dejaría. ex fumadora desde 07 Con CHANTIX puedes fumar durante la primera semana de tratamiento. Además, es una pastilla sin nicotina que funciona al concentrarse en los receptores de nicotina en el cerebro, adherirse a ellos y bloquear la nicotina antes de que llegue a los receptores. En los estudios, el 44% de los usuarios de CHANTIX había dejado de fumar durante la 9ª a 12ª semana del tratamiento (comparado con 18% que tomaron placebo). Para saber más acerca de CHANTIX y escuchar a otros ex fumadores, visite Únase nunca tuvo más sentido que ahora. A los beneficios usuales que siempre otorgó la Asociación Médica a sus asociados, se suman los provenientes del Registro Electrónico de Salud: descuentos sustanciosos en los costos de configuración y licencias y en la cuota mensual de mantenimiento; acceso a información epidemiológica y estadísticas y ser los reales custodios de la información de salud que se almacene en nuestro datacenter. CHANTIX es una opción de tratamiento que usted y su médico pueden considerar. Llame al CHANTIX ( ). Información Importante de Seguridad: Algunas personas han tenido cambios en el comportamiento, hostilidad, agitación, estado de ánimo deprimido, pensamientos o conducta suicida mientras están usando CHANTIX para ayudarlas a dejar de fumar. Algunas personas han tenido estos síntomas cuando comenzaron a usar CHANTIX, mientras otras los manifestaron luego de varias semanas de tratamiento o después de que dejaron de usar CHANTIX. Si usted, su familia o la persona que le cuida observan agitación, hostilidad, depresión o cambios de comportamiento, pensamiento o estado de ánimo, que no son típicos en usted, o si manifiesta pensamientos o conducta suicida, ansiedad, pánico, agresión, coraje, manía, sensaciones anormales, alucinaciones, paranoia o confusión, deje de tomar CHANTIX y llame a su médico inmediatamente. Dígale también a su médico si tiene un historial de depresión u otros problemas de salud mental, antes de tomar CHANTIX, puesto que estos síntomas se pueden agravar mientras toma CHANTIX. Algunas personas pueden tener reacciones cutáneas graves mientras están tomando CHANTIX, algunas de las cuales pueden ser potencialmente mortales. Estas pueden incluir erupción, hinchazón, enrojecimiento y descamación de la piel. Algunas personas pueden tener reacciones alérgicas a CHANTIX, algunas de las cuales pueden ser potencialmente mortales e incluyen: hinchazón de la cara, boca y garganta, las cuales pueden causar problemas respiratorios. Si tiene estos síntomas o tiene una erupción con piel descamada o ampollas en la boca, deje de tomar CHANTIX y busque ayuda médica de inmediato. Los efectos secundarios más comunes son náuseas, problemas para dormir, estreñimiento, gases y vómitos. Si tiene efectos secundarios que le incomodan o persisten, llame a su médico. Los pacientes también informaron que tuvieron problemas para dormir y sueños demasiado intensos, inusuales o extraños. Tenga cuidado al manejar u operar maquinaria hasta que sepa cómo CHANTIX le puede afectar. Puede que necesite una dosis más baja de CHANTIX si tiene problemas renales o recibe diálisis. Antes de comenzar a tomar CHANTIX, infórmele a su médico si está embarazada, espera quedar embarazada, o si toma insulina, medicamentos para el asma o anticoagulantes. Medicamentos como estos pueden funcionar de manera distinta cuando deje de fumar. CHANTIX no se debería tomar con otros medicamentos para dejar de fumar. Si tiene una recaída y vuelve a fumar, siga intentando dejar de fumar. CHANTIX es un medicamento con receta para ayudar a adultos de 18 años o más a dejar de fumar. Por favor véase el resumen del paciente de "Important Facts about Chantix en la próxima página. Le exhortamos a informar al FDA sobre efectos secundarios adversos de los medicamentos recetados. Visite or call FDA CHU01195SP 2009 Pfizer Inc. Todos los derechos reservados.

14 ABSTRACT Alpha-1 Antitrypsin Deficiency (AATD) is an inherited disorder that can cause lung and liver disease in adults and children. Homozygosity for the Z phenotype is the principal cause of AATD. There are about 100,000 people with AATD in the United States (not including the Island of Puerto Rico), and about the same number in Europe. Despite being one of the most common potentially lethal genetic diseases among Caucasian adults, AATD often remains unidentified, in part because related pulmonary symptoms often do not manifest until midlife when significant pulmonary functional degradation has already occurred. Our study aims to determine what is the prevalence of AATD in a specific population in Puerto Rico. Index words: alpha-1, antitrypsin, deficiency, Caguas, Puerto Rico INTRODUCTION Alpha-1 Antitrypsin (AAT) is a glycoprotein synthesized in the liver that circulates in blood and helps to protect the body s organs from the harmful effects of other proteins; the lung being one of the most important in Alpha-1 Antitrypsin Deficiency (AATD). It displays different genetically determined phenotypes. Phenotype M is the normal variant and phenotypes S and Z are the two most frequent abnormal variants.1-2 AAT protects the lungs from attack by neutrophil elastase, an enzyme produced by white blood cells which digests damaged tissue in the lungs in response to infection or irritants.3-4 Deficiency of the protein is caused by a mutation in the SERPINA I gene on chromosome 14 and it is an autosomal recessive condition.5-6 In AATD, SERPINA I is mutated and the abnormal AAT gets stuck in the liver and is unable to pass into the bloodstream. The accumulation of AAT damages the liver. The liver has hepatocytes containing cytoplasmic globules, which are made up of polymerized AAT molecules. The accumulation of these molecules appears to damage the liver, but there is no consensus regarding the specific mechanism of this injury.7 There are several categories of AAT in blood serum including two which are principal: Normal, not associated with lung or liver disease of which there are several variants Type M (M1 M4) being the most common; Deficient, reduced levels of AAT associated with high risk of development of lung and liver conditions, which includes type Z and S variants.8 A normal lifespan may be attained if there are no serious complications in patients with AATD. Many nonsmokers who have AATD do not develop any serious related lung diseases. Smoking is the leading risk factor for developing life-threatening lung disease with AATD; it can shorten lifespan by as much as 20 years.8,9 TESTING 300 PATIENTS FOR ALPHA-1 ANTITRYPSIN DEFICIENCY IN CAGUAS, PUERTO RICO Ramonita Correa PhD*, Jorge Pérez MD*, Yocasta Brugal MD**, José Terrasa MD*, José Pérez Gumá MD**, Arnulfo Santana MD, Edwin Colón MS, Gisela Puig MS From the *Department of Anatomy, **Department of Pathology and ***Department of Obstetric and Gynecology, San Juan Bautista School of Medicine, Caguas, Puerto Rico. (MS medical students from the San Juan Bautista School of Medicine) Address reprints request to: Ramonita Correa, PhD - Anatomy Department, San Juan Bautista School of Medicine, PO Box 4968, Caguas, PR Smoke damages the lungs by increasing the secretion of neutrophil elastase, and by inhibiting alpha-1 antitrypsin. The risk may also increase if the patient is exposed to dust, fumes, or other toxic substances. Although awareness of this genetic disorder is increasing, the vast majority of individuals at risk for developing AAT deficiency-related disorders remain undiagnosed. Individuals are often not diagnosed until middle adulthood. Despite the fact that AATD is a common disorder, it is poorly recognized in clinical practice.10 AATD has no cure, but there are treatments, which in most cases, are based on the manifestations of the disease. There are about 100,000 people with AATD in the United States not including the Island of Puerto Rico, and about the same number in Europe. Given the wellknown under diagnosis of AATD, this investigation aims to reveal the prevalence of AATD in a specific population in Puerto Rico. 11, 12 METHODS The present research includes the central area of Puerto Rico, targeting 300 volunteers. The volunteers are adult patients from the outpatient clinics of the San Juan Bautista Medical Center, and patients referred by local medical doctors; males and females were included without discrimination. Subjects signed an informed consent authorization. The patients were tested utilizing the A1AT kits donated by Baxter Pharmaceuticals. Asociación Médica de Puerto Rico 23

15 The blood samples were obtained through a fingertip puncture, the blood dropped to a filter paper, and samples dried from one to 4 hours at room temperature. After completing the above process the samples were sent for processing to the Alpha-1 Center in the United States. RESULTS Of 300 kits available, 292 patients were tested, and reported to the Alpha-1 Center. The results include: 14 patients (4.7%) not processed because of lack of blood in the sample-, leaving 278 patients reported as negative for the deficiency. Twenty seven (9.7%) were reported as carriers- which were identified as: 24 patients (8.2%) Pi MS; 2 patients (0.71%) Pi SS; and 1 patient (0.35%) Pi MZ- DISCUSSION This was a randomized, controlled study that demonstrated that in the municipality of Caguas, Puerto Rico the prevalence of AATD is 9.7%. The fact that there is prevalence Pi MZ and Pi SS in this group confirms the importance of the present research and the continuation of this study to embrace a higher population, which should include other municipalities in the Island. Further experimentation is important and is projected from the present research. REFERENCES 1. Yang, Ping, MD, PhD; Sun, Shifu, MD; Krowka, Michael J. MD; Aubry, Marie-Christine, MD; Bamlet, William R., MS; Wampfler, Jason A., BS; Thibodeau, Stephen N. PhD; Katzmann, Jerry A, Phd; Allen Mark S. MD; Midthun, David E. MD; Marks, Randolph S.MD; De Andrade, Mariza, PhD. Alpha1 Antitrypsin Deficiency Carriers, Tobacco Smoke, Chronic Obstructive Pulmonary Disease, and Lung Cancer Risk. Arch Intern Med/ Vol 168 (No. 10), May 26, Silverman, E; Miletich, Joseph; Pierce, John; Sherman, Laurence; Endicott, Scott; Broze, George; Campbell, Edward. Alpha- 1-Antitruypsin Deficiency; High Prevalence in the St. Louis Area Determined by Direct Population Screening. Am REV RESPIR DIS 1989; 140: Strange, Charlie, MD; Moseley, Mary Allison; Jones Yonge; Shwarz, Laura; Xie, Lianqi; Brantly, Mark L. MD. Genetic Testing of Minors for Alpha 1 Antitrypsin Deficiency. Arch Pediatr Adolesc. Med/Vol 160, May DeMeo, Dawn L.; Sandhaus, Robert A.; Barker, Alan F.; Brantly, Mark L.; Edward, Eden, Edward; McElvaney, N. Gerard; Rennard, Stephen; Burchard, Esteban; Stocks, James M.; Stoller, James K.; Strange, Charlie; Turino, Gerard M.; Campbell, Edward J.; Silverman, Edwin K. Determinants of airflow obstruction in severe alpha- 1-antitrypsin deficiency. Thorax 2007; 62: Colp, Charlotte; Pappas, John; Moran, Donald; and Lieberman, Jack. Variants of Alpha 1-Antitrypsin in Puerto Rican Childeren with Asthma. Chest 1993; 103; ; DOI /chest, DeMeo, Dawn L.; Campbell, Edward J.; Barker, Alan; Brantly, Mark L. Eden Edward; McElvaney, N. Gerard; Rennard, Stephen I.; Sandhous, Robert A.; Stocks, James M.; Stoller, James K.; Strange, Charlie; Turino, Gerard; Silverman, Edwin K. Am J Respir Cell Mol Biol Vol 38. Pp , Eden, Edward; Strange, Charlie; Holladay, Brian; Xie, Lianqi. Asthma and allergy in alpha-1antitrypsin deficiency. Respiratory Medicine (2006) 100, Silverman, Edwin K. MD., PhD; Sandhaus, Robert A. MD., PhD. Alpha 1 Antitrypsin Deficiency. The New England Journal of Medicine. Volume 360 (26) 25 June, p Mayer, Annyce S.; Stoller, James K.; Bartelson, Becki Bucher; Ruttenber, A. James; Sandhous, Rober A. Newman Lee. Occupational Exposure Risks in Individuals with PIZ Alpha 1 Antitrypsin Deficiency. Am J Respir Crit Care Med Vol 162. pp , Kok, K.F.; Wahab, P.J.; Houwen, R.H.J.;Drenth, J.P.H.; de Man, R.A. ; van Hoek, B.; Meijer, J.W.R.; Willekens, F.L.A.; de Vries, R.A. Heterozygous alpha-1 antitrpsin deficiency as a co-factor in the development of chronic liver disease: a review. The Netherlands Journal of Medicine. May 2007,Vol.65, No. 5. pp Dykes, D.; Miller, S; Polesky, H. Distribution of Alpha 1-Antitrypsin Variants in a US White Population. Hum. Hered. 34: (1984). 12. de Serres, Frederick. Worldwide Racial and Ethnic Distribution of Alpha 1-Antitrypsin Deficiency. Summary of an Analysis of Published Genetic Epidemiologic Surveys. Chest 2002; 122; ; DOI /chest RESUMEN Deficiencia de Alpha-1 Antitripsina es un desorden hereditario que puede ocasionar enfermedad pulmonar y hepática. Homozigocidad para el fenotipo Z es la causa principal de deficiencia de Alpha-1 Antitripsina. Se estima en 100,000 las personas en los Estados Unidos, sin incluir la isla de Puerto Rico, con esta deficiencia enzimática, y un numero similar en Europa. Aun cuando es una enfermedades genética potencialmente letal en Caucásicos, la deficiencia enzimática de Alpha-1 Antitripsina se mantiene sin identificar en los afectados hasta que estos no manifiestan degradación pulmonar significativa. El objetivo de nuestro estudio es determinar la prevalencia de este defecto enzimático en una población especifica de Puerto Rico. Únase nunca tuvo más sentido que ahora. Defensa del médico Representación local y federal Educación Médica Continua Actividades sociales y culturales Registro Electrónico de Salud Soluciones para la oficina médica con educación y soporte continuo 24 Asociación Médica de Puerto Rico ABSTRACT 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 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-transfused group hematocrit values averaged 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. Index words: hematocrit, cardiopulmonary, bypass, coronary, artery INTRODUCTION Coronary artery bypass grafting (CABG) is the most common type of cardiothoracic surgical procedure in the United States, with more than 300,000 procedures performed each year (1-4). The majority of CABG procedures are performed under cardiac arrest and use of cardiopulmonary bypass (CPB). CPB hemodilutes blood, imposing extremes in the hematologic system (1). Hemodilutional anemia can lead to inadequate oxygen delivery and, consequently, to ischemic organ injury (2, 3, 4). LOWEST SAFE HEMATOCRIT LEVEL ON CARDIOPULMONARY BYPASS IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING Anna DiMarco MD*, Héctor Vélez MD*, Ernesto Soltero MD**, Miguel Magraner MD*, Rafael Bredy MD* From the *Department of Internal Medicine, and **Section of Cardiothoracic Surgery, Department of Surgery Hospital Damas, Ponce, Puerto Rico. Presented at the Damas Hospital Annual Scientific Meeting. Ponce, Puerto Rico, 2009 and Annual Scientific Meeting American College of Physicians Puerto Rico Chapter, San Juan, Puerto Rico, 2009 Address reprints request to: Anna DiMarco, MD - Programa de Educación Médica, Edificio Parra 2225,Suite 407, Ponce By Pass, Ponce, Ponce, PR, Cardiac surgical procedures consume significant blood bank resources, and there is a well-known morbidity associated to the use of blood products (1, 5, 6). There is evidence that patients who receive packed red blood cell transfusions while hospitalized for CABG surgery are more likely to develop an infection after surgery and are at a greater risk of mortality than those who do not receive blood transfusions (7-16). Red blood cell transfusion has been associated with multiple postoperative complications like low output cardiac failure, and infections (4). Women do require greater quantities of transfusions than men, and have greater mortality. This is probably related to factors like the difference in body surface area and preoperative lower hemoglobin values. Intraoperative hematocrit values along with other comorbidities are pondered when decision of transfusion needs is to be taken (10-12, 15). Many times, it is the individual physician s decision the reason for transfusion and not necessarily the patient s blood loss during the procedure (13-15). Since the optimal hematocrit during cardiopulmonary bypass has not yet been defined, many of these blood transfusions may be unnecessary, imposing new risks to the patient. Although preoperative anemia and its outcomes have been studied previously, there is no study assessing lowest level of hematocrit that is tolerable on CPB, without complications and without need of blood transfusion during and after surgery. Identifying factors that can predict the need of packed red blood cell trans- Asociación Médica de Puerto Rico 25

16 fusion is essential to prevent undesired complications and excessive usage of scarce blood products. In the present study, we retrospectively reviewed a sample of patients undergoing isolated CABG procedure from 2005 to 2008 in a single academic institution treating patients in Puerto Rico. We estimated the lowest safe tolerable hematocrit level on CPB where no postoperative complications were identified. One of our aims with this study was to develop a preoperative patient clinical profile capable of predicting the need for blood transfusion during CABG surgery. MATERIALS AND METHODS Outcomes were pre-specified. Our primary outcome was to determine the lowest safe hematocrit level achievable while a patient is on CPB during CABG that results in no transfusion and no postoperative complications. Secondary outcomes were as follows: To create a preoperative patient profile that would guide medical staff to make a wise decision when blood transfusion is considered. To determine the overall rate of complications in the patients post -CABG procedure, transfused and non-transfused. Finally, to investigate if preexisting co-morbidities influence transfusion related complications. This was an observational, descriptive, cross-sectional, pilot study conducted in Damas Hospital Cardiovascular Center in Ponce, Puerto Rico. We reviewed medical records of patients with first time, isolated coronary artery bypass graft surgery from January 2005 to January We included all patients who had first time CABG procedure and all patients that had to be placed on CPB while on surgery. We reviewed sociodemographics and clinical data. Sociodemographic data was related to age and gender. Clinical data was related to hematocrit value prepump and on-pump of complicated and non-complicated groups; hematocrit value pre-pump and on-pump of non-complicated transfused and non-complicated/ non-transfused groups. We also collected clinical information related to weight, height, BSA (Body surface area), BMI (Body mass index), type of surgery (elective or urgency) and previous health conditions (history of Diabetes Mellitus, a baseline creatinine of more than 1.5 mg/dl, history of recent myocardial infarction, history of cerebrovascular accident, and an ejection fraction of less than 35%) of non-complicated transfused and non-complicated/non-transfused groups. Patients who had concomitant valvular or other cardiac surgical procedure during CABG were excluded. Our analysis included patients with ages from 21 to 89 and both genders for a total of 136 patients. The study received approval from the local IRB authorities. Biostatistical analysis employed was univariable analysis of percentage, standard deviation and student T-test (using STATA program). A p < 0.05 was considered statistically significant. RESULTS We studied 136 patients who had first time CABG procedure; characteristics as summarized in Figure 1. In this study, 31% of patients developed complications postoperatively; 68% were free of complications. In the non-complicated patient group, 40% were non-transfused. This non-complicated non-transfused group consisted of four females and 33 males. We compared the overall hematocrit values while on CBP. The average hematocrit on pump was 22.6% for the complicated group versus 23.7% non-complicated ( p = 0.032). Hematocrit values of complicated cases were evaluated and found that values of hematocrit averaged 22% in transfused versus 24% in non-transfused group (p = 0.039). When focusing in the non-complicated group and comparing transfused patients with the nontransfused group we found statistical significance (p = 0.003). Hematocrit values averaged 25.1% ± 2.8 with a minimum of 19% in the non-complicated, non-transfused group. This data demonstrate that in our sample, a minimum of 19% in hematocrit while on CPB without the need of transfusion is tolerable and will not yield in complications. The percentage of decrease in Hematocrit between the pre-pump value and the on-pump value was evaluated in an attempt to find a practical measuring number to use as reference while a patient is in CPB. Results show an average decrease of 14%. This value was not statistically significant but of clinical importance. Literature states that there is a difference in outcome when genders are compared. For this reason we compared males and females who had no postoperative complications. We found no difference in them if they were transfused with packed red blood cells or not. Upon reviewing our data we recognized a pattern that characterized the population of patients that had no complications and compared differences between the two groups: those who received and did not received transfusions. The comparison was made with all the variables of the study. We found that the non-complicated and non-transfused group followed this pattern: a pre pump hematocrit of 39.1% ± 3.7% (p=0.001), an on pump hematocrit of 25.1% ± 2.8% (p=0.003), a median age of 60 (p=0.019), a median weight of 87.3 ± 17.6 kg (p=0.008), a median height of ± 17.6 cms (p=0.003), a BSA of 2 +/- 0.2 (p=0.002), and a BMI of 30.3 ± 5.3 (p=0.002) (See Table 4). In this non-complicated group the urgency of the procedure had no relevance on postoperative outcome, whether patients received packed red blood cell transfusion or not. Upon analyzing the presence of preexisting comorbidities as to development of postsurgical complications we found that the history of diabetes mellitus, a baseline creatinine of more than 1.5 mg/dl, history of recent myocardial infarction, history of cerebrovascular accident, and an ejection fraction of less than 35% was of no significance in the development of postoperative complications in the non transfused group. Figure 1. Patient s characteristics and distribution by gender Complicated CABG procedure Non-complicated CABG procedure Average SDev Max Min p value SDev: Standard deviation. Max: Maximum. Min: Minimum Table 1. Complicated vs. non-complicated hematocrit pump values comparison Average 14.03% SDev 3.72 Max 21% Min 5% Table 3. Percentage of decrease in hematocrit between the pre-pump value and the on-pump value in non-complicated non-transfused group Non-complicated transfused Non-complicated non-transfused Average SDev Max Min p value 0.03 SDev: Standard deviation. Max: Maximum. Min: Minimum Table 2. Non-complicated transfused vs. non-complicated non-transfused hematocrit pump values comparison Transfused Non-transfused p- value Htc Pre Pump Htc Pump Age Male 53%(29) 89% (33) NSS Female 47% (26) 11% (4) NSS Weight Height BMI Elective 82% (26) 74% (28) NSS Urgent 18% (10) 26% (9) NSS Table 4. Characterization of transfused vs. nontransfused population 26 Asociación Médica de Puerto Rico Asociación Médica de Puerto Rico 27

17 Figure 2 shows the postsurgical complications of all the patients in this study. 68% of all patients who underwent surgery had no complications. Acute renal insufficiency was the most common complication with an incidence of 15%. This complication was transient and no patient required hemodialysis. Other postoperative complications including respiratory failure, bleeding, deep sternal infections and myocardial infarction where 6% or below. The postoperative mortality in this group of patients was 1%. REFERENCES 1. Dial S., Delabays E., Albert M., et al. Hemodilution and surgical hemostasis contribute significantly to transfusion requirements in patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg. 2005(3) Habib R., Zacharias A., Schwann T., et al. Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: Should current practice be changed? J Thorac Cardiovasc Surg 2003(125) Karkouti K., Beattie W., Wijeysundera D., et al. Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Thorac Cardiovasc Surg 2005(129) Figure 2. Post surgical complications of all the patients (transfused and non-transfused) in this study 14. Arora R., Légaré J,, Buth J., et al. Identifying Patients at Risk of Intraoperative and Postoperative Transfusion in Isolated CABG: Toward Selective Conservation Strategies. Ann Thorac Surg 2004(78) Murphy G., Angelini G. Indications for Blood Transfusion in Cardiac Surgery. Ann Thorac Surg 2006(82) Ranucci M., Biagioli B., Scolletta S., et al. Lowest Hematocrit on Cardiopulmonary Bypass Impairs the Outcome in Coronary Surgery. Tex Heart Inst J. 2006(3) RESUMEN El injerto de arteria coronaria es la cirugía más común en los Estados Unidos. Pacientes sometidos a esta intervención son conectados a una bomba cardiopulmonar que mantiene la circulación. Esta bomba hemodiluye la sangre imponiendo condiciones extremas en el sistema hemostático. Pacientes transfundidos durante la cirugía de injerto coronario demostraron tener mayor morbididad y mortalidad. Nuestro estudio determinó el nivel mínimo de hematocrito en la bomba cardiopulmonar durante la cirugía de injerto de arteria coronaria en el cual el paciente no desarrolle complicaciones postoperatorias sin el uso de transfusiones de sangre. Métodos: Revisión de expedientes de datos sociodemográficos, hematocrito (pre-bomba y en bomba), trasfusiones administradas, y complicaciones post quirúrgicas. Resultados: Se evaluaron 136 casos de cirugía de injerto de arteria coronaria. 68% no tuvo complicaciones postoperatorias. De este grupo no complicado, 60% fue transfundido, mientras que solo 40 % no recibió transfusión. El nivel de hematocrito para el grupo no-transfundido, nocomplicado fue de 25 +/- 2.8% con un mínimo de 19% (p=0.003). Fallo renal agudo fue la complicación más común. Conclusión: El nivel mínimo de hematocrito en la bomba cardiopulmonar fue de 19% con un promedio de 25 ± 2.8%. Se estableció un perfil preoperatorio de paciente donde la edad, el peso, la altura, el BSA, el BMI y los valores de hematocrito pre-bomba y en bomba pueden ayudar sobre las decisiones de transfusión de sangre. AUTORES - AUTHORS DISCUSSION Despite many studies which discuss red blood cell transfusions and complications after CABG surgery, there is no consensus on the lowest acceptable hematocrit level while on CPB. Making the clinical decision to transfuse blood products is, very often, a biased one. 4. Surgenor S., DeFoe G., Fillinger M., et al. Intraoperative Red Blood Cell Transfusion During Coronary Artery Bypass Graft Surgery Increases the Risk of Postoperative Low-Output Heart Failure. Circulation. 2006(114)I-43 I Koch C., Li L., Duncan A., et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med. 2006(6) Karkouti K., Wijeysundera D., Beattie W., et al. Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation. 2008(4) Kulier A., Levin J., Moser R, et al. Impact of Preoperative Anemia on Outcome in Patients Undergoing Coronary Artery Bypass Graft Surgery. Circulation. 2007(116) Kulier A. Anemia and morbidity and mortality in coronary bypass surgery. Curr Opin Anaesthesiol. 2007(1) Rogers M., Blumberg N., Saint S., et al. Allogeneic blood transfusions explain increased mortality in women after coronary artery bypass graft surgery. Am Heart J. 2006(6) Murphy G., Reeves B., Rogers C., et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation. 2007(22) Shehata N., Naglie G., Alghamdia A., et al. Risk factors for red cell transfusion in adults undergoing coronary artery bypass surgery: a systematic review. Vox Sanguinis 2007(1) Bracey A., Radovancevic R., Riggs S., et al. Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome. Transfusion. 1999(10) Shander A., Moskowitz D., Rijhwani T. The safety and efficacy of "bloodless" cardiac surgery. Semin Cardiothorac Vasc Anesth. 2005(1) This study had four main findings: 1) The lowest tolerable hematocrit on CPB where no postoperative complications were observed was 19%. With a median of 25% +/- 2%. 2) Preexisting co-morbidities as mentioned above or the urgency of surgery did not influence the development of complications in non-transfused patients, so should not be taken in consideration when in doubt of administering a red blood cell transfusion. 3) Acute renal insufficiency was the most common postoperative complication. This complication was transient in all cases, and is not clear whether this complicationis related to red blood cell transfusion or due to the hemodilution associated with CPB that leads to a further decrease in the blood arterial oxygen content. 4) A preoperative patient profile was identified that could assist the medical staff in identifying patients who most likely will not require blood transfusions during CABG surgery. 28 Asociación Médica de Puerto Rico Los invitamos a continuar colaborando con sus artículos en nuestro Boletín Médico-Científico. Por favor, antes de enviar su material lea las instrucciones para autores. We invite you to colaborate with your articles in our medical-scientific Boletin. Please, read our instructions for authors before send your writings. NO ENVIE PAPEL DON T SEND PAPERS

18 PRIMERA VEZ EN PUERTO RICO que acreditan planes de salud en calidad. Los son los más primeros pasos grandes ABSTRACT 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. Index words: independent, association, LDL-C, HDL- C, acute, coronary, syndrome, Hispanic INTRODUCTION INDEPENDENT ASSOCIATION OF LDL-C AND NON HDL-C WITH ACUTE CORONARY SYNDROME IN A HISPANIC POPULATION Rafael Trinidad MD*, José Gómez MD**, José García Mateo MD***, Miguel Magraner MD*, Rafael Bredy MD* From the *Department of Internal Medicine, **Section of Cardiology and ***Section of Endocrinology, Hospital Damas, Ponce, Puerto Rico Address reprints request to: Rafael Trinidad, MD - Programa de Educación Médica, Edificio Parra 2225,Suite 407, Ponce By Pass, Ponce, Ponce, PR, Presented at the Damas Hospital Annual Scientific Meeting. Ponce, Puerto Rico, 2010, and the Annual Scientific Meeting American College of Physicians Puerto Rico Chapter, San Juan, Puerto Rico, 2011 MMM obtiene Acreditación en Calidad de NCQA NCQA (National Committee for Quality Assurance) es una compañía sin fines de lucro que busca optimizar la calidad de los servicios de salud con los estándares de acreditación más rigurosos en toda la nación Americana. En Medicare y Mucho Más (MMM) (HMO), junto a nuestra compañía hermana PMC Medicare Choice (PMC) (HMO), estamos estrenando Acreditación Encomiable. Lograr esta acreditación es señal que un plan de salud tiene como prioridad la calidad. Se le otorga a aquellos planes cuyos servicios y calidad clínica cumplan o excedan los requisitos rigurosos de NCQA en velar por la seguridad de clientes y mejoría de calidad. Además de ser pioneros en el mercado Medicare Advantage en Puerto Rico, con esta acreditación queda demostrado que MMM es tu opción de CALIDAD. Hoy Puerto Rico da un paso adelante en el cuidado de la salud! MMM Healthcare, Inc. es un plan de salud con un contrato Medicare. H4003 MMM Healthcare, Inc. Y0049_ File & Use There is a relationship between increasing plasma cholesterol and the incidence of Acute Coronary Syndrome (ACS) (1-24). 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 (HDL-C) as the second target in patients with elevated triglyceride levels between 200 and 500mg/ dl (2). Non HDL-C is calculated by subtracting HDL-C from total cholesterol, and it reflects circulating levels of the atherogenic apoliprotein-b-containing lipoprotein including LDL-C, Very low density lipoprotein cholesterol (VLDL-C), IDL-C and Chylomicrons (1-11). Paradoxically, in epidemiologic studies non HDL-C is a superior predictor of cardiovascular risk compared with LDL-C (3-12). Treating to new targets (TNT) and Increments Decrease in End point through Aggressive Lipid lowering (IDEAL) trials, Non HDL-C levels were a better predictor of cardiovascular risk (3-4). Previous studies addressing the relationship between non HDL-C and LDL-C levels and ACS, have been done (6). We don t know the independent association of non HDL-C and LDL-C in Hispanic populations with ACS. As a general aim, this study tries to determine the independent association between LDL-C and Non HDL with Acute Coronary Syndrome in a Hispanic population. If Non HDL-C levels was better predictor for ACS than LDL-C; then it should be reconsidered as an equally important target as LDL-C. METHODS This is a descriptive - cross-sectional pilot study. The time period of the study was from September 2009 to March The population of the study included Hispanic patients between age years, male and female. Patients with an acute coronary syndrome (ACS) admitted to Damas Hospital Coronary Care Unit, Intensive Care Unit & Telemetry Unit, were considered. The sample consisted of 71 records. We excluded patients with current liver disease, nephrosis, pregnancy, unexplained elevated creatine kinase levels and patient with both LDL-C and non HDL elevated levels. The study methodology was a previous data report. The initial evaluation consisted of record reviewing of Hispanic patient with ACS, to determine the goal of LDL-C and Non HDL depend of risk factors and/or risk equivalent by the criteria of American Diabetes Association Asociación Médica de Puerto Rico 31

19 (ADA) and American College of Cardiologists (ACC) consensus statement of Lipid management (see Table 1). Highest-risk patient Known CVD Diabetes plus 1 additional major CVD risk factor* LDL-C (mg/dl) Non HDL-C (mg/dl) Apo B (mg/ dl) <70 <100 <80 High-risk patients No diabetes o r k n o w n C V D b u t 2 m a j o r C V D risk factors* Diabetes but no <100 <130 <90 other major CVD risk factors* *Major risk factors beyond dyslipidemia include smoking, hypertension, and family history or premature CHD. Table 1. ADA/ACC consensus statement of Lipid management. Non HDL-C was calculated by subtracting HDL-C levels from total cholesterol (1-12). Follow up reviews were made and the patients were divided by the criteria diagnosis of the ACS as unstable angina, non STelevation myocardial infarction and ST-elevation myocardial infarction, and an independent association was made. We performed the research under the confidentially and ethical definitions. The methodological design was reviewed by the Institutional Review Board of Ponce School of Medicine and received approval number RT. RESULTS The age of the study group were between 31 to 88 years, with average of A total of 71 medical records were reviewed and 26 of them were finally enrolled on the study; 18 male, and 8 female (see Table 2). Figure 2. Kind and ACS and independent association with non HDL-C or LDL-C elevation Average Standard deviation Maximum Minimum years ± years 88 years 31 years Table 2. Population distribution by age Figure 1. Association of ACS with independent elevation of non HDL-C and LDL-C Regardless the categorization of the ACS event, 6 of the 8 female patients had predominantly elevated blood levels of LDL as an independent factor and 2 of 8 female patients had Non-HDL elevated blood level elevated. On the other hand 3 of the 18 male patients had predominantly elevated blood levels of LDL as an independent factor and 15 of 18 male patients had Non-HDL elevated blood level elevated (see Figure 3). DISCUSSION The first point to consider is our research question and the study results. In this pilot study we wondered what was the independent association between LDL-C and non HDL-C with Acute Coronary Syndrome in a Hispanic population. In our study the association of ACS with independent lipid levels of LDL and non HDL seemed to be equivalent in the Hispanic population. We could not conclude a preponderance of the association of LDL-C with ACS, similar to different studies described in the scientific literature (3-24) Figure 3. Gender and independent elevation of non HDL-C or LDL-C in patients with ACS overall. There seems to be a female predominance in independently elevated blood level of LDL and a male predominance independently elevated blood level of Non-HDL associated with cardiovascular events. We wonder how can the controversy between National Cholesterol Education Program Adult Treatment Panel that identified LDL-C as the first target of therapy and non HDL-C as the second target and different data (predominance of non HDL-C in ACS) of recent literature be explained? Is there a real association of lipids abnormalities with genre in the Hispanic population? If so, how can it be explained? It is important to point out that our study had limitations. From the methodological point of view, lack of information on medical records and from the clinical point of view, the absence of clinical follow-up guidelines is some of those limitations. We consider justifiable to extend this study to a larger population of patient in order to evaluate the association of lipids abnormalities with gender in a Hispanic population. We also identified the need to evaluate the eventual association of advanced lipid testing Apo B by nuclear magnetic resonance with ACS in the Hispanic population (24, 25). REFERENCES 1. Robinson J., Wang S., Smith B. et al. Meta-Analysis of the relationship between non-hdl cholesterol reduction and coronary artery disease risk. J Am Coll Cardiol 2009(53) National Cholesterol Education Panel. Third report of national Cholesterol Education Program (NCEP) expert Panel detection, Evaluation, and Treatment of High Cholesterol in Adult (ATPIII): final report. Circulation 2002; 106: Incremental Decrease in End Points Througst Aggressive Lipid Lowering Trials; J Am Coll Cardiol 2009(54) Sarwar H Orakzai, et al. Non-HDL cholesterol is strongly associated with coronary artery calcification in asymptomatic individuals. Atherosclerosis. 2009(202) LaRosa J., Grundy S., Waters D., et al, for the Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005(14) Brunzell J., Davidson M, Furberg C, et al. Lipoprotein management report in patient with cardiometabolic risk: Consensus conference report from American diabetes association and the American College of Cardiology foundation. J Am Coll Cardiology 2008(51) Liu J,, Sempos C, Donahue R. et al. Non High-Density Lipoprotein and Very- Low-Density Lipoprotein Cholesterol and Their Risk Predictive Values in Coronary Heart Disease. The American Journal of Cardiology, 2010(98) Orakzai S.,Nasir K.., Blaha M.et al. Non-HDL cholesterol is strongly associated with coronary artery calcification in asymptomatic individuals. Atherosclerosis 2009(202) Blaha M, Blumenthal R., Brinton E. et al. The importance of non HDL-C reporting in lipid management. J Clin Lipidol 2008; 2: Robinson J. Are You Targeting Non High-Density Lipoprotein Cholesterol?; J Am Coll Cardiol, 2010(55) Arsenault B., Rana J., Stroes E. et al. Beyond Low-Density Lipoprotein Cholesterol Respective Contributions of Non High- Density Lipoprotein Cholesterol Levels, Triglycerides, and the Total Cholesterol/High-Density Lipoprotein Cholesterol Ratio to Coronary Heart Disease Risk in Apparently Healthy Men and Women ; J Am Coll Cardiol, 2010(55) Felix-Getzik E Kuvin J., Richard H., Karas R. Non optimal high-density lipoprotein cholesterol levels are highly prevalent in patients presenting with acute coronary syndromes and well-controlled low-density lipoprotein cholesterol levels; J of Clin Lipidol, 2010(4) Christie M. Ballantyne, Joel S. Raichlen, and Valerie A. Cain Statin Therapy Alters the Relationship Between Apolipoprotein B and Low-Density Lipoprotein Cholesterol and Non High-Density Lipoprotein Cholesterol Targets in High- Risk Patients: The MERCURY II (Measuring Effective Reductions in Cholesterol Using Rosuvastatin therapy II) Trial J. Am. Coll. Cardiol., 2008(52) Assmann G, Schulte H. Relation of high-density lipoprotein cholesterol and triglycerides to incidence of atherosclerotic coronary artery disease (the PROCAM experience). Prospective Cardiovascular Munster study. Am J Cardiol. 1992(70) Smith S., Allen J, Blair S. et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol (10) Liu J, Sempos C, Donahue R. et al Joint distribution of Non- HDL and LDL cholesterol and coronary heart disease risk prediction among individuals with and without diabetes. Diabetes Care 2005(28): Alberti K., Eckel R, Grundy S., et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; the National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation.2009(16) Genest J, McPherson R, Frohlich J, et al. Canadian Cardiovascular Society/Canadian guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease in the adult recommendations. Can J Cardiol.2009(25) Gami A, Witt B, Howard D, et al. Metabolic syndrome and risk of incident cardiovascular events and death. J Am Coll Cardiol. 2007(49) Miller M, Cannon C., Murphy S. et al. Impact of triglyceride levels beyond low-density lipoprotein cholesterol after acute coronary syndrome in PROVE IT-TIMI 22 Trial. J Am Coll Cardiol.2008(51) Tirosh A., Rudich A., Shochat T, et al. Changes in triglyceride levels and risk for coronary heart disease in young men. Ann Intern Med. 2007(147): Miller M, Cannon CP, Murphy SA, Qin J, Ray KK, Braunwald E; PROVE IT-TIMI Investigators. Impact of triglyceride levels beyond low-density lipoprotein cholesterol after acute coronary syndrome in PROVE IT-TIMI 22 Trial. J Am Coll Cardiol.2008(51) Cordero A, Andres E, Ordonez B, et al; Metabolic Syndrome Active Subjects Study Investigators. Usefulness of triglyceridesto-high-density lipoprotein for cholesterol ratio predicting the first 32 Asociación Médica de Puerto Rico Asociación Médica de Puerto Rico 31

20 coronary event in men. Am J Cardiol.2009 (104): Ferrario M., Chiodini P., Chambless L, et al. Prediction of coronary events in a low incidence population. Assessing accuracy of the CUORE Cohort Study prediction equation. Int J Epidemiol. 2005(34) Bitzur R. Triglycerides and HDL Cholesterol Stars or second leads in diabetes?; Diabetes Care November 2009(32)S373-S377. Acknowledgement to Miguel Perez-Arzola, MD for manuscript review. RESUMEN Se ha descrito la relación entre el incremento en los niveles plasmáticos de colesterol y la incidencia del síndrome coronariano agudo (SCA). El Panel Nacional de Educación en Colesterol de Adultos identifico al LDL-C como el primer blanco en la terapia y al no HDL-C como el Segundo blanco. Acérquese a: Estudios epidemiológicos reportan que el no HDL-C es un predictor superior de riesgo cardiovascular cuando se compara con LDL-C. Nosotros no conocemos la asociación independiente del no HDL-C y del LDL-C en pacientes hispanos con SCA. Métodos. Evaluamos pacientes con SCA admitidos a las unidades de cuidados coronarios, intermedios y telemetría del Hospital Damas durante 5 meses con criterios previos de no estar en meta, de forma independiente para no HDL- C y LDL-C. Comparamos la asociación independiente de estos niveles lipídicos con la presencia en SCA. Resultados: De 26 pacientes, el 58% tenía asociación independiente de no- HDL-C y SCA y un 42% se asoció con LDL-C. De estos pacientes, 6 de 8 pacientes femeninas tenía predominantemente niveles elevados de LDL-C y 15 de 18 pacientes masculinos, niveles elevados de no HDL-C. Discusión: En nuestra población, la asociación de no HDL-C y LDL parece ser equivalente con un predominio femenino de niveles elevados de LDL-C y uno masculino de no HDL-C. MedBook ABSTRACT 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. Index words: outcomes, severe, sepsis, Damas Hospital INTRODUCTION OUTCOMES ASSOCIATED WITH CONVENTIONAL MANAGEMENT OF SEVERE SEPSIS AT DAMAS HOSPITAL Vera Rosado MD*, Lisandra Pérez MD*, Héctor Guerra MD*, Ricardo Hernández MD**, Miguel Magraner MD*, Rafael Bredy MD* From the *Internal Medicine Residency Program, Damas Hospital, Ponce School of Medicine, Ponce, Puerto Rico and the **Internal Medicine Residency Program, Hospital de la Concepcion, Ponce School of Medicine, Ponce, Puerto Rico. Presented at the 58th Damas Hospital Annual Scientific Meeting. Ponce, Puerto Rico, and the Annual Scientific Meeting American College of Physicians Puerto Rico Chapter, San Juan, Puerto Rico, Address reprints requests to: Vera Rosado, MD - Programa de Educación Médica Edificio Parra 2225, Suite 407, Ponce Bypass, Ponce, Ponce, PR, Primer sistema comunitario para profesionales de salud; incorpora herramientas de información que se actualizan en tiempo real, acceso a bibliotecas virtuales internacionales (sistema Lilacs) y próximamente una gran variedad de servicios especialmente pensados para ustedes. Sepsis is a complex syndrome that is difficult to define, diagnose, and manage. It is a major cause of mortality, killing approximately 1,400 people worldwide every day, similar in scale to lung, breast, and colon cancer (1). It is one of the leading causes of death in the Medical Intensive Care Unit (MICU) (1-3). Thirty percent of patients die within the first month of diagnosis and 50% die within the following six months (4-6). Twenty eightday mortality rates for severe sepsis are comparable to the 1960 s hospital mortality rate for patients with acute myocardial infarction (7). The number of cases is believed to grow at a rate of 1.5% per annum, with an additional one million cases per year in the USA alone by 2020 (8). This is mainly due to the growing use of invasive procedures along with increased numbers of surviving elderly and high-risk individuals. Sepsis places a significant burden on healthcare resources, with up to 40% of total MICU expenditure, representing up to 7.6 billion Euros annually in Europe (8) and $16.7 billion dollars in the US in 2000 (9). The average cost per individual case is $22,000 dollars. immediate attention to avoid rapid deterioration. It is necessary to manage the patient concomitantly to confirming the diagnosis. Due to the challenges of diagnosing and treating this complex condition, 10% of sepsis patients do not receive prompt appropriate antibiotic therapy, which increases mortality by 10 to 15% (10). Scientific efforts have brought consensus on the variables that have direct impact in the survival of patients with severe sepsis (11), and therefore, on improved management of healthcare resources. Several institutions have reported improved outcomes after following the Severe Sepsis Campaign (SSC) recommendations (12-17). The purpose of this study is to register mortality of severe sepsis and septic shock at our institution, which may justify the need to redefine the standards of care and consider the implementation of SSC recommendations. METHODS Institutional Review Board approval was obtained before data collection. A retrospective record review cross Rapid diagnosis and management of sepsis is critical to successful treatment. A septic patient requires place at Damas Hospital, Ponce, Puerto Rico. Our inssectional study from January 2007 to August 2009 took Asociación Médica de Puerto Rico 35

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