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BACKGROUND AND OBJECTIVES: In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others. RESULTS: Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P<0.001) and Asians (HR, 2.01; 95% confidence interval, 1.78 to 2.27; P<0.001) living in the territories versus their matched 50 states counterparts. There were no significant differences in mortality among white or black patients in the territories versus the 50 states. CONCLUSIONS: Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.
Assuntos
Asiático , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Hispânico ou Latino , Nefropatias , Diálise Renal/mortalidade , Adulto , Negro ou Afro-Americano , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Nefropatias/diagnóstico , Nefropatias/etnologia , Nefropatias/mortalidade , Nefropatias/terapia , Masculino , Pessoa de Meia-Idade , Ilhas do Pacífico/epidemiologia , Porto Rico/epidemiologia , Fatores Raciais , Diálise Renal/efeitos adversos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , População BrancaRESUMO
Chronic kidney disease is a non-communicable disease that is now well recognized as a major source of premature morbidity and mortality. In general, racial/ethnic minorities in the United States are more likely than non-minority groups to develop end-stage renal disease (ESRD), but paradoxically most have a lower mortality risk. Unlike most minorities, dialysis patients in Puerto Rico have a mortality risk nearly 50% higher than the national average. Multiple factors such as medical conditions, socioeconomic, environmental, and health system factors can influence health outcomes for patients with ESRD. We describe one potential health system factor that may contribute to this finding, a unique interpretation and implementation of the ESRD Medicare Secondary Payer provision in the Commonwealth of Puerto Rico. We conducted a search of regulatory documents and key stakeholder interviews to help envision the potential implications of these differences for dialysis facilities, health care providers, and patients with ESRD.
Assuntos
Disparidades em Assistência à Saúde , Falência Renal Crônica/terapia , Medicare/economia , Mecanismo de Reembolso , Diálise Renal/economia , Etnicidade/estatística & dados numéricos , Política de Saúde , Disparidades nos Níveis de Saúde , Humanos , Falência Renal Crônica/economia , Falência Renal Crônica/etnologia , Falência Renal Crônica/mortalidade , Grupos Minoritários/estatística & dados numéricos , Porto Rico/epidemiologia , Diálise Renal/estatística & dados numéricos , Medição de Risco , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To compare complete hydatidiform mole (CHM) clinical presentation and risk factors associated with GTN development between North American and South American adolescents. METHODS: This non-concurrent cohort study was undertaken including adolescents with CHM referred to centers in North America (New England Trophoblastic Disease Center, Harvard University, USA), and South America (Botucatu Trophoblastic Disease Center-São Paulo State University, Brazil; Trophoblastic Unit of Central University of Venezuela and Maternidad Concepcion Palacios of Caracas, Venezuela) between 1990 and 2012. Data were obtained from medical records and pathology reports. Study participants were allocated into 2 groups: North America (NA) and South America (SA). RESULTS: In NA and SA, 13.1% and 30.9% of patients with hydatidiform mole were adolescents, respectively. Of these, 77.6% in NA and 86.1% in SA had pathologic diagnosis of CHM (p=0.121). Vaginal bleeding (SA=69% vs NA=51%; p=0.020), anemia (SA=48% vs NA=18%; p<0.001), and elevated serum hCG (SA=232,860mIU/mL vs NA=136,412mIU/mL; p=0.039) were more frequent in SA than in NA. Median gestational age at diagnosis (SA=12weeks, NA=11weeks; p=0.030) differed whereas GTN development rate (SA=20%, NA=27%; p=0.282) showed no significant difference between groups. Compared to NA, medical complications and clinical factors associated with post-molar GTN were more frequent among SA adolescents. CONCLUSIONS: Medical complications and clinical factors associated with GTN development were more frequent in SA than in NA adolescents with CHM, suggesting that, in South America, awareness about the importance of diagnosing molar pregnancy early and considering CHM in the differential diagnosis in adolescents suspected to be pregnant should be raised.
Assuntos
Doença Trofoblástica Gestacional/epidemiologia , Mola Hidatiforme/epidemiologia , Adolescente , Adulto , Fatores Etários , Criança , Estudos de Coortes , Feminino , Humanos , América do Norte , Gravidez , Estudos Retrospectivos , América do Sul , Adulto JovemRESUMO
Objetivo: Evaluar las características de la enfermedad trofoblástica gestacional, diagnosticada en restos ovulares obtenidos de pacientes con abortos espontáneos, atendidas en Sala de Partos de la Maternidad Concepción Palacios entre enero 2012 y enero 2014. Métodos: Estudio descriptivo, prospectivo, de corte transversal, que incluyó 325 pacientes con diagnóstico de aborto espontáneo. Previo consentimiento informado, se obtuvo información de la historia clínica, hallazgos del ultrasonido y de los resultados histopatológicos. Resultados: La frecuencia de mola parcial fue de 0,3 %. La edad promedio de las pacientes fue 27 años ± 7 años, la edad gestacional promedio fue 9 semanas + 3 días ± 4 semanas. La mediana de gestas obtenida fue 2, con un rango de 1 a 11. Un 89,84 % de las pacientes se encontraban sintomáticas al momento del ingreso, 55,4 % ingresó con cuello cerrado. Desde el punto de vista macroscópico 96,3 % eran de aspecto ovular, 3 % parcialmente hidrópicos, y 0,6 % hidrópicos y desde el punto de vista microscópico, 92,9 % correspondió a restos ovulares, 7 % a abortos con degeneración hidrópica y 0,3 % a mola parcial. No se encontró correlación estadística entre el ultrasonido y la histología para diagnóstico de enfermedad trofoblástica gestacional. Conclusión: La frecuencia de mola parcial fue baja.
Objective: To evaluate the characteristics of gestational trophoblastic disease, diagnosed in POC from patients with spontaneous abortions, attending Birthplace of Concepcion Palacios Maternity between January 2012 and January 2014. Method: A descriptive, prospective, cutting cross, which included 325 patients with a diagnosis of spontaneous abortion. Prior informed consent information from the clinical history, ultrasound findings and histopathological results were obtained. Results: The frequency of partial mole was 0.3 %, the average age of the patients was 27 years ± 7 years, mean gestational age was 9 weeks + 3 days ± 4 weeks. Median deeds obtained was 2 with a range of 1 to 11 A 89.84 % of patients were symptomatic at the time of admission, 55.4 % were admitted with high collar. From the macroscopic viewpoint aspect 96.3 % were ovulating, 3 % partially hydropic and hydropic and 0.6 % from the microscopic, 92.9.% are POC, 7% to abortions with hydropic degeneration and 0, 3 % a partial mole. We did not find that there is statistical correlation between ultrasound and histology for the diagnosis of gestational trophoblastic disease. Conclusion: the frequency of partial mole was low.
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BACKGROUND: Aneurysm of the splenic artery is diagnosed when the diameter of the splenic artery is greater than 1cm. It occupies third place among abdominal aneurysms. It is more frequent in women (4:1). It is associated with trauma, haemodynamics and local hormonal effects during pregnancy, portal hypertension (including the Caroli syndrome), arterial degeneration, atherosclerosis, and liver transplantation. It is difficult to diagnose, and it generally presents as ruptured, thus once the diagnosis is made, the surgical approach is indicated due to its high mortality. CLINICAL CASE: Female of 66 years of age with a diagnosis of splenic artery aneurysm, with pulsing sensation at epigastric level of 8 months onset. On physical examination there is a palpable throbbing mass of 9 cm of diameter approximately, for which she was admitted. The computed tomography angiography with reconstruction showed three splenic aneurysms. Two were tied and the larger one was repaired by endo-aneurysmorrhaphy. DISCUSSION: Visceral aneurysms are extremely rare. They are currently increasing and are the third leading cause of cardiovascular death, as morbidity/mortality is high. The surgical treatment must be done selectively according to their size. Selection of the surgical techniques depends on the anatomic location and the need for revascularisation, the aetiology and the experience of the surgeon. CONCLUSION: A review has been presented on the advances in diagnostic, and management, concluding that the best is to preserve the spleen, and whatever the technique it must be performed by trained surgeons.
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Aneurisma/cirurgia , Tratamentos com Preservação do Órgão/métodos , Baço/cirurgia , Artéria Esplênica/cirurgia , Idoso , Aneurisma/diagnóstico por imagem , Angiografia , Embolectomia com Balão , Feminino , Humanos , Ligadura , Circulação Esplâncnica , Baço/irrigação sanguínea , Artéria Esplênica/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
Presentamos el caso de una paciente de 35 años de edad, VII gestas, VI molas I aborto, portadora de la mutación en la proteína NLRP7, evaluada en el servicio de patología del primer trimestre del embarazo de la Maternidad Concepción Palacios entre los años 1998- 2010. Ambos padres tenían cariotipos normales y se detectó un antecedente familiar de embarazo molar. Este caso forma parte de un raro subconjunto de molas cuyo origen es biparental, generalmente recurrente y a menudo familiar y se asocia a imposibilidad de obtener un embarazo exitoso.
We report the case of a 35 years old patient, with 7 pregnancies, 6 molas, 1 abortion, carrier of a mutation in the protein NLRP7, evaluated in the pathology service of the Maternidad Concepcion Palacios between 1998-2010. Both parents had normal karyotypes and a family history of molar pregnancy was detected. This case is part of a rare subset of molas with biparental origin, usually recurrent and often family and associated with failure to obtain a successful pregnancy.
Assuntos
Humanos , Masculino , Feminino , Gravidez , Complicações na Gravidez , Mola Hidatiforme , Incidência , Doença Trofoblástica Gestacional , Hiperplasia , Fatores de Risco , GenesRESUMO
Objetivo: Proporcionar material didáctico útil al estudiante y al médico general para conocer la técnica de venodisección en un modelo biológico no vivo. Sede: Departamento de Cirugía, Facultad de Medicina, UNAM. Diseño: Modelo de enseñanza. Material y método: Se proporcionan indicaciones, contraindicaciones, características anatómicas y técnica a considerar. Empleamos pata de cerdo como modelo didáctico por ser accesible en costos, disponibilidad y un modelo fácilmente reproducible por los alumnos. Por su semejanza con los eventos clínicos que suceden en los pacientes a nivel hospitalario, consideramos que representa un buen método de enseñanza de habilidades quirúrgicas en el pregrado. Conclusión: El actual modelo biológico es una opción viable y representativa de la venodisección; el alumno aprende a identificar al paciente que requiere de este procedimiento; una vez identificado, podrá realizar el procedimiento de manera adecuada evitando, en la medida de lo posible, cualquier tipo de complicación.
Objective: To provide teaching material useful for the medical student and the general physician to learn the venous cutdown technique in a non-live biological model. Setting: Department of Surgery, School of Medicine, UNAM. Design: Teaching model. Material and method: Indications, contraindication, anatomical characteristics and technique to be considered will be provided. We use a pig foot as didactic model because it is accessible in terms of costs, availability, and can be reproduced easily by students. Due to its similarity with clinical events occurring in patients at the hospital level, we consider that it represents a good teaching method of surgical skills at the undergraduate level. Conclusion: The current biological model is a viable option and representative of venous cutdown. The student learns to identify the patient that requires this procedure, once identified he will be able to perform the procedure adequately avoiding, as much as possible, any type of complication.
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Mutations in the breast cancer 1, early onset (BRCA1) and breast cancer 2 (BRCA2) genes are responsible for the majority of hereditary breast cancers. Knowledge of the incidence and prevalence of BRCA mutations in a specific population or ethnic group is necessary to provide accurate genetic counseling for breast cancer patients and their families; however, these data have not been gathered in the population of Puerto Rico. We conducted a retrospective study of female breast cancer patients undergoing genetic testing for BRCA mutations in the highest-volume breast surgery practices in San Juan, Puerto Rico. Data collection includes three-generation family cancer history and results from complete BRCA sequencing. A total of six different deleterious mutations were observed, including one mutation in BRCA1 and five mutations in BRCA2. Three recurrent mutations (BRCA1 del exon1-2, BRCA2 4150G>T, and BRCA2 6027del4) account for over 70% of all the BRCA mutations observed in this study population. This study examines for the first time the characteristics of hereditary breast cancer in Puerto Rico and assesses the accuracy of existing genetic risk assessment tools in that population. This data is expected to contribute to providing accurate and efficient tools for the clinical management of hereditary breast cancer in Puerto Rico.
Assuntos
Proteína BRCA1/genética , Proteína BRCA2/genética , Neoplasias da Mama/genética , Neoplasias da Mama/epidemiologia , Feminino , Predisposição Genética para Doença , Heterozigoto , Humanos , Cobertura do Seguro , Seguro Saúde , Mutação , Porto Rico/epidemiologia , Estudos Retrospectivos , Medição de RiscoRESUMO
Determinar la asociación entre el síndrome metabólico y las complicaciones maternas, fetales y neonatales, en un grupo de embarazadas entre agosto 2008 y septiembre 2009.En el Servicio Prenatal de la Maternidad Concepción Palacios. Estudio prospectivo, longitudinal, comparativo, con una muestra de 130 embarazadas, 38 cumplieron los criterios de la Federación Internacional de Diabetes para síndrome metabólico y 92 fueron el grupo control. El promedio de edad de las pacientes con síndrome 29,86 años, significativamente mayor que el del grupo control (24,11 años). Entre las gestantes con síndrome metabólico 34,2 por ciento presentó trastornos hipertensivos del embarazo, 23,7 por ciento tuvieron diabetes, 26,3 por ciento parto pretérmino y 2,6 por ciento infección puerperal. En el grupo control hubo 13,0 por ciento de trastornos hipertensivos del embarazo 6,6 por ciento de parto pretérmino y ningún caso de diabetes o infección puerperal (P< 0,05). La complicación fetal más frecuente fue la macrosomía, 10,5 por ciento de las gestantes con síndrome metabólico y 4,3 por ciento del grupo control (P>0,05). Hubo 23,7 por ciento de casos con bajo peso al nacer, 18,4 por ciento con hipoglicemia y 10,5 por ciento con sepsis en el grupo de recién nacidos de madres con sindrome metabólico. Este estudio mostró una mayor tasa de complicaciones maternas y neonatales en embarazadas con síndrome metabólico, en comparación con el grupo control
To determine the association between metabolic syndrome and maternal complications, fetal and neonatal in a group of pregnant patients between August 2008 and September 2009. Prenatal care service at the Concepcion Palacios Maternity. A prospective, longitudinal, comparative study with a sample of 130 pregnant women was done, from which 38 patients met the International Diabetes Federation metabolic syndrome criteria and 92 patients were part of the control group. The mean age of the patients with metabolic syndrome was 29.86 years, and the control group was 24.11 years. Among pregnant women with metabolic syndrome, 34.2 percent showed hypertensive disorders of pregnancy, 23.7 percent had diabetes, 26.3 percent were preterm delivery and 2.6 percent had preterm puerperal infection. In the control group there were 13.0 percent hypertensive disorders of pregnancy, 6.6 percent preterm deliveries and no cases of diabetes or puerperal infection (P <0.05) were reported. The most frequent complication was fetal macrosomia, with 10.5 percent of cases in pregnant women with metabolic syndrome and 4.3 percent in the control group (P> 0.05). There were 23.7 percent of cases with low birth weight, hypoglycemia 18.4 percent and 10.5 percent with sepsis in the group of infants from mothers with metabolic syndrome. This study showed a higher rate of maternal and neonatal complications in pregnant women with metabolic syndrome compared with the control group
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Idoso , Complicações na Gravidez/diagnóstico , Hipertensão Induzida pela Gravidez/patologia , Relações Materno-Fetais , Síndrome Metabólica/complicaçõesRESUMO
Se revisaron 468 historias de embarazadas con presentación de hombro, en embarazos simples, asistidas entre 1985 y 1989 en 106.763 partos dando una incidencia de 0,44 por ciento, ó 1 por cada 228 partos. La edad osciló entre 16 y 38 años, promedio 28. Fueron primigestas 13,46 por ciento y 86,54 por ciento tenían 2 o más gestaciones. En 55,13 por ciento fueron embarazos a término, 48,38 por ciento pretérmino y 1,49 por ciento postérmino. En 76,07 por ciento se diagnosticó la presentación durante el trabajo de parto, 23,93 por ciento mediante estudio radiológico y ecosonograma. En 23,93 por ciento se trató de una dorso superior, en 17,95 por ciento dorso inferior y en 58,12 por ciento no se precisó. En 97,01 por ciento se realizó cesárea y en 2,99 por ciento el parto fue por conduplicato corpore. El Apgar al nacer estuvo entre 8 y 10 en 31,57 por ciento, entre 4 y 7 en 52,63 por ciento y menor de 4 en 15,78 por ciento. La morbilidad materna fue de 14,96 por ciento y la fetal 55,51 por ciento. Hubo 5 muertes neonatales (10,68 por ciento) y 14 mortinatos (29,91 por ciento) dando una mortalidad perinatal de 40,59 por mil
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Gravidez , Recém-Nascido , Adolescente , Adulto , Humanos , Feminino , Idade Gestacional , Parto/efeitos adversos , Parto/mortalidade , ObstetríciaRESUMO
Se presenta el caso de una malformación cerebral arteriovenosa produciendo hipertensión pulmonar con fallo del ventrículo derecho. Esta es una manifestación rara de esta enfermedad