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1 B LETIN médico-científico de la asociación médica de puerto rico https://www.asocmedpr.org Año Volumen Número 1

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4 Asociacion Medica de Puerto Rico Junta de Directores 2013/2014 Dra. Wanda G. Velez Andujar Presidente Dr. Ricardo Marrero Santiago Presidente electo Dr. Natalio Izquierdo Encarnación Presidente saliente Dr. José R. Villamil Rodríguez Tesorero Dra. Ilsa Figueroa Secretaria Dra. Hilda Ocasio Maldonado Vicepresidente AMPR Dr. Raúl A. Yordán Vicepresidente AMPR Dr. Jaime M. Díaz Hernandez Vicepresidente AMPR Dr. Benigno López López Pres. Cámara Delegados Dr. Eliud López Vélez Vicepres. Cámara Delegados Dr. Gonzalo González Liboy Delegado AMA Dr. Rolance G. Chavier Roper Delegado AMA Dr. Luis A. Román Irizarry Delegado Alt. AMA Dr. Rafael Fernández Feliberti Delegado Alterno AMA Dr. Salvador Torrós Romeu Pres. Distrito Este Dra. Mildred R. Arché Pres. Distrito Central Dr. Rubén Rivera Carrión Pres. Distrito Sur Dr. Humberto Lugo Vicente Presidente de la Junta Editora del Boletin 2

5 5 MENSAJE DEL PRESIDENTE Wanda G. Velez Andujar, MD ORIGINAL ARTICLES / ARTICULOS ORIGINA- LES 6 OSTEOPOROSIS KNOWLEDGE IN PA- TIENTS WITH A FIRST FRAGILITY FRACTURE IN PUERTO RICO Leyda M. Díaz-Correa MD, Lilliana M. Ramírez- García MD, Leslianne E. Castro-Santana MD, Luis M. Vilá, Mda 12 PSYCHOSOCIAL FACTORS ASSOCIAT- ED WITH FAILURE TO USE CONTRACEPTION AMONG ADOLESCENTS WITH REPEAT PREG- NANCIES IN PUERTO RICO Malieri Colón MD, Rosa Martínez MD, Michelle Tulla MD, José Pérez MD, Yadiris Santaella RN, Linda Laras MD 17 MANEJO ENDOVASCULAR DE LAS FIS- TULAS DURALES AL SENO CAVERNOSO Marco Zenteno MD, Jorge Santos Franco MD, Luis Rafael Moscote-Salazar MD, Angel Lee MD 27 RISK FACTORS FOR HYSTERECTOMY IN ABNORMAL PLACENTATION AT THE UNIVER- SITY DISTRICT HOSPITAL Mireily Rivera-Rosado, MD, Iehsus S. Flores-Pérez MD, Keimari Méndez MD, Juana I. Rivera-Viñas MD CASE REPORT / REPORTE DE CASOS 30 MENINGEAL MELANOCYTOMA: Case Report and Literature Review Rodrigo Kraft Rovere, Carini Dagnoni, Godofredo Gomes de Oliveira, Jaqueline Sapelli 33 SORDERA NEUROSENSORIAL Y ANEU- RISMA DE LA ARTERIA VERTEBRAL: Manejo Endovascular Marco Zeneno MD, Luis Rafael Moscote-Salazar MD, Hernando Alvis-Miranda MDb, Angel Lee MD 40 ABRUPT ONSET OF MUSCLE DYSFUNC- TION AFTER TREATMENT FOR GRAVE S DIS- EASE: A Case Report José Hernán Martínez MD, Alfredo Sánchez MD, Oberto Torres MD, Coromoto Palermo MD, Mónica Santiago MD, Carlos Figueroa MD, Rafael Trinidad MD, Michelle Mangual MD, Madeleine Gutierrez MD, Eva González MD, María de Lourdes Miranda MD 43 PASTEURELLA MULTOCIDA: A nightmare for a replaced joint and the challenge to save it Felipe A. Vélez MD, Iván Enrique Laboy Ortiz MD, Reynaldo López MD, Alfredo Sánchez MD, Miguel Colón MD, José Hernán Martínez MD 46 JUST A FLARE The Pandora s Box approach Maryangely Moreno MD, Iván Enrique Laboy Ortíz MD, Felipe A. Vélez MD, Alfredo Sánchez MD, Adolfo Rodríguez MD, Miguel Colón MDc, José Hernán Martínez MD 49 YOUNG FEMALE WITH ACROMEGALOID FEATURES AND PITUITARY MACROADENOMA: What is your Diagnosis? José Hernán Martínez MD, Carlos Figueroa-Núñez MD, Paola Mansilla-Letelier MD, Coromoto Palermo-Garofalo MD, Mónica Santiago MD, Oberto Torres MD, Rafael Trinidad MD, Michelle Mangual-García MD, Alfredo Sánchez MD, Madelin Gutierrez MD, María de Lourdes Miranda MD, Eva González MD 54 AN UNUSUAL CASE OF A BORDERLINE BRENNER TUMOR ASSOCIATED WITH BILATER- AL SEROUS CYSTADENOMA AND ENDOMETRI- AL CARCINOMA Daniel Cruz-Galarza MD, Omar Pérez-Rodríguez MD, Joaquín Laboy-Torres MD, Silvia Gutiérrez-Rivera MD 57 WANDERING SPLEEN TORSION CAUS- ING ACUTE ABDOMINAL PAIN IN A CHILD: Case Report and Review of Literature Carlos I. Llorens Marina, Alex Cedeño, Humberto Lugo-Vicente, Cristel Chapel, Glorimar Rivera, Antonio Diaz REVIEW ARTICLES / ARTICULOS DE RESEÑA 60 MANEJO NEUROCRÍTICO DE LA GLICE- MIA EN LA HEMORRAGIA INTRACEREBRAL ES- PONTÁNEA: Revisión de la Literatura Sandy Zuleica Navas-Marrugo, Hernando Raphael Alvis-Miranda, Luis Rafael Moscote-Salazar 69 UTERINE CURETTAGE IN POST-PAR- TUM PATIENTS WITH SEVERE PREECLAMPSIA: Removal of Trophoblastic tissue can alter the progression of this condition Alma C. Ponton MD, Iehsus S. Flores MD, Juana I. Rivera-Viñas MD, Susana Schwarz MD Pintura de la portada: La peste de Atenas (1652), por Michael Sweerts Basado en el contexto histórico narrado por el historiador Tucídides en el año 428 a.c. I N D E X 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 OFICINAS ADMINISTRATIVAS: Asociación Médica de Puerto Rico PO Box 9387 SANTURCE, Puerto Rico Tel Fax: ANUNCIOS EN BOLETIN, WEBSITEy NEWSLETTER: Tel.: (787) Ext. Informártica - Web Site: Ilustración digital de cubierta y diseño gráfico realizados por Juan Laborde-Crocela en la Oficina de Informática de la AMPR. Impreso en los talleres gráficos digitales de la Asociación Médica de Puerto Rico 3

6 of Puerto Rico, Inc. Nuestras Estrellas de Calidad Felicidades doctores. Rompieron la curva al lograr un nivel de 4 a 5 en sus métricas de calidad. Dra. Ada San Antonio Piñeiro, Grupo Cuidado Geriátrico Médico Integral, San Juan Dra. Ana Padró Díaz, Southern Medical Alliance, Ponce Dr. Antolín Padilla Morales, Grupo Médico Geriátrico, Guaynabo Dr. Baltazar Rodríguez Cruz, Villa los Santos Advantage, Lares Dr. Benjamín Velázquez López, East Coast Medical Group, Fajardo El compromiso con la calidad que tienen los proveedores de nuestra red queda evidenciado al haber obtenido las puntuaciones más altas en su ejecución de medidas de cuidado preventivo, manejo de condiciones crónicas y tratamientos farmacológicos para nuestros afiliados. Dr. Carlos Ariza Arias, Castellana Physician Services MN, San Juan Dr. José Colón Gaztambide, Castellana Physician Services SE, Juana Díaz Dr. Domingo Acosta Albino, Solidarity Medical Group, Mayagüez Dr. José Pastrana Sierra, Grupo Médico Geriátrico, Guaynabo Dr. Edwin Rodríguez Allende, Castellana Physician Services SE, Aibonito Dr. Kevin Toro Barros, Southern Medical Alliance, Yauco Dr. Ferdinand Marín Rivera, Advantage Medical Group, Salinas Dra. Lynette Ortiz Toro, Grupo Advantage del Oeste, Cabo Rojo Dr. José Ayala Berríos, Grupo Médico Geriátrico, Bayamón Dra. María Hernández Morales, Castellana Physician Services MN, Naranjito En MMM y PMC establecimos estas métricas para evaluar el desempeño de los proveedores basado en indicadores específicos de calidad en una escala de uno a cinco. El cumplimiento sobresaliente de nuestros proveedores con estas medidas nos ayuda a cumplir con el Programa de Clasificación 5 Estrellas establecido a los Medicare Advantage por los Centros de Servicios de Medicare y Medicaid. Ya son sobre 190 médicos primarios que oficialmente han alcanzado un nivel entre 4 a 5. Cada día se suman más! Dr. Pablo Acosta Vélez, Southern Medical Alliance, Yauco Dra. Patricia Rodríguez Valdés, Castellana Physician Services E, Caguas Dr. Radamés Marín Vieira, Southern Medical Alliance, Yauco Dr. Ramón Torrado Frías, Island Medical Group, Arecibo Dr. Víctor Zapata Guzmán, Island Medical Group, Bayamón Estos 20 médicos se destacan en los primeros lugares, tomando en cuenta la complejidad y volumen de sus respectivos paneles de pacientes. Estamos orgullosos del compromiso de nuestros proveedores con nuestros afiliados para lograr un cuidado adecuado y el seguimiento preventivo que necesitan.

7 Mensaje del Presidente Wanda G. Vélez Andújar MD 5 Hola! Al igual que todos los pasados presidentes de la AMPR, estoy trabajando para continuar dándole servicio a nuestros miembros. Entre los muchos campos que quiero atender, he centrado mi interés en las Educaciones Médicas Continuadas ( CME en inglés). Cuanto más les facilitemos a nuestros médicos el mantenerse al día en sus conocimientos, cuanto mejor servicio le brindarán a sus pacientes y por ende a todo nuestro pueblo. Mi ambición de educación se extiende más allá de la medicina. Por razones históricas, en este momento la generación de médicos que se levanta tiene un completo dominio del mundo cibernético. No obstante, muchos de los médicos en cuyos hombros sigue estando la salud de Puerto Rico no necesariamente son tan diestros en las computadoras como quisieran y/o necesitan. Por esto, hemos incluido cursos de cómo aprovechar y disfrutar de las computadoras. Tenemos que todos llegar al siglo 21! Para las CME, tenemos programadas múltiples jornadas los sábados por la tarde, dónde presentaremos importantísimos y variados temas de actualidad. Presentaremos conferencias sobre el ICD-10, HIPAA, HITECH, OMNIBUS, el Récord Electrónico de Salud, entre otros. Este año ofreceremos dos mini convenciones en nuestra Casa Sede no sólo para actualizar a los participantes, sino que también ofreceremos CME para cumplir con las educaciones exigidas por la Junta de Licenciamiento y Disciplina Médica de Puerto Rico para nuestra recertificación trienial. La Asociación Médica de Puerto Rico se tiene que reconocer y distinguir por las educaciones. Y, como no sólo de pan vive el hombre, después del verano tendremos invitados a varios artistas puertorriqueños que expondrán sus obras en la Asociación Médica de Puerto Rico. Ya tenemos confirmados al Sr. Wichie Torres, la señora Violeta Guzmán Matos, el Sr. Wichie Torres Wale, el Sr. Julián Ruiz y el Sr. Francisco García Burgos. Todos son artistas reconocidos en Puerto Rico e internacionalmente. Prontamente les daremos más detalles para que nos puedan acompañar durante esos días. Para los aficionados del Golf, ya estamos trabajando un torneo. El Dr. Mickey Lugo de Guayama aceptó la responsabilidad de dirigir esta actividad, la cual tenemos programada para mayo A así que a practicar! Seguiré informándoles de nuestras actividades en nuestra página cibernética A los que aún no se han unido a nuestra Asociación, los invitamos a que llenen su solicitud.

8 6 Original Articles/Articulos Originales OSTEOPOROSIS KNOWLEDGE IN PATIENTS WITH A FIRST FRAGILITY FRACTURE IN PUERTO RICO Leyda M. Díaz-Correa MD a, Lilliana M. Ramírez- García MD b, Leslianne E. Castro-Santana MD a, Luis M. Vilá, MD a * a Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico. b Department of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico. *Corresponding author: Luis M. Vilá MD - Chief and Program Director, Division of Rheumatology University of Puerto Rico Medical Sciences Campus, PO Box , San Juan, PR INTRODUCTION Osteoporosis is a common disease characterized by low bone mass and micro-architectural deterioration of bone tissue resulting in skeletal fragility and increased risk for fractures (1). In 2002, the National Osteoporosis Foundation estimated that 44 million people in the United States had osteoporosis or low bone mass, accounting for 55% of the population aged 50 years or older (2). According to the National Health and Nutrition Examination Survey, an estimated 5.3 million of older men and women in the US had osteoporosis at the femoral neck, and 34.5 million had osteopenia (3). Osteoporotic fractures are those occurring from a fall from a standing height or less, without major trauma. In 2000 there was an estimate of nine million osteoporotic fractures worldwide, of which 1.6 million occurred in the hips, 1.7 million in the forearms, and 1.4 million in the vertebrae (4). Fractures of the hip and spine are associated with an increased morbidity and mortality, and may result in limitation of ambulation, depression, loss of independence, and chronic pain (5). In particular, hip fractures result in 10% to 20% mortality within the next six months (5). Screening for osteoporosis involves fracture risk assessment and measurement of bone mineral density (BMD). Patients knowledge about osteoporosis is essential in the evaluation and management of patients at risk for osteoporotic fractures. Palacios et al, found that patients with adequate knowledge about osteoporosis tend to be more compliant with osteoporosis therapy (6). Another study showed that patients with adequate knowledge about osteoporosis risk factors have more confidence in performing activities of daily living, greater lower extremity strength, and lower fall risk (7). Only few studies have evaluated the knowledge about osteoporosis in patients with fragility fractures (8-9). Furthermore, to date, there are no studies evaluating the knowledge about osteoporosis in hospitalized patients with a first osteoporotic fracture. Thus, the aim of this study was to evaluate the level of knowledge about osteoporosis in patients with a first fragility fracture, and to determine the factors associated with lack of knowledge. ABSTRACT Purpose: To determine the level of knowledge about osteoporosis and factors associated with low level of knowledge in patients with a first osteoporotic fracture. Methods: A cross-sectional study in adult patients with a first osteoporotic fracture admitted to the University Hospital of the Puerto Rico Medical Center, San Juan, Puerto Rico was performed. Socio-demographic parameters, clinical features, and pharmacologic treatment were examined. A validated questionnaire was used to assess subjects level of knowledge about osteoporosis. Differences between study groups were evaluated using chi-square and Student s t tests, as appropriate. Results: A total of 54 patients participated in the study. The mean (SD) age was 73.7 (10.7) years; 77.8% were females. Overall, 61.1% of the participants had a low level of knowledge about osteoporosis. Patients with low level of knowledge were more likely to have the Puerto Rico Government health insurance, lower level of education, and higher hip FRAX scores than those with mid/high level of knowledge. Also, they were less likely to receive osteoporosis counseling by their primary care physicians (PCP), have prior BMD measurement, receive bisphosphonates/raloxifene treatment, and to take calcium and vitamin D supplements. Conclusions: In this population of Hispanic patients with a first osteoporotic fracture, the majority had a low level of knowledge about osteoporosis. Low knowledge was associated with low socio-economic status, lack of counseling about osteoporosis by PCP, prior BMD measurement, and osteoporosis treatment. Better efforts should be undertaken to educate, identify, and manage patients at risk for osteoporotic fractures. Index words: osteoporosis, knowledge, patients, first, fragility, fracture, Puerto Rico

9 METHODS Study population A cross-sectional study was performed in adult patients with a first low-trauma osteoporotic fracture admitted to the orthopedic ward of the University Hospital of the Puerto Rico Medical Center, San Juan, Puerto Rico. Female adult patients aged 50 years or older, and patients admitted to the orthopedic ward with their first low-trauma osteoporotic fracture were included in the study. Patients younger than 50 years of age, history of previous fragility fractures, and patients with dementia or mental illness who were unable to consent were excluded from the study. Patients were enrolled from January 2011 to April A written informed consent was obtained for each patient. The Institutional Review Board of the University of Puerto Rico Medical Sciences Campus approved the study. Variables A structured questionnaire was used to gather the socio-demographic parameters, health-related behaviors, comorbid conditions, and pharmacologic treatments in patients with a first osteoporotic fracture. Socio-demographic parameters included age, gender, ethnicity, annual income, level of education, and type of healthcare insurance. Comorbid conditions included overweight/obesity; diabetes mellitus, thyroid disease, chronic kidney disease, liver disease, hyperparathyroidism, asthma, dementia, intestinal diseases, epilepsy, anxiety, depression, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, polymyositis/ dermatomyositis, and systemic vasculitis were determined. Pharmacological treatments for osteoporosis and drugs that may induce osteoporosis were examined. Also, prior counseling about osteoporosis by primary care physicians (PCP) and previous BMD measurement were ascertained. The World Health Organization (WHO) Fracture Risk Assessment (FRAX) tool was used to estimate the major risk factors for osteoporotic fractures. Using risk factors for osteoporosis and the femoral neck T-score, the FRAX estimates the 10-year probability of hip fracture or major osteoporotic fractures combined (hip, spine, shoulder, or wrist) for an untreated patient (10). The risk factors to calculate the FRAX score includes age, sex, body mass index, previous fracture, parental hip fracture, current smoking, glucocorticoid use, rheumatoid arthritis, disorders strongly associated with osteoporosis, and alcohol intake. In our study, the FRAX was calculated without the femoral T-score because most patients did not have previous measurement of BMD. Subjects knowledge about osteoporosis and its risk factors were determined using a validated questionnaire developed by Azoh (11). This instrument comprises 18 items in three categories. The first category (items 1 to 8) inquires about the association of osteoporosis with fractures, the second category (items 9 to 15) ascertains knowledge about risk factors, and the last category (items 14 to 18) pertains to preventive measures. Each affirmative answer had a value of 1. Level of knowledge was categorized as follows: high level o f knowledge (score from 15 to 18), mid level of knowledge (score from 10 to 14), and low level of knowledge (score less than 10). Statistical analysis The Statistical Package of Social Sciences (version 14.0; SPSS, Chicago, Illinois) program was used to perform the univariate and bivariate analyses. Differences in the socio-demographic parameters, health-related behaviors, comorbid conditions, and pharmacologic treatments were compared between patients having low level of knowledge about osteoporosis and those with mid to high level of knowledge. The chisquare test was used to evaluate differences between dichotomous variables and the Student t test was used to evaluate mean differences. A p value of <0.05 was considered to be statistically significant. RESULTS A total of 157 patients with osteoporotic fractures were screened, but only 52 met the inclusion criteria. Of the patients excluded, 62 had altered mental status and were unable to consent or participate in the study, 35 had previous fragility fractures, and 6 refused to participate in the study. The mean (standard deviation, SD) age was 73.7 (10.7) years; 42 (77.8%) were females. Fifty-two (96.3%) patients were Puerto Ricans and 2 (3.7%) were non-puerto Rican Hispanics. Overall, 33 (61.1%) of the participants had a low level of knowledge about osteoporosis, 12 (22.2%) had mid level of knowledge, and 9 (16.7%) had high level of knowledge. Only 20 (37.0%) patients acknowledged having counseling about osteoporosis by their PCP. Previous BMD measurement was done in 14 (25.9%) patients. Thirteen (24.1%) patients were taking calcium supplements and 13 (24.1%) were taking vitamin D supplements at the moment of the fracture. Current use of osteoporosis therapy with either bisphosphonates or raloxifene was reported by 3 (5.6%) patients. Table 1 shows the socio-demographic features and counseling about osteoporosis in patients with low and mid/high level of knowledge. Patients with low level of knowledge were more likely to have the Puerto Rico Government healthcare insurance or being uninsured (54.5% vs. 45.5%, p=0.009), and have < 12 years of education (69.7% vs. 28.6%, p=0.003) than those with mid/high level of knowledge. Also, they were less likely to receive counseling about osteoporosis by their PCP (15.2% vs. 71.4%, p<0.001). No significant differences were found for age, gender, and annual income among the study groups. Comorbid conditions, FRAX scores, and prior BMD measurement are depicted in Table 2. Patients with low level of knowledge had higher FRAX scores (mean [SD]) for hip fracture (8.1 [8.6] vs. 4.7 [6.2], p=0.049), and were less likely to have previous BMD measurement (15.2% vs. 42.9%, p=0.023) and have type 2 diabetes mellitus (27.3% vs. 61.9%, p=0.012) than those with mid/high level of knowledge. No significant differences were found for overweight/obesity, osteoarthritis or chronic kidney disease. Other comorbid conditions 7

10 Table 1. Socio-demographic features and counseling about osteoporosis in patients with low level and mid/high level of knowledge about osteoporosis (n=54). were either not present (intestinal diseases, epilepsy, systemic lupus erythematosus, scleroderma, polymyositis/dermatomyositis, and systemic vasculitis) or present in only few patients (thyroid disease, liver disease, hyperparathyroidism, asthma, dementia, anxiety, depression, rheumatoid arthritis); thus, group comparisons could not be performed. Current intake of calcium supplements, vitamin D supplements, bisphosphonates and raloxifene are shown in Table 3. Patients with low level of knowledge were less likely to take calcium supplements (12.1% vs. 42.9%, p=0.010), vitamin D supplements (12.1% vs. 42.9%, p=0.010) and bisphosphonates / raloxifene (0% vs. 14.3%, p=0.025) than those with mid/high level of knowledge. DISCUSSION In this population of Hispanic patients with a first osteoporotic fracture, most had a low level of knowledge about osteoporosis. Low level of knowledge was associated with low socioeconomic status, lack of counseling about osteoporosis by their PCP, higher FRAX scores for hip fracture, no prior BMD measurement, and no current treatment for osteoporosis. Conversely, those with mid/high level of knowledge were more likely to have type 2 Diabetes Mellitus. Our results are in agreement with previous studies (6-7,12). Burke-Doe and colleagues determined the knowledge about osteoporosis risk factors in a sample of an independent living retirement community of people aged 50 years or older, and showed that 64% of participants had less than 50% correct response rate (7). Also, in patients with postmenopausal osteoporosis Palacios et al found that only 22.6% had an adequate knowledge about osteoporosis (6). Finally, a study evaluating knowledge about osteoporosis in women aged 50 years or older in Puerto Rico showed that three quarters of respondents could not identify risk factors for osteoporosis (12). 8 Osteoporosis knowledge among patients with osteoporotic fractures has been evaluated in some studies (8-9). Giangregorio et al, reported that in a population of patients treated for fragility fractures, 75% knew the definition of osteoporosis (8). When compared to our study, a higher-level knowledge was achieved in those patients most likely because that study was conducted within 24 months after the incident fracture, and included patients with previous fragility fracture; therefore, it is plausible that they had received education about osteoporosis. Conversely, a study of postmenopausal women with minimal trauma fractures demonstrated that most were unaware about the association between osteoporosis and minimal trauma fractures (9). To our knowledge, no previous studies have evaluated hospitalized patients having their first fragility fracture. Our study revealed that patients having the Puerto Rico Government health insurance or being uninsured and those with low level of education were more likely to have low level of knowledge about osteoporosis. In order to be eligible for the Puerto Rico Government health insurance, the annual family income must be at or below poverty level according to US standards. Therefore, having this insurance is an indicator of a low socioeconomic status. Similarly, a study of Costa-Paiva et al showed that the level of education and socioeconomic status was closely associated with the level of knowledge about osteoporosis in postmenopausal women with osteoporosis (13). Also, Giangregorio et al, demonstrated that higher education level was associated with the probability of an individual to provide a correct definition of osteoporosis (8). Patients with mid/high level of knowledge were more likely to have type 2 Diabetes Mellitus. This finding could be explained by the fact that patients with diabetes mellitus tend to visit more frequently their PCP and endocrinologists and thus, are more likely to receive counseling about osteoporosis. According to the United States Preventive Services

11 Table 2. Selected comorbid conditions, FRAX score, and previous bone mineral density measurement in patients with low level and mid/high level of knowledge about osteoporosis (n=54). Table 3. Bone mineral density ascertainment and intake of calcium and vitamin D supplements, bisphosphonates and raloxifene in patients with low level and mid/high level of knowledge about osteoporosis (n=54). Task Force, screening for osteoporosis is recommended for all women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of 65-year-old white women who have no additional risk factors (14). Women older than 65 years of age mainly comprised our study population; therefore, most of them had a clear indication for BMD measurement. However, we found that only one fourth of our patients had previous BMD measurement. Also, nearly 25% were using calcium and vitamin D supplements, and only 5.6% were using either bisphosphonates or raloxifene. Physicians could relate these findings to lack of screening and education, as 37.0% of respondents did not receive counseling about osteoporosis by their PCP. This observation is consistent with the study by Cohen et al, which showed that osteoporosis screening was conducted in only 56% of patients seen at a large multisite primary care group practice (15). Our study had some limitations. First, was a cross-sectional study and as such has the limitations inherent to this type of design. Second, the study sample size was small. Several patients were excluded because they had altered mental status that could be related to pain medications, Alzheimer s disease or other types of dementia. Nonetheless, our findings are so evident that enrolling further patients probably would not affect the results. In conclusion, in this population of Hispanic patients with a first osteoporotic fracture most had a low level of knowledge about osteoporosis. Better efforts should be undertaken to educate, identify and manage patients at risk for osteoporotic fractures. Group-based multidisciplinary education programs may improve patients knowledge about osteoporosis (16). Also, an effort should be done to educate hospitalized patients with osteoporotic fractures before discharge to continue adequate follow up and management of this condition. Orthopedic surgeons play an important role in the management of hospitalized patients with fractures, but some studies have demonstrated that they lack expertise in managing osteoporosis (17-18). Therefore, other healthcare providers should be involved in the management of hospitalized patients to ensure the best possible patient care. REFERENCES 1. Consensus development conference: prophylaxis and treatment of osteoporosis. Am J Med. 1991;90: National Osteoporosis Foundation. America s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. Washington, DC: National Osteoporosis Foundation; Looker AC, Melton LJ 3rd, Harris TB, Borrud LG, Shepherd JA. Prevalence and trends in low femur bone density among older US adults: NHANES compared with NHANES III. J Bone Miner Res. 2010;25: Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006; 17(12): Riggs BL, Melton LJ 3rd. The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone 1995; 17(5 Suppl):505S-511S 6. Palacios S, Sánchez-Borrego R, Neyro JL, Quereda F., Vazquez F, Pérez M, Pérez, M. Knowledge and compliance from patients with post-menopausal osteoporosis treatment. Menopause Int. 2009; 15: Burke-Doe A, Hudson A, Werth H, Riordan DG. Knowledge of osteoporosis risk factors and prevalence of risk factors for osteoporosis, falls, and fractures in functionally independent older adults. J Geriatr Phys Ther 2008; 31:11-7 9

12 8. Giangregorio L, Thabane L, Cranney A, Adili A, debeer J, Dolovich L, Adachi JD, Papaioannou A. Osteoporosis knowledge among individuals with recent fragility fracture. Orthop Nurs. 2010;29: Edwards BJ, Iris M, Ferkel E, Feinglass J. Postmenopausal women with minimal trauma fractures are unapprised of the existence of low bone mass or osteoporosis. Maturitas ;53: Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 2008; 19: Azoh BJ. Responsabilidad familiar y conocimientos sobre la osteoporosis: Un estudio de gerontología social.. Rev Salud Publica Nutr 2002; 3(1). 12. Monsanto HA. Level of awareness about osteoporosis among women 50 years and older in Puerto Rico. PR Health Sci J. 2010;29: Costa-Paiva L, Gomes DC, Morais SS, Pedro AO, Pinto-Neto AM. Knowledge about osteoporosis in postmenopausal women undergoing antiresorptive treatment. Maturitas. 2011;69: U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011;154: Cohen K, Maier D. Osteoporosis: evaluation of screening patterns in a primary-care group practice. J Clin Densitom. 2008;11: Nielsen D, Ryg J, Nissen N, Nielsen W, Knold B, Brixen K. Multidisciplinary patient education in groups increases knowledge on osteoporosis: a randomized controlled trial. Scand J Public Health. 2008;36: Mehrpour SR, Aghamirsalim MR, Sorbi R. Are hospitalized patients with fragile fractures managed properly in relation to underlying osteoporosis? J Clin Rheumatol. 2012;18: Sorbi R, Aghamirsalim MR. Knowledge of orthopaedic surgeons in managing patients with fragility fracture. Int Orthop. 2012;36: RESUMEN El propósito de este estudio fue evaluar el conocimiento sobre osteoporosis y los factores asociados a un nivel de bajo conocimiento en pacientes con su primera fractura de fragilidad. Metodología: Se llevó a cabo un estudio transversal de los pacientes admitidos con su primera fractura de osteoporosis en el Hospital Universitario del Centro Médico de Puerto Rico, San Juan, Puerto Rico. Se examinaron los parámetros socio-demográficos, clínicos y farmacológicos. Se utilizó un cuestionario validado para evaluar el nivel de conocimiento sobre osteoporosis. Las diferencias entre los pacientes con nivel de conocimiento bajo y mediano/alto fueron evaluadas utilizando pruebas estadísticas significativas. Resultados: Un total de 54 pacientes participaron en el estudio. El promedio (desviación estándar) de edad fue de 73.7 (10.7) años; 77.8% fueron mujeres. Se encontró un nivel de conocimiento bajo sobre osteoporosis en un 61.1% de los participantes. Los pacientes con un nivel de conocimiento bajo tenían mayor probabilidad de tener el seguro médico del gobierno de Puerto Rico, un nivel de educación menor y un mayor riesgo para fracturas de cadera calculado por el FRAX que aquellos con un nivel de conocimiento mediano/alto. Además, éstos pacientes tenían menor probabilidad de haber recibido orientación sobre osteoporosis por su médico primario, tener medidas previas de densidad ósea, recibir tratamiento con bifosfonatos/raloxifeno, y de utilizar suplementos de calcio o vitamina D. Conclusión: En esta población de pacientes hispanos con su primera fractura de osteoporosis la mayoría tenía un nivel bajo de conocimiento sobre osteoporosis. Un nivel bajo de conocimiento se asoció a un nivel socioeconómico bajo, y falta de educación sobre osteoporosis a los pacientes por los médicos primarios, pruebas previas de densidad ósea y de tratamiento de osteoporosis. Se debe hacer un esfuerzo para identificar, educar y manejar los pacientes que estén a riesgo de fracturas por osteoporosis. Porque es más cómodo y protegemos al medio ambiente se publica en versión digital 10

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14 12 PSYCHOSOCIAL FACTORS ASSOCIATED WITH FAILURE TO USE CONTRACEPTION AMONG ADOLESCENTS WITH REPEAT PREGNANCIES IN PUERTO RICO Malieri Colón MD a *, Rosa Martínez MD a, Michelle Tulla MD c, José Pérez MD a, Yadiris Santaella RN c, Linda Laras MD a a Department of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, Medical Science Campus, San Juan, Puerto Rico. b Obstetrics and Gynecology, Private Practice, San Juan, Puerto Rico. c Clinical Researcher at the University of Puerto Rico School of Medicine, Medical Science Campus, San Juan, Puerto Rico. *Corresponding author: Malieri Colón, MD - Urb. Country Club QL6 Calle 533 Carolina, Puerto Rico INTRODUCTION Teen pregnancy in Puerto Rico presents a substantial problem for society. Even though statistics from the United States indicate that there has been a decrease in incidence of teen pregnancy, current percentages reveal that conception and birth in adolescents continues to be significant. 1 In Puerto Rico, the amount of research and information available about the subject of repeat adolescent pregnancies and social circumstances is limited. In this study, our goal is to identify the common psychosocial and motivational barriers that impede Puerto Rican adolescent mothers from effectively utilizing contraception, whether it is lack of education, motivation or health services availability. The project is designed as a descriptive cohort survey. Participants were females between 12 and 19 years of age with at least one prior pregnancy during their adolescent years who attended the obstetric or postpartum clinics at the Adult University Hospital. A questionnaire along with study information was given to them, which they returned in a closed envelope after they filled it. Our goal was to identify the common psychological and motivational barriers that impede Puerto Rican adolescent mothers from effectively using contraception. Due to no available statistics detailing the number of repeat teen pregnancies that are routinely seen at this clinic and postpartum clinics, no predictions could be done regarding the number of participants. MATERIAL AND METHODS This is a cross sectional survey study of adolescents younger than 19 years of age with repeat pregnancy attending prenatal or post partum clinics at the Adult University Hospital in Puerto Rico Medical Center between November 2008 and February Trained screeners and recruiters performed initial contact to patients at the medical clinics, just before prenatal or postpartum visit. The recruiters presented the informed consent and after participant signed it, the survey was given. The participants answered the questionnaire in a private room and returned it in a manila envelope to the recruiter. The survey was short, in Spanish, simple, needing only a sixth grade scholar level to understand it. We included information related ABSTRACT Social, medical, psychological and economic problems are often associated to teen pregnancy. This is a reality worldwide; Puerto Rico is not an exception, documented in statistics and previous research projects. There are many risks associated with pregnancies among adolescents, including increased maternal morbidity and infant morbidity. In Puerto Rico, the adolescent repeat births reported are 22% for a second child and 6% for a third child. Repeated teen pregnancy has a higher than expected incidence; therefore the investigation of psychosocial factors associated with failure to use contraception is needed, especially to address the intervention at clinics with this population of different needs, mainly when these patients with repeated teen pregnancies have been through the health care system already. Methodology: The project is a cross sectional survey study, seventy participants between years of age who attended obstetrics or postpartum clinics at an adult University Hospital. A self-administered questionnaire included some psychosocial factors that have been associated with the failure to use contraceptives as well as demographics information, education, socioeconomic status and support system. Results: Their partner s age ranged from 15 to 38 years of age. Most participants lived with their partner. Their main activity at the time of the study was housework. Most had left school before becoming pregnant and received government help. Of all participants, a small number was legally married. The lack of use of contraceptive was found to be significantly associated to partner (p < 0.05). Conclusion: The lack of contraceptive use is a key factor in adolescent pregnancy. It is expected that this data can be helpful for documentation and intervention measurements something can be done at an educational level, family planning and medical care. Index words: psychosocial, factors, failure, contraception, adolescent, repeat, pregnancy

15 to demographics, education, socioeconomic status, support system, pregnancy history and reasons for not using contraception. The data was then gathered and analyzed using descriptive and Yates correction for X 2. This protocol was approved by the Institutional Review Board. RESULTS Our participant population was composed of seventy female s ages from years of age. Their partner s ages ranged from 15 to 38 years of age. Only 47% of participants referred they wanted to get pregnant, while 49% of partners wanted the pregnancy as well and only 10% were married. Participant s age: 47% were 19 years of age, 27% were 18, 12% were 17, 13% were 16, 1% was 12 years old (see Figure 1). Participants partners ages were: 46% (21-25) years of age, 31% were less than 20 years old, 12% ranged from 30 to 38 years old, 10% ranged from 26 to 29 years of age (see Figure 2). Only 1% of participants reported not knowing her partners age. When asked regarding reproductive history: 51% reported to be at their second pregnancy, 19% at their third pregnancy, 7% at their fourth pregnancy, 1% at their fifth pregnancy. Upon demographics our participants came from 24 different towns in Puerto Rico, but the majority were from San Juan. Of the total 44% referred that they hadn t received any orientation regarding contraception, 91% expressed they knew how to gain access to oral contraceptive pills (OCP). Of the ones that reported some orientation on contraception, 32% received it from a health service supplier and 24% came from other sources but only 29% had used Family Planning Services. Fifty-one of the participants referred they never used contraceptive method. Regarding living status, 57% referred living with partner, 31% with parents, 9% with other than parents family members and 3% reported living alone. Upon questions regarding occupation, 46% of participants referred working inside their homes, 33% reported they were students, 19% reported working outside their homes, 2% reported working inside and outside their homes. Figure 1: Graphic presentation of distribution in patient s ages. Figure 2: Graphic distribution of participant s partners ages. The psychological factors of our population included that most participants lived with their partner. Their main activity at the time of the study was housework. Most had left school before becoming pregnant and received some type of government help. Of all participants, a small number was legally married. (see Table 1 & 2 and Figure 3). The lack of use of contraceptive was found to be significantly (p < 0.05) associated to partner (see Table 3). DISCUSSION Statistics have showed that the birth rates of adolescent mothers aged between 15 and 19 in Puerto Rico are higher when compared to the United States. In the year 2000, they ranged from 67 per 1,000 births in Puerto Rico vs. 49 per 1,000 births in the United Figure 3: Distribution and comparison upon wanted pregnancies upon participants and partners participants. 13

16 States. 2 The most up to date statistics from the CDC, with data up to 2011 shows a decrease in these numbers to 51.7 per 1000 births in Puerto Rico vs per 1000 births in the United States from mothers 15 to 19 years old. 1 Even though there is a decreasing trend still there is much to be studied to be able to reduce it more. Several studies have identified some of the risks associated with adolescent pregnancy. Including: increased maternal morbidity and mortality (they are less likely to receive regular prenatal care), as well as being at increased risk of complications as anemia, eclampsia, pregnancy-induced hypertension, cephalopelvic disproportion leading to cesarean section, among others. 3 Studies have shown that pregnant teens have twice the mortality rate of pregnant adults. 4 Psychological differences in younger mothers has been reported in studies with higher levels of stress, depression, and substance abuse. 5,6 Infants born from adolescent mothers have an increased morbidity as well, since they have twice the incidence of delivering babies with low birth weight, the neonatal death rate is three times higher, as well as having additional health risks including those associated to prematurity, sudden infant death syndrome, accidental trauma, and poisoning. 4,5,6 Psychological consequences of teen pregnancy have also been studied, showing a decreased rate of school completion among teen mothers. 3,4,7 Although some studies have found that a significant proportion of adolescent mothers go on to finish high school in the future, the outcome of their children remains negatively affected as they have a greater risk of failing a grade in school and having behavioral problems in school or at home. 3,4,5 Infants born to adolescent mothers also have an increased incidence of developmental disabilities and cognitive deficits, as well as more aggression and less impulse control. Researchers have suggested this might be due to poorer parenting skills by the parents as demonstrated by a decreased frequency of vocalization, touching, and smiling, as well as decreased acceptance of infant s behavior and less realistic developmental expectations. 8 Children born to adolescent mothers carry certain risks into adult lives with 31% incidence of depression, 16% incidence of incarceration, and 25% incidence of adolescent pregnancy. 3 It is important to mention that adolescent mothers are less likely to find stable, well paying jobs than their peers and often depend on public assistance for economic support, leading to the children being subject to the stressors of poverty. It is therefore difficult to separate the effects of the mother s age from the general socioeconomic situation. 5,9,10 The economic burden is remarkable considering that the U.S. spends around $7 billion yearly in costs related to adolescent pregnancy, including money spent on welfare, food stamps, and medical expenses. When all the adverse consequences are taken into account, the gross annual cost of adolescent pregnancy and parenting is estimated to be $34 billion. 11,12 Most Adolescent pregnancies are unintended resulting from not using contraception. Studies have reported 14 Table 1: Distribution of living status and our participant s occupations at the time of the study. Most of them lived with their partners. Table 2: History of contraceptive methods used by our participants and source of contraception orientation. that teens who have gotten pregnant believed that they would not get pregnant after having sexual intercourse and lacked focus in taking steps to prevent it. 13 A study performed in England with 6,348 female pupils from 51 secondary schools revealed that at the moment of first intercourse (median age of 15) 54% reported the use of condoms only, 11% used oral contraceptive pills (OCP s) and condoms, 4% OCP s only, 4% used emergency contraception, and 21% used no effective method. After associations were made between these methods and rate of pregnancy, it was determined that young teens may use OCP s less efficiently than condoms for pregnancy prevention. 14 Among the most frequent reasons given for first unintended pregnancy from years old, according to survey studies, are concerns about parents finding out about sexual activity, followed by lack of knowledge about contraception, unexpected sex, unwanted sex (mostly in women under 15), ambivalence about contraception, and discontinuation of methods. 15

17 Table 3: Presents the analysis of our data using Yates correction for chi-square for possible association of factors and the lack of use of contraceptive methods among teenager Several factors have been associated with increased odds of discontinuation of OCP s in a predominantly Hispanic population: being younger than 21, not taking the first pill in the clinic, not having used it before, being less certain about wanting the pill, intending to use it for a year or less, and feeling happy about being pregnant within 6 months. 16 A study that included interviews to teen pregnant mothers, found that barriers to obtaining and utilizing contraception included embarrassment in discussing the topic, concerns regarding confidentiality and the lack of ability to obtain contraception without parental knowledge, as well as lack of knowledge regarding the different methods available. 13 These factors are important to be able to evaluate why this is occurring and should help understand the process and mechanisms available for adolescents to prevent pregnancy at such an early age. This is very worrisome. Even more worrisome, is the significant rate of repeat pregnancies among adolescents in Puerto Rico. Puerto Rican statistics show that every year, there are around 12,000 births to mothers under 19 years old. In 1998, this represented 20.4% of all births in Puerto Rico; of these, 22% were of a second child and 6% were of a third child. Even in the United States, this represents a problem with a rate of 35% of births to adolescents are repeat births as quoted by the American Academy of Pediatrics in A very revealing study with a sample comprised mostly of black and Puerto Rican adolescent mothers established that 39.6% of the participants became pregnant again within a 12 month interval. 17 Review of articles from 1966 to 1997 concluded that significant predictors of rapid repeat teen pregnancy (those within a 24 month period after a pregnancy) included: younger age, low socioeconomic status, low education of the teen s mother or head of the house, marriage, intended or desired first pregnancy, and the use of contraceptives other than Norplant postpartum. 18 Research published in 2001 confirmed the finding that long acting contraceptive starting immediately after birth is needed to effectively prevent repeat pregnancies. 19 In Puerto Rico, some of the reasons for lack of contraceptive use by a group of adolescents with a repeat pregnancy found in our study were: partner related, means by which they assess risk, and lack of education. The factor that was found that influenced the most was having a partner over 20 years of age. Half of this group of adolescents, in spite of having a prior pregnancy experience, didn t think it could happen to them. As with education, it is of utmost importance that only 31% of the adolescents reported receiving family planning education from a Heath service provider, despite receiving medical care at Health care system at least once. This should be started with a different approach for medical care to this population of special psychosocial needs. Reminding always that this should be a multidisciplinary effort, more than 50% of the participants referred to be in constant communication with their families, therefore parenting skill programs should be addressed as well. This study reminds us that we must not forget the basics in the interventions that will result in adequate family planning and in wellbeing of 15

18 women. Incorporate the partner and support system in health care; educate adolescents in risk assessment and decision-making, and adequate family planning education. CONCLUSION The factors that were more prevalent are of great concern. Adolescents with repeated pregnancy have a partner that wants this repeated pregnancy while still adolescents, while still uneducated, most of them working only in their homes. While this happens, most of teens in spite of going through a health system, don t get contraceptive, therefore health education that is a concern at their stage of development. Neither variable for partner abuse are explored. Maybe post partum care program should last a year. What is the basis for giving all women the same postpartum care? This study has a small population but it is in fact an eye opener to a direction we need to address to improve adolescent well-being. More research is needed on the psychosocial factors as they vary with social changes, as health care system changes and in adolescent s age subgroups. REFERENCES 1. Births: Final data for NVSR Volume 61(1) 2. Birth to teenagers in the United States, NVSR Volume 49(10) 3. American Academy of Pediatrics, Committee on Adolescence. Care of Adolescent Parents and Their Children. Pediatrics. 2001; 107(2) 4. American Academy of Pediatrics, Committee on Adolescence. Adolescent Pregnancy: Current Trends and Issues. Pediatrics. 1998; 103: Bondy, K and Kane M. Teen Parenting and the Care of Young Families. Clinics in Family Practice. 2000; 2 (4) 6. Stevens-Simons C. Providing Effective Health Care and Prescribing Contraceptives for Adolescents. Pediatrics in Review. 1998; 19: Carter, DM et al. When Children Have Children: The Teen Pregnancy Predicament. America Journal of Preventive Medicine. 1994; 10: Furstenberg FF Jr, Levine JA, Brooks-Gunn J. The Children of Teenage Mothers: Patterns of Early Childbearing in Two Generations. Family Planning Perspective. 1990; 22: Panzarine S. Teen Mothering: Behaviors and Interventions. Journal of Adolescent Healt Care. 1988; 9: East PL, Felice ME. Outcomes of parent-child relationships of former adolescent mothers and their 12 year-old children. Journal of Developmental & Behavioral Pediatrics. 1990; 11: Maynard R.A. Kids Having Kids: A Robin Hood Foundation Special Report on the Costs of Adolescent Childbearing, New York: Robin Hood Foundation, The National Campaign to Prevent Teen and Unplanned Pregnancies Lemay, Celeste A; Cashman, Suzanne B; Elfenbein, Dianne S; Felice, Marianne E. Adolescent Mothers Attitudes toward Contraceptive Use before and after Pregnancy. Journal of Pediatrics and Adolescent Gynecology. 2007; 20: Parkes A et al. Contraceptive method at first sexual intercourse and subsequent pregnancy risk: findings from secondary analysis of 16-year-old girls from the RIPPLE and SHARE studies. Journal of Adolescent Health Jan; 44(1): Iuliano, A Danielle; Speizer, Ilene S; Santelli, John; Kendall, Carl. Reasons for Contraceptive Nonuse at First Sex and Unintended Pregnancy. American Journal of Health Behavior; Jan/Feb 2006; 30, 1; ProQuest Central p Kerns, Jennifer; Westhoff, Carolyn; Morroni, Chelsea; Aikins Murphy, Patricia. Partner Influence on Early Discontinuation of the Pill In a Predominantly Hispanic Population. Perspectives on Sexual and Reproductive Health. 2003; 35 (6): Linares LO et al. Predictors of repeat pregnancy outcome among black and Puerto Rican Adolescent Mothers. Developmental & Behavioral Pediatrics. 1992; 13: Rigsby DC. Risk Factors for Rapid Repeat Pregnancies Among Adolescent Mothers: A Review of Literature. Journal of Pediatric & Adolescent Gynecology. 1998; 11: Stevens-Simons, C; Keely, L; Kulick, R. A village would be nice but it takes a long-acting contraceptive to prevent repeat adolescent pregnancies. American Journal of Preventive Medicine. 2001; 21: RESUMEN Los problemas psicosociales, emocionales, médicos y económicos están frecuentemente asociado al embarazo durante la adolescencia. Esto es una realidad bien documentada a nivel mundial y Puerto Rico no es la excepción. Hay un sinnúmero de riesgos asociados con embarazos en la adolescencia, incluyendo morbilidad tanto materna como del infante. En Puerto Rico, los embarazos repetidos en las adolescentes fueron un 22% para un segundo infante, 6% para uno tercero. El embarazo repetido durante la adolescencia ocurre más frecuentemente de lo esperado, por lo tanto es necesaria la investigación de los factores psicosociales asociados con la falla en el uso de medidas anticonceptivas efectivas. Especialmente para implementar una intervención efectiva en las clínicas médicas que atienden esta población con necesidades especiales; más aún cuando las pacientes adolescentes con embarazos repetidos ya han recibido tratamiento, orientación y cuidados en el sistema de salud. Este proyecto es un estudio de corte transversal, donde setenta participantes entre las edades de años de edad que recibieron su cuidado médico en las clínicas obstétricas o postparto en el Hospital Universitario de Adultos se auto administraron un cuestionario que incluía factores psicosociales que han estado relacionados con la falla de uso de anticoncepción, tanto como información demográfica, educación, nivel socioeconómico y sistema de apoyo. La edad de sus parejas sentimentales variaba entre años de edad. La mayoría de las participantes vivían con sus parejas. Su actividad principal para el tiempo del estudio era trabajo en el hogar. La mayoría habían abandonado la escuela antes de quedar embarazadas, tenían contacto frecuente con sus familias y las describían como cariñosas. La mayoría recibía algún tipo de ayuda gubernamental al momento del estudio. La falta de uso de anticoncepción estaba estadísticamente asociada a la pareja (p<0.05). Se espera que esta data sea de utilidad tanto para documentación, como para el desarrollo de medidas de intervención: a nivel de educación, planificación familiar y cuidado médico.

19 RESUMEN Objetivos: Describir los resultados de pacientes diagnosticados de fístula carótido-cavernosa indirecta y tratados mediante vía endovascular predominantemente por vía arterial y con material acrílico. Diseño: Es un estudio retrospectivo de una serie de casos. Participantes: Doce pacientes con fístula dural al seno cavernoso con importante compromiso oftalmológico, admitidos y tratados en el Instituto Nacional de Neurología y Neurocirugía entre Febrero de 1990 y Enero del Intervención: Los pacientes fueron tratados por vía endovascular para embolización de las fístulas. Medida de evolución: Se practicaron controles angiográficos a 24 horas así como a 6 y 12 meses. Resultados: 67% fueron mujeres y 33% varones. La edad media fue 44 años. 67% fueron espontáneas y 33% de origen traumático. Todos los pacientes presentaron afección oftalmológica con proptosis (92%) y afección de nervios oculomotores (67%). La cefalea y el acúfeno pulsátil fueron datos no oftalmológicos frecuentes. Todos fueron diagnosticados mediante angiografía cerebral, 33% correspondieron al tipo C, 67% al tipo D, y ninguno al tipo B de la clasificación de Barrow. En 17% de los casos el robo arterial distal se mostró severo. Predominaron los drenajes venosos anterior y superior en 83% y 42% de los casos respectivamente. La vía de abordaje fue arterial en 84% de los casos, mientras que en 17% fue venosa a través de la vena oftálmica superior. Se utilizó cianoacrilato como único material embolizante en 58% de los casos mientras que fue asociado al uso de balón desprendible y partículas de polivinil-alcohol en 16% y en los casos de abordaje venoso se utilizaron bobinas desprendibles de Guglielmi (17%). No hubo complicaciones. En controles angiográficos a las 24 horas se apreció oclusión del 100% en los casos tratados con cianoacrilato (58%) (p 0.03). Al 42% restante se les indicó maniobra de compresión manual. En control angiográfico a 12 meses todos los pacientes presentaron oclusión de 100% de la fístula carótido-cavernosa. Conclusiones: Es la segunda serie más grande del mundo con fístulas carótido-cavernosas indirectas tratadas por origen traumático. Se observó la curación del 100% de los casos a largo plazo con el uso mayoritario del abordaje transarterial y de N-butil-cianoacrilato. Palabras índices: manejo, endovascular, fistulas, durales, seno cavernoso MANEJO ENDOVASCULAR DE LAS FISTULAS DURALES AL SENO CAVERNOSO 17 Marco Zenteno MD a, Jorge Santos Franco MD b, Luis Rafael Moscote-Salazar MD c *, Angel Lee MD d a Instituto Nacional de Neurología y Neurocirugía, Manuel Velasco Suarez, México D.F, México. b Centro Medico LA RAZA IMSS, México D.F., México. c Universidad de Cartagena, Cartagena de Indias, Colombia. d Hospital Angeles del Pedregal, México D.F., México. *Correspondencia: Dr. Luis Rafael Moscote-Salazar MD, Universidad de Cartagena, Cartagena de Indias, Colombia. INTRODUCCION La fístula dural al seno cavernoso (FDSC) es una patología infrecuente que consiste en la comunicación anómala entre ramas meníngeas de la arteria carótida interna (ACI) y/o carótida externa (ACE) hacia el seno cavernoso. Estas forman parte del grupo de las fístulas carótido-cavernosas (FCC) indirectas. A diferencia de las FCC directas las cuales son frecuentemente evocadas por un trauma (1-5), las FCC indirectas suelen ocurrir espontáneamente, siendo rara la etiología traumática (5,6). La clínica sigue un curso generalmente menos severo que las FCC directas, siendo los síntomas oftalmológicos y la presencia de drenaje superior los datos más importantes a tener en cuenta sobretodo para una adecuada decisión terapéutica. En la actualidad el manejo de elección es el endovascular. En este artículo describimos las características de una serie de pacientes con diagnóstico de fístula dural al seno cavernoso que fueron tratados en el Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez de México. MATERIALES Y METODOS Es un estudio retrospectivo que consistió en la revisión de los expedientes clínicos y radiológicos de 86 pacientes con diagnóstico de FCC que ingresaron al Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, de México, en un periodo comprendido entre Febrero de 1990 y Enero del De los 86, se excluyeron 21 pacientes por contar con expedientes clínicos y/o radiológicos incompletos, por lo tanto se recolectaron 65 expedientes completos. De estos, 55 fueron tratados mediante terapia endovascular, de los cuales 12 pacientes (22%) presentaban FDSC. Se extrajeron diversas variables tales como sexo, edad, etiología, datos clínicos oftalmológicos y no oftalmológicos. Dentro de los hallazgos angiográficos se tomaron en cuenta ciertas características como el tipo de aferencia arterial (ramas de la ACI y/o ACE), tipo de drenaje venoso, tipo de fístula en relación a la clasificación de Barrow et al (7). Todos los pacientes fueron tratados mediante terapia endovascular neurológica para la oclusión de sus fístulas. Prestamos atención al tipo de abordaje ya sea arterial o venoso, el número de tratamientos, y el tipo de material embolizante utilizado. La vía arterial se realizó mediante punción de la arteria femoral con colocación de un introductor corto, y cateterización selectiva de la ACE mediante un catéter guía de 6 F (Envoy, Cordis, Miami, FL) y superselectiva a la rama involucrada con microcatéteres de flujo que variaron de entre 1.2 a 1.5 F (Magic, Balt, Montmorency) montados sobre microguías de pulgadas

20 (Mirage, Microtherapeutics, Irving, CA), en otros casos se utilizaron microcatéteres (Tracker Excel, Boston Scientific, Fremont, CA) montados sobre microguías de pulgadas (Transend EX Platinum, Boston Scientific, Fremont, C). El abordaje venoso mediante la punción y colocación de un introductor corto en la vena femoral para lograr la cateterización con catéter guía de 6 F y luego la cateterización supraselectiva de la vena facial y subsecuentemente de la vena oftálmica superior para luego acceder al seno cavernoso con microcatéteres (Tracker Excel, Boston Scientific, Fremont, CA) montados sobre microguías pulgadas (Transend EX Platinum, Boston Scientific, Fremont, C). Destacamos las complicaciones y el grado de oclusión obtenido tanto en la angiografía de control a las 24 horas así como a los 6 y 12 meses del tratamiento. Realizamos un análisis multivariado para correlacionar el tipo de material utilizado y el grado oclusión angiográfica. RESULTADOS Tabla 1: Principales síntomas y signos encontrados en 12 pacientes con FDSC. Nc: nervio craneal, AV: agudeza visual. Ocho pacientes pertenecieron al sexo femenino (67%) y 4 al masculino (33%). La media de edad fue 44 años. Durante la determinación de la etiología de la FDSC no se encontró un factor o causa desencadenante en 8 casos (67%), por lo tanto se comprendieron como espontáneas, mientras que en 4 casos (33%) prevaleció el antecedente de traumatismo cráneo-encefálico moderado o severo. Los signos y síntomas relevantes se anotan en la Tabla 1. Encontramos que todos los pacientes presentaron afección neuro-oftalmológica (ver Figura 1), de estos los signos más importantes fueron la proptosis (92%) y la afección de alguno de los nervios oculomotores (67%), preferentemente del motor ocular común y motor ocular externo. La cefalea y el acúfeno pulsátil fueron datos no oftalmológicos frecuentes e importantes de destacar. A todos los pacientes se les realizó ASD que determinó el diagnóstico definitivo. En ocho casos (67%) la fístula presentaba un patrón mixto con participación tanto de la ACI como de la ACE. La participación de la ACI fue a través de ramas del tronco meningo-hipofisiario. Dentro de las aferencias dadas por la ACE, observamos que en 10 casos presentaban participación de la arteria meníngea media (83.33%), en uno la participación de la arteria faríngea ascendente (8.33%) y en otro la participación tanto de la meníngea media como de la faríngea ascendente (8.33%). En 2 casos (17%) el robo arterial distal hacia el encéfalo se mostraba severo debido al alto flujo de la fístula. El patrón de drenaje venoso lo representamos en la Tabla 2, donde se resalta el predominio de los drenajes anterior y superior en 10 (83%) y 5 casos (42%), respectivamente. Según la clasificación de Barrow et al, encontramos 4 casos correspondientes al tipo C (33%), 8 tipo D (67%), y ninguno tipo B. Figura 1: Paciente con una FCC tipo D. Nótese la proptosis y el edema bipalpebral derechos (A). En un acercamiento se logran apreciar la dilatación de los vasos conjuntivales (B y C). Tabla 2: Tipo de drenaje venoso en 12 pacientes. En 11 pacientes (92%) solamente se requirió de un 18

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