ASOCIACIÓN MÉDICA DE PUERTO RICO Vol. 100 - Núm 2

Transcription

B LETÍN
ASOCIACIÓN MÉDICA DE PUERTO RICO
PERMIT No. 3007
Vol. 100 - Núm 2 - Abril-Junio 2008
SAN JUAN, PR
PAID
U.S. POSTAGE
STANDARD
PRESORT
B LETÍN
CONTENIDO
2 JUNTA DE DIRECTORES / JUNTA EDITORA
3 MENSAJE DEL PRESIDENTE Y PORTADA
Por: Eduardo Rodríguez Vázquez, MD
7 From the Editorial Desk...
Por Humberto Lugo-Vicente, MD
ARTÍCULOS ORIGINALES - ORIGINAL ARTICLES
8 A COMPETENCY-BASED COMMUNICATION SKILLS WORKSHOP SERIES FOR PEDIATRIC RESIDENTS
By Débora H. Silva, MD
14 HEMOLYTIC UREMIC SYNDROME IN CHILDREN IN PUERTO RICO:
A RARE DISEASE WITH ATYPICAL FEATURES
By: Yasmín Pedrogo-Rodríguez, MD, Juan O. Pérez-Rodríguez, MD, Melvin Bonilla-Felix, MD
18 THROMBOCYTOSIS IN ILLICIT DRUGS-EXPOSED NEWBORNS
By: Thea Calderón MD, Sonia Medina MD, Inés García MD, Lourdes García MD, Marta Varcárcel MD
21 MANEJO DE LACTANCIA Y AMAMANTAMIENTO: ROL DEL MEDICO RESIDENTE
Por: Nerian Ortiz Matos MD, Lourdes García Fragoso MD
24 GENITOANAL FINDINGS IN PUERTO RICAN CHIL-
DREN WITH SUSPECTED SEXUAL ABUSE
By: Amaris Rivas Carlo MD, Brenda Mirabal MD, MPH
28 LUPUS NEPHRITIS IN PUERTO RICAN CHILDREN AND ADOLESCENTS
By: Tami O. Tiamfook MD, Ivonne Arroyo MD, Enid Del Valle MD , Juan O. Pérez-Rodríguez MD, Anarda González MD, and Melvin Bonilla-Félix MD
PORTADA
33 PERCEPTION OF PARENTS REGARDING THEIR CHILDREN’S WEIGHT
By: Ilsa J. Nazario Rodriguez MD, Wanda I. Figueroa MD , Jaime Rosado MD, Iris del C. Parrilla MS
39 DO PARENTS KNOW ABOUT THE ADVERSE EF-
FECTS OF PASSIVE SMOKING AND THE RELA-
TIONSHIP WITH RESPIRATORY ILLNESS ON THEIR CHILDREN?
By:Cristina Jiménez-González MD, Vanessa Santini MD, Wanda I. Figueroa Cosme MD, Iris del C. Parilla MS
ARTÍCULOS DE REPASO - REVIEW ARTICLES
47 DEVELOPMENTAL SEX DISORDERS: BRIEF RE
VIEW ON CURRENT ETHICAL ASPECTS.
By: Francisco Nieves-Rivera, MD and Lilliam González-Pijem, MD
52 DIABETIC KETOACIDOSIS IN PEDIATRICS:
MANAGEMENT UPDATE
By: Ricardo García-De Jesús MD
REPORTES DE CASOS - CASE REPORTS
57 EVIDENCED BASED MANAGEMENT OF NEONA-
TAL HEMANGIOLYMPHANGIOMA: A Case Report.
By: Maribel Campos MD, Víctor Ortiz MD, Maria S. Correa MD, Pedro J.Santiago Borrero MD, Ines Garcia MD, Lourdes Garcia MD, Marta Valcárcel
60 PORTADA
62 CME Credits for Vol. 100 Núm 2.
BOLETIN - Asociación Médica de Puerto Rico
Ave. Fernández Juncos Núm. 1305
P.O.Box 9387 - SANTURCE, Puerto Rico 00908-9387
Tel.: (787) 721-6969 - Fax: (787) 724-5208
e-mail: [email protected]
Web site: www.asociacionmedicapr.org
Catalogado en Cumulative Index e Index Medicus
Listed in Cumulative Index and Index Medicus No. ISSN0004-4849
Registrado en Latindex -Sistema Regional de Información en
Línea para Revistas Científicas de América Latina, el Caribe,
España y Portugal
Dr. Manuel Quevedo Báez
Óleo de Miguel Pou, 1955
Diseño Gráfico y Emplanaje realizado por el Departamento de
Prensa y Publicidad de la AMPR
E-mail: [email protected]
Vol. 100 - Núm 2 - Abril - Junio 2008
2
BOLETÍN - ASOCIACIÓN MÉDICA DE PUERTO RICO
ASOCIACIÓN MÉDICA DE PUERTO RICO - 2008
PRESIDENTES
SECCIONES DE ESPECIALIDAD
JUNTA DE DIRECTORES
Eduardo Rodríguez Vázquez, MD
Presidente
Ricardo Marrero Santiago, MD
Presidente Saliente
Verónica Rodríguez, MD
Secretaria
Raúl Casstellanos Bran, MD
Tesorero
Hilda Ocasio Maldonado, MD
Vicepresidente AMPR
Rolance Chavier Roper, MD
Vicepresidente AMPR
Raúl A. Jordán Rivera, MD
Vicepresidente AMPR
Arturo Arché Matta, MD
Presidente Cámara de Delegados
José I. Iglesias, MD
Vicepresidente Cámara de Delegados
Rafael Fernández Feliberti
Delegado Alterno AMA
Eladio Santos Aponte, MD
Wanda Vélez Andujar, MD
José Gerena Díaz
Presidente Distrito Este
Gustavo Cedeño Quintero, MD
Presidente Distrito Noreste
Wanda Vélez Andujar, MD
Presidente Distrito Sur
Mildred Arché Matta
Presidente Distrito Central
Verónica Rodríguez, MD
Presidente Consejo de Educación Médica Continuada
Ismael Toro Grajales, MD
Presidente Consejo Ético-Judicial
Alejandro Medina Vilar
Presidente Consejo Relaciones Públicas y Servicios Públicos
Jorge Vélez Soto, MD
Presidente Consejo Servicios Médicos
Presidente Consejo Salud Pública y Bienestar Social
Natalio Debs Elías, MD
Presidente Consejo Política Pública y Legislación
Emilio Arce Ortiz, MD
Presidente Comité Asesor Presidente
Ilia E. Zayas Ortiz, MD
Presidente Instituto Educación Médica
ANESTESIOLOGÍA
Carlos Estrada Gutiérrez, MD
CIRUGÍA GENERAL
José García Troncoso, MD
CIRUGÍA ORTOPÉDICA
Kenneth Cintrón, MD
CIRUGÍA ESTÉTICA Y RECONSTRUCTIVA
Natalio Debs Elías, MD
CIRUGÍA TORÁCICA Y CARDIOVASCULAR
José O’Neill Rivera, MD
CIRUGÍA DE MANO
José Santiago Figueroa. MD
DERMATOLOGÍA
Luis J. Ortiz Espinosa, MD
ENDOCRINOLOGÍA
MEDICINA DE FAMILIA
Marina Almenas, MD
MEDICINA FÍSICA Y REHABILITACIÓN
Miguel Berríos, MD
MEDICINA INTERNA
Ramón A. Suárez Villamil
MEDICINA PREVENTIVA Y SALUD PÚBLICA
Roberto Rosso Quevedo, MD
OFTALMOLOGÍA
Emilio Arce López, MD
OTORRINONARINGOLOGÍA
Charles Juarbe
PSIQUIATRÍA
Pedro Colberg, MD
NEUROLOGÍA
Edwin Lugo Piazza, MD
UROLOGÍA
Pedro Piquer Merino, MD
MEDICINA DE EMERGENCIA
Pablo Laureano Marti, MD
JUNTA EDITORA
Humberto Lugo Vicente, MD
Presidente
Luis Izquierdo Mora, MD
Melvin Bonilla Félix, MD
Carlos González Oppenheimer, MD
Eduardo Santiago Delpin, MD
Francisco Joglar Pesquera, MD
Yocasta Brugal, MD
Juan Aranda Ramírez, MD
Francisco J. Muñiz Vázquez, MD
Walter Frontera, MD
Mario. R. García Palmieri, MD
Raúl Armstrong Mayoral, MD
José Ginel Rodríguez, MD
Vol.: 100 - Núm 2 - Abril - Junio 2008
3
Mensaje del Presidente
Message from the President
Por: Eduardo Rodríguez Vázquez, MD
Presidente, Asociación Médica de Puerto Rico
La Asociación Médica de Puerto Rico fue
fundada en 1902 por el Dr. Manuel Quevedo Báez,
en unión a otros distinguidos médicos. Como todos los grupos en que median los seres humanos,
la Asociación Médica ha atravesado y sobrepasado
varias crisis en su historia.
En el último año de su presidencia en la
Asociación Médica de Puerto Rico, el sabio científico Dr. Agustín Sthal (1905-1909) publicó en el
periódico La Correspondencia de Puerto Rico el
anuncio de su renuncia, “obedeciendo a la indiferencia completa de los asociados observada desde
hace un año y su retraimiento de este centro profesional y científico y conceptuó extinguida la
Asociación”. Una de las razones que alegaba para
su acción era que nuestro Boletín Científico no se
había publicado durante más de un año.
Gracias a la iniciativa de varios médicos,
entre ellos el Dr. Pedro Gutiérrez Igaravidez y el
Dr. Rafael Vélez López, se llevó a cabo una
reunión en Ponce, pudiéndose, entonces, reorganizar nuestra Asociación Médica.
De esto resultó el que nos uniéramos, al
año siguiente, a la Asociación Médica Americana,
por primera vez.
La carta que reproducimos a continuación,
escrita por el Dr. Manuel Quevedo Báez y dirigida
al Dr. Manuel Pavía Fernández, obedece a otra de
las crisis institucionales por las que atravesó la
Asociación Médica en la década de 1930.
Me he tomado la libertad de reproducir
todo el contenido de la misma para que sirva de
mensaje aleccionador a nuestros colegas que aspiran a ser los futuros líderes de esta venerable institución.
Las palabras de nuestro fundador y primer presidente tienen, todavía, gran vigencia en
nuestros días.
4
Carta del Dr. Manuel Quevedo Báez al
Dr. M. Pavía Fernández
16 de diciembre de 1935
Dr. M. Pavia Fernández
Santurce, P.R.
Mi querido y buen amigo: no puedo silenciar la satisfacción con que he visto su nombramiento, surgido con unanimidad de la Asamblea,
para la presidencia de la Asociación Médica, durante el año próximo.
Es motivo justificado para mi la felicitación que debo darte, bien sentida y franca, por
el honor que recibes.
Espero que seas, en ese puesto, un continuador feliz del pensamiento original y básico que
trajo a la vida esa Asociación y de los empeños
puestos en práctica, por cuantos te hemos precedido en esa posición de tanta responsabilidad.
Sé que arribas a ella en días y momentos
difíciles, porque llega, hasta nosotros, a través de
todas las distancias, esa ola agria y funesta de los
ciegos egoísmos, de irreverencias y de maldades
que ha echado a correr, loca, por el mundo.
¡Ojalá no fueran motivos míseros y pobres los que han sembrado la cizaña en nuestro
campo!
¡Ojalá que fueran motivos políticos de
honda significación y trascendencia; que obedecieran a esa política de verdad, de alto sentido
moral y constructivo; la que enaltece a hombres
y pue-blos y deja honda huella a su paso por la
historia, y no a esa menguada y mezquina que más
bien sirve de bochorno y de descrédito a los que la
sirven y, de ella, regocijados se nutren!
Si ello no se consiguiese, tendríamos dolorosamente, que acusarnos todos, de una grave
responsabilidad, porque estaríamos haciendo traición a uno de los más firmes exponentes de la cultura puertorriqueña y, así, estaríamos culpables,
maculando el manto de bien ganado prestigio,
que, durante un cuarto y más de siglo, cubrió, con
grandes honores, a esta Institución Médica.
Las páginas que llenan su historia durante
treinta y tres laboriosos y fecundos años, son más
que luminosas y brillantes.
En ellas se copia todo ese proceso maravilloso de avance, que ha seguido el pensamiento médico, desenvolviéndose a tono con los
progresos médicos, que se realizan en el mundo
científico.
La medicina que hemos cultivado, nos ha
permitido ver como, en fases sucesivas de progreso,
hemos ido pasando de las viejas normas de pura
intuición, a través de lo objetivo y sintomático, a
las formas que, por mediación del microscopio
arrancábamos a la “Anatomía Patológica”. Y ya
esta en nsus vastos campos explorada, comenzamos a entrar vislumbrando un campo nuevo prometedor de grandes conquistas para la Clínica: el
de la Biología.
Con estos créditos nuestra gloriosa Asociación tiene un buen crédito conquistado y nuestro
deber médico y cívico, como verdaderos puertorriqueños, es mantenerlo y defenderlo, a toda costa.
Está todo eso, de gloria y prestigio, en
tus manos y yo me prometo grandes éxitos para tu
honor y el de la clase médica.
Sinceramente, compañero y amigo
Fuera una fortuna y no pequeña para ti
y para cuantos amamos la cordialidad y la unión
sincera y fraternal de todas las fuerzas médicas y
para cuantos, primero y principalmente, por encima de todo credo u opinión sectarios, nos senti
mos puertorriqueños; fortuna grande fuera que,
bajo tu presidencia, lograras conjurar esas bochornosas diferencias que tanto lastiman al honor
y prestigio de nuestra clase médica.
Yo así lo espero: primero, por la virtud
médica y el patriotismo de nuestros alejados compañeros, quienes tienen, siempre, muy hondas sus
raíces vinculadas en la Asociación Médica y segundo, porque me abona, para esperarlo así, la
confianza que tengo en tu probada discreción y
buen juicio y tu buena disposición a mantener incólume el espíritu de cordialidad entre la clase.
P.S.: Aparte esto, buscar quiero un refugio de
honor en esta carta para poner en él una flor, que
prendieras en el noble pecho de Mimi tu inspiradora y colaboradora de tus exitos.
¡Ahí va la flor!
5
Dr. Manuel Quevedo Báez
Versión en tamaño real de esta carta puede obtenerse en nuestro web site www.asociacionmedicapr.org en
la sección President Desk
:FD@E>JFFE
Copyright © 2008 Daiichi Sankyo, Inc. and Eli Lilly and Company. All Rights Reserved. PG51957 Printed in USA. June 2008.
7
“Since the opportunity is there I will take
advantage of it.”
From the Editorial Desk...
By: Humberto Lugo-Vicente, MD FACS FAAP
Editor-in-chief Boletín Asociación Médica de PR
While we move the golden pages of this
journal a little further we have dedicated this second issue of the Boletin to pediatrics. To the effort
of those local scientist who care for the health of
newborns, infants and children around our island.
Our guest editor for this issue is Dr. Melvin Bonilla, a pediatric nephrologists and member of the
editorial board. He has compiled a fruitful group
of interesting original articles, reviews and case
report. We have managed to continue with providing 4.0 CME credits awards after reviewing and
studying several articles.
Not so long ago, reckon was the 2004, that
we had the sad news of losing one of our beloved
pediatrician in our community. He was the heart
and soul of academics pediatrics within the private
practice organizing for eighteen years the Annual
Ashford Presbyterian Hospital Pediatric Course.
Of course I’m referring to our beloved and friend
Dr. Simon Piovanetti.
Two weeks after the idles of March Dr.
Piovanetti was born in the rural areas of Sabana
Grande. Finishing high school in San German, he
did a bachelor degree in science at the University
of Puerto Rico. The Second World War caused a
personal and academic parenthesis in his life while
serving with the 65th battalion of infantry. After
serving in the army, he completed his general
medicine doctorate and pediatric residency at the
Jefferson Medical College in Philadelphia. Marries Provi Keelan Capo and has a daughter, Yvette.
Yvette is a renowned pediatrician with a keen interest in breast feeding. After finishing the residency years, Simon returns to Puerto Rico where he
serves as pediatrician for more than 50 years.
Simón Piovanetti, MD FAAP
1920-2004
Dr. Piovanetti directed the Department of Pediatrics of the Ashford Presbyterian
Hospital for more than fifteen years and participated as member of the directive board of the Puerto
Rico Medical Association for more than ten years.
Since then he wrote four didactic books in Pediatrics such as: ‘Manual de Pediatría’, ‘Simón Dice’
y las ‘Perlas de Pediatría I and II’.
Patients and family members describe his
best assets as the ability to listen and the ability to
forgive without resentments. He could transform
pain and suffering into happiness and humor in the
blink of an eye.
In memorial, this pediatric issue is dedicated to the loving character of Dr. Simon Piovanetti, a great community pediatrician.
From a friend to a friend,
8
Artículos Originales - Original Articles
A COMPETENCY-BASED COMMUNICATION SKILLS
WORKSHOP SERIES FOR PEDIATRIC RESIDENTS
By: Débora H. Silva, MD
ABSTRACT
Background: The use of advanced communication skills to deal with difficult situations is essential to deliver adequate medical care.
Description: A four-unit competency-based workshop series was developed for Pediatric Residents.
The units are: Communicating Bad News, Communicating in Difficult Physician-Patient Situations,
Communicating with Adolescents and Providing
Telephone Consultation. The Communicating Bad
News unit was fully developed, implemented and
pilot tested.
Evaluation: The intervention group performed
significantly better (p = 0.001) than the non-intervention group in the Pilot Test. Residents found
the instructional sessions to be excellent and effective.
Conclusions: A competency-based curriculum is
likely to be an effective way to teach the use of advanced communication skills needed in complex
situations. In addition to learning the skills, residents are also likely to feel more prepared to deal
with the situations they encounter. Both skill and
confidence are necessary for the adequate delivery
of medical care.
Key words: Communication Skills, Clinical Skills,
Giving Bad News
* From the Department of Pediatrics, University of
Puerto Rico, School of Medicine Michigan State
University Primary Care and Faculty Development Fellowship.
Address reprints to: Débora H. Silva MD, FAAP,
Curriculum Office, U.P.R. School of Medicine P.O.
Box 365067 San Juan PR 00936-5067. <dsilva@
rcm.upr.edu>
Good doctor-patient communication is essential for delivery of adequate medical care (1-9,
20). Effective communication is a core clinical
skill and should be taught and evaluated at different levels in medical education (1, 10-13).
Although most medical schools have established a
communication skills curriculum giving emphasis
to the medical interview, less attention has been
given to teaching advanced communication skills
at the residency level (4-5, 16-17).
The Accreditation Council on Graduate Medical
Education (ACGME) is requiring evidence of residents’ competence in communication skills since
2003 (13). In addition, by 2010, pediatricians who
want to re-certify will need to provide evidence of
competency in interpersonal communication skills
to the American Board of Pediatrics (14).
Although residency programs are starting to develop communication skills curriculums, descriptions
are usually narrow in scope, do not address assessment of the curriculum, or do not address the use
of skills in a more complex context (4, 15, 17-21,
24). Two developers describe their curriculum and
include the use of advanced communications skills.
Morgan et al. found that residents thought the curriculum was valuable and effective, but there was
no significant change in communication skills.
They argued that residents were already evaluated positively in the pre-test, so no change was
observed (17). On the other hand, Smith and his
colleagues observed that residents trained in communication were superior to untrained residents in
knowledge, attitudes and interviewing skills (4).
The Pediatric Residency Program at the
UPR School of Medicine needs an advanced communication skills curriculum. The residency program is mostly located at a tertiary care center,
which serves most of the population in Puerto
Rico. In this context, dealing with complex and
difficult situations is a common occurrence for
residents and they should be adequately prepared.
We conducted a literature review and
needs assessment at the residency program and developed a competency-based, advanced communication skills curriculum. The curriculum contains
four units: Communicating Bad News, Communi
cating in Difficult Physician-Patient Situations,
9
Figure 1: Curriculum Structure
Residents will use adequate communication skills
to deal complex situations
Communicating
Bad News
Giving Dx/Prognosis
Taking DNR
Communicating in
Difficult Physician-Patient Situations
Anxious
Angry
Depressed
Denial
Communicating with
Adolescents
Health Maintenance
Education
Providing Telephone
Consultations
Communicating with Adolescents and Answering
Telephone Consultations (See Figure1). To begin
the assessment of the curriculum, we fully developed, implemented and tested the unit on Communicating Bad News.
METHODS
Unit Development Process
In able to develop the Communicating
Bad News Unit, an extensive literature search was
conducted. Also the goals and objectives on communication skills of the Residency Program (23)
and of the ACGME Competencies were revised
(13). Taking all this into consideration, unit objectives, unit content, instructional and evaluation
strategies were developed (See Table 1).
Unit Implementation
The unit on Communicating Bad News
was implemented in March 2004. Two social
workers and five standardized patients (SP) were
trained to teach, give feedback and evaluate residents’ performance in giving bad news following the Giving Bad News Checklist based on the
SPIKES Protocol for Giving Bad News (26). The
first year pediatric residents were divided into an
intervention and a non-intervention group by following the residency programs’ master program
in which some residents are required to attend the
teaching activities each month and some are exempt. Those residents required to attend the activities during the month of March 2004 comprised
the intervention group; those exempt were the controls.
Those residents required to attend the activities
during the month of March 2004 comprised the intervention group; those exempt were the controls.
They all signed consent forms to participate in the
pilot Objective Structured Clinical Exam (OSCE).
Five residents were used as controls in the nonintervention group. Seven residents comprised the
intervention group; six completed the training. The
intervention group underwent four hours of training.
In session one, residents listened to a lecture on how to give bad news according to the
Giving Bad News Checklist, viewed a live demonstration given by an SP and a faculty member
and received the article on the SPIKES Protocol
to read (26). In session two, they viewed two videotapes of scenarios where bad news was given in
an appropriate and an inappropriate manner. Then
the residents analyzed the performances shown in
the videotapes according to the checklist. In session three, residents role-played various scenarios
in which the physician had to give bad news. Each
resident received feedback from a standardized patient (SP). Only two residents also received feedback from one social worker. They had 15 minutes
to complete each role-play and 5 minutes for feedback. In the last session residents were divided in
groups of two and assigned to an SP. Each student
had 15 minutes to give bad news to an SP, following the instructions given to them at the beginning
of the interaction. At the completion of the interaction they received five minutes of feedback from
the SP. While one student was giving the bad news
to the SP, the other was evaluating the interaction
following the checklist.
10
Table 1: Unit Development Table
Unit Objectives
Given a scenario
where they have to
communicate
bad
news to a patient/family (Giving Prognosis,
Diagnosis and taking
DNR) residents will
follow the Giving
Bad News Checklist adapted from the
SPIKES Protocol for
Giving Bad News
Unit Content
Instructional Strategies
Learner Evaluation
E x p l a n a t i o n : Following OSCE for1.
Article on the 1.
SPIKES Protocol for Pre-lecture reading. En- mat residents will
communicate
bad
hanced Skills Lecture
Giving Bad News (26)
news to 2 simulated
Demonstration: patients/families fol2.
The Giving Bad 2.
News Checklist Based Live and video dem- lowing the Giving
onstration
following Bad News Checkon SPIKES Protocol
the Giving Bad News list adapted from the
3.
Examples and Checklist
SPIKES Protocol for
criterion for the Giving
3.
Practice: Role- Giving Bad News.
Bad News Checklist
Playing between resi- They will be expected
dents and practice with to complete 100% of
simulated patients giv- the major checklist
ing bad news following criteria and 80% of the
the Giving Bad News sub-criteria on each
encounter
Checklist
Unit Pilot Test- Evaluation of Learners
Three weeks after the four training sessions
were completed and after receiving IRB approval,
eleven residents, six of the intervention group and
five of the non-intervention group, participated in
a two station OSCE. During the OSCE they had to
give bad news in two different scenarios: announce
to the parents the sudden death of their child due
to trauma; and give the diagnosis of Down’s syndrome to the grandparent of a newborn child. Both
encounters were evaluated by SPs following the
Giving Bad News Checklist. Prior to entering the
first station, the intervention group also completed
a quiz on knowledge about the SPIKES Protocol.
Evaluation of the Teaching Strategies
To evaluate the teaching strategies used
in this unit, the residents in the intervention group
filled out an evaluation at the end of the four sessions. In this questionnaire residents were asked
to use a Likert Scale to evaluate the overall effectiveness of the sessions in their learning process,
and how each of the teaching strategies helped
them learn. They were also asked about their confidence level in the skill of giving bad news.
Both groups of residents also completed
another questionnaire at the end of the OSCE.
By means of open-ended questions, they
were as ked their opinion about the OSCE, their
perceived preparedness and their confidence level
in giving bad news.
RESULTS
Results of Pilot Test-Learner Evaluation
The intervention’s group average result on
the SPIKES Protocol quiz was 93%. The results for
the intervention and non-intervention group on the
OSCE were compared using the Mann-Whitney
Test (Table 2). The intervention group performed
significantly better than the non-intervention group
on the OSCE (p = 0.001). When evaluating each
case separately, the intervention group performed
significantly better than the non-intervention
group on the sudden death case (p = 0.01), while
this difference was marginally significant for the
Down’s syndrome case (p = 0.05). Based on an
item analysis we noted that the intervention group
had one checkpoint in each scenario consistently
missing: for the sudden death case they did not ask
how the caretaker was feeling; and for the Down’s
syndrome case they did not ask about expectations
or hopes. On the other hand, the non-intervention
group missed a wide variety of checkpoints. The
only consistent checkpoints they followed well
were giving empathic and validating statements
and offering to call for support.
Table 2: Results of Pilot Test
N=11
p = .010
p = .052
p = .001
Sudden Death Case Down’s Syndrome Case
(Mean Checklist Score) (Mean Checklist Score)
Intervention N=6
Intervention N=5
96 %
68 %
91 %
78 %
Overall Score
93 %
73 %
Results of Teaching Strategies Evaluation
The responses of the intervention group in
the evaluation of the teaching strategies indicated
that they were very satisfied with the curriculum.
All of them rated the overall effectiveness of the
sessions as excellent. They all strongly agreed or
agreed that the article on the SPIKES Protocol, the
demonstrations, the role-playing, and the practice
with SPs helped them learn. They also strongly
agreed or agreed that they received adequate feedback about their performance and they felt more
confident in giving bad news after the sessions.
They consistently gave two valuable recommendations: to assign more time for each session, and
to involve more faculty members.
The questionnaire that the intervention and
non-intervention group completed at the end of the
OSCE revealed that all the residents in the intervention group felt prepared to give the bad news
while none in the non-intervention group did. On
the other hand, at the time of the OSCE, only two
of the six residents in the intervention group felt
comfortable giving the bad news; the other four
and all the residents in the non-intervention group
felt uncomfortable and thought they needed considerable practice to improve. All residents agreed a
curriculum is necessary to learn these techniques.
DISCUSSION
As evidenced by the results, in the pilot
test residents in the intervention group performed
significantly better than those in the non-intervention group when asked to give bad news. The item
analysis found that residents in the intervention
group did not ask about feelings and hopes. Both
gaps are consistent with the usual fears of giving
bad news. When someone dies it is hard to ask how
the family is feeling because the expected answer
is that they are devastated. Further, when we give
a diagnosis of a chronic illness, such as Down’s
syndrome, we do not want to hear the parents’
hopes because we do not want to destroy them.
More meaningful is the fact that the residents in the intervention group stated they felt prepared to give bad news even when they still felt uncomfortable with the situations. At the same time,
those in the non-intervention group felt uncomfortable and ill prepared. A reasonable question would
be if physicians can ever feel comfortable giving
bad news, irrespective of training. Therefore, feeling prepared could arguably be “good enough”.
The didactic component of the curriculum
is being implemented in a stepwise manner. At this
time all the residents have attended the Communicating Bad News workshops, which have been
repeated very two years since 2004. The Unit on
Adolescent Communication was offered in 2006.
11
The Unit on Communicating in Difficult Physician
Patient Situations was offered to all second year
residents as part of the Residents-as-Teachers Curriculum of the Medical School in 2007. The next
unit to be developed and implemented will be the
Telephone Interview Unit. For this curriculum to work, faculty must
be trained to teach and assess learners in order to
achieve consistency in the residents’ performance.
Faculty must give reliable feedback throughout the
years and among the clinical settings. For this to be
achieved, the Faculty Development Program at the
University of Puerto Rico School of Medicine has
developed a Clinical Educators Curriculum which
includes training in Giving Bad News, Dealing
with Difficult Physician-Patient Situations and
Giving Feedback. All of these topics have been offered in a yearly basis since 2006.
The next step will be the development of
an OSCE that tests all the clinical skills expected
of a pediatrician, since it would be too costly to
do one just for communication skills. Meanwhile,
evaluation of learners is being done in a monthly
manner as part of the usual resident evaluation.
The faculty member in charge evaluates and gives
feedback on these skills as observed during that
month’s rotation.
With the new era of competency assessments and the increasing requirements by the general public and the accreditation agencies, we must
teach residents the use of communication skills
needed to deal with complex situations. We developed and tested a curriculum to teach advanced
communication skills. The results of the pilot test
suggest that residents are likely to learn these skills
when properly taught in a competency-based manner.
REFERENCES
1.
Association of American Medical Colleges, Report
III Contemporary Issues in Medicine: Communication in
Medicine. Medical School Objectives Project, October 1999.
P.1-23.
2.
U.S. Department of Health and Human Services,
Healthy People 2010 Conference Edition. January 2000. Volume 1: p.11-3 - 11-21.
3.
NYU Macy Initiative on Health Communication,
Curriculum. Retrieved August 17, 2003 from the World Wide
Web: http://nyumacy.med.nyu.edu
4.
Smith, R., et al., The Effectiveness of Intensive
Training for Residents in Interviewing A Randomized, Controlled Study. Annals of Internal Medicine, 1988. 128 (2): p.
118-126.
5.
Kurtz, S., J. Silverman, and J. Draper (1998).
Teaching and Learning Communication Skills in Medicine.
Radcliffe Medical Press, UK.
6.
Meryn, S., Improving doctor-patient communication. BJM, 1998. 316: p. 1922-1930.
12
7.
Pfeiffer, C., H. Mandray, A. Ardolino, and F. Willms,
The rise and fall of students’ skills in obtaining a medical history. Medical Education, 1998. 32: p. 283-288.
Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement. Academic Medicine, 2001. 76(4): p. 390-393.
8.
Suzuki Laidlaw, T. et. al.,Implementing a communication skills programme in medical school: needs assessment and programme change. Medical Education, 2002. 36:
p. 115-124.
23.
General Pediatrics Residency Program, University
of Puerto Rico, School of Medicine, Goals and Objectives
Manual, 2002. p. 8-12.
9.
Van Dalen, J., et. al., Teaching and assessing communication skills in Maastricht: the first twenty years. Medical Teacher, 2001. 23(3): p. 245-251.
10.
Kurtz, S. and J. Silverman, The Calgary-Cambridge
Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Medical Education, 1996. 30: p. 83-89.
24.
Roth, C.S., et. al., A communication Assessment
and Skill-building Exercise (CASE) for First-year Residents.
Academic Medicine, 2002. 77: p. 746-747.
25.
Coulehan, J. L. and M. R. Block (2001). “Difficult
Feelings in the Medical Interview”. The medical Interview:
Mastering Skills for Clinical Practice Fourth Edition. F.A.
Davis. p. 208-218.
11.
Grant, V.J. and S. J. Hawken, What do they think of
it now? Medical graduates’ views of earlier training in communication skills. Medical Teacher, 2000. 22(3): p. 260-264.
26.
Baile, W. F., et.al. SPIKES-A Six Step Protocol for
Delivering Bad News: Application to the Patient with Cancer.
The Oncologist, 2000. 5: p. 302-311
12.
Spencer, J. and J. Silverman, Education for communication: much already known, so much more to understand.
Medical Education, 2001. 35(3): p. 188-190.
27.
Vanderkieft, G. K. Breaking Bad News. American
Family Physician, 2001. 64(12): p. 1975-1978.
13.
ACGME Outcome Project, UPDATE/VERIFY
GENERAL COMPETENCIES ASSESSMENT. Retrieved
August 17, 2003 from the World Wide Web: http://www.
acgme.org
14.
Stockman, J. A., P. Miles, and H. P. Ham, The Program for Maintenance of Certification in Pediatrics. Pediatric
Diplomats, Fall 2003. p. 1-5.
15.
Dalhousie University, Communication Skills Program. Retrieved August 17, 2003 from the World Wide Web:
http://www.dme.dal.ca/medcomm/program
16.
Hulsman, R.L., et.al., Teaching clinically experienced physicians communication skills. A review of evaluation studies. Medical Education, 1999. 33: p. 655-668.
17.
Morgan E. and R. Winter, Teaching Communication
Skills: An Essential Part of Residency Training. Archives of
Pediatric and Adolescent Medicine, 1996. 150: p. 638-642.
18.
Langewitz, W.A., et. al., Improving communication
Skills-A Randomized Controlled Behaviorally Oriented Intervention Study for Residents in Internal Medicine. American
Psychosomatic Society, 1998. 60(3): p. 268-276.
19.
Chou, C. and L. Kewchang, Improving Residents’
Interviewing Skills by Group Videotape Review. Academic
Medicine, 2002. 77: p. 744.
20.
Oh, J., et. al., Retention and Use of Patient-centered
Interviewing Skills after Intensive Training. Academic Medicine, 2001. 76(6): p. 647-650.
21.
Ruiz Morales, R., et. al., Effectiveness of a Clinical
Interviewing Training Program for Family Practice Residents:
A Randomized Controlled Trial. Family Medicine, 2003.
35(7):p. 489-494.
22.
Participants in the Bayer-Fetzer Conference on
Physician-Patient Communication in Medical Education,
Acknowledgements
The author would like to thank Dr. Ken Sheets, Dr. Suzanne
Kurtz, Dr. Karen Kent and Dr Barbara Korsch for their critical
review of the overall curriculum manuscript, submitted as part
of the Michigan State University Primary Care and Faculty
Development Fellowship at Michigan State University. Special thanks to Dr. Steve Yelon and John Williamson at Michigan State University Primary Care and Faculty Development
Fellowship for all the advice and mentorship through out all
the steps of the curriculum development and the pilot test implementation.
Resumen
Introducción:
Saber utilizar destrezas de comunicación
avanzadas en situaciones difíciles es un componente esencial
de la relación médico-paciente.
Descripción: Con este propósito, se desarrolló un currículo
basado en competencias de comunicación avanzada para residentes de Pediatría. El currículo consta de cuatro unidades.
La primera unidad, Como Comunicar Malas Noticias, se
desarrolló en su totalidad como proyecto piloto. La unidad
se implementó utilizando el protocolo de SPIKES para dar
malas noticias como base. Los residentes que participaron del
grupo de intervención recibieron práctica y retro-insumo en
la destreza de ofrecer malas noticias. Al finalizar el piloto,
los residentes del grupo de intervención y un grupo control
fueron examinados a través de un examen práctico, objetivo y
estandarizado utilizando la metodología de Pacientes Estandarizados.
Evaluación: Se observó que el grupo de intervención ejecutó
significativamente mejor que el grupo control en este examen
(p<0.001).
Conclusión: En conclusión, un currículo basado en competencias parece ser una manera efectiva de enseñar las destrezas
de comunicación avanzadas que se necesitan en situaciones
difíciles.
Web Site de la Asociación Médica de Puerto Rico
www.asociacionmedicapr.org
Calendario de actividades
Publicaciones on-line
Créditos Educación Médica Continuada
Servicios con PayPal y tarjetas de crédito
Suscripciones on-line
y mucho más..
14
HEMOLYTIC UREMIC SYNDROME IN CHILDREN
IN PUERTO RICO:
A RARE DISEASE WITH ATYPICAL FEATURES
By:Yasmín Pedrogo-Rodríguez, MD *, Juan O. Pérez-Rodríguez, MD **, Melvin Bonilla-Felix, MD **
ABSTRACT
Hemolytic Uremic Syndrome (HUS) consists of a triad of acquired hemolytic anemia, thrombocytopenia, and renal failure that occurs acutely
in otherwise healthy individuals. HUS may be divided into two broad categories, typical, preceded
by a diarrheal prodrome, and atypical. The clinical
symptoms of HUS as well as its course, prognosis,
and response to treatment appear to be significantly
influenced by a number of factors, including age at
onset, type and severity of underlying infections,
and/or systemic diseases. A retrospective case series review of five patients diagnosed with Hemolytic Uremic Syndrome at the Pediatric University
Hospital in Puerto Rico between 1997-2007 was
performed. The study showed that the incidence of
HUS in children in Puerto Rico is lower than other
countries. However, the majority of cases have an
atypical presentation, which places our patients at
higher risk for life-threatening complications.
Index words: hemolytic, uremic, syndrome, pediatrics
Hemolytic Uremic Syndrome (HUS)
consists of a triad of acquired hemolytic anemia,
thrombocytopenia, and renal failure that occurs
acutely in otherwise healthy individuals. Since its
description in 1955 (1), HUS has been recognized
predominantly in children and in this age group
is a common cause of acute renal failure. Initially
believed to be a renal disorder with secondary hematologic manifestations, the syndrome should be
regarded as a systemic disease. It occurs most commonly in young children with a mean age of four
years old. HUS may be divided into two broad categories, typical, preceded by a diarrheal prodrome,
and atypical. The disease most frequently follows
an episode of gastroenteritis caused by an enterohemorrhagic strain of Eschericia coli 0157:H7,
(2). Atypical HUS is often insidious in onset, it
does not follow a diarrheal illness; and has a high
incidence of extrarenal involvement, especially
neurologic abnormalities such as focal or generalized seizures, transient hemiparesis, or even coma
(2, 4).
Secondary forms of HUS have been reported following use of oral contraceptives, cyclosporine,
mitomycin and pyran copolymer. Several reports
describe occurrence in more than one member of
a family, but the role of genetics factors in predisposition to the disease is unkown. The severity of
the renal involvement and the complications, vary
from mild renal insufficiency to acute renal failure
requiring dialysis and/or plasmapheresis (5).
The incidence of HUS is apparently lower
in Puerto Rico than in the United States and other
countries. The clinical symptoms of HUS as well
as its course, prognosis, and response to treatment
appear to be significantly influenced by a number
of factors, including age at onset, type and severity
of underlying infections, and/or systemic diseases.
We herein report the clinical features of the pediatric patients diagnosed with HUS at the Pediatric
University Hospital between 1997 and 2007.
METHODS
A retrospective review of the medical
records of five patients diagnosed with Hemolytic
Uremic Syndrome at the Pediatric University Hospital in Puerto Rico between 1997 and 2007 was
performed. All children presented with the classic triad of microangiopathic hemolytic anemia,
thrombocytopenia, and acute renal failure. A small
group of older children diagnosed during the same
period with thrombotic thrombocytopenic purpura
due to presence of prominent neurological symptoms with mild or absent renal disease, were not
included in this analysis.
The data collected included the age at
presentation of the disease, gender, the presence
of sings and symptoms such as diarrhea, bloody
stools, anuria, hypertension, neurological features, the treatment modalities used (dialysis, plasmapheresis, platelet and pack red blood cell transfusions). In addition, important laboratory data
such as the urinalysis, estimated glomerular filtration rate (GFR) at presentation and on last evaluation were collected. The GFR was calculated using
Schwartz formula (6).
* Fom the Department of Pediatrics and ** Section of Pediatric Nephrology, Department of Pediatrics, University of Puerto Rico – Medical Sciences
Campus.
Address reprints to: Melvin Bonilla-Félix, MD, Department of Pediatrics, University of Puerto Rico – Medical Sciences Campus. PO Box 365067,
San Juan, Puerto Rico 00936-5067. Tel 787-777-3535 x7300. Fax 787-777-3227. [email protected].
These results were compared with the course of
illness and survival of patients.
RESULTS
The demographic and clinical features are
shown on Table 1. There was no significant gender predominance. Ages ranged between 6 to 204
months, with a mean age of 82 months. Three out
of the five patients presented with diarrhea, two of
them with bloody stools (patients 2 and 3). There
was no family history of HUS, and no neurological changes associated with the diagnosis. Also
four out of 5 patients had hypertension at presentation. One of them had history of high blood pressure since infancy (patient 1) and presented with a
hypertensive crisis before developing the classic
features of HUS (anemia, thrombocytopenia and
acute renal failure symptoms). All the patients presented with hematuria and proteinuria at the time
of diagnosis of HUS (Table 2).
At the time of last follow up (2 – 14 months
after diagnosis), two of the patients showed no
evidence of proteinuria (patients 1 and 2). All the
patients had decreased GFR at presentation. Only
one patient showed complete resolution of renal
disease demonstrated by a normal GFR and urinary sediment. Four out of five patients required
acute dialysis (Table 3). Three out of five patients
required transfusions with red blood cells and
platelets. Two of the patients died. Both of them
had recurrent episodes of hemolysis and thrombocytopenia associated with decreased GFR, requiring treatment with plasmapheresis.
15
This may delay the diagnosis and treatment since it
can be confused with other febrile illnesses that are
common in the island, such as leptospirosis and
dengue fever. Since most of our patients required
acute dialysis, early recognition and prompt referral to a Pediatric Tertiary Hospital with dialysis
facilities available is important in order to prevent
life-threatening complications.
The lower incidence of the disease in
Puerto Rico as compared with other countries in
the world could result from the cultural preference
of most Puerto Ricans to eat well-cooked meat,
which decreases the risk of contamination with
Eschericia coli. Although we were not able to obtain data on the association of E. coli 0157:H7 and
HUS in our population, the absence of diarrheal
prodrome in three out 5 patients suggests that most
of our cases are not associated with E. coli, which
might explain the severity of the disease and high
mortality rate observed.
In summary, the incidence of HUS in the
pediatric population in Puerto Rico is low. However, because of the absence of a diarrheal prodrome,
the disease usually follows an atypical course, resulting in significant morbidity and mortality. We
believe that all children with the triad of anemia,
thrombocytopenia and renal symptoms should be
referred immediately to a pediatric tertiary care facility to begin aggressive therapy, including dialysis, if necessary.
DISCUSSION
The incidence of HUS in children in Puerto Rico is lower than other countries. The mean
age for HUS in the island (82 months) is similar to
other countries (48 months) with higher incidence
of the disease. Our report most likely represents
most, if not all the cases of HUS in Puerto Rico
in the last 10 years. The majority of these cases
did not show the typical features of HUS. Only 2
out of 5 had a prodrome of bloody diarrhea. Two
out of five patients presented recurrent episodes
of hemolysis, thrombocytopenia and renal failure.
Both of these patients died during the course of
the disease. One of them died from Staphylococcal
sepsis, since he had reached end stage renal disease
and was receiving peritoneal dialysis. In addition,
these two patients received dialysis, plasmapheresis, platelet and pack red blood cell transfusions
due to multiple relapses of the illness, ending in
death.
Hemolytic Uremic Syndrome is a rare disease in Puerto Rico. However, the absence of the
typical diarrheal prodrome in the majority of our
patients, place them in a higher risk category.
REFERENCES
1. Tarr PI, and, Hickman, Robert: Hemolytic Uremic Syndrome
epidemiology: A population-based study in King
County, Washington, 1971 to 1980, Pediatrics July 1987;
80 (1): 41-45.
2. Walters M, Levin M, Smith C, Nokes T, Hardisty R, Dillon M, Martin Barrat T: Intravascular platelet activation in the
hemolytic uremic syndrome, Advances in Pediatrics Infectious Diseases 1989; 4: 51-81.
3. Neill MA, Tarr PI, Clausen CR, Christie DL, Hickman RO:
Eschericia coli 0157:H7 as the predominant pathogen associated with the Hemolytic Uremic Syndrome: A prospective
study in the Pacific Northwest, Pediatrics July 1987; 80(1) :
37-40.
4. Remuzzi G, Garella S: HUS and TTP: Variable expression
of a single entity, Kidney International 1987; 32: 292-308.
5. Rizzoni G, Claris A, Edefonti A, Facchin P, Franchini F,
Gusmano R, Imbasciati E, Pavanello L, Perfumo F, Remuzzi
G. Plasma infusion for hemolytic-uremic syndrome in children: Results of a multicenter controlled trial, J Pediatrics
1988; 112: 284-290.
6. Robertson J, Shilkofski N: The Harriet Lane Handbook,
17th Ed., Pennsylvania, Elsevier Mosby, 2005: 494 – 495.
16
TABLES
Table 1. Demographic and Clinical Data
Patient
Age (months)
Gender
Bloddy diarrhea
HTN
Anuria
1
32
M
-
+
-
2
120
F
+
+
+
3
6
F
+
+
+
4
48
M
-
-
-
5
204
M
-
+
-
HTN = Hypertension
Table 2. Laboratory Data and Prognosis
Patient Urine sediment (Last F/U) GFR (presentation) GFR (Last F/U)
Outcome (Death)
-
+
22
66.7
2
-
20
162
-
3
+
29
4.9
+
4
+
48
unknoww
+
+
26
87
-
1
5
U/A = Urinalysis
F/U = Follow up
GFR : Ml/min/1.73m2
Table 3. Treatment Data
Patient
Dialysis
Plasmapheresis
PRBC transfusion
Platelet transfusion
1
+
-
+
-
2
+
-
+
+
3
+
+
+
+
4
+
+
+
+
5
-
-
+
-
PRBC = Pack Red Blood Cell
RESUMEN
El síndrome hemolítico urémico (HUS)
consiste de la triada de anemia hemolítica, trombocitopenia y fallo renal que ocurre de forma
aguda en individuos saludables. Éste síndrome se
puede clasificar en dos categorías amplias; típico,
precedido por diarreas, usualmente sanguinolentas
y atípico, o no asociado a diarreas.
Los síntomas clínicos de HUS, al igual que su curso, pronóstico y respuesta a tratamiento parecen
estar influenciados por un grupo de factores,
incluyendo la edad del paciente y presencia de otr
os factores o infecciones.
Se realizó una revisión retrospectiva de los
pacientes diagnosticados con HUS en el Hospital
Pediátrico Universitario de Puerto Rico entre 1997
y 2007. El estudio demostró una incidencia baja de
HUS en Puerto Rico. La mayoría de los casos observados tuvieron una presentación atípica, lo cual
coloca nuestros pacientes a un riesgo mayor de
manifestaciones serias y pobre pronóstico a largo
plazo.
18
THROMBOCYTOSIS IN ILLICIT
DRUGS-EXPOSED NEWBORNS
By: Thea Calderón MD *, Sonia Medina MD *, Inés García MD **,
Lourdes García MD **, Marta Varcárcel MD **
ABSTRACT
MATERIALS AND METHODS
Thrombocytosis in infants exposed in-utero to illicit drugs has been associated to methadone
exposure. Although is reported to present in the
first two weeks, few studies address its duration
and timing of resolution. This study evaluated the
presence, duration, and complications of thrombocytosis in newborns exposed to illicit drugs. Methods: A retrospective review of medical records
of newborns with intrauterine drug exposure admitted to the San Juan City Hospital from 1999
to 2001 was performed. Results: Thirty-one newborns were included. Eighty-seven percent (87%)
presented abstinence syndrome. Of these, 96%
presented thrombocytosis. All infants exposed to
methadone presented thrombocytosis and 75% of
those exposed to heroin and cocaine. Thrombocytosis presented at ten days of life with a median
resolution at 26 days. Conclusions: In this group
of newborns, thrombocytosis was associated to
intrauterine exposure to methadone, heroin, and
cocaine. Thrombocytosis presented at ten days of
life and resolution was seen in three to 4 weeks
without complications observed.
Medical records of newborns with intrauterine exposure to illicit drugs, admitted to the San
Juan City Hospital during the period of 1999 to
2001 were reviewed. Data gathered included sex,
birth weight, and gestational age. Serum platelet
counts throughout hospitalization were recorded.
Presence of thrombocytosis, duration, and complications were recorded. Thrombocytosis was
defined as platelet levels higher than or equal to
450,000 x 103/ul for term infants and higher than
or equal to 600,000 x 103/ul for preterm infants3.
Exclusion criteria included medical conditions associated to thrombocytosis such as infections or
inflammation, Down syndrome, congenital adrenal hyperplasia, and exposure to cephalosporins
(3, 4). The study was approved by the Institutional
Review Board.
Index words: thrombocytosis, illicit-drugs, newborns
The use of drugs during pregnancy presents
consequences to the fetus and neonate. Short and
long- term neurobehavioral problems have been
documented in infants born to substance-abusing
mothers (1). Frequently, these infants are also exposed to lack of prenatal care, poor nutrition, and
infectious agents. Thrombocytosis in infants with
intrauterine exposure to illicit drugs has been reported in the literature (2). Most reports associate
thrombocytosis to methadone exposure. Thrombocytosis is reported to present in the first two weeks
of life, but few reports address its duration and timing of resolution. The purpose of this study was to
obtain further information on the effects of illicit
drugs on newborns along with the natural history
of thrombocytosis in this group of patients.
RESULTS
Thirty-one newborns met inclusion criteria. Mean gestational age was 36 weeks and mean
birth weight 2600 grams. Forty-eight percent
(48%) of the newborns were males (17 males, 14
females) and 87% presented positive urine toxicology.
Eighty-seven percent (87%) of all infants
presented drug withdrawal syndrome and all of
these infants were treated with paregoric, phenobarbital or both. Twelve percent (12%) of the term
infants were products of mothers that used more
than one illicit drug during pregnancy, in comparison with 54% of the preterm infants (p= 0.0127).
The most frequent illicit drug used by mothers was
cocaine (40%) followed by multiple drugs (30%),
methadone (13.3%), heroin (13.3%), and marihuana (3.3%).
Ninety-six percent (96%) of patients admitted due to drug withdrawal syndrome presented
thrombocytosis. Median platelet count in infants
with thrombocytosis was 693,000 x 103/ul (range
456,000 x 103 /ul to 1,343,000 x 103/ul).
* From the Department of Pediatrics, San Juan City Hospital, and ** Section of Neonatology, Department of Pediatrics, U.P.R. School of Medicine,
San Juan, Puerto Rico.
Address reprints to: Lourdes García MD, UPR School of Medicine, Department of Pediatrics, Neonatology Section, GPO Box 365067, San Juan,
PR 00936-5067. Tel. 787-777-3225, fax 787-758-5307, e-mail [email protected]
Increased in platelet count presented initially at ten days of life (range 1-35 days) with a
median resolution at 26 days (range 24-49 days).
All infants exposed to methadone presented
thrombocytosis and 75% of infants exposed to
heroin and cocaine. No thrombocytosis was seen
in infants exposed to marihuana. Term babies were
more likely to present thrombocytosis (88% vs.
57%, p=0.049). Only 4 patients (12.9%) received
treatment with aspirin when the platelet count exceeded over 900,000 x 103/ul. None of the babies
presented complications associated to the increase
in platelet count.
DISCUSSION
In neonates, thrombocytosis is defined as
an elevated platelet count above 450,000 x 103/
ul for term newborns and above 600,000 x 103/
ul for preterms (3). The causes of elevated platelet
count range from physiologic to vitamin deficiencies, being the most described cause, “reactive”,
from infections or inflammatory processes (5, 6).
The mechanism that regulates platelet count in the
preterm infant is unknown. It is suggested that the
thrombocytosis noted in preterm infants during the
first months of life might result from the sizable
expansion of blood volume that accompanies rapid
weight gain (4).
Platelets originate from megakaryocytes,
which form proplatelets in the bone marrow and the
lung; this occurs by two megakaryocyte progenitors that determine the number of megakaryocytes:
the burst-forming unit- megakaryocyte (BFU-MK),
which is the more differentiated progenitor, and the
colony-forming unit- megakaryocyte (CFU-MK),
which is the more differentiated progenitor (3).
In the neonate there is increased number of megakaryocytes circulating but they are smaller in size
in comparison to adult megakaryocytes. It is described that because larger megakaryocytes generate more platelets than do smaller megakaryocytes,
the megakaryocyte of the neonate produces fewer
platelets. These megakaryocytes produce small
buds called proplatelets, which are then released as
platelets.
We observed the presence of significant
thrombocytosis seen in babies admitted to our neonatal service due to exposure to illicit drugs. Upon
reviewing medical strategies of intervention with
these newborns, we did not find standard protocols
for identification and management of thrombocytosis in this group of patients. The impact and
possible short and long-term consequences of this
hematological signs is not well understood. These
neonates are not always admitted and studied due
to the lack of clinical symptoms associated to the
thrombocytosis. In some cases, the babies of illicit
drug using mothers are not identified due to the absence of withdrawal signs and the denial of drug
use by the mother.
19
Burstein et al (2) recognized this disturbance of the hematological system and the complications associated with it in newborns exposed to
illicit drugs. He also reported an increase in platelet-aggregating activity. The complications most
commonly reported associated to thrombocytosis
include: focal cerebral infarcts, subarachnoid and
germinal plate hemorrhages, and consequently
neurological degenerations. Nevertheless, even a
marked degree of thrombocytosis is rarely associated to complications and nonspecific treatment is
usually necessary (5). Most authors do not recommend treatment with aggregation inhibitors unless
additional risk factors exist such as cyanotic heart
disease or immobilization (6).
Newborns with intrauterine drug exposure may require pharmacological treatment and
the possible effects of these medications should
be considered in the analysis of hematological
derangements of these newborns. Phenobarbital
presents physiologic complications such as megaloblastic anemia and hepatic toxicity. Paregoric
may cause a decrease in white blood cells and
platelets. None of these medications is associated
to thrombocytosis.
In this group of newborns, thrombocytosis
was associated to intrauterine exposure to methadone, heroin, and cocaine. Thrombocytosis was
seen in 100% of newborns exposed to methadone
and in 75% of infants exposed to cocaine and heroin. No thrombocytosis was seen in infants exposed
to marihuana.
Evaluation of the pathogenesis of thrombocytosis in newborns with intrauterine drug exposure is beyond the scope of this study. Increased
platelet production mediated by thrombopoietin,
redistribution within the circulation, and prolonged
platelet survival, have been proposed as possible
mechanisms (2). The present analysis provides
useful descriptive data to understand the occurrence and duration of thrombocytosis in these infants, which is might represent the first step to define the molecular and biochemical derangements
that occur in any mechanism of disease.
REFERENCES
1.
Bell G, Lau K. Perinatal and neonatal issues of substance abuse. Pediatr Clin North Am 1995;42(2):261-281.
2.
Burstein Y, Giardina PJ, Rausen AR, Kandall SR,
et al. Thrombocytosis and increased circulating platelets
aggregates in newborn infants of polydrug users. J Pediatr
1979;94(6):895-899.
3.
Christensen R. Hematologic Problems of the Neonate. Philadelphia: WB Saunders; 2000. p. 43-50, 273-281.
4.
Sirota L, Bessler H, Weissman Z, Dulitzky F, Djaldetti M. Thrombopoietic activity in preterm newborns and
infants. Arch Dis Child 1986;61(6):585-588
20
5.
Chan KW, Kaikov Y, Wadsworth LD. Thrombocytosis in childhood: A survey of 94 patients. Pediatrics
1989;84(6):1064-1067.
6.
Sutor AH. Thrombocytosis in childhood. Semin
Thromb Hemost 1995;21(3):330-339.
RESUMEN
Trombocitosis en infantes expuestos a drogas ilícitas en útero se ha asociado a exposición a metadona aunque son pocos los estudios que evalúan su
duración y resolución. Este estudio evaluó la presencia, duración y complicaciones de la trombocitosis en neonatos expuestos a drogas ilícitas. Métodos: Se llevó a cabo una revisión de expedientes
médicos de neonatos expuestos a drogas admitidos
al Hospital Municipal de San Juan desde 19992001. Resultados: Se incluyeron 31 neonatos de
los cuales 87% presentaron síndrome de abstinencia. De estos, 96% presentaron trombocitosis. Todos los infantes expuestos a metadona presentaron
trombocitosis y 75% de los expuestos a heroína y
cocaína. La trombocitosis se presentó a los 10 días
con una resolución de 26 días. Conclusiones: En
este grupo de neonatos, la trombocitosis se asoció
a exposición intrauterina a metadona, heroína y
cocaína. La trombocitosis se presentó a los 10 días
resolviendo a las 3-4 semanas sin complicaciones.
ASOCIACIÓN MÉDICA DE
PUERTO RICO
Jornadas Científicas
Clínicas Multifásicas
Conferencias culturales
Series de Cine
Conciertos
Manténgase informado de las actividades
consultando la sección Eventos
de nuestro web site
Av. Fernández Juncos 1305 - Santurce - Tel.: (787) 721-6969
21
MANEJO DE LACTANCIA Y AMAMANTAMIENTO:
ROL DEL MEDICO RESIDENTE
Por: Nerian Ortiz Matos MD *, Lourdes García Fragoso MD **
RESUMEN
Los médicos están en posición ideal para
influenciar la decisión de una mujer sobre la
lactancia. Estudios demuestran que los residentes
reconocen su rol en promover y apoyar la lactancia, pero tienen deficiencias de conocimiento y dificultad en aconsejar a madres con problemas de
lactancia. El objetivo de este estudio es evaluar la
necesidad de un currículo formal sobre lactancia
para residentes de Pediatría. Métodos: Participaron 12 residentes en su primer año de entrenamiento. Cinco de ellos (casos) recibieron sesiones
educativas sobre lactancia. Se le administró una
pre-prueba, post-prueba y un examen clínico objetivo estructurado. Resultados: Los participantes
de la intervención tuvieron mejor rendimiento en
las pruebas administradas y demostraron mejoría
en conocimiento sobre manejo de lactancia. Conclusión: Este estudio demuestra la necesidad de
mejorar el conocimiento de los residentes sobre
el manejo de la lactancia y su confianza al educar a las madres lactantes. Recomendamos la integración de un currículo estructurado de lactancia
durante la residencia.
Los médicos están en una posición ideal para influenciar la decisión de una mujer sobre la lactancia
ya que ellas los visitan en momentos claves y decisivos de la vida del niño.
Estudios han demostrado que los residentes
reconocen la importancia de su rol en promover
la lactancia y dar apoyo a las madres pero tienen
deficiencias de conocimiento y reportan dificultad
en aconsejar a madres que presentan problemas
con el proceso de lactancia y amamantamiento. Se
recomienda el desarrollo de entrenamiento formal
en lactancia y amamantamiento en las escuelas de
medicina, programas de residencia y a pediatras en
la comunidad (1).
El objetivo de este estudio es evaluar la necesidad
de un currículo formal y estructurado sobre manejo de lactancia y amamantamiento para médicos
residentes de Pediatría.
MATERIALES Y METODOS
La Academia Americana de Pediatría
identifica la lactancia como el método ideal de alimentación para el infante llevándolo a obtener un
crecimiento y desarrollo óptimos (1).
Doce residentes de primer nivel del Programa de Adiestramiento en Pediatría de la Escuela de Medicina de la Universidad de Puerto Rico
participaron en el estudio. Los residentes llevan a
cabo su entrenamiento en el Hospital Pediátrico
Universitario y en la Unidad de Recién Nacidos
del Hospital Universitario de Adultos. Ambos hospitales son instituciones afiliadas a la Escuela de
Medicina de la Universidad de Puerto Rico. Estos
hospitales sirven mayormente a una población de
escasos recursos económicos. Las embarazadas de
alto riesgo son referidas para recibir servicios obstétricos en el Hospital Universitario de Adultos.
Existen muchos factores que influyen en
la decisión de una madre para iniciar y continuar
el amamantamiento. Los profesionales de la salud
deben estar entrenados para llevar a cabo una promoción y manejo adecuado de la lactancia tanto en
las unidades de recién nacidos saludables como en
las unidades de cuidado crítico.
Cinco de los residentes, asignados al
azar (casos), recibieron sesiones educativas sobre manejo de lactancia y amamantamiento en un
período de tres meses incluyendo charlas, videos,
demostraciones y representación de roles. Los temas discutidos se desglosan en la Tabla 1. A todos
los participantes se les administró una pre-prueba,
Palabras índices: lactancia, amamantamiento,
medico residente
INTRODUCCION
* Departamento de Pediatría, Escuela de Medicina, Universidad de Puerto Rico. ** Sección de Neonatología, Departamento de Pediatría, Escuela de
Medicina, Universidad de Puerto Rico. Apoyo: Oficina para el Desarrollo de Destrezas Clínicas y el Programa de Pediatría de Comunidad (HRSA
Grant D58HP00413)
Este trabajo ha sido presentado en los siguientes foros: 1. II Congreso Iberoamericano de Neonatología en Porlamar, Venezuela, 30 de junio de 2005.
2. Reunión Asociación Americana de Escuelas de Medicina (AAMC) – Abril 2005. 3. Foro Investigación Recinto de Ciencias Médicas – Marzo
2005. 4. Reunión anual Academia Americana de Pediatria – Octubre 2005.
Correspondencia a: Nerian Ortiz MD, Escuela de Medicina, Universidad de Puerto Rico, Departamento de Pediatría, PO Box 365067 San Juan, PR
00936-5067. Tel. 787-756-4020, Fax 787-777-3227, <[email protected]> ó <[email protected]>
22
Tabla 1.
Intervenciones Educativas
CHARLAS
Características de la leche materna
Beneficios de la lactancia
Influencias en la decisión de lactar
Tabla 2.
VIDEO
Posición y enlace para
una lactancia efectiva
DISCUSIÓN DE CASOS
Pezones adoloridos
Mastitis
Depresión materna
Uso de medicamentos en la madre
Ictericia en el neonato
Pobre ganancia de peso neonatal
Examen de Competencia Clínica
Caso #1
Caso #2
Madre primeriza que enfrenta dificultades con el
proceso de lactancia
Madre lactante que se prepara para regresar a
trabajar fuera del hogar
Historial de alimentación
Técnicas de alimentación
Observación de posición y enlace
Educación
Escala de proceso
Extracción y almacenaje de la leche
Preparación de banco de leche
Derechos de la madre y leyes laborales
Apoyo
Estimulación
Figura 1. RESULTADOS
DISCUSIÓN
En el 1990 se encontró que solo un 38%
de las madres lactaban en el hospital y que la
lactancia exclusiva a los dos meses era menos de
un 4%.(2).
20
Porciento
Once residentes completaron las pruebas
escritas y prácticas. La puntuación obtenida en el
examen escrito por los residentes que participaron
de las sesiones educativas fue mayor que la de los
controles (89% vs. 49%, p=0.0000). La mejoría en
el examen escrito (post-prueba) fue significativa
en el grupo intervenido (17% vs. 2%, p=0.0009)
como demuestra la Figura 1. La puntuación promedio en el examen de competencia clínica también fue mayor en los casos que en los controles.
En el primer caso clínico práctico, los casos obtuvieron un promedio de 92% mientras que los controles obtuvieron un promedio de 30% (p=0.0000).
Lo mismo fue cierto para el segundo caso clínico
(91% vs. 40%, p=0.0001). La figura 2 demuestra
las puntuaciones obtenidas por ambos grupos en
los exámenes de competencia clínica.
Mejoría en la ejecutoria de los residentes en la prueba escrita luego de exposición a sesiones educativas:
25
15
10
5
0
Casos
Figura 2.
Controles
Ejecutoria de los residentes en el examen de competencia clíni
ca luego de intervención educa
tiva:
100
80
Porciento
post-prueba y un examen de competencia clínica
con un paciente estandarizado debidamente entrenado. Los casos discutidos se resumen en la Tabla
2. El análisis de lo datos se hizo utilizando la prueba t. Un valor de p menor de 0.05 fue considerado
significativo.
60
40
20
0
Casos
Controles
Luego de una década, se ha encontrado que el
número de madres que lactan ha ido aumentando
paulatinamente, no así el número de madres que
lacta exclusivamente, pues éste se ha mantenido
constante. En Puerto Rico han sido varios los esfuerzos realizados para promover la lactancia. En
el 1995 el Departamento de Salud de Puerto Rico
desarrolló una política pública dirigida a promover
la lactancia (3). El capítulo de Puerto Rico de la
Academia Americana de Pediatría ha trabajado
para proteger las prácticas de lactancia y amamantamiento (4). Un estudio realizado en el 2000 demostró que solo 62% de las madres lactaba a su bebé
al momento de ser dada de alta (5). Meaux reportó
la falta de conocimiento en tópicos relacionados a
lactancia y muy poca experiencia en el manejo de
lactancia entre pediatras en Puerto Rico (6). Reportes más recientes han demostrado que los médicos se encuentran en una posición idónea para mejorar el número de madres que amamantan. Freed
y colegas encontraron que los médicos reconocen
la importancia de que se involucren en el proceso
de promoción de lactancia pero solo la mitad se
clasificó como eficiente en la consejería a las pacientes (7). Residentes de Pediatría han reportado
que reciben muy poca educación en lactancia, especialmente por medio de técnicas interactivas de
enseñanza como representación de roles o interacción directa con pacientes en pleno proceso de
amamantamiento y lactancia (6).
En este estudio piloto los residentes de Pediatría
demostraron claramente la falta de conocimiento
en aspectos relacionados a lactancia y amamantamiento. Sin embargo se evidencia la mejoría
en la ejecutoria luego de ser expuestos a sesiones
educativas formales y estructuradas tanto de tipo
pasivas como activas. En las mismas se enfatizan
conceptos básicos del manejo de lactancia y amamantamiento incluyendo consejería y apoyo a las
madres.
La política de lactancia de la Academia
Americana de Pediatría hace un llamado a estructurar el desarrollo de entrenamiento formal en temas de lactancia y amamantamiento en escuelas de
medicina, programas de adiestramiento y a pediatras en la comunidad (1). Este estudio piloto demuestra la necesidad de integrar educación formal
de lactancia en el currículo de Pediatría general
del programa de adiestramiento. De esta manera
se logrará que nuestros residentes de Pediatría, al
momento de terminar su entrenamiento, se sientan
cómodos promoviendo y apoyando la lactancia habiendo recibido educación formal con las herramientas necesarias. Así se contribuirá no solo al logro
de los objetivos de salud 2010, los cuales tienen
como meta que el 75% de las madres lacten en el
periodo posparto inmediato y un 50% mantenga la
lactancia a los 6 meses de edad, sino también a
23
la recomendación de la Academia Americana de
Pediatría de que todo infante sea lactado exclusivamente hasta los seis meses de edad y hasta al
año de vida según lo decidan madre e infante
REFERENCIAS
1.
American Academy of Pediatrics: Breastfeeding
and the use of human milk, Pediatrics 2005; 115(2) 496-506.
2.
Becerra JE, Smith JC: Breastfeeding patterns in
Puerto Rico, Am J Public Health 1990; 80(6): 694-697.
3.
Política Pública del Departamento de Salud de
Puerto Rico para la Promoción de la Lactancia Materna.
1995. Accessed on 7/18/2003 at www.prlacta.org.
4.
Piovannetti Y: Puerto Rico chapter breastfeeding
activities, Breastfeeding 2001; 3(1): 15.
5.
Parrilla AM, Gorrin JJ: Breastfeeding in Puerto
Rico: traditional patterns, national trends and future strategies, PR Health Sciences Journal1999; 18(3): 223-228.
6.
Meaux L, Davila RR, Aviles J, Parrilla AM: Gynecologists-obstetricians and pediatricians: knowledge and experience concerning breastfeeding, PR Health Sciences Journal 1999; 18(3): 251-256.
7.
Freed GL, Clark SJ, Lohr JA, Sorenson JR: Pediatrician involvement in breastfeeding promotion: A national
study of residents and practitioners, Pediatrics 1995; 96(3):
490-494.
ABSTRACT
Doctors are in an ideal position to influence a woman’s decision about breastfeeding.
Studies have shown that residents recognize the
importance of their role in promoting and supporting breastfeeding, but they have knowledge deficits and difficulty in advising mothers with lactation problems. The objective of this study is to
assess the need of a formal, structured curriculum
on breastfeeding for Pediatrics residents. Methods:
Participants included twelve residents in their first
year of training. Five of them (cases) received educational sessions on breastfeeding.
Pre-test, post-test, and an objective structured clinical examination (OSCE) were given
to all participants. Results: Residents who participated in the educational intervention did better
than controls in the practical and written tests, and
showed improvement in their knowledge about
breastfeeding management. Conclusion: This study
has shown the need to improve residents’ knowledge in breastfeeding management, practices, and
confidence when educating breastfeeding mothers.
A structured breastfeeding curriculum during the
residency is recommended.
24
GENITOANAL FINDINGS IN PUERTO RICAN
CHILDREN WITH SUSPECTED SEXUAL ABUSE
By: Amaris Rivas Carlo MD *, Brenda Mirabal MD, MPH *
ABSTRACT
Background: Even though the child sexual abuse
literature has described and classified the most
common genitoanal findings in children evaluated
for suspected sexual abuse, there is scarce information about abused Puerto Rican children. The
purpose of this study was to describe the most
common genitoanal findings in children referred
to the Bio-psychosocial Program for evaluation of
suspected sexual abuse between 2003 and 2007.
Methods: A record review of 55 patients was
conducted to collect data on genitoanal findings,
socio-demographic characteristics and other variables related to the abuse.
Results: Most patients (56.4 %) were between
3-8 years of age. The father was the most common alleged aggressor (25.5%). One third reported
anal penetration (34.5%). Most patients (65.5%)
had a normal genitoanal exam. A total of 27.3 %
had genitoanal findings diagnostic of abuse. The
most prevalent risk factors were domestic violence
(36.4%) and illicit drug abuse (30.9%).
Conclusion: There was a higher prevalence of diagnostic findings (27.3%), including anal injuries
(14.5%) compared to other studies. Since most
children had a normal genitoanal exam, the child’s
disclosure is the most important evidence of sexual abuse.
Index words: genitoanal, sexual, abuse, children
Child sexual abuse is a serious public
health problem. Over 78,000 children were estimated to be victims of sexual abuse in 2006 in the
United States (1). In Puerto Rico, 46,444 children
were reported as active cases of child abuse in
2007; of these, 2031 were cases of sexual abuse
(2).
Sexual abuse occurs when a child is engaged in sexual activities that he or she cannot
comprehend, for which he or she is developmentally unprepared and cannot give consent, and/or
that violate the law or social taboos of society (3).
The pediatrician is likely to encounter patients with
signs and symptoms suggestive of sexual abuse in
his/her practice.
He/she may be the first professional to learn about
the situation and be responsible for activating the
child protection system. As a mandated reporter
(PR Law 177 of 2003) he/she is expected to conduct a history, physical exam, document the findings and report the case to the appropriate authorities for investigation and child protection services
(4). The pediatrician plays an essential role in the
diagnosis and treatment of sexually transmitted
diseases, and other physical and mental conditions
associated to the situation of sexual abuse. Pediatric residencies recognized the need for curriculum
changes, and education about child abuse became
compulsory for US pediatric residencies in 1997
(3). The evaluation of suspected victims of child
sexual abuse, however, often involves detailed interviews, collection of forensic evidence, specialized examination techniques, including colposcopy, and many pediatricians do not feel prepared to
conduct such comprehensive medical evaluations.
They may prefer to refer these children to physicians who have the training and experience.
During the last twenty years, the child
sexual abuse literature has contributed to the
wealth of knowledge of normal genitoanal findings
in children, changes observed with normal development, normal variants, and changes due to acute
and chronic blunt force penetrating trauma (5, 6, 7,
8, 9). In a study by Berenson (5), to describe genitoanal findings associated with child sexual abuse,
positive findings were found in 2.5% of the study
population; a hymenal transection, perforation, or
a deep notch were found to be definite evidence
of sexual abuse or trauma. In a five year prospective study, Heger (6) evaluated 2,384 children with
suspected sexual abuse and found that 96.3% had
normal medical examinations.
The positive findings described in this
study were acute injuries, sexually transmitted
diseases, and complete hymenal transections; only
0.04% of patients showed diagnostic anal findings.
In a previous study conducted by Adams, (7) to describe examination findings of legally confirmed
child sexual abuse, 10% of children were described
with diagnostic genital findings, and only 1% presented diagnostic anal findings.
* From the Department of Pediatrics, U.P.R. School of Medicine, San Juan, Puerto Rico.
Address reprints to: Brenda Mirabal MD, Department of Pediatrics, UPR School of Medicine, PR Health Science Center, San, Juan, PR 00936.
The purpose of this study was to describe
genitoanal findings in children who had been referred for suspected child sexual abuse to the
Bio-psychosocial Program, of the Department of
Pediatrics, U.P.R. School of Medicine in the last
five years. The Program, a sub-grantee of the Department of Justice’s Victims of Crime funds since
1986, offers interdisciplinary services to child victims of family violence, 0 -17 years old, including
social evaluations, abuse-focused psychotherapy,
parenting groups and forensic medical exams. The
interdisciplinary team also conducts case discussions, offers expert testimony and provides emotional support to the child victim during the legal
process. Cases are referred from the entire island
by child protection services, law enforcement,
schools, courts, hospital staff and health professionals.
METHODS AND MATERIALS
This is a descriptive, retrospective study
of children 0 to 17 years of age evaluated for suspected sexual abuse at the Bio-psychosocial Program of the UPR School of Medicine, from 2003
to 2007. A total of three hundred seventeen children were seen for suspected child sexual abuse
during this five year period; systematic randomization was used to select a sample of fifty five patients for chart review. The UPR Medical Sciences
Campus Institutional Review Board approved the
study. The variables studied were: socio-demographic characteristics, age of the child, type of
sexual contact reported, relationship to alleged
perpetrator and the genitoanal findings of each patient in the colposcopic exam. The program Statistix 8 was used to conduct statistical analyses, such
as frequency distributions and chi squares.
RESULTS
Our study sample included 33 females and 22
males; 56.4% were in the range of 3-8 years of
age, with a mean of 6.3 years. The alleged aggressor was a family member in 68.7% of the cases;
the father was the most common (25.5%); another male family member was identified in 43.2%
(grandfather, brother or other). No penetration was
reported in 16.4%, vaginal penetration (digital or
penile) was disclosed in 23.6%, anal penetration
(digital or penile) in 34.5%, and oral penetration in
12.7%. Some patients referred more than one type
of abuse. In 30.9% of the cases, the type of contact was unknown, because the patient did not disclose, was too young to disclose or abuse was not
confirmed (one case). The most prevalent risk factor for child sexual abuse was domestic violence
(36.4%), followed by illicit drug abuse (30.9%),
(See Table 1).
Most patients (65.5%) had a normal genitoanal
exam (See Figure 1). A total of fifteen patients
(27.3%) had diagnostic genitoanal findings, which
included: healing laceration in the fossa
25
Figure 1. Genitoanal Findings*
27%
7.30%
65%
Normal
Indeterminate
Diagnostic
* See classification in Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, Botash AS, Kellogg ND, et al. Guidelines for medical care of children who may have been sexually
abused. J Pediatr Adolesc Gynecol. 2007 Jun; 20(3):163-72.
Table 1. Sociodemographic Data of Patients
Total patients: 55
Females
Males
Gender (%)
Age (%)
60
40
0-2 y/o
10.9
3-8 y/o
56.4
9/12 y/o
18.2
≥ 13 y/o
14.5
Aggressor (%)
Father
25.5
Male relative
Type of abuse (%)
43.2
No penetration
Vaginal penetration
16.4
Anal penetration
34.5
Oral penetration
12.7
Unknown
30.9
23.6
Risk factors (%)
Domestic violence
36.4
Drug abuse
30.9
navicularis (16.4%), healing anal laceration
(14.5%), partial healing hymenal laceration (3.6%),
loss/attenuation of hymen (1.8%). An interesting
finding observed in our study was one male patient
with penile/scrotal scar. Some patients had more
than one diagnostic finding. There were a total of
five indeterminate findings in four patients (7.3%):
a notch at 9 o’clock, condyloma acuminata in hymen and fossa navicularis, and two patients with a
small ulcer in the anus (Table 2).
26
In order to identify factors that might help
the clinician to predict the likelihood of finding an
abnormality in the physical examination, we analyzed a group of variables, including the age of the
victim, time since last contact with alleged aggressor, and if the child referred vaginal or anal penetration. None of the variables studied correlated
with findings in the physical examination (Table
3).
There was a higher prevalence of diagnostic genitoanal findings in this study (27.3%),
including anal area (14.5%), when compared to
other studies (5-7). Heger described 4% of patients with diagnostic findings, 1 patient (0.04%)
presented anal findings (5). In the study by Adams
(7), 9% of patients presented with these, and only
1% of anal findings. Berenson (6), described 2%
of patients with diagnostic findings; anal findings
were not assessed in that study (See Table 4).
DISCUSSION
Even though the majority of the children in this
study had a normal genitoanal exam, there was a
higher prevalence of diagnostic findings (27.3%),
compared to other studies (5-7) which report normal findings in more than 95% of children evaluated for suspected sexual abuse. This unexpectedly high prevalence may be related to the small
sample size. Eight patients (14.5%) had diagnostic
anal findings, which contrasts with 1% of subjects
reported by other studies. In this study population,
the most common abuse reported (30.9%) was penile anal penetration, contrary to what is reported
in the literature and in the local statistics, where
fondling and lascivious acts is more prevalent.
The small sample size, delayed reporting, and/or
the complex nature of the cases being referred to
the Program for expert medical forensic evaluation
may have contributed to this finding. One third of
these families were involved in illicit drug use,
which may place the child at higher risk for more
severe abuse.
Cultural practices, beliefs and myths may also help
to explain this unexpectedly high rate of anal penetration. The myth of defining virginity as an “intact” hymen is still common among some Puerto
Ricans and other Latinos. The belief that penetration of “other” body orifices may go undetected,
may also be a contributing factor. Further studies
are recommended, with larger study samples, to
determine the prevalence of genitoanal findings,
and describe current sexual practices and myths in
the Puerto Rican community.
We recognize that our results could be limited by
the small sample size, and that study subjects are
not representative of all reported sexual abuse cases in the island. However, the striking differences
observed from previous studies suggest that cultural practices and beliefs may have an effect
Table 2. Abnormal findings/injuries on genito
anal exam*
Findings (N (%))
Fossa
Penis/
Hymen Navicularis/ ScroP.Fourchette tum
Anus
2 (40)
1 (20)
2 (40)
3 (14.3)
9 (42.8)
Indeterminate
Diagnostic*
0
1 (4.8) 8 (38.1)
* See classification in Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, Botash AS, Kellogg ND, et al. Guidelines for medical care of children who may have been sexually
abused. J Pediatr Adolesc Gynecol. 2007 Jun; 20(3):163-72.
Table 3. Odds ratio and confidence interval of
variables analyzed by diagnostic findings.
Variable
Odds Ratio
95% CI
p value
History and Type
of Penetration
0.90
0.1504, 5.3619
NS
Time since last
contact
1.86
0.4305, 8.0118
NS
Age of patient
0.90
0.1447, 1.6576
NS
2
0.5322, 7.5162
NS
1.04
0.2943, 3.665
NS
Vaginal penetration alone
Anal penetration alone
Table 4. Comparison of findings in children
referred for suspected sexual abuse
Investigator
Publication
year
N
Adams Berenson
1994
2000
236
Female: Male 215 : 21
Heger
2002
Rivas
2008
192
2384
192 : 0
1963: 421 33 : 22
55
Age (years)
Findings (%):
< 17
<8
< 17
≤ 17
Normal
90%
97.5 %
96.3%
65.5%
Indeterminate
7.3%
Diagnostic:
Genital
9%
2%
4%
12.7%
Anal
1%
Not assessed
0.04%
14.5%
on the prevalence of diagnostic findings in this
population. Furthermore, most acute sexual abuse
is seen at the hospital’s 24-hour Emergency Room,
which explains the low prevalence of acute injuries in this study.
Physicians caring for children should
make it a priority to screen for signs and symptoms
of sexual abuse, particularly if there are family risk
factors such as domestic violence and illicit drug
use. Socio-demographic variables do not appear to
be associated to the presence of diagnostic findings. The evaluation, diagnosis and treatment of
children with suspected child sexual abuse should
document the history, including a detailed account
of the alleged incident/s. Since most of these children have a normal genitoanal exam, the child’s
disclosure is often the most important evidence of
sexual abuse.
REFERENCES
1. U.S. Department of Health and Human Services, Administration
on Children, Youth and Families. Child Maltreatment 2006 (Washington, DC: U.S. Government Printing Office, 2008). Obtained :26
April 2008, http://www.acf.hhs.gov/programs/cb/stats_research/index.htm#can
2. Puerto Rico Family Department, Family and Children’s Administration. Active cases with minors, families and minors involved, yearly
evolution. Obtained May 5, 2008. http://www.tendenciaspr.com/Poblacion/Tablas_familia/maltrato_de_menores/Casos_activos_2005.
htm
3. Kellogg N and the Committee on Child Abuse and Neglect. The
Evaluation of Sexual Abuse in Children. Pediatrics. 2005; 116: 506512.
4. Ley Núm. 177 de 1 de agosto de 2003: Ley para el Bienestar y la
Protección Integral de la Niñez, deroga La ley Núm. 342 de 1999: Ley
para el amparo de Menores en el Siglo XXI. (P. del S. 2285), 2003,
ley 177. Obtained May 5, 2008, http://www.lexjuris.com/LEXLEX/
Leyes2001/lex2001177.htm
5. Berenson AB; Chacko MR; Weimann CM; Mishaw CO; Friedrich
WN; Grady JJ. A case-control study of anatomic changes resulting
from sexual abuse. Am J Obstet Gynecol. 2000; 182: 820-834.
6. Heger A; Ticson L; Velasquez O; Bernier R. Children referred for
posible sexual abuse: medical findings in 2384 children. Child Abuse
and Neglect. 2002; 26: 645-659.
27
RESUMEN
Trasfondo: Aunque la literatura acerca del abuso
sexual en niños ha descrito y clasificado los hallazgos genito-anales más comunes en niños evaluados
por sospecha de abuso sexual, existe escasa información acerca de estos hallazgos en niños puertorriqueños. El propósito de este estudio fue describir
los hallazgos genito-anales más comunes en niños
referidos al Programa de Bio-sicosocial para evaluación por sospecha de abuso sexual, desde los
años 2003-2007.
Métodos: Se llevó a cabo una revisión de expedientes de 55 pacientes para recolectar datos sobre hallazgos genito-anales, características sociodemográficas y otras variables relacionadas al
abuso.
Resultados: La mayoría de los pacientes (56.4%)
se encontraban entre las edades de 3-8 años. El
alegado agresor fue el padre en la mayoría de los
casos (25.5%). Un tercio de los pacientes refirió
penetración anal (34.5%). La mayoría de los pacientes (65.5%) tuvo un examen genitoanal normal. Un total de 27.3% presentó hallazgos genitoanales diagnósticos de abuso sexual. Los factores
de riesgo más prevalentes fueron violencia doméstica (36.4%) y abuso de drogas ilícitas (30.9%).
Conclusión: Se encontró una mayor prevalencia
de hallazgos diagnósticos (27.3%), incluyendo
hallazgos anales (14.5%), comparado con otros estudios. Dado que la mayoría de los niños tuvo un
examen genitoanal normal, la revelación del niño
es la evidencia más importante de abuso sexual.
Serigrafía
por
José Alicea
7. Adams JA; Harper K. Examination findings in legally confirmed
child sexual abuse: it’s normal to be normal. Pediatrics 1994; 94:310317.
8. Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, Botash
AS, Kellogg ND, et al. Guidelines for medical care of children who
may have been sexually abused. J Pediatr Adolesc Gynecol. 2007
Jun; 20(3):163-72.
José Alicea nació en 1928 en
Ponce, Puerto Rico. Entrenado
como pintor, comenzó su actividad
como diseñador gráfico en 1957,
bajo la tutoría de Lorenzo Homar.
En 1967 fue nombrado Profesor de
Imprenta y fundó la Escuela GráPuerfica del Instituto de Cultura Puer
torriqueña.
9. Berenson A; Grady J. A longitudinal study of hymenal development from 3 to 9 of years of age. J Pediatr 2002; 140:600-607.
ACKNOWLEDGMENTS
We would like to thank Dr. Lourdes García, of the UPR Department of Pediatrics, and Noemí Vázquez, María N. De Jesús, Jennifer García and Karim Torres, of the Bio-psychosocial Program of the
UPR School of Medicine for their collaboration in this study. The
Biopsychosocial Program is a subgrantee of VOCA grant # 2007-VAGX-0054; 2007-VA-HP-01.
De venta en la Asociación Médica
de Puerto Rico
(787) 721-6969
Web Site de la Asociación Médica de Puerto Rico
Calendario de actividades
Publicaciones on-line
Créditos Educación Médica Continuada
Servicios con PayPal y tarjetas de crédito
Suscripciones on-line
y mucho más..
28
LUPUS NEPHRITIS IN PUERTO RICAN
CHILDREN AND ADOLESCENTS
By: Tami O. Tiamfook MD *, Ivonne Arroyo MD **, Enid Del Valle MD €, Juan O.
Pérez-Rodríguez MD ₤, Anarda González MD ‡,and Melvin Bonilla-Félix MD ₤
ABSTRACT
Background: Lupus nephritis is associated with an unfavorable outcome. Its incidence
is higher in children. It has been the impression
of pediatric nephrologists and rheumatologists
in Puerto Rico that the clinical manifestations in
Puerto Rican children differ from what has been
described in other geographic regions. The potential deleterious effects of sun exposure could
suggest that Puerto Rican children living in the Island are at high risk for severe nephritis. Purpose/
Method: To describe the manifestations and identify predictors of patient and renal survival, we reviewed the medical charts of children diagnosed
with lupus nephritis in Puerto Rico between 1987
– 2001. Results: Mesangial glomerulonephritis
(Type II) was the most common histopathological
lesion observed. We observed a high incidence of
nephritis among males, with a male: female ratio
of 1:1.9. Conclusions: The presence of type IV nephritis and need for acute dialysis at presentation
were identified as predictors of poor clinical outcome (development of end stage renal disease or
death).
Index words: lupus, nephritis, Puerto Rico, children
Lupus nephritis (LN), the renal involvement in systemic lupus erythematosus (SLE), is
associated with an unfavorable outcome. Its incidence is higher in children (7, 23) and is second
only to infection as the most common cause of
death (19). Because of the age of the patients at
onset of the disease and the duration of the illness,
the pediatric population with LN is at high risk for
long-term morbidity and mortality.
The World Health Organization has classified lupus renal disease into five categories (3).
Class I is rarely reported whereas, class II develops in about 24% of adult patients, class III in
15%, class IV in 43%, and class V in 15% (1). As
in adults, most of the studies in children report that
the proliferative lesions (classes III and IV) are
the most frequently observed (1, 6, 28). However,
more recent reports have suggested that this
pattern might be changing, with an increase in
class V lupus nephritis among pediatric patients
with SLE (9).
The treatment of lupus nephritis is dependent on the histopathology. Often, histology
can be predicted based on clinical characteristics.
For instance, the degree of renal function at time
of biopsy has been recognized as an important predictor of histology (8). Thus, it would be important
to study certain populations to describe correlations between clinical factors and histopathology
in order to predict prognosis and target aggressive
therapies to those at higher risk.
In addition, differences in ethnicity may
play a key role in the clinical expression of the
disease (8). Studies in Asians, African-Caribbeans
and African-Americans have shown a higher incidence of nephritis in these 3 ethnic groups (9). A
higher degree of severity in clinical manifestations
associated with higher mortality was reported in a
group of Hispanic children from New York, comprised primarily by Puerto Rican and Caribbean
children (22). Studies in Latin American patients
have shown that class IV (diffuse proliferative
glomerulonephritis), which carries the worst prognosis for renal survival, is the most common histological lesion observed (15).
It has been the impression of pediatric
nephrologists and rheumatologists in Puerto Rico
that the clinical and pathological features of LN in
Puerto Rican children differ from what has been
described in other geographic regions. In addition
to ethnicity, the potential deleterious effects of sun
exposure, well documented in SLE (25), would
suggest that Puerto Rican children living in the Island are at high risk for severe nephritis. Studies in
adult Puerto Rican patients with SLE contrast with
this view (26).
MATERIALS AND METHODS
To identify predictors of patient and renal survival,
we studied the clinical, laboratory and histological
characteristics of Puerto Rican children with LN.
From * Harvard Medical School, Boston, MA, ** San Juan City Hospital, San Juan, PR, € San Jorge Children’s Hospital, San Juan, PR, ₤ Section
of Nephrology, Departments of Pediatrics, UPR School of Medicine, San Juan, PR and ‡ Department of Pathology, University of Puerto Rico, San
Juan, PR
Address reprints to: Melvin Bonilla-Felix MD, Department of Pediatrics, University of Puerto Rico-Medical Sciences Campus PO 365067San Juan,
PR 00936-5067. Tel: 787-777-3535, ext. 7300 Fax: 787-777-3227. <[email protected]>
The medical charts of 29 children between
the ages of 1 - 18 y/o diagnosed with LN between
1987 and 2001 were retrospectively reviewed. The
patients were recruited from three different hospitals in San Juan, Puerto Rico, including University
Pediatric Hospital, San Jorge Children’s Hospital,
and San Juan City Hospital. These three hospitals
together provide more than 90% of the pediatric
tertiary care in Puerto Rico.
The diagnosis of SLE was established
based on the clinical presentation, according to the
American Rheumatism Association’s revised classification criteria for lupus and/or laboratory evaluation consistent with SLE, such as the presence
of autoantibodies specific for SLE. Patients were
diagnosed with LN if there were manifestations
in the urinary sediment (red blood cells and/or red
blood cell casts in the urine, proteinuria), and/or
abnormal renal function as reflected by an elevated
serum creatinine level for age or presence of hypertension. Hypertension was defined as systolic
and/or diastolic blood pressure value over the 95%
for age and height, according to the data published
by the Update on the 1987 Task Force Report on
high blood pressure in children and adolescents
(17).
The renal pathologist performed the histological analysis of renal biopsies, based upon the
1982 classification of the World Health Organization (5). Biopsies with essentially normal glomeruli
or with mild mesangial changes were categorized
as class I. Patients with mesangial proliferation
or increased mesangial matrix were categorized as
class II. Class III was categorized as patients with
focal and segmental proliferation of mesangial and
endothelial cells, class IV as patients with diffuse
proliferation, and class V as patients with membranous glomerulonephritis.
There were no patients lost to follow-up.
Nephrotic syndrome was defined as having proteinuria, hypoalbuminemia, edema, and hypercholesterolemia. ESRD was defined as the need for
chronic dialysis and/or renal transplantation. GFR
was calculated based on height and serum creatinine, according to Schwartz formula (20).
Data from groups of patients are reported as mean ± SE or as percentages. Multivariate
analysis was used to determine prognostic factors.
Statistical analysis was performed using Fisher’s
Exact Test.
RESULTS
Clinical Features
The mean age at diagnosis of SLE was 11.0 + 3.4
years (mean + standard deviation; range, 2.8-16.8
yr), with a mean age at diagnosis of LN of 11.4 +
3.3 years (range, 2.8-16.8). The average time from
diagnosis of SLE to diagnosis of LN was 0.4 + 0.7
year (range, 0-2.0).
29
Thirty four percent of our patients were males,
with a male: female ratio of 1:1.9 (Table 1). Rash
was the most common extrarenal manifestation
observed in our group of children with nephritis
(66%). A total of 6 (20.7%) patients presented with
acute renal failure, with 5 of them requiring acute
dialysis at the time of presentation.
All the patients were treated with corticosteroids. At the time of data collection, the patients
had been receiving corticosteroids for an average
of 4.3 + 3.6 years (range, 0.3-14.3). Cyclophosphamide had been given to 44.8% of patients and
azathioprine to 48%. Two patients had been receiving mycophenolate for less than 6 months.
Table 1. Baseline clinical features
CHARACTERISTICS
N
%
Male
10
34.5
Female
19
65.5
Fever
10
34.5
Rash
19
65.5
Arthritis
13
44.8
Pleuritis
4
13.8
Pericarditis
2
6.9
Need for Acute Dialysis
6
20.7
Hypertension
10
38.5
GENDER
CLINICAL
Laboratory Features
Hematuria was the most common laboratory finding at the diagnosis of LN (82.8%), with
about half of them showing gross hematuria (Table
2).
Table 2. Baseline laboratory features
CHARACTERISTICS
N
%
Hypocomplementemia
18
78.3
Hematuria
24
82.8
Gross Hematuria
13
44.8
Proteinuria
23
79.3
Nephrotic Syndrome
7
28.0
Hypercholesterolemia
12
41.4
Altered CBC
21
72.4
Altered Liver Function Tests
3
10.3
6
20.7
Decreased GFR
(< 80 ml/min/1.73m2)
30
Proteinuria was present in 23 patients (79.3%), and
the nephrotic syndrome, reported by some as a predictor of poor prognosis, was observed in 28% of
the patients. Hypercholesterolemia was a frequent
finding (41.4%), often seen in the absence of nephrosis. The average GFR at presentation was 120.2
+ 62.4 cc/min/1.73m2. Six patients (20.7%) had
renal insufficiency (GFR < 80 ml/min/1.73m2) at
presentation.
Histopathological Features
Renal biopsy was performed on 24 of the
29 patients. Three of the five patients who were not
biopsied presented with severe nephritis (renal insufficiency, massive proteinuria, severe hypertension) and severe extrarenal manifestations. They
developed renal failure and had poor response to
corticosteroids. One of the patients developed pulmonary hemorrhage and cardio-respiratory arrest
within few weeks after admission. This patient
received hemodialysis until his death, 9 months
after presentation. Due to the severity of the renal
manifestations, we presumed that these three patients had diffuse proliferative glomerulonephritis
(WHO Class IV). They were classified as that for
data analysis, and treated accordingly with intravenous methylprednisolone and cyclophosphamide.
The other 2 patients who were not biopsied were
not included in the analysis of histological data.
Mesangial glomerulonephritis (class II), present
in 12 (41%) patients, was the most common histological lesion observed in our population (Table
3). Five patients (17.2%) had diffuse proliferative
(class IV) nephritis. Together (class III and IV),
only represented 34.4% of our population. This
contrasts with previous reports reporting class III
and IV as the most common types (1,6,10).
Table 3. Renal hitopathology.
WHO CLASSIFICATION Type II
(mesangial
glomerulonephritis) Type III
(focal proliferative
glomerulonephritis)
Type IV
(diffuse proliferative
glomerulonephritis) Type V
(membranous
glomerulonephritis)
N
%
12
41.4
5
17.2
5
17.2
4
13.8
Table 4. Follow-up characteristics.
LONG-TERM OUTCOME
N
%
End Stage Renal Disease (ESRD) 2
6.9
Death
2
6.9
Nephrotic Syndrome
3
15.8
Chronic Renal Insufficiency
4
14.8
Hypertension
2
7.1
Table 5. Prognostic Factors
VARIABLES
P Value
Age at presentation
0.21
Follow-up Clinical Characteristics
WHO Classification
0.0002*
Patients had been followed for an average
of 4.3 years (range: 3 months – 10.3 years).
Cyclophosphamide
0.68
Need for Acute Dialysis
0.001*
During this time four patients had developed renal
insufficiency, 2 patients progressed to ESRD and
2 patients died. One of these patients had ESRD.
The second patient who died was not ESRD at
time of death, however, had required dialysis at
time of presentation. Although her GFR was normal at presentation, she had massive proteinuria,
severe manifestation of nephrotic syndrome with
anasarca, deep vein thrombosis, infectious complications, requiring acute dialysis for ultrafiltration. She had been on prednisone for 2 years from
the time of diagnosis until death, had received 2
monthly treatments with cyclophosphamide, and
had taken azathioprine as well. The second patient
died 9 months after diagnosis and had received
prednisone during that time. The clinical characteristics at last follow up visit are presented in Table 4.
Hypertension
0.16
Gender
0.67
Prognostic Factors
In order to identify clinical or histopathological features that could predict clinical outcome,
we performed a multivariate analysis using age,
histological class, presence of hypertension, gender, need for cyclophosphamide and need for acute
dialysis at presentation as variables. The analysis
showed that need for acute dialysis at presentation and the presence of Class IV Nephritis (p =
0.001 and p= 0.0002, respectively) were predictive
of poor outcome, defined as having chronic renal
failure or death (Table 5). None of the other variables were predictive of outcome.
DISCUSSION
Our most significant finding is that type
II LN (mesangial glomerulonephritis) is the most
common histopathological lesion (41.4%) in our
group. This contrasts with reports from other studies in children, which report Class IV as the most
frequent lesion (4). Tejani had reported several
years ago that type IV LN is the most common
histological type seen in Hispanic children in New
York (22). In addition, the overall prognosis was
worst in Hispanic children. Since the population
of Hispanic children living in New York is primarily comprised by immigrants from the Caribbean
(Puerto Rico and Dominican Republic), we were
expecting several similarities between Tejani’s
data and our population. Nevertheless, the differences observed could be explain by a greater genetic homogeneity in Puerto Ricans living in the
Island and environmental differences, including
weather and sun exposure. In addition, our data
represent patients diagnosed after 1990. Tejani’s
data was reported in 1983, therefore, patients had
been diagnosed in the 1970. Thus, another potential explanation could be a change in histopathology of LN over time, as reported with other renal
diseases (29).
Prior to collecting these data, we had hypothesized that since our children live in the tropic
under continuous sun exposure, the renal manifestations of the disease would be more severe
in our population. The role of sun exposure has
been widely described. In a group of Puerto Rican adults with SLE living in the Island Vila et al.
reported milder clinical manifestations and lower
incidence of LN in patients using photoprotection
regularly (25). Although we did not evaluate the
use of photoprotection, the finding of milder renal
histological lesions in our population, despite continuous sun exposure, at least suggest that living
in the tropic is not a risk factor for the presence of
type IV nephritis. We cannot explain our findings
of milder histological types of LN in our patients
based on a referral bias. The hospitals included in
the analysis represent the 3 major pediatric tertiary
care centers in the Island, which receive the most
complex pediatric cases, including the only center
with pediatric dialysis services (University Pediatric Hospital). Our data is consistent with a report
form Vila, who observed that Puerto Rican adults
with SLE tend to have milder forms of the disease
and lower incidence of LN when compared with
other geographical areas (26).
Although type II LN was the predominant
histological class observed, clinical manifestations
such as hypocomplementemia, hematuria, proteinuria, and hematological manifestations were
present in the majority (>70%) of our patients. It
has been reported that mesangial lupus nephritis is
generally accompanied by normal diagnostic findings or with a mild degree of hematuria but
31
typically absence of hypertension or other severe
urinary findings (3). The incidence of NS and hypertension in our population was not different from
the incidence reported in other populations. Therefore, there was not a clear correlation between the
histological findings and the initial clinical manifestations in our patients.
The high incidence of LN among Puerto
Rican males is surprising and not previously reported for other populations. Males represented
thirty five percent of our population with LN,
with a male: female ratio of 1:1.9. This is markedly elevated when compared with other adult and
pediatric populations (18). A report form the North
American Pediatric Renal Transplant Cooperative
Study describes that 82% of the pediatric patients
requiring a kidney transplant for lupus are females
(2). A much higher incidence in females, with
male: female ratio between 1: 7 to as high as 1:
50 have been reported in adult populations (2,10).
Since inheritance seems to play an important role
in the pathogenesis of lupus, genetic homogeneity
among Puerto Ricans in the Island might have a
stronger effect than gender differences (16).
The level of renal function at presentation
of LN and the presence of Class IV nephritis are
associated with worst prognosis, defined as development of ESRD or death. This is not a surprising finding. The association of bad prognosis with
type IV has been described in children and adults
(6, 12-14, 18). The renal function at presentation
has been also described as an important prognostic factor (6, 14). However, in contrast with other
studies in children, we did not find any association
between hypertension or complement levels and
prognosis (6).
In summary, our study reports important
clinical features of LN in Puerto Rican children
living in the Island that differ from the classical
features describe elsewhere. To our knowledge, the
higher frequency of type II nephritis and higher incidence in males have never been reported in other
populations. The identification of type IV nephritis
and need for acute dialysis as predictors of poor
clinical outcome indicate that the renal biopsy and
degree of renal function at onset serve to identify
patients requiring aggressive therapy.
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ACKNOWLEDGEMENTS
Supported in part by a grant from The Center for Excellence in Academic Medicine, University of Puerto Rico - Medical Sciences Campus.
Resumen
El desarrollo de nefritis en un paciente con
lupus sistémico eritematoso (SLE) se asocia a pobre pronóstico a largo plazo. Esta complicación se
observa con mayor frecuencia en niños que en la
población adulta. Por años, los nefrológos y reumatólogos pediátricos en han tenido la impresión
que las manifestaciones de SLE en Puerto Rico
varían de lo que se reporta en otras áreas geográficas. Debido al efecto potencial de la continua exposición a la luz solar en el Caribe, es posible que
la enfermedad se manifieste de forma más severa.
Para describir las manifestaciones de la nefritis lúpica en los pacientes pediátricos en Puerto
Rico e identificar factores pronósticos, se revisaron los expedientes de los pacientes diagnósticados
con SLE entre 1987 – 2001. La nefritis mesangial
(Tipo II) fue la nefritis mas común en nuestra población. En adición, observamos una incidencia alta
en varones con una distribución por género de 1:
1.9 (M : F), lo cual contrasta marcadamente con
todos los reportes a nivel mundial. La clasificación
histológica de la nefritis (Tipo IV) y la necesidad
de diálisis aguda en el momento de la presentación
se asociaron a un pronóstico adverso (desarrollo
de fallo renal permanente o muerte).
33
PERCEPTION OF PARENTS REGARDING
THEIR CHILDREN’S WEIGHT
By: Ilsa J. Nazario Rodriguez MD *, Wanda I. Figueroa MD *, Jaime Rosado MD
*, Iris del C. Parrilla MS *
ABSTRACT
Background: The prevalence of overweight and obesity in 2003 was 63.6% in P.R.
and 60.1% in USA. An overweight school-aged
child with an obese parent has over 70% chance
of being obese in young adulthood. Objectives: To
study perceptions of parents about their children’s
weight and to determine which factors are associated with parent’s failure to perceive when their
children are overweight. Methods: Cross sectional
survey, the sample was population of children and
their parents, selected by availability, between
4-12 years old in elementary schools (private and
public schools), N=234. The instrument was a
self-administered questionnaire of 23 questions.
SSPS version 10.0 was used for analysis with
significance of p < 0.05. Results: 51% of parents
perceived themselves overweight while they perceived their children in adequate weight (62%), so
they don’t get professional help. There’s no significant difference between genders and schools. The
study revealed that children’s weight follows the
role modeling of their parents (p<0.001). In BMI
curve (>85%) showed that 84.3% children have at
least one parent with overweight (ow) or obesity
(ob) while 15.7% children have no parent with ow/
ob (p<0.05). Study showed that 33% of parents do
nothing about their children’s weight. Parents consider themselves to be responsible for childhood
obesity. Conclusions: The majority of the parents
does not perceive their children at risk of becoming overweight or be overweight, so they do not
get help early.
Keywords: perception, body mass index, overweight, obesity, children
Obesity in children and adolescents represents one of the most frustrating and difficult
diseases to manage. Overweight has recently received considerable attention because of the large
increase in its prevalence in the USA over the past
two decades, in both adults and children, and because of its consequences for health.1 The World
Health Organization defines health as a state of
complete physical, mental and social well-being
and not merely the absence of disease. It is recognized that obesity, eating disorders, body image are all interrelated and need to be addressed in
comprehensive ways that do no harm.
Authors recognized in a study of childhood overweight that early childhood is a critical period in
the development of obesity due to the adipose tissue rebound. This is the time, usually between ages
four and 6, when a child’s adiposity begins to increase after a low point in the early years of life.2
The American Academy of Pediatrics recommends
yearly calculation of body mass index (BMI), nutritional assessment and counseling at every health
maintenance visit. The advantage in treating overweight children at early ages is that they seem to
respond to interventions more readily than older
children.3 Furthermore, as recent data from the
National Center for Health Statistics indicate approximately one in five children in the USA is now
overweight. Obesity represents a chronic illness.
Therefore, frequent visits, continuous monitoring,
and reinforcement will be required for success but
will not ensure it.4
In Puerto Rico, 25% of population is obese
and 35% is overweight.16 The prevalence of overweight and obesity in 2003 was 63.6% in P.R. and
60.1% in USA. There is an increase (1996-2002)
of 54% in the prevalence of obesity among children
of 6-11 years old.12 In Puerto Rico; obesity has
massive and sustained increase in publicity though
no published papers have reported about the perception of parents regarding their children’s obesity. There are no studies available about perception
of childhood’s obesity in our country. Thus, recognition of children who are overweight or at risk for
becoming overweight is important so that prevention and treatment strategies may be implemented early in life.19 Dr. Fontanet, President of the
Puerto Rico Pediatric Society stated that 35% of
children in Puerto Rico are obese and maybe due
to lack of exercise and unbalanced diet.22 Parents
and caregivers may not initiate preventive changes
unless they first perceive that their child is at risk
for some adverse outcome.28
According to Hirschler (2006), the mother’s perception of body image and eating behavior
of their children is a predictor of overweight.18
The majority of mothers of overweight children
(80%) didn’t view them as overweight and these
misperceptions were related to education level.
Mother’s perceptions about their children’s body
image may contribute to obesity in children and
* From the Department of Pediatrics, Universidad Central del Caribe School of Medicine and Ramon Ruiz Arnau Hospital, Bayamon, PR.
Address reprints to: Ilsa Nazario Rodriguez MD, Department of Pediatrics, Universidad Central del Caribe, School of Medicine, Bayamon, PR.
34
need to be addressed in nutrition education.11
Communities are encouraged to support fitness and
physical activity by providing parks, playgrounds,
and other facilities that are safe, convenient, appealing and affordable places for children and parents to spend time.2
This study aimed to evaluate parent’s failure to perceive their children at risk for overweight
or be overweight. An overweight school-aged child
with an obese parent has over 70% chance of being
obese in young adulthood.
METHOD
The study was a cross sectional survey.
The sample was population of children with their
parents, selected by availability, between 4-12
years old in two elementary schools (one private
and one public school) in the urban zone of Bayamon, Puerto Rico, n=234.
Every child was weighted and measured
with portable digital scale and wall’s metric rule
in his/her respective school. The instrument was
a self-administered questionnaire of 23 questions
lasting approximately 10 minutes. The questionnaire was administered to parents and their children in two elementary schools (one private and
one public school) in Bayamon. The first eight
questions were demographics and the subsequent
questions were based in the perception concerning
weight of own parents and about their children.
The parent reported her or his own height
and weight and provided demographic information, including child education level (grade) in the
questionnaire.
Parent’s perception of their children’s
weight was assessed from responses to the question: “Do you consider your child to be overweight, underweight, about the right weight or
obese?” These responses were compared with the
children’s body mass index (BMI) determined
from the CDC/NCHS sex and age specific percentiles for BMI (weight/stature2) calculated from
measured values for weight and stature. Children’s
BMI values were plotted for sex and age, and values ≥95th percentile were considered overweight,
values between 85th and 95th percentile were
considered at risk for overweight, values >5th to
84th percentile were considered normal weight
and values ≤5th percentile were considered underweight. Other variables of interest included were
each child’s age, sex, and grade level, which care
the child, father and mother’s weight and height to
calculate BMI.
Data were analyzed using SSPS version
10.0. The significance level was p<0.05. Also
were used frequency distributions, chi-square test
and correlation analysis.
RESULTS
There were a total of 234 children with
their parents, selected by availability, between
4-12 years old in two elementary schools in the urban zone of Bayamon, Puerto Rico. A total of 117
girls and 117 boys were weighted and measured at
both elementary schools (Table 1). There were 110
children from public school and 124 children were
from private school.
The 51% of parents perceived themselves
overweight while they perceived their children in
62% of adequate weight (Figures 2-3). The study
revealed that child follows the role modeling
of their parents (p<0.001). In child’s BMI curve
comparing with parent’s BMI (>85%) showed that
84.3% children have any parent with overweight
or obesity while 15.7% of children have no parent with overweight/obesity (p<0.05) (Figure 6).
There were no significant differences between
boys and girls of both types of schools (Figure
7). The comparison of BMI between public and
private schools (ages 4-12 years old) showed that
12% of children in public school tend to risk for
becoming overweight while 44% of children in the
private school tend to the overweight (Figure 8).
In the questionnaire, 90% of parents answered that
obesity is a health problem while 3% of parents
considered that children are healthier if they are fat
because they get sick less than slim kids (Figures
10-11).
The 33% of parents did nothing about
their children’s weight while 67% of parents did
something about it like get nutritionist counseling
or evaluation, prepared diet for their children, encouraged them to exercise, and enrolled the child
in sport (Figures 12, 13). Parents considered been
responsible for the childhood obesity (Table 3).
DISCUSSION
The study highlights an important problem in health promotion. Despite the high rate of
overweight risk and overweight among children of
4-12 years old in this study, 33% of parents answered in the questionnaire that they did nothing
about their children’s obesity while 67% of parents
expressed concern that their child was currently
overweight. These findings are consistent with the
study of Campbell et al. showing equally low rates
of concern for child overweight.9 For children
currently at overweight risk or be overweight, this
was related to the number of overweight parents,
so that means that children follow their parental
modeling. According to the study of Baughcum
et al. only one in five mothers correctly identified
their overweight children as overweight.5
Health professionals can help improve
recognition of childhood overweight. The charting
of child BMI could be encouraged as a part of
normal practice, not only to provide an objective
Figure 1. Prevalence of overweight in children of second
grade of elementary schools (private and public schools) of
Puerto Rico in 2002-2003.
35
Table 1. Prevalence to risk of overweight and be overweight between genders (male vs. females) of both elementary schools at Bayamon, Puerto Rico.
Percent
Overweight Prevalence between 2nd Grade
Children of Private/Public Schools of P.R.
60%
50%
40%
30%
20%
10%
0%
54%
Total UnderRisk of
Overweight
Under- Adequate
weight
Overweight
57%
28% 24%
16%18%
2% 3%
UW
Results
AW
OR
n=234
Private
Public
Boys
2
56
15
44
n=117
(2%)
(48%)
(13%)
(37%)
OW
Classification of BMI
Nutritional Evaluation of 2nd Grade Students of Private/ Public Schools of P.R.
Sunday, February 11, 2006. The Nuevo Dia Newspaper. Pp. 12
Figure 2. This graphic shows that 51% of parents perceived
themselves as overweight according to their answers in the
questionnaire. N=224.
Girls
1
54
9
53
n=117
(1%)
(46%)
(8%)
(45%)
Table 2. Parent’s perception vs. real classification of children’s BMI with percentiles respectively.
Perception vs. Reality
Parent’
’
Parent s Perception vs. Child’
Child’s BMI
Perception of own parents (n=224)
Perception
of parents
Total of
Students
OB
5%
14%
38%
UW
AW
OW
OB
51%
1 (1.8%)
2 (3.5%)
1 (1.8%)
53 (93%)
n=57
AW
1 (0.7%)
84 (60.4%)
21 (15.1%)
33 (23.7%)
n=139
UW
1 (4.8%)
19 (90.5%)
1 (4.8%)
n=21
2%
25%
1%
10%
VUW
UW
AW
62%
n=3
3 (100%)
Classification
children’
children’s BMI
Perception of their children’s weight
(n=224)
n=4
OW
VUW
Figure 3. This graphic shows that 62% of parents perceive
their children in adequate weight. N=224.
4 (100%)
UW
AW
OR
OW
Table 3. Who is responsible for childhood obesity? Parents
answered that they have the major responsibility of their children’s obesity. This question was multiple choices and was
marked all that apply.
Responsible for Childhood Obesity
according to their parents
Greasy Foods
96
Cafeteria
29
Candies Machine
OW
Fast Foods
OB
Own Child
58
100
74
Grandparents
70
Parents
196
0
measure of weight status, but also to reassure parents who are anxious about underweight, and to
start discussion. Other research has suggested that
mothers of obese children believed that concern
was not indicated if children were otherwise happy
and healthy, that children would grow out of their
“puppy fat”, and that there was a fear of stigmatization or blame. 15
50
100
150
200
250
In this study, two thirds of parents (62%) perceived
their children about the right weight (adequate
weight) while one third of these children were
classified at risk for overweight and overweight
according to their BMI (Figure 3) (Table 2). This
finding may reflect a failure of parents to recognize
overweight status of their child, a reluctance to
admit that their child is overweight, or a lack of
understanding of what “overweight” means. In the
current study there were no data available to examine reasons surrounding parent’s misclassification
of child overweight status.
Additionally, according to our findings,
many parents admitted that they feel responsible
about their children’s obesity despite they know in
90% that obesity is a health problem (Figure 10).
In conclusion, the majority of the parents
do not perceive their children as overweight or
at risk for becoming overweight. Despite people
concern about childhood’s obesity in Puerto Rico,
most parents surveyed were not concerned about
their children’s weight, and many parents did not
perceive their overweight children as different
from their peers. This may have implications for
interventional plans because if their parents did
not look for professional help early, thinking that
their children were healthy, maybe cause direct
negatively impact on their children’s health.
Obesity is easier to prevent than to treat,
and prevention focuses in large measure on parent
education. In early childhood, education should include proper nutrition, selection of low-fat snacks,
good exercise/activity habits, and monitoring of
television viewing. Aggressive prevention and
intervention in childhood in schools and communities are urgently needed.14 Optimally; BMI
changes would be discussed with families before
the child becomes severely overweight.
To prevent cardiovascular diseases in the
adulthood, parents need to involve with their children in exercises like walking, tennis, swimming,
baseball, jogging, dancing among others. Also is
very important that parent counsel their child to
balanced diet or food.
Figure 4. BMI Classification between children’s parents
and own child, according to their weight and height. N=234.
Figure 5.
Both graphics shows the parental role modeling in their children. We can see that the child directly compares with their
parent’s BMI. N=234.
Do the child follows the role modeling
of their parents?
OR/OW/OB
p < 0.001
0-84%
>85%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Child BMI comparing
with Father's BMI
71.1%
64.8%
UW/AW
35.2%
28.9%
OR/OW/OB
p < 0.001
0-84%
>85%
Child BMI comparing
with Mother's BMI
Figure 6.
Child’s BMI compared with any of their parent with overweight or obesity, and 84.3% follows their parental modeling.
N=234.
Do the child follows the role
modeling of their parents?
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
84.3%
74.6%
No parent with
OW/OB
25.4%
Any parent with
OW/OB
15.7%
0-84%
p < 0.05
>85%
Child's BMI
Figure 7. Comparison between male and female genders.
N=234.
Comparison between Genders (234 children)
50
50
45
45
40
40
35
35
30
25
Father
Mother
Child
20
15
Percent (%)
Percent (%)
UW/AW
33.5% 31.4%
BMI Classification
30
25
10
5
AW
OR
OW
OB
Girls
15
5
UW
Boys
20
10
0
68.6%
66.5%
70%
60%
50%
40%
30%
20%
10%
0%
Percent
36
0
UW
AW
OR
OW
Figure 8. Comparison of BMI between public and private
schools (aged 4-12 years). N=234.
Comparison of BMI between Public and
Private Schools (Ages 44-12 years)
47% 46%
50%
44%
Percent
40%
37
Figure 11. 97% of parents answered that children are not
healthier if they are fat or chubby because get sick less than
slim kids. N=219.
Children are more healthy if they are fat because
they get sick less than slim kids. (n=219)
39%
97%
100%
30%
Private
9% 12%
10%
Public
0%3%
0%
UW
AW
OR
80%
Percent
20%
TRUE
60%
40%
20%
OW
0%
BMI Classification
FALSE
3%
Parent's Answers
Figure 9. Perception of parents regarding to their children’s weight vs. the reality (BMI classification of children).
p<0.001.
Figure 12. 33% of parents did nothing about their children’s weight (overweight risk or be overweight).
Perception vs. Reality
Parent’
Parent’s Perception vs. Child’
Child’s BMI
Do parents get some help about
their children’
children’s weight ?
160
140
120
p < 0.001
No. Students
100
33%
BMI Classification
of Child
80
60
67%
OW
40
OR
AW
20
0
VUW
UW
AW
OW
Doing nothing
Do something (Professional help, Diet, Exercise, Sports)
UW
OB
Parent's perception of their child
Figure 13. This graphic shows what parents did about their
Figure 10. 90% of parents answered in the questionnaire
that obesity is a health problem. N=223.
children’s weight. 29% of parents did nothing while 13%
get professional help (doctor, nutritionist) and 87% did other
things.
Do parents get some help about
their children’
children’s weight ?
Obesity is a health problem? (n=223)
100%
80%
60%
40%
20%
0%
90%
5.50%
TRUE
FALSE
4.50%
DON’T
KNOW
Parent's Answers
REFERENCES
1.
American Academy of Pediatrics. (2004) Preventing
childhood obesity: A national conference focusing on pregnancy, infancy and early childhood factors. Pediatrics. 114: Part 2 of 3. Supp.
1139-1173
2.
Ariza AJ, Greenberg RS and Unger R. (2004) Childhood
overweight: Management approaches in young children. Pediatric
Annals. 33(1): 33-38.
Percent
Percent
Doing Nothing
35%
30%
25%
20%
15%
10%
5%
0%
33%
29%
Professional Help
25%
Diet
12%
13%
17%
Animate to
Exercise
Sports
Parent's getting help
Other things
3.
Barlow SE, and Dietz WH. (1998) Obesity evaluation
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4.
Batch, JA and Baur, LA. (2005) Management and prevention of obesity and it’s complications in children and adolescents.
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5.
Baughcum AE, Chamberlin LA, et al. (2000) Maternal
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38
6.
Behrman R, Kliegman R and Jonson HB. (2004) Obesity.
Nelson Textbook of Pediatrics. 17th Ed: 173-177.
7.
Boutelle K, Fulkerson JA et al. (2004) Mother’s perceptions of their adolescent’s weight status: Are they accurate? Obesity
Research. 12(11): 1754-1757.
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Brener N, Eaton D. et al. (2004) The association between
weight perception and BMI among high school students. Obesity Research. 12(11): 1866-1874.
9.
Campbell M, Williams J, Hampton A & Wake M. (2006)
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CDC: Prevalence of overweight among children and adolescents: USA 1999-2000. http://www.cdc.gov
Acknowledgements
I gratefully acknowledge the thoughtful comments, corrections, and advice of my proctor and mentor Dr. Wanda I. Figueroa,
General Pediatrician and Central del Caribe University Researcher.
Also I want to thanks to Dr. Jaime Rosado, Pediatric Gastroenterologist at Ramon Ruiz Arnau Hospital, Bayamon, who revised my research project. My personal appreciation to Dr. Iris Parrilla and Prof.
Mike Velez for support in the statistical analysis of data collected.
Thanks to Mrs. Elsa Velez and Mrs. Morales, both Directors of public
and private schools respectively in Bayamon, whose facilitated and
made possible my investigative project. Also I want to appreciate the
collaborative help of Mrs. Carmen Ortiz, Interim Superintendent of
Scholar District I of Bayamon. Thanks a lot to Dr. Fermin Sanchez
and Dr. Vanessa Santini, my Residency Program’s Director and Program’s Coordinator respectively, who’s made possible my research
presentation at the Annual Puerto Rico Pediatric Convention 2007.
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Contento I, Basch C, Zybert P. (2003) Body image,
weight and food choices of latina women and their young children.
Journal of Nutrition Education and Behavior. 35: 236-247.
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Danon M, MD (2006) Obesity: The facts 2006, Endocrinologist Perspective, Miami Children’s Hospital. Conference at
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Dennison B, and Boyer PS. (2004) Risk evaluation in
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Dutt S and Ten S. (2007) Complications of obesity in
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Eckstein KC, Mikhail L, Ariza AJ. (2006) Parent’s perceptions of their child’s weight and health. Pediatrics. 117(3): 681-690.
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EFE Agency. (2005) Lupa a los niños obesos. El Nuevo
Día Newspaper. Con Salud. March 13, 2005. Pp. 11.
17.
Etelson D, Brand D, Patrick P and Shirali A. (2003) Childhood obesity: Do parents recognize this health risk? Obesity Research. 11(11): 1362-1368.
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Hirschler V. et al. (2006) Como perciben las madres de
ninos de jardin de infantes a sus hijos con sobrepeso? Arch. argent.
Pediatr. 104(3): 221-226.
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Hossain N. Obesity, overweight classification and perception among FIU students. http://www.fiu.edu/~health/reports/obesity.
Dpt. of Public Health.
20.
Jain A, Sherman SN, Chamberlin LA, et al. (2001) Why
don’t low-income mothers worry about their preschoolers being overweight? Pediatrics. 107: 1138-1146.
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Maynard M, PhD, Galuska D, PhD et al. (2003) Maternal
perceptions of weight status of children. Pediatrics. 111(5): 12261231.
22.
Periódico El Nuevo Día (2007) A combatir la obesidad y
la mortalidad infantil. Puerto Rico Hoy. Domingo, 18 de febrero de
2007. Pp. 25.
23.
Rodríguez AM. (2006) Evaluación nutricional de los niños
de segundo grado de escuela elemental. Overweight and Obesity National Conference in Paradisus Hotel, P.R. October 18-19, 2006.
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Rudolf MC, Sahota P. (2000) Increasing Prevalence of
Obesity in Primary School Children: Cohort Study. Community Pediatrics.
Médico,
Estudiante
de Medicina:
Forma parte de una de las
más antiguas y acreditadas
asociaciones profesionales .
Goza de los beneficios de
pertenecer a la Asociación
Médica de Puerto Rico y
ayúdanos a mejorar la
calidad de vida de nuestro
Pueblo.
25.
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Education. (2004) The Obesity Epidemic. December 2004. http://
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26.
Weight relatives Division of the Society for Nutrition
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39
DO PARENTS KNOW ABOUT THE ADVERSE EFFECTS
OF PASSIVE SMOKING AND THE RELATIONSHIP
WITH RESPIRATORY ILLNESS ON THEIR CHILDREN?
By:Cristina Jiménez-González MD *, Vanessa Santini MD *, Wanda I. Figueroa Cosme MD *, Iris del C. Parilla MS *
ABSTRACT
Recent studies still show parental smoke
as the number one environmental exposure agent
causing asthma in pediatric population. Objective:
The purpose of this study is to determine the knowledge of parents about the adverse effects of passive
smoking and the prevalence of passive smoking in
children. Design: Cross sectional study, participants were caregivers of students from first to sixth
grade (three private and two public schools) who
answered a self-administered survey. Data was
analyzed using SPSS. Results: Surveys were collected by availability. Total of caregivers was 594,
(47% from private and 53% from public school).
The total of estimated children in the survey was
1318, and 48.3% in general had recurrent respiratory illness. Among caregivers, 12.1% (72) reported to be smokers. There were 127 participants
who revealed at least 1-3 smokers in their home;
these smokers are affecting 167 children who are
exposed to secondhand smoke. Among smokers,
16.9% smoked inside the house, 15.5% in their cars
and 12.3% smoked in the presence of their children.
Participants with higher education had a higher average score on knowledge about adverse effects of
smoking (p<.001). Over half of the participants
(52%) reported seen anti-smoking promotion on
T.V. during previous days. Non-smokers revealed
they have seen such promotion recently (p=0.00),
but 31% of all participants reported not seen any
anti-smoking promotion at all. Conclusions: The
prevalence of smokers in our study was 12.1%. We
estimated there was more than one smoker in those
households where smoking was allowed. There
was a higher prevalence of smokers among parents
from public schools. There was no significant difference between passive smoker households and
non-smoker households for respiratory illness in
their children. Pediatricians are giving information
to caregivers about active and passive smoking but
still, 34% of smokers reported not receiving any
information. We need to reinforce the counseling
given to caregivers about the adverse effects of
smoking has on environmental pollution, and as a
cause of other cancers besides lung cancer, recurrent infections and SIDS.
Keywords: Passive smoking, second hand smoking, tobacco smoke, parental smoking
Passive or second hand smoking is defined
as the involuntary breathing of other people’s tobacco smoke. Environmental Tobacco Smoke
(ETS) is a complex mixture of more than 4,000
chemical compounds produced by a burning cigarette, pipes, or cigars. ETS has been classified by
the US Environmental Protection Agency (EPA)
as a human lung carcinogen; it is based on the
chemical similarity of side stream and mainstream
smoke (Cardenas et al, 1997). Tobacco smoke contains carcinogens as benzene (related to myeloid
leukemia), polycyclic aromatic hydrocarbons, Nnitrous compounds (associated with lung cancer),
aryl amines (related to bladder cancer) and carbon
monoxide. Also, tobacco smoke is related to nasal cavity, sinuses, nasopharynx, stomach, liver,
kidney and uterine cancers (Vineis et al, 2004). It
has been estimated that tobacco smoking is currently responsible for approximately 30 % of all
cancer deaths in developed countries, causing 4-5
million deaths per year worldwide. It is projected
to increase to 10 million deaths per year by year
2030 (Vineis et.al, 2004). A national survey indicated that 43 % of children 2 months to 11 years of
age live in homes with at least one smoker in the
United States (Pediatrics, 1997).
In children, ETS is associated with otitis
media, pharyngitis, sinusitis, lower respiratory infections, asthma exacerbations, reduced lung function and Sudden Infant Death Syndrome (Murphy,
2004). Passive smoking is a risk factor for new
cases of asthma for children (Murphy 2004, Pediatrics 2007). Tobacco smoke produces an adverse
physiologic response on the respiratory system; it
increases excess mucous production, white blood
cells, and permeability of allergens, and decreases
the ciliary’s movement, lung elasticity and prevents the normal function of the mechanism to remove the excess mucous. All of these changes predispose for progression of an infection and even
lung cancer. Worldwide studies have demonstrated
that parental smoking is a major identifiable cause
for excess hospitalizations and respiratory infections in children (Peat et.al, 2001, Shiva 2003).
Most smoke exposure occurs at home
where responsible adults’ smoking is allowed and
75 % of children who lived with a smoker, are also
exposed
to smoke outside the house,
* From the Department of Pediatrics, Universidad Central del Caribe School of Medicine and Ramon Ruiz Arnau Hospital, Bayamon, PR.
Address reprints to: Cristina Jiménez-González MD, Department of Pediatrics, Universidad Central del Caribe, School of Medicine, Bayamon,
PR.
40
inside vehicles, and at grandparent’s house among
other expositions (Hopper and Craig 2000, Rapiti
1999).
Cloutier and colleagues (2002) revealed
that tobacco smoke was the number one environmental exposure agent causing asthma among
children from 5 to 10 years of age, seeking Medicaid services in Connecticut. Additionally, the study
showed the asthma prevalence was higher among
Puerto Ricans.
A survey by Mannino (2002) provided
evidence that passive smoking increases asthma
severity and is strongly associated with high levels of cotinine. Cotinine is a metabolic compound
or by product of nicotine that has a half-life of 16
hours. Cotinine is used to measure recent exposure
to tobacco smoke and is measured in urine, serum
and hair (Vineis 2005, Murphy 2004, and Mannino
2002).
Ramos-Valencia in 2001 estimated that
the prevalence of smoking in Puerto Rico is 14.7
%, and about a half million of the population is
passive smoker. The study also showed that 7 % of
children from 5 to 15 years of age missed at least
1 day per month of school due to asthma (Ramos,
2001). ETS causes an accumulative detrimental lung effect in children when they are exposed
both during pregnancy and later after birth (Rizzi,
2004). The children whose mothers had smoked
during pregnancy, showed an increase in bronchial
reactivity at school age (between 5 to 13 years of
age), compared with children whose mothers had
not smoked during the entire pregnancy (Landau
2001, Joad 2000, Nuesslein 2002, Henderson
2001, Lux 2000). A review of literature found that
thirty studies have demonstrated the undeniable
association between exposure to maternal tobacco
smoke during the pregnancy and cancer in childhood (Boffetta et.al 2000).
Children exposed to second hand smoking for several hours per day were 3.6 times more
likely to develop lung cancer during adulthood
than unexposed people (Vineis 2005). Several other studies confirmed that breathing other people’s
tobacco smoke causes reactive airway diseases
and the lung cancer (Hacksaw 1997, Copas 2000,
Nyberg 1998, Brownson 2002, Lee 2000, Reuters
2005, Rapiti 1999).
Due to the overwhelming scientific evidence of the adverse health risk for general population from second hand smoke, Puerto Rico state
legislature passed the Law # 40 on August 3, 1993,
to prohibit smoking in closed public places except bars and casinos. On March 2, 2006, Law #
66 emended Law # 40 and prohibited smoking in
bars, casinos and private vehicles when there is a
minor in a car seat or a minor younger than 13 yrs
old (Lexjuris, 2006).
The purpose of this study is to: 1) determine the
knowledge of parents about the adverse effects of
passive smoking and its relationship to respiratory
illness on children, 2) determine the prevalence of
passive smoking in children in a random population in Bayamón, Puerto Rico, and 3) impact parents about the adverse effects of passive smoking.
Even though the adverse consequences of
second-hand smoking has been publicized and informed to the general public, the recent studies still
show parental smoking as the number one environmental exposure agent causing asthma in pediatric
population. There are few studies done in Puerto
Rico about adverse effects of passive smoking and
its relationship to respiratory illness on children.
Our hypothesis is that parents are not
well informed of the adverse effects and the consequences of second-hand smoking on their children.
MATERIAL AND METHODS
Study Design was a cross sectional survey done between August and December 2006.
Participants were caregivers of students from
first to sixth grade selected randomly from three
private schools: one Catholic, one Luteran and
one Laic and two public schools from an Urban
Area in Bayamón, Puerto Rico. Permits were obtained from the school directors of private schools
as well as from the Puerto Rico’s Department of
Education. An informed consent was provided to
caregivers along with a self-administrable survey
that consisted of twenty four questions in Spanish. Areas covered were status of smoker, places
were smoking is allowed, knowledge of adverse
of smoking, and demographic data. The estimated
time to answer the survey was about fifteen minutes. The material was distributed by teachers in
the students’ notebooks and a reasonable time was
given to collect the survey. After all surveys were
collected an informative brochure “Children and
Second Hand Smoking” in Spanish, published on
February 2000 by the Environmental Protection
Agency (EPA) was given to all students.
Variables
Demographic data: Questionnaires were classified
by school system, those answered by caregivers
at private schools (system 1) and those answered
at public schools (system 2). Relationship of participant with the child, age of the caregiver, educational level and occupation, number of family
members and number of children per household
were some of the demographic data asked.
Characteristics of smoker: Participants answered
if he/she was a smoker and how many years he/she
was smoking, number of smokers per household,
quantity of cigarettes smoked, place were smoking
is allowed (inside/outside house, in the car, near
children).
Knowledge about smoking: Participants answered
if smoking was a habit, an addiction, as well as,
its adverse effects related to smoking active, passive or social smoking.
41
Figure 2: Percentage of Participants
Education about smoking: Participants answered
if they have seen anti-smoking promotion and if
they gave advice to their children about the side
effects of smoking.
Statistical Analysis: The survey was coded and
responses were transferred to a Microsoft Excel
2002 spreadsheet. Analyses were performed using
Statistical Package for Social Sciences version 10.
Data was analyzed by frequencies, cross tabulation, Pearson Chi-Square, Fisher’s Exact Test, TTest and Pearson Correlation. The level of significance was established at p <0.05.
Figure 3: Percentage of Participants Who Work
RESULTS
Demographic Data
A total of 840 questionnaires were handed
at three private elementary schools from Bayamón
urban area and 279 were returned, for a 33% response rate. Private school was classified as System I.
Two public elementary schools were chosen from Bayamón urban area. The total enrollment of both schools was 1242 students, and 830
questionnaires were handed and 315 were returned,
for a response rate of 38%. Public school was classified as System II. The total of participants on the
sample was 594, 47% were from private schools
and 53% from public schools (Fig.1).
Figure 4: Participant Education by System
Informants
Mothers answered 85% (506) of the surveys, followed by fathers with 11% (65), grandmothers 2% (11) and others 0.9% (5) (as guardian,
parents, stepfather, aunt and sister, see) (Fig.2).
Age of participants ranged from 21-70 years, with
a mean age of 37 years old. Regarding employment status, 35.6% of the participants worked for
a company, 25% were housewives, 21% had a
profession, and 11% worked on their own. Others
were government workers (2.7%), retired (1.7%),
students (1.7%) and unemployed (0.8%) (Fig. 3).
The average school years of the sample was 16
years, 41% of the total informants had a bachelor’s
degree (Fig.4). Figure 5: Diseases in Children among General
Population
Figure 1:
The average family size were FOUR members, the majority of families (47.3%) had 2 children. The total of estimated children in the survey
was 1318. Among the conditions these children
presented: 48.3% had respiratory diseases, 17.4%
42
had recurrent otitis, 15.5% had recurrent pharyngitis, 19.9% had recurrent upper respiratory infections (viral illness), and 7.1% had other diseases
not related to smoking (Fig. 5).
Figure 6: Prevalence of Smokers in Urban Area
in Bayamón
Characteristics of smokers
Total prevalence of smokers among participants was 12% (72) (Fig.6). There was a higher
prevalence of smokers in public (14.6%) than private schools (9.3%) (Fig.7). Of those smokers
who reported the number of year they have been
smoking (56 out of 72), more than a third (34.8%)
had been smoking between 1~10 years. (Fig.8)
Among all the participants 6.7% quit
smoking, 17.7% have tried smoking but do not
smoke, and 62.1% have never smoked.
Figure 7: Prevalence of Smokers per System
There were 127 participants that reported
between 1~3 smokers in their home, for a total of
158 smokers (Fig.9).
The majority of smokers (45.1%) smoked
half a pack, followed by one pack (25.6%) and
9.8% smoke more than 2 packs a day (Fig. 10).
Among smokers, 34.7% (n=25/72)
smoked inside the house versus 83.1% who did
not smoke inside their house. Forty six percent
of those smokers who smoked inside the house revealed smoking 1-2 days; while 22% smoked 7
days, followed by 22% (3-4 days) and 10% for 5-6
days. Other places where they smoked: 88.4% revealed smoked outside the house, 15.5% smoked
inside the car and 12.3% smoked in presence of
their children (Fig.11). In our study 167 children
were exposed to second hand smoke. (Fig. 12)
Figure 8: Number of Years Smoking by Total
Smokers
Over all 12.5% cannot quit smoking and
3.8% do not want to quit smoking.
Exposure of pregnant women to passive
or active smoking was reported by 12.1% of the
participants.
Knowledge of Smoking
There were ten questions on knowledge
about the adverse effects of passive smoking. For
each participant a score of knowledge about smoking was determined based on the proportion of correct answers. “Good knowledge” was established
for those participants having at least seven correct
answers out of ten. Almost all participants (99.5%)
know that smoking is harmful, and 74.6% know
about secondhand smoking. Most of the sample
(98.1%) knows smoking is harmful to the active
as well as passive smoker. Still 43.9% did not consider smoking as part of the environmental pollution. Among the diseases related to smoking, 81%
of participants know smoking causes respiratory
diseases as asthma, bronchitis and emphysema and
79% know about lung cancer (Fig.13).
Figure 9: Smokers per Household
Figure 10: Pack of Cigarettes Smoked per Day
43
There was no difference about the score of knowledge about smoking between smoker and nonsmoker participants (Fig.14).
On the other hand, 60.1% did not know that smoking is related to other cancers, 81.9% did not
know passive smoking is related to high incidence
of recurrent otitis and 66.6% did not know about
sudden death of newborn (Fig.15).
Figure 14: Knowledge about Smoking: Nonsmoker versus Smoker
Figure 11:
Smokers
Smoking Exposure Revealed by
Figure 15: Awareness of General Public about
Adverse Effects of Passive Smoking
Figure 12: Number of Children per Homes Exposed to Second Hand Smoking
Promotion
A total of 88.1% of participants recalled
that they were informed as children about the harm
of smoking.
Figure 13: Knowledge about Adverse Effects of
Smoking
PS= Passive Smoker
RD= Respiratory Diseases
CA= Cancer
OM= Otitis Media
SIDS= Sudden Infant Death Syndrome
Most (93.7%) have talked to their children
about cigarettes, smoking and the side effects.
Some participants made the observation in the
survey they have not talked about smoking due to
the child’s young age. Almost 53% of participants
revealed to have seen promotion on television in
the last month about adverse effects of smoking
(Fig.16).
Figure 16: Promotion Received in the Last
Month about Smoking Adverse Effects
44
Most non-smokers revealed that they have seen
promotion recently (p=0.000). Among all of the
participants, 30% (55% of smokers and 26.5% of
non-smokers) informed that a doctor or health professional has informed them in the past year about
side effects of smoking. The rest 70% did not
receive any information by a doctor (Fig.17).
Figure 17: Orientation by Doctor or Health
Professional in the Last Year
With regards to pediatricians, 47% of participants received verbal, written or both type of
orientation by their Pediatrician about smoking
and its side effects on their children. On the other hand, 53% did not receive any information by
Pediatrician (Fig.18).
DISCUSSION
Among all participants, our study revealed a
prevalence of smoking of 12.1% in a sample of an
urban area in Bayamón. This prevalence is close
to the prevalence of the Ramos-Valencia study of
2001, which determined that 14.7% of the population in Puerto Rico is smoker. There is a higher
prevalence of smokers in public than in private
school and this is significant (p=0.032). These
smokers are affecting 167 children who are passive
smokers (estimated percentage of children who are
passive smokers, 12.7%) in our study. A National
Health and Nutrition Examination Survey done in
1988~1994 revealed that 38% of children were exposed to Environmental Tobacco Smoke in their
home, and these children had three or more episodes of wheezing , chronic bronchitis, and asthma among children from two months to five years
old attributable to ETS exposure (Gergen Peter J
et al.). Gonzales and colleagues revealed among
their population in New Mexico, that 36% of Hispanic children (between 2 and 12 years of age)
born to U.S. and Mexico Hispanic mothers lived
with a smoker household. In our study, most smokers revealed they smoke outside the house but still,
there is smoking exposure near children (12.3%),
inside the house (34.7%) and in the car (15.5%).
Also, 46% of those smokers who smoked inside
the house revealed smoking 1-2 days per week. It
is interesting, those children who are not expose
to ETS at home (34%) as reported by Gonzales
and colleagues, were exposed to passive smoking
when spent time in their grandparent’s house. In
our study, three participants wrote in an open question (how many people smoke in your home?) that
their child was not exposed to ETS at home but,
there was exposition when divorced father took the
child on the weekend, at a grandparent’s house and
other relatives’ houses. Hopper and Craig (2000)
found that non parental sources of ETS exposure
are reported to be common in urban children, so
this is another fact we must take in consideration
when approaching and performing a complete history taken when addressing a patient especially
with asthma or other respiratory diseases.
Mannino and colleagues concluded from
Figure 18: Orientation given by Pediatrician
Revealed by Smoker versus Non-smoker
the Third National Health and Nutrition Examination Survey (1988~1994) that environmental
tobacco smoke exposure affects children of all
ages, although the exact effects vary between age
groups. It is also an important predictor of respiratory health outcomes in children 4 years and older.
In a study done in North Carolina, Sturm and colleagues (2004) revealed there was a stronger association between asthma symptoms and passive
tobacco smoke than active smoking. In our study,
there was no significant difference between passive smokers and non-smoking households for respiratory illness prevalence (Fig.19 and Table 1). A
Swiss study conducted between 1992 and 1993
reported 47% of all children were exposed to ETS,
16% of mothers smoked during pregnancy and
children exposed at home to more than 20 cigarettes per day were at higher risk for respiratory
problems (Hajnal BL et al, 1999).
The participants with a higher education
had a higher average score on their knowledge
about adverse effects of smoking.
Children learn behaviors done by caregivers and may repeat what they see. A smoker caregiver is a negative role model for children. We
need to reinforce to quit smoking and prevent passive smoking in children.
Among the topics that need to be reinforced to general population about the adverse effects of passive smoking are: environmental polVol.: 100 - Núm 2 - Abril - Junio 2008
Figure 19: Recurrent Diseases in Children Exposed to Non-smokers versus Smokers
45
The AAP states tobacco-free environment
is imperative, because tobacco is major health hazard to infants, children, adolescent and their families.
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[35] Winickoff JP, Berkowitz AB, Brooks K, Tanski SE, Geller A,
Thompson C, Lando HA, Curry S, Muramoto M, Prokhorov AV,
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Acknowledgments
I would like to thank to Dr. Wanda I. Figueroa, Dr. Vanessa
Santini, Prof. Iris Parilla and Prof. Mike Vélez for all their guidance
and their help including the statistical work. Thanks to all participants in the study for taking time to answer the survey, to all teachers
and school nurse for distributing and gathering all the information, to
all Directors, and to the Department of Education for all the permits
and their interest in this study. Thanks to all Faculty Members and
Attending at H.U.R.R.A. Dr. Carmen Sanchez-Bartolomei, Dr. Haydee Garcia, Dr. Jesus Balestra and Dr. Fermin Sanchez for all their
knowledge and support over the years at the Residency. And last but
not least, thanks to my husband Dr. Ben Y. Ju and all my family especially my mom Dr. Jean M. Gonzalez for all the moral support during
this work and my training.
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Artículos de repaso - Review Articles
DEVELOPMENTAL SEX DISORDERS: BRIEF
REVIEW ON CURRENT ETHICAL ASPECTS
By: Francisco Nieves-Rivera, MD and Lilliam González-Pijem, MD *
ABSTRACT
Among the urgent issues of the current
medical ethics is the patient-doctor relationship.
The care of patients with disorders of sexual differentiation (DSD) is an example of this relationship and its clinical ethical aspects. For centuries
differences in gender have captured our attention. We illustrate examples of DSD patients. The
standard of care based on previously accepted hypothesis is discussed. Adult population with DSD
provided evidence which challenged the way we
used to care these individuals. The latter served as
an opportunity to revised and develop the current
standard of care for individuals with DSD.
The relationship between the suffering
person and the ones empowered with the knowledge to heal remains as the urgent issue of current medical ethics. This is portrayed daily in the
patient-doctor relationship (6). Disorders of sexual
differentiation are not the exception.
For centuries differences in gender have
captured our attention. In Genesis 1:27 we have
one of the earliest recording on the subject: In
the beginning, “God created human beings at his
own image, as its own image created them, man
and woman…” This would pose an immediate
challenge to individuals born unable to fit either
definition. It is likely that acquired or congenital
problems of sexual differentiation have existed for
more than two thousand years: “Because there are
eunuchs –unable to have sex— who were born this
way…. Mathew 19:12. ”. In our society, sex is assigned at the time of birth based on the inspection
of the external genitalia. Although uncommon,
occasionally mother nature challenges us with individuals to whom it is difficult to assign sex at
birth because they seem to have ambiguity or an
intermediate sex stage of development previously
called hermaphrodites or intersex and now referred
as developmental sex disorders (DSD).
The relationship between the suffering
person and the ones empowered with the knowledge to heal remains as the urgent issue of current medical ethics. This is portrayed daily in the
patient-doctor relationship (6).
Disorders of sexual differentiation are not the exception.
For centuries differences in gender have
captured our attention. In Genesis 1:27 we have
one of the earliest recording on the subject: In
the beginning, “God created human beings at his
own image, as its own image created them, man
and woman…” This would pose an immediate
challenge to individuals born unable to fit either
definition. It is likely that acquired or congenital
problems of sexual differentiation have existed for
more than two thousand years: “Because there are
eunuchs –unable to have sex— who were born this
way…. Mathew 19:12. ”. In our society, sex is assigned at the time of birth based on the inspection
of the external genitalia. Although uncommon,
occasionally mother nature challenges us with individuals to whom it is difficult to assign sex at
birth because they seem to have ambiguity or an
intermediate sex stage of development previously
called hermaphrodites or intersex and now referred
as developmental sex disorders (DSD).
From the cultural perspective, DSD have
been addressed differently ranging from total acceptance to complete rejection. For instance, the
Greeks adored DSD, as illustrated by the cult to
Hermaphroditus. According to Greek beliefs,
Hermes and Aphrodite had a son they named Hermaphroditus. One day Hermaphroditus went for
a walk and plunged into a lake to get some relief
from the heat. Salmacis, a nymph, immediately
fell desperately in love with him. Since the boy
rejected her, she hugged him tightly and asked the
gods to allow them to stay together forever. Her
wish was granted and they stayed together as a
single individual with two sexes. The Romans did
not share the beliefs of the Greeks and used to kill
individuals with DSD. They would let the vultures
eat the newborn with DSD by leaving them at the
top of a mountain.
Subjects with DSD born with 5 alpha reductase deficiency (i.e., the enzyme that catalyzes
conversion of testosterone to dehydrotestosterone), and initially assigned female sex as a rearing
gender, have found social acceptance to switch to
male gender during pubertal years, when male
* From the Section of Pediatric Endocrinology, Department of Pediatrics, U.P.R. School of Medicine, San Juan, Puerto Rico.
Address reprints to Francisco Nieves-Rivera, M. D., Pediatric Endocrinology Section, Department of Pediatrics, University of Puerto Rico School
of Medicine, San Juan, Puerto Rico 00936-5067. <[email protected]>
48
secondary sexual characteristics appear. This is
entirely accepted within their community (e.g.,
Salinas, Dominican Republic) since it is perceive
as advantageous situation for labor – more hands
would be available to work in the crops for their
survival.
During the Middle Ages, DSD were considered God’s punishment to sin. By the Renaissance, DSD were seen as a curiosity or Mother
Nature’s error. In the 18th and 19th centuries,
DSD became a subject of scientific interest. But
it was not until the 40s and 50s, that the pivotal
role played by hormones in sexual differentiation gave us a better understanding on the subject.
Fine details on the molecular-biological control of
sexual differentiation (i.e, gene expression) were
described later during the 80s and 90s providing
an in depth insight in the intricate signaling system
responsible for sexual differentiation (5).
Case Illustration
A typical case of DSD is illustrated in the
following example. An 18 hour-old newborn is
brought for evaluation because of ambiguous genitalia. Family history was negative for babies born
with similar alterations. The external genitalia
showed an enlarged genital tubercle (~2 cm) with
ventral chordee. There was posterior to anterior fusion of labioscrotal folds, with an opening at the
base of the genital tubercle. There was a palpable
mass in the left inguinal canal that did not resemble
gonadal tissue. The right inguinal canal was empty.
A pelvic sonogram showed the presence of müllerian structures –i.e., uterus, fallopian tubes, and
upper vagina. At the end of the first week of life,
the baby developed electrolyte derangements i.e.,
hyponatremia and hyperkalemia. Laboratory studies showed an elevated 17 alpha hydroxyprogesterone serum levels (i.e., compatible with congenital
adrenal hyperplasia secondary to 21 hydroxylase
deficiency) with barely detectable cortisol. Karyotype resulted in 46, XX chromosome complement
in 100% of the analyzed cells. Congenital adrenal
hyperplasia (CAH) was confirmed as the etiology
accounting for DSD in this subject.
DISCUSSION
Despite over 50 years of experience, the
management of DSD secondary to CAH is still a
challenge to the medical community.
A newborn female with CAH and DSD
requires urgent expert medical attention (2). The
ambiguity is highly distressing to the family,
therefore, immediate comprehensive evaluation is
needed by referral to, or visit by, a pediatric endocrinologist. An important goal is to ensure that
the parents develop a positive relationship toward
their child.
A well-organized multidisciplinary team
(including specialists in pediatric endocrinology,
psychosocial services, pediatric surgery/urology,
and genetics) is essential for the diagnosis and
management of the infant with DSD. It is important
for the coordinator of the team to have experience
in the long-term care of newborns with CAH and
to provide a consistent message to the parents. The
members of the medical team should be cautious
and avoid using confounding terminology related
to the sex of the newborn. It is, thus, preferable
to speak about gonads instead of testes or ovaries
while information is being gathered.
In the late 90’s individuals with DSD
challenged the scientific community management
practices based on the belief that nurture could
overcome nature. The standard of care based on
this belief plus the paternalistic and secrecy approach were not feel to be appropriate according
to the patient’s own experience –i.e., nurture did
not override nature. More recently, studies on the
biological, psychological, and sociological aspects
of gender identity –i.e., the sex with which we psychologically identify ourselves and which is usually established by 18 months of age– have questioned the theory of Money where brain can be
modified by environment stimuli to adapt to desire
rearing sex. Specifically, these studies challenge
the concept that the sexual identity of an individual
can be totally overcome by the environment (e.g.,
nurture vs. nature). Perhaps the major limitation of
Money’s theory is its lack of follow-up studies and
lack of systematic evaluation of individuals with
DSD.
An illustration of this was the actual case
cited often by Money of the identical twin siblings,
known by the pseudonyms of John/Joan (3) born
in the 60’s in Canada. By the age of seven months,
both began to experience difficulties with voiding
secondary to phymosis. At 8 months of age, both
twins were taken to a local hospital for a routine
circumcision. The electrocautery employed in the
procedure in the first twin was apparently malfunctioning and burned John’s penis, causing irreversible damage. Several months later, while
John/Joan’s parents were watching television, they
came across a program in which an expert psychologist in DSD from Johns Hopkins was being
interviewed. The family called the expert psychologist, Dr. Money, and were immediately scheduled
to travel to Baltimore, Maryland.
Dr. John Money was a psychologist born
in New Zealand in 1921. He had completed his
Ph.D. degree in Harvard at age 25. The topic of
his dissertation was gender identity disorders. He
became famous worldwide with the theory that it
would be possible to modify gender identity early
in life irrespective of genetic sex, by providing the
desired sex rearing environment. In fact, the case
of John/Joan gave him a worldwide reputation as
an expert in the field.
Money realized the great opportunity to test his
hypothesis upon the evaluation of the affected
twin. Thus, female sex reassignment for John was
recommended. John lived as Joan for his (her) first
14 years of life. As Joan (John) grew up she became isolated, having few friends. Money was still
convinced that sexual identity could be completely
modified by manipulating the environment. However, in spite of environmental manipulations such
as dressing as a girl and having long hair, Joan
(formerly John) showed constantly male behavior,
e.g., playing with cars. She was constantly rejected by her peers since her behavior was perceived
as unusual. By the time she reached adolescence,
Joan felt attracted to females. After years of receiving psychotherapy sessions, Joan’s therapists
recognized the need to tell the actual facts of her
infancy. Finally, her father explained to her the accident experienced when she was 8 months of age,
opening a new chapter in Joan’s life. This would
be followed by re-assuming a male gender identity which was always present although in a hidden
way.
Concomitantly, new reports challenging
the validity of John Money’s theory on gender
identity began to appear while former Joan began
a new life. John required testosterone hormonal replacement; because of orchiopexies he had earlier
in life, plus several surgical interventions to improve the appearance of the phallus. He had a family of his own by marrying a woman with children.
Unfortunately, John committed suicide at age 38.
Fausto Sterling, an embryologist from
Brown University, has rejected the concept that
human beings come solely with two sexes and two
genders. In other words, sexual organs encompass
a spectrum that ranges from a penis and scrotum
to a clitoris and vagina. This is true when speaking
solely on the ontogeny of the anatomic homologous sexual structures (Table 1).
Table
1. External genitalia embryological homolo
gous
Female structures
Embriological
structure
Male structure
Clitoris
Genital Tubercle
Labia majora
Labioscrotal folds
Scrotum
Labia minora
Urethral folds
Penile shaft
Fallopian tubes,
Mullerian ducts
uterus, inner
vagina
Wolfian ducts
Glans
Utricle
Epididymus, vasdeferens, seminal
vesicles, prostate
From the medical care perspective, in the past it
was accepted that secrecy and paternalism were
the proper way to deal with DSD.
49
Emphasis was placed on the capacity to
function as a male, i.e., void standing up and having a phallus that would likely respond to testosterone or could be successfully surgically repaired. It
was believed that the brain was malleable enough
so as to easily adjust to the sex and gender identity
assigned. As time went by, this position was challenged by groups of affected individuals such as
the “Intersex Society of North America” and the
“Androgen Insensitivity Support Group” (8). The
former group’s founder was born as a genetic male
with incomplete virilization. Although his parents’
initial decision was to raise him as a boy, at age 1 ½
they were so worried about the appearance of the
external genitalia that they decided to raise him as
a girl. He underwent several surgical interventions
to obtain an external appearance of the genitalia
that would resemble the assigned sex, i.e., removal
of the genital tubercle. At 19 she discovered her
true DSD identity, i.e., 46, XY male pseudohermaphrodite. She felt horrified and angry, and this
gave her the determination to become activist and
speak up gathering other similarly affected individuals under the Intersex Society of North America
support group. The organization has already contacted approximately 400 individuals with similar
situations. More recently, The American Academy
of Pediatrics and the Lawson Wilkins Pediatric
Endocrine Society have become sensitive to specific concerns brought up by these groups.
Recent studies suggest that chromosomes
may have an influence in the sexual behavior of
some individuals independent of the hormonal
milieu. This, in turn, speaks in favor of the notion that prenatal, and possibly postnatal, biological factors may play a major role in the human,
gender specific behavior that cannot be obliterated
or even modified by the environment. Dr. Milton
Diamond, a psychologist from the University of
Hawaii-Manoa, has expressed that we do not come
into this world in a completely neutral fashion (4).
There seems to be a certain degree of preexisting
masculinity or femaleness at the time of birth that
goes beyond whatever society might attempt to
add. Drs. Keith Sigmundson and Diamond have
brought to the scientific community the end results
of Money’s experiment –“the thesis that social
learning is above the imperatives imposed by biology”. Specifically, Diamond proposes that gender identity and sexual orientation are present to
a large extent at the time of birth. These are both
the result of exposure to hormones and to other genetically predetermined influences in the brain and
central nervous system. As a consequence, there
are limitations in terms of the degree of flexibility an individual has that would enable him/her to
cross over from one gender to the other. Although
the environment plays a role in assisting the individual to express his/her maleness or femaleness,
Diamond says that nature has the predominant
strength in terms of the innermost feelings of the
50
individual that allow him/her to identify either
with a male or female, boy or girl (i.e., gender
identity). Diamond and Sigmundson believe that
we should continue to assign male or female sex
to babies born with intersex, but to limit interventions to hair length, clothing, and names (i.e., reversal aspects). Permanent surgical interventions
should be deferred until the patient can articulate
the gender with which he/she identifies better.
This position has also been supported by
The Harry Benjamin International Gender Dysphoria Association (7). John/Joan’s case demonstrated that the biological marks left in the psychosocial identity cannot be easily erased by the
environment . In fact, in somewhat isolated communities where babies born with 5 alpha reductase
deficiency whose brains are exposed to endogenous
testosterone and who are initially raised as girls,
accept without hesitation gender change at age
twelve when often virilization becomes evident.
This is also reassured by the social advantages
it gives and in agreement with the gender with
which they identify. In terms of biological differences, studies in the mid 80s in Amsterdam identified an area in the hypothalamus that was twice
the size in homosexual males compared to heterosexuals. Dean Hamer reported differences in X
chromosome patterns in studies in 1993 and 1995
performed in gay brothers.
However, some studies have supported
the capability of a psychosexual development that
is congruent with gender even in the presence of
DSD such as female psychosexual identity in female pseudohermaprhodites with congenital adrenal hyperplasia (1). Females with CAH show
behavioral masculinization, most pronounced in
gender role behavior, less so in sexual orientation,
and rarely in gender identity. Currently, there is
insufficient evidence to support rearing a 46, XX
infant fully virilized (i.e., Prader stage 5) as a
male. Whereas studies of women whose surgery
was performed 20-30 years ago indicate a range
of psychosexual difficulties, there is reason for
optimism in that the outcome will be better with
current surgical and medical treatment. Decisions
concerning sex assignment and associated genital
surgery must consider the culture in which a child
and her/his family are embedded. The decision
about surgery should be made by the parents, together with the clinical team, after complete disclosure of all relevant clinical information and all
available options have been discussed, and after
informed consent has been obtained (9). The goals
of the surgery are: 1) genital appearance compatible with gender; 2) unobstructed urinary emptying
without incontinence or infections; and 3) good
adult sexual and reproductive function.
Nowadays, the decision regarding an in-
dividual with intersex ought to be shared with the
patient and his/her guardians –e.g., parents–, following the contemporary practices in medicine.
Physicians should assume that the parents of a
newborn with ambiguous genitalia can participate and contribute in the discussion openly and
honestly in terms of the available options. Psychological support should be provided to the patient
and the relatives at the time of the diagnosis and
subsequently, as needed. Counseling should address areas related to adequate sexual functioning,
possible reconstructive surgeries, gender role, and
living with a chronic illness. In addition, anxiety,
depression, contraception, dyspareunia, or other
aspects of sexual dysfunction must be addressed.
In spite of the advances attained in understanding changes at the molecular biology level responsible for sexual ambiguity in the newborn, the
main consideration in the management of these
patients remains the sensitive and compassionate
care that ought to be provided by health professionals at all times in their interaction with the parents.
The Harry Benjamin International Gender
Dysphoria Association published a set of standards
of care for gender identity disorders in February
2001. The standards set guidelines based on consensus from professionals who care for patients
with gender identity disorders.
In summary, physicians and health professionals have witnessed the development of means
to better understand the regulation of sexual differentiation in the human being. The interplay among
the genetic sex, phenotypical expression, and psychological gender sex identity in DSD has been
reviewed. We have learned that biological factors
seem to set limits in the capacity to adapt a new
gender identity that nurturing cannot overcome.
Ethical aspects pertaining to DSD are discussed.
Parents should be encouraged to participate in the
decision of sex assignment and provided with the
appropriate support.
REFERENCES
1.
Bomalaski, M.A. (2005). A practical approach to intersex.
Urology Nursing, 25(1), 11-18, 23-24.
2.
Clayton, P.E., Miller, W.L., Oberfield. S.E., Martin Ritzén,
E., Sippell, W.G., Speiser, P.W. (2002). Consensus statement on 21hydroxylase deficiency from the Lawson Wilkins Pediatric Endocrine
Society and The European Society for Paediatric Endocrinology.
Journal of Clinical Endocrinology and Metabolism, 87(9), 40484053.
3.
Colapinto, J., (2001). As nature made him: The boy who
was raised as a girl. New York: HarperCollins Publisher, 1-289
4.
Diamond, M. (2004). Sex, gender, and identity over the
years: a changing perspective. Child Adolescent Psychiatry Clinics
of North America, 13, 591-607.
5.
Feldman Witchel, S., Lee, P. (2002). Ambiguous Genitalia In: Pediatric Endocrinology. Sperling, M. (Editor) Saunders, 111133.
6.
Lugo, E. (2001). Relación Médico/Paciente: Encuentro
interpersonal ética y espiritualidad, 1-222
7.
Meyer, W., Bockting. W.O., Cohen-Kettenis, P., Coleman, E., DiCeglie, D., Devor. H., Gooren, L., Joris Hage, J., Kirk, S.,
Kuiper, B., Laub, D., Lawrence, A., Menard, Y., Monstrey, S., Patton,
J., Schaefer, L., Webb, A., Christine Wheeler, C. (2001) The Harry
Benjamin International Gender Dysphoria Association’s Standards of
Care for Gender Identity Disorders, 6th revision.
8.
Domurat-Greger, A. 240 pp. Intersex in the Age of Ethics
Hagerstown, Md., University Publishing 1999
9.
Lee PA, Houk Christopher, Ahmed SF, Hughes IA , et al
Consensus Statement on Management of Intersex Disorders. Pediatrics 2006;118;488-500
Acknowledgements
The authors would like to thank Professor María L. Collazo for her
extensive review of the manuscrip
51
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Entre los temas urgentes de la ética clínica
actual está la relación médico-paciente que continúa siendo fundamental. El manejo de pacientes
con desórdenes de diferenciación sexual (DSD)
representa una instancia de aspectos éticos en la
clínica. A través del tiempo DSD ha sido tema
de interés colectivo. Se ilustran ejemplos de pacientes con DSD. Se discute la hipótesis que sirvió de base en el manejo aceptado y que posteriormente fue desafiada por la evidencia recogida en
seguimiento de adultos con DSD. Esto último sirvió de referencia en la revisión y establecimiento
del estándar vigente para el cuidado de pacientes
con DSD.
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52
DIABETIC KETOACIDOSIS IN PEDIATRICS:
MANAGEMENT UPDATE
By: Ricardo García-De Jesús MD *
ABSTRACT
The management of diabetic ketoacidosis
has remained unchanged for several years. Lately,
as more evidence has been available, practice has
been modified to simplify the management and
avoid complications. For the last twenty years patients admitted to the Pediatric Intensive Care Unit
(PICU) at the University Pediatric Hospital, were
managed following a protocol where the patient’s
volume deficit was calculated based on the degree of dehydration (mild, moderate, and severe)
and then administered accordingly over 36 hours.
Also, we administered an insulin IV bolus (0.1u/
kg) prior to starting the insulin drip. Our experience employing this approach in the pediatric population had been successful having no morbidity
or mortality due to cerebral edema. Nevertheless,
new evidence, based on studies and international
consensus, suggest changes should be made in the
management of DKA. It is the new consensus that
patients should be rehydrated over 48 hour period,
and that the initial insulin bolus should be avoided.
Of course, it needs to be pointed out, that the clinical status of each patient is the barometer by which
therapy should be tailored. The following information is the new suggested guideline in the management of DKA.
Severe diabetic ketoacidosis (DKA) is a
life-threatening complication of diabetes mellitus.
The frequency of DKA at onset of diabetes correlates with the regional incidence of type 1 diabetes
and is more common in young children, children
without a first-degree relative with type 1 diabetes,
and individuals whose families are of lower socioeconomic status.1 The mortality rate for DKA in
children is around 0.15% to 0.31%.2 Despite the
more apparent issues of hypovolemia and acidosis,
clinically significant cerebral edema, which occurs
in 1% of cases, is the most serious risk to children.
Because cerebral edema occurs in the context of
DKA, reduction of the incidence of DKA should
be a major goal of treating children with diabetes.
Diabetic ketoacidosis is the result of complex metabolic derangements caused by absolute or relative
insulin deficiency resulting in hyperglycemia and
a n accumulation of ketone bodies in the blood, with
subsequent metabolic acidosis and dehydration.
In addition, there are increased levels of counter
regulatory hormones (glucagon, catecholamines,
glucocorticoids and growth hormone) causing abnormal metabolism of carbohydrates, proteins and
fat. The reported mortality rates in children with
DKA are usually low, but once cerebral edema develops, death occurs in some 20–25%, and significant morbidity, including pituitary insufficiency,
occurs in 10 - 25% of survivors. Where medical
services are less well developed, the risk of dying
from DKA is greater, and children may die before
receiving treatment. Overall, cerebral edema accounts for 60 – 90% of all DKA related deaths in
children.
Clinical features of DKA include history
of polyuria, polydipsia, polyphagia, and weight
loss (especially in the diabetes de novo cases).
The child will also have signs and symptoms of
dehydration and/or shock: mottled skin, delayed
capillary refill, dry mucosa, tachycardia, tachypnea (Kussmaul breathing), decreased peripheral
pulses, sensory changes, oliguria or anuria. Some
patients may also present with nausea, vomiting,
and abdominal pain that may mimic an acute abdomen. Fever, increased leukocyte count with left
shift, and nonspecific elevation of serum amylase
may also be found.
The biochemical criteria for the diagnosis of DKA
include hyperglycemia (blood glucose higher than
200 mg/dL) with acidosis (venous blood pH < 7.3
or serum bicarbonate <15 mmol/L), elevated serum
ketones (β-hydroxybutyrate and acetoacetate), and
ketonuria.3, 4 Clinical symptoms also may vary
from mild to severe. Usually hyperapnea, lethargy,
headache, acetone breath and sensorium changes
maybe indicative of severity and possible cerebral
edema. DKA is generally categorized by the severity of the acidosis, with mild DKA defined as
a venous pH <7.3 and bicarbonate <15 mmol/l;
moderate DKA as a pH <7.2 with a bicarbonate
<10 mmol/l; and severe DKA as a pH <7.1 and
bicarbonate <5 mmol/l. 3, 4
* From the Pediatric Critical Care Medicine Section, Department of Pediatrics UPR School of Medicine, University Pediatric
Hospital
Address reprints to: Ricardo García-De Jesús MD – Department of Pediatrics, UPR School of Medicine, PR Health Science Center,
Rio Piedras, P.R. 00936. E-mail < [email protected]>
Once DKA is identified, the objectives of
patient management are: correction of dehydration, restoration of blood glucose to near normal
levels, correction of acidosis and reversion of ketosis. Also attention should be given to identify
and treat precipitating events and to individualize
treatment depending on patient’s age and severity
while avoiding therapeutic complications. These
considerations and recommendations are in agreement with those recently endorsed by the Lawson
Wilkins Pediatric Endocrine Society (LWPES),
European Society for Pediatric Endocrinology
(ESPE), and the International Society for Pediatric
and Adolescent Diabetes (ISPAD).5, 6
During the initial emergency assessment
and evaluation, the clinician should take the following steps:
•
•
Perform a clinical evaluation to establish the
diagnosis and determine its cause (while carefully looking for evidence of infection).
Weight the patient and measure height or
length. Determine body surface area. (see Figure 1)
Figure 1.
A commonly used formula is the Mosteller formula, published in 1987: Metric (area in square
meters from weight in kilograms and height in centimeters):
•
Assess the patient’s degree of dehydration.
•
Assess level of consciousness.
At the same time, several supportive measures should be undertaken:
•
Secure the airway and empty the stomach by
continuous nasogastric suction to prevent pulmonary aspiration in the unconscious or severely obtunded patient.
•
Give antibiotics to febrile patients after obtaining appropriate cultures of body fluids.
•
Provide supplementary oxygen to patients
with severe circulatory impairment or shock.
•
Bladder catheterization, if a child is unconscious or unable to void on demand (e.g., infants and ill young children).
•
Consider placing a heparin-locked peripheral
intravenous catheter for convenient and painless repetitive blood sampling.
53
•
A cardiac monitor should be used for continuous electrocardiographic monitoring.
•
Use a flow chart to record a patient’s clinical
and laboratory data, including vital signs (e.g.,
heart rate, respiratory rate, blood pressure,
level of consciousness [Glasgow coma scale]),
details of fluid and electrolyte therapy, amount
of administered insulin, and urine output.
•
Place an intravenous line (or intaosseous, if
necessary) for fluid resuscitation and management. Preferentially two access sites.
After initial evaluation and assessment obtain
blood sample for laboratory measurement of:
•
serum or plasma glucose;
•
electrolytes (basic metabolic panel (BMP) or
Renal Profile with magnesium)
•
venous (arterial only in critically ill patient)
pH; pCO2; pO2;
•
complete blood count (CBC);
•
HbA1c
•
Perform a urinalysis for ketones.
•
If there is evidence of infection, obtain appropriate specimens for culture (blood, urine, and
throat).
•
If laboratory measurement of serum potassium
is delayed, perform an electrocardiogram for
baseline evaluation of potassium status;
•
Dextrostick every hour from the moment of
admission
Once initial stabilization is performed, the
child should receive care in a unit that has:
•
Experienced nursing staff trained in written
guidelines for DKA management and appropriate monitoring in children.
•
Access to laboratories for frequent and timely
evaluation of biochemical variables.
•
A specialist with training and expertise in the
management of DKA should direct inpatient
management.
•
Children with severe DKA (long duration of
symptoms, compromised circulation, or depressed level of consciousness) or those who
are at increased risk for cerebral edema (e.g.,
<5 years of age, low pCO2, high urea nitrogen)
should be considered for immediate treatment
in a pediatric intensive care unit (PICU).
Hydration
The patient should receive maintenance
intravenous fluids (IVF’s) plus the deficit correction.
54
The objectives of fluid and electrolyte replacement
therapy are restoration of circulating volume, sodium replacement, intra and extra cellular water
deficit correction and restoration of glomerular filtration to enhance renal clearance of glucose and
ketones. Avoid excessive rates of fluid administration so as not to exacerbate the risk of cerebral
edema.5, 6, 7
•
This occurrence generally can be avoided if
potassium phosphate concentration in the intravenous fluid does not exceed 20 mEq/L.
•
Remember to re-evaluate the patient frequently and chart intake and output closely.
Administer a Fluid Bolus of an isotonic
solution (0.9NSS or Ringer’s Lactate) at 10-20ml/
kg over 1 hour. In the presence of decompensated
shock consider more rapid infusion rate, and even
repeat the dose if necessary. Voiding usually implies that vascular space has been expanded. Remember, try to obtain two IV access to facilitate
patient management. Once this initial fluid bolus
has been given, subsequent fluid management
should be given with a solution that has a tonicity
of 0.45% saline or more (0.9% saline or Ringer’s
lactate) with added potassium. To ensure proper
hydration, total fluid rate must remain constant;
this will minimize rapid changes in serum osmolarity, which may be associated to cerebral edema.8
All patients must receive insulin. Insulin
is essential for restoring blood glucose to normal
and suppressing lipolysis and ketogenesis. Rehydration alone decreases the blood glucose concentration but does not reverse ketoacidosis. Start an
insulin infusion after the patient has received initial volume expansion. Do not give insulin loading dose. Insulin should be given as a continuous
infusion (See Figure 2). The infusion rate should
be at 0.1 unit/Kg/hr. The serum glucose should fall
approximately at 50-100 mg/dL/hr.
The rate of intravenous fluid (IVF’s) administration should be calculated to rehydrate a
patient at an even rate over 48 hours.
•
Calculate total fluid to be administered at
3000ml/m2/day for the next 48 hrs. Subtraction of the initial fluid bolus is NOT necessary.
•
Add dextrose 5% to IVF’s when glucose falls
to 250mg/dL.
•
Potassium replacement therapy will be required regardless of the serum potassium
concentration; start replacing potassium after
initial volume expansion, presence of voiding
and concurrent with starting insulin therapy.
However, if the patient is hypokalemic, start
potassium replacement immediately after initial volume expansion and before starting insulin therapy. If the patient is hyperkalemic,
defer potassium replacement therapy until
urine output is documented. If immediate serum potassium measurements are unavailable,
an electrocardiogram may help to determine
whether the child has hyper- or hypokalemia.
Add the amount of potassium sufficient to
maintain serum potassium levels in the normal
range. Usually 20-30 mEq/L KCL.
•
Serum phosphate levels should be monitored,
and severe hypophosphatemia (<1mg/dL)
should be treated with potassium phosphate
while carefully monitoring serum calcium
concentrations to avoid phosphate-induced
hypocalcemia.
Insulin therapy
Figure 2.
Insulin drip may be prepared as follows:
a.
100 units regular insulin diluted in 100
ml normal saline; (1 unit=1ml)
b.
50 units regular insulin in 500 ml
0.9NSS (0.1 unit= 1ml)
Infusion rate should remain between 0.05
- 0.1 U/kg/h until resolution of ketoacidosis (pH
> 7.30 and bicarbonate > 15 mmol/L or closure of
the anion gap). However, even if the blood glucose
concentration is normal or near to normal, intravenous insulin therapy should not be discontinued
until ketoacidosis has resolved. To prevent the development of hypoglycemia, dextrose should be
added to the intravenous fluid when the plasma
glucose has fallen to approximately 250 mg/dL.
When ketoacidosis has resolved and the
change to subcutaneous insulin is planned, the first
subcutaneous injection should be given at an appropriate interval before stopping the insulin infusion to allow sufficient time for the subcutaneously injected insulin begin to be absorbed. The
starting dose of subcutaneous insulin in new-onset
patients recovering from DKA is based on a total
daily dose (TDD) of insulin of 0.75 U/kg/day in
prepubertal children, and 1 U/kg/day in pubertal
patients.4,7,8 This should be discussed with the
endocrinology service by consultation. After patient starts to tolerate diet, the dextrose should be
removed from IVF’s, and depending on the rehydration status IVF’s may be decreased.
During the management of the patient
with DKA the following clinical and biochemical
monitoring should be performed:
55
•
Initially, plasma glucose should be measured
hourly.
•
Serum glucose, serum electrolytes (and calculated sodium), urinalysis (ketones), pH, pCO2,
TCO2, anion gap, calcium and phosphorus
levels should be measured every 4 hours for
the first 8 hours and then every 6 hours until
they are normal.
•
All data must be recorded carefully on a flow
sheet.
•
In all patients, continuous cardiovascular and
respiratory monitoring should be performed.
•
Close Intake and output should be followed
every hour.
•
Close neurological monitoring should be documented on the initial 48 hours of management.
Corrected Sodium:
Cerebral edema should be ruled out in cases of sudden and severe headaches, changes in the
level of consciousness, combativeness, disorientation, changes in vital signs and/or changes in the
pupillary reaction.8,9 Re-evaluation of the ABC’s,
fundoscopic examination and emergency head CT
should be rapidly performed. If brain edema is the
cause of patient’s signs and symptoms administer
0.25- 0.5 gm/Kg mannitol 25% or 3ml/Kg 3%NSS
over 20 minutes to control brain swelling. Rapid
sequence intubation should be considered if patient’s neurological status continues deteriorating
or doesn’t improve with the osmolar therapy
Serum Osmolarity:
It is important to remember that even severe
acidosis is reversible by fluid and insulin replacement. Insulin stops further synthesis of ketoacids
and promotes ketone use. The metabolism of ketoanions results in the regeneration of bicarbonate
and correction of acidemia. Treatment of hypovolemia improves tissue perfusion and restores renal
function, which increases the excretion of organic
acids and reverses any lactic acidosis, which may
account for up to 25% of the acidemia. There is no
data to support the routine use of bicarbonate in
the management of DKA.
Figure 4.
Initially serum sodium can be factitiously decreased. It is important to calculate the true sodium levels (See Figure 3). If the patient is hypernatremic, then fluid replacement should be even
more gradual to avoid rapid changes in osmolarity. Occasionally after patients acidosis has been
resolving, it may re-appear or persist. It may be
due to inadequate hydration, discontinuation of
insulin infusion or hyperchloremic metabolic acidosis. The last one is usually secondary to the prolonged use on normal saline solution (NSS), and it
resolves without treatment. If persistent, you may
need to decrease the amount of NSS administered,
changing IVF’s temporarily to Ringer’s lactate.
Figure 3.
Formulas
Measured Serum Na+* {1.6 mEq Na+ * (Serum
glucose – 150 mg/dL) / 100}
(N=285-295 mOsm/L)
(2 X Serum Na+) K+ + (Serum glucose / 18) +
(BUN / 2.8)
Always watch for complications of therapy, like
inadequate rehydration, hypoglycemia, hypokalemia, and cerebral edema.
Once diet is initiated, calories may be calculated as shown in Figure 4. Total calories must
be divided as 55% carbohydrates, 30% fat, and
15% proteins. The diet should be given in six feedings: breakfast (20% total calories), morning snack
(10%), lunch (20%), evening snack (10%), dinner
(20%) and night snack (10%).
All patients on DKA should always be
consulted to the pediatric endocrinology service.
The patient and parents will need orientation and
training to deal with the newly diagnosed diabetes.
Max. 2500 kcal/ day, unless recommended by dietitian or endocrinologist
Age
Calories Kcal/day
Weight (Kg)
CaloriesKcal/Kg
First year
1000
<10
100
Each year after
100
10-20
50
20>
20
56
In the case of the known diabetic with an
episode of DKA, the patient and the family will
also need a multidisciplinary evaluation and intervention to asses the reasons that precipitated the
event and educate them in manners to avoid this
serious complication. In addition the diabetic patient will need a multidisciplinary evaluation that
includes, but is not limited to: dietitian, social
worker, ophthalmologist, dentist, psychologist,
and diabetes specialist nurse.
In summary, DKA is a life-threatening
complication of insulin dependent diabetes mellitus which carry a significant morbidity and mortality for the pediatric population. Adequate identification, evaluation and management of DKA are
essential for the successful recovery of the patient.
Although our past experience in treating DKA using a more rapid hydration protocol had been uneventful, we are presenting the new protocol to be
employed following evidence-based recommendations by the Pediatric Endocrine Society consensus
statement among others. The recommendations
are easier to follow, and try to ensure the lowest
complications. Always remember, that the clinical
status of each patient is the barometer by which
therapy should be tailored.
REFERENCES
1.
Curtis JR, To T, Muirhead S, et al. Recent trends in
hospitalization for diabetic ketoacidosis in Ontario children.
Diabetes Care 2002;25:1591–6.
2.
Pinkey JH, Bingley PJ, Sawtell PA, et al. Presentation and progress of childhood diabetes mellitus: a prospective population-based study: The Bart’s-Oxford study group.
Diabetologia 1994;37:70– 4.
3.
Diabetes Care. 2005;28(1):186-212.
4.
Diabetes Care, Volume 29, Num. 5, MAY 2006
5.
Wolfsdorf J. Diabetic ketoacidosis. Pediatr Diabetes ; 8(1): 28-43 01-FEB-2007
6.
European Society for Paediatric Endocrinology/
Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents.
Dunger DB. Pediatrics; 113(2): e133-40 01-FEB-2004.
7.
Diabetes Mellitus, Type 1, e-Medicine. William H
Lamb, MD, FRCP, FRCPCH, Clinical Lecturer, Department
of Child Health, The General Hospital, Bishop Auckland, UK.
Article Last Updated: Oct 19, 2007
8.
Berrios, F. Diabetic Ketoacidosis: recognition and
management. Pediatric Critical care Newsletter. Vol. 3 Num.
1 Jul-Sep 2001.
9.
Glaser N, Barnett P, McCaslin I, et al. Risk factors
for cerebral edema in children with diabetic ketoacidosis: the
Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med
2001;344:264–9
Resumen
El manejo de cetoacidosis diabética (CD) a permanecido sin cambiar por varios años. Últimamente, según más evidencia ha estado disponible,
se ha modificado la práctica para simplificar la
terapia y evitar complicaciones. Por los pasados
diez años, los pacientes admitidos a la unidad de
cuidado intensivo pediátrica (UCI) en el Hospital
Pediátrico de la Universidad de Puerto Rico, fueron manejados usando un protocolo donde el déficit del volumen del paciente era calculado basado
en el grado de deshidratación (leve, moderado, y
severo) y re-hidratado agresivamente sobre 36 horas. También, administrábamos un bolo de la insulina intravenosa (0.1u/kg) antes de comenzar el
goteo de la insulina. Nuestra experiencia, que empleaba este acercamiento en la población pediátrica, había sido acertada no teniendo ninguna mortalidad secundario a edema cerebral. Sin embargo,
la nueva evidencia, basada en estudios y consenso
internacional, sugiere que cambios sean realizados
al manejo de CD. Las nuevas tendencias sugieren
que los pacientes deben ser rehidratados sobre un
período de 48 horas, y que el bolo inicial de la insulina debe ser evitado. Por supuesto, necesita ser
precisado, que el estado clínico de cada paciente es
el barómetro por el cual la terapia debe ser adaptada. El siguiente artículo repasa el manejo de CD
basado en las nuevas sugerencias.
Clínicas de Salud
Multifásicas
Todos los meses en diferentes
Municipios
Un servicio gratuito
para la comunidad
Invitamos a nuestros medicos, enferr
meras y voluntarios a participar en este
servicio desinteresado a la Comunidad
Auspicia:
Asociación Médica de Puerto Rico
Infórmese en la seccion Eventos de nuestro web site o llamando al (787) 721-6969
57
Reporte de Casos - Case Reports
EVIDENCED BASED MANAGEMENT OF
NEONATAL HEMANGIOLYMPHANGIOMA:
A Case Report.
By: Maribel Campos MD *, Víctor Ortiz MD **, Maria S. Correa MD ‡, Pedro J.Santiago Borrero MD ₤,
Ines Garcia MD *, Lourdes Garcia MD, Marta Valcárcel *
ABSTRACT
Hemangiolymphangioma is a mixed vascular malformation that is detected in the prenatal period by
sonography. Five cases of prenatal diagnosis have
been reported that have resulted in termination of
pregnancy (two) or aggressive versus purely surgical post-natal management. We present the case of
an infant with pre-natal diagnosis of a multicystic
intra-abdominal mass that received surgical management followed by conservative treatment.
The surgeon observed invasion of the pre-vertebral vessels. The entire complex mass including
the kidney and the adrenal was fixed in formalin
and sent to Pathology.
INDEX WORDS: Antenatal diagnosis, hemangiolymphangioma, ultrasonography, fetus.
CASE REPORT
This is a baby boy with a prenatal diagnosis of
a cystic abdominal lesion in the left flank. At 32
weeks of gestation age (GA), intrauterine drainage of the mass was performed for treatment and
diagnostic purposes, due to evidence of severe abdominal distention. Cyst aspirate revealed blood
stained fluid. The plan was to allow the pregnancy
to continue towards term. At 34 weeks GA, the
patient was re-evaluated and obstetric sonogram
revealed mass enlargement due to fluid re-accumulation. Elective cesarean section performed at
34.6 weeks GA, due to findings on 34-week sonogram. At birth, he presented respiratory difficulty
requiring assisted ventilation. APGAR score was
six & 7 at 1 and 5 minutes, respectively. KUB performed on admission revealed displacement of the
umbilical venous and arterial catheter (Figure 1).
Abdominal sonogram revealed a large cystic mass
in the left flank without visualization of the left
kidney. Abdominal CT confirmed the extension
of the cystic mass with displacement of the prevertebral vessels and a small left kidney located
anteriorly within the mass. At 24 hours of age, a
surgical team including both members of Pediatric
Surgery and Pediatric Urology Service performed
an exploratory celiotomy. The Pediatric Surgeon
excised the mass in total including the left kidney,
adrenal gland and a portion of the diaphragm (Figure 2).
Figure 1. Note the displacement of the umbilical
catheters and bowel
Figure 2. Mass during surgery.
* From the Section of Neonatology, Department of Pediatrics, UPR School of Medicine, ** Department of Surgery University Pediatric Hospital, ‡
Department of Pathology, UPR School of Medicine, and ₤ Section of Hematology-Oncology, Department of Pediatrics UPR School of Medicine.
Address Reprints to: Maribel Campos MD, UPR School of Medicine, Department of Pediatrics, Neonatology Section, P.O. Box 365067, San Juan,
PR 00936-5067. Tel. 787-777-3225, Fax 787-758-5307, [email protected].
58
On macroscopic examination, the specimen consisted of an irregular soft tissue mass that
measured 8.0 x 6.0 x 1.5 cm, and weighed 41.0 gm.
Upon sectioning, the kidney and the adrenal gland
were adhered to an edematous multicystic soft tissue mass located at the hilar region of the kidney
and extending beyond the adrenal gland. The cysts
ranged in size from 0.5 to 3.0 cm in greatest diameter. Most were empty but the largest ones contained a dark tan fluid. The internal lining was tan
and trabeculated. The kidney measured 5 x 3 x 1.5
cm and weighed 16 gm. Upon sectioning, it presented well demarcation between the cortex and
the medulla. The cortex measured 0.2 to 0.3 cm in
thickness. The pyelocaliceal system appeared to
be unremarkable. The adrenal gland measured 3
x 2 x 1 cm and weighed 2 gm. Externally and on
section, it was grossly unremarkable.
considered to have extensive fetal involvement.
We received an infant with a large intra-abdominal
cystic mass diagnosed at 32 weeks GA. Differential
diagnosis of the mass included meconium
pseudocyst, mesenteric cyst status post hemorrhage
or infection, lymphangioma and a renal cystic
mass with secondary hemorrhage or infection.
We assessed the final diagnosis of the mass when
histopathologic evaluation was completed. As
reported by Tseng et al, hemangiolymphangioma
should be suspected in any fetus that presents with
a multilocular mass with both cystic and solid
components and a propensity for rapid growth and
invasion into adjacent structures.4
Microscopic examination of the mass revealed a vascular malformation composed of large
vascular channels with blood content admixed with
lymphatic channels; hence our pathologic designation of hemangiolymphangioma (Figures 3, 4). In
some areas, these vascular channels had a calcified
lining and no endothelium at all. Few vessels were
larger with a thicker wall. The kidney and the adrenal gland were histologically normal.
On the postoperative period, the patient
developed severe pulmonary hypertension and
recurrent pneumothoraces. He suffered a complicated neonatal course that included episodes
of hypoxemia that required treatment with High
Frequency Oxilatory Ventilation (HFOV) and Milrinone. After extubation, the patient continued to
be oxygen dependent, requiring treatment with
diuretics. Following stabilization, follow up radiographic studies were performed that showed recurrence of the cystic lesion with extension from subdiaphragmatic area to the pelvis. Although the use
of interferon 2a and sclerosing agents are effective
in some cases3, we decided to manage the patient
conservatively with close follow up; and consider
its use at a later stage. Follow up ultrasounds revealed persistence of a cystic mass with a vascular component (Figure 5). He is now 15 months
old and has continued gaining weight, tolerating
feedings with minimal respiratory findings. He is
not requiring oxygen supplementation. Based on
the latest radiographic findings, the location of the
mass, and the patient’s clinical status; it was decided to continue conservative management of the
mass.
Figure 3. Note dilated vascular channels with blood content and unremarkable endothelium. H & E, 100X.
Figure 4. Note vessels devoid of blood; instead contained
lymph. H & E, 40X.
DISCUSSION
Prenatal diagnosis of hemangiolymphangioma has
been proven to be possible by current sonographic
technology.1-5 Intrauterine identification of such
a complex mass aids in the obstetric management,
especially in the delivery. In the previously reported case of intra-abdominal presentation, it led to
termination of pregnancy, because it was
Figure 5. Flow diagram within the mass.
59
Detection of blood flow signals by Doppler can
also aid in the diagnosis. Although our patient presented many of these characteristics, the inability
to visualize the left kidney suggested that the mass
was of renal origin. Pre-natal evaluation in this
case lead to the delivery of the infant in a tertiary
center and involvement of both pediatric surgery
and urology services in his initial management that
was limited to mass resection. Involvement of the
major vessels precluded complete mass excision
that lead to mass recurrence after an uphill neonatal course.
6.
Izquierdo Ramírez J, Angulo Hernández O, Arias y Arias
J and Farfan Canto JM: Hemangiolymphangioma of the abdominal
cavity complicated with consumption coagulopathy. Bol Med Hosp
Infant Mex. 1975 Mar-Apr;32(2):277-85.
Although surgical excision is reported
as the method of management for hemangiolymphangioma, 9-12 incomplete resection carries the
risk of recurrence. In intra-abdominal lymphangiomas, resection followed by marsupialization of the
remaining tissue is recommended.12 In the case of
a mixed lesion such as a hemangiolymphangioma;
this could lead to uncontrollable bleeding, as it is
difficult to distinguish from a hemorrhagic lymphangiomatous cyst and the vascular component
of the mass.
10.
Mulliken JB and Glowaski J. Hemangiomas and vascular
malformations in infants and children: A classification based on endothelial characteristic. Plast Reconstruct Surg. 1982;69:412-20.
Review of the existing literature revealed
the use of interferon 2 a and sclerotherapy with
OK 432 to be effective in the management of hemangiolymphangioma; but aggressive management was not proven to be effective in other cases
and the use of interferon 2 a has been associated to
significant side effects in infants. Izquierdo et al.,
reported a case of a 4 year old with intra-abdominal hemangiolymphangioma treated with steroids
without improvement that resulted in death due
to massive hemorrhage associated to KasabachMerritt coagulopathy.6 Of the other cases reported
in the literature, those were a total excision of the
mass was accomplished presented the best prognosis.4,7,8,13,14 This finding and the possibility
of spontaneous regression, guided our decision to
manage the patient conservatively with close follow up.
This case represents the possibility that
these patients are able to thrive even in the presence of a large invasive mass due to its capacity of
spontaneous regression.
7.
Morán Penco JM, Borella F, Garibaldi L, Toma P, Dodero
P. Hepatic hemangiolymphangioma in an infant. An Esp Pediatr. 1983
Nov;19(5):411-3.
8.
Chadna, S, Bhatnagar V, Mitra, DK and Upadhyaya P:
Hemangiolymphangioma of the Urinary bladder in a child. J
Pediatr Surg. 1987 Nov;22(11):1051-2.
9.
Aston SJ, Beasley RW and Thorne CHM. Grabb and
Smith’s Plastic Surgery, Fifth Ed, Lippincott-Raven, 1997: 191-203.
11.
Oldham KT, Colombani PM and Foglia RP. Surgery of
Infants and Children Scientific principles and practice, LippincottRaven Publishers, 1997: 1727-1742.
12.
Stringel G. Pediatric Surgery, Third Ed, Saunders. 2000:
965-983.
13.
Vitalta J and Mascaro JM. Hemangiolymphangioma of the
tongue treated by transfixion technique. J Dermatol Surg Oncol. 1985
Feb;11(2):168-70.
14.
Zacharia TT, Ittoop A, Perumpillichira JJ and Chavham
G. Sonographic appearance of a congenital parotid gland hemangiolymphangioma simulating malignancy in an infant. J Clin Ultrasound.
2003 Nov-Dec;3(19):493-6.
RESUMEN
El hemangiolinfangioma es una malformación
vascular mixta que se puede detectar prenatalmente por medio de sonografía. De los cinco casos
reportados que han diagnosticados intraútero, dos
han resultado en terminación del embarazo y tres
en tratamiento agresivo versus manejo puramente
quirúrgico. Le presentamos el caso de un infante
con historial de una masa multi-cística intra-abdominal que fue diagnosticada prenatalmente y se
trató quirúrgicamente seguido por manejo conservador.
La Asociación
Médica en acción...
REFERENCES
1.
Shah KD, Chevernak FA, Marchevsky AM, Rosenberg JC
and Berkowitz, RL. Fetal giant hemangiolymphangioma: report of a
case. Am J Perinatol. 1987 Jul;4(3):212-4.
2.
Giacalone PL, Boulot P, Marty M, Deschamps F, Laffargue F, Viala JL: Fetal hemangiolymphangioma: a case report. Fetal
Diag Ther. 1993 Sep-Oct;8(5):338-40.
3.
Senoh D, Hanaoka U, Tanaka Y, Tanaka H, Hayashi K,
Yanagihara T and Hata T. Antenatal ultrasonographic features of fetal
giant hemangiolymphangioma.
Visita nuestro Web Site y
entérate de las múltiples
actividades y servicios
que realiza tu Asociación
4.
Tseng JJ, Chow MM and Ho ES. Fetal axillary hemangiolymphangioma with secondary intralesional bleeding: serial ultrasound findings. Ultrasound Obstet Gynecol. 2002 Apr;19(4):403-6.
5.
Miño Mora M, López Pedrera, MC, Povedano Cañizares,
B, etal: Antenatal diagnosis of a cervical hemangiolymphangioma.
Prog Diag Prenat. 2002;14(3):136-39.
60
Portada
Manuel Quevedo Báez, MD
Por Eduardo Rodríguez Vázquez, MD
Presidente de la Asociación Médica de Puerto Rico
El Dr. Manuel Quevedo Báez nació en el
año 1865 en el pueblo de Sabana Grande localizado en el sur de la isla de Puerto Rico. Sus padres
fueron Domingo Quevedo y Carmen Báez. En su
pueblo natal cursó los primeros grados y al igual
que otras familias acomodadas de la época fue enviado a continuar sus estudios de bachillerato en
el Colegio de la Congregación de los Padres Jesuitas localizado en Santurce. Este Colegio había
sido fundado en el 1858, en el antiguo Seminario
Conciliar de San Idelfonso en el Viejo San Juan y
trasladado a Santurce posteriormente al año 1886,
debido a problemas con las Autoridades Gubernamentales de Puerto Rico, los Jesuitas tuvieron
que cerrar el Colegio de Santurce, trasladando el
mismo, a la ciudad de Quito, en Ecuador.
El joven Quevedo terminó sus estudios de
bachillerato ese mismo año del 1886 en el Instituto Civil de Segunda Enseñanza, localizado en
el mismo edificio que albergaba el Colegio de los
Jesuitas (este edificio está localizado en la parada
19 de la Avenida Ponce de León en Santurce y es
hoy ocupado por el Departamento de Salud del Estado Libre Asociado de Puerto Rico.)
Tanto el Colegio como el Instituto contaron entre sus alumnos con un sinnúmero de
jóvenes, luego estudiantes de medicina y médicos,
que después se distinguirían en diferentes áreas de
la cultura, la ciencia y la política de nuestro país;
entre estos figuraban: Antonio Fernández Vega,
Manuel Quevedo Báez, Cayetano Coll y Toste,
Manuel Guzmán Rodríguez, Manuel Martínez
Roselló, José Luis Padilla Otero, Ángel Franco,
José Marxuach, Francisco Del Valle Atiles, Gabriel Ferrer Hernández, Rafael Del Valle Rodríguez, Gabriel Villarronga, Pedro Hernández, José
De Jesús Tysol, entre otros.
En esa misma época fundó, siendo su director, el periódico El Palenque de la Juventud, en
unión de otros jóvenes estudiantes. En esta gestión
participaron, entre otros, Luis Sánchez Morales,
Mariano Auril y Pedro de Angelis.
Es alrededor de esta época que parte
rumbo a España a iniciar sus estudios de medicina.
Sus inclinaciones literarias no fueron ininterrumpidas durante los años que cursó sus estudios
en la facultad de medicina de Madrid.
“Siempre, en la historia humana, la juventud ha
sido la de impulsos generosos, la que ha sentido más los anhelos de avance de progreso. Sin
titubear ni temer, en su afán de ir hacia adelante
aún rompiendo con normas de viejo establecidas.
Sólo así es que puede realizarse el progreso en todos los órdenes”
Manuel Quevedo Báez, MD
En el año del 1894 finalizó su carrera de médico obteniendo el grado de doctor
en medicina y cirugía. Luego de su regreso
a Puerto Rico y revalidar su titulo de médico,
practicó la medicina en varios pueblos de la isla
como Utuado, Mayagüez y Barceloneta, estableciéndose, finalmente, en San Juan. En esos años
se unió al grupo de los liberales que perseguían el
ideal autonomista.
Luego de la Guerra Hispanoamericana ingresa en las filas del Partido Republicano que dirigía su colega, el Dr. José Celso Barbosa. Es con
el inicio del siglo XX que hace realidad su sueño,
colaborando en la fundación de un organismo que
albergara a los médicos de Puerto Rico. El 21 de
septiembre de 1902 el Dr. Quevedo Báez, en unión
a los doctores Ramón Ruiz Arnau, José E. Saldaña,
Manuel Figueroa, J.M. Amadeo, Rafael Vélez
López, José N. Carbonell, Manuel Fernández Nacer y otros visionarios, celebran la Asamblea Constituyente de la Asociación Médica de Puerto Rico.
En ese año el Dr. Manuel Quevedo Báez es electo
primer Presidente de la Asociación Médica de
Puerto Rico. Durante su presidencia (1902-1904)
funda, en 1903, el Boletín de la Asociación Médica
de Puerto Rico, siendo su primer editor el Dr.
Ramón Ruiz Arnau. Contribuye en la organización
de una Junta de Reválida, siendo su Secretario de
1903 a 1931. Durante esos primeros años mantiene
una columna en el Boletín, la que llamó “Nuestras
Capacidades Médicas”. En la misma uno de los
personajes al que rinde homenaje, a pesar de haber
sido su adversario político, fue al Dr. Ramón Emeterio Betances. Como médico durante esas décadas, fue el que publicó más artículos sobre asuntos pediátricos, totalizando cinco (5). Dirigió en el
1905 la Revista del Ateneo, además de contribuir
en diversas revistas y periódicos como El Puerto
Rico Ilustrado, El Mundo, El Boletín Mercantil,
Plumas Amigas y otras.
61
Fue el Presidente del Ateneo Puertorriqueño del 1912 a 1914, fundador y presidente
de la Academia de Medicina Puertorriqueña, Sindico de la Universidad de Puerto Rico, Profesor y
Presidente del Instituto Universitario José de Diego, Fundador de la Academia Antillana de la Lengua y Conferenciante en la Escuela de Medicina
Tropical. Son algunas de las múltiples posiciones
que ocupó durante su vida. Le hizo honor otro antiguo alumno del Colegio, el historiador y médico
Cayetano Coll y Toste, preparando el voluminoso
trabajo sobre la Historia de la Medicina y Cirugía
de Puerto Rico, en dos (2) tomos, publicados en
1946 y 1949, respectivamente, por la Asociación
Médica de Puerto Rico.
Referencias
Como decía el Dr. Salvador Alana Soto y cito: “El
Dr. Quevedo Báez fue uno de los más fecundos y
fáciles prosistas que ha producido la clase medica
del país”.
Dr. S. Arana-Soto - Diccionario de Médicos Puertorriqueños - Año
1963 - Pag. 48
Dr. S. Arana-Soto - Catálogo de Médicos de PR de Siglos Pasados Año 1966 - Pag. 345
Antonio López de Santa Ana, S.I. - Los Jesuitas en Puerto Rico de
1858 a 1886 - Contribución a la Historia General de la Educación en
Puerto Rico.
Asociación Médica de Puerto Rico - Memorias 1902-1989
Asociación Médica de Puerto Rico - Prensa Médica - Año 14 , Núm.
2 - Los primeros cien años de la Asociación Médica de Puerto Rico Trasfondo histórico - Pag. 7
Asociación Médica de Puerto Rico - Boletín - Vol 95, Núm 1 - EneroFebrero 2003 - Eduardo Rodriguez Vázquez, MD - Apuntes para la
Historia de la Pediatría en Puerto Rico - Pág. 42
Norberto Lugo Negron - Un precursor sabaneño: Doctor Manuel
Quevedo Báez - Asociación Médica de Puerto Rico - Año 2002
En resumen, nuestro primer presidente, el
Dr. Quevedo Báez se formó emulando al hombre
del renacimiento, convirtiéndose al final de sus
días en uno de ellos: conocimiento todo y plenitud.
El Dr. Manuel Quevedo Báez en dos
etapas diferentes de su lucha por el engrandecimiento de la clase médica y los
principios sagrados de la profesión.
62
CME Credits Vol.100 No 02, 2008
Instructions:
From article:
To obtain CME four (4) credits AMA 1, you should
read and study the following articles and be able
to answer the questions correctly. After answering
the questions below fill in your personal information, cut and send with a check for $20.00 payable
to: Asociacion Medica de Puerto Rico.
‘PERCEPTION OF PARENTS REGARDING
THEIR CHILDREN’S WEIGHT’
Nazario Rodriguez IJ, et al.
4. Most parents perceive their child has an adequate weight, when he is overweight due to:
From article:
A) a failure of parents to recognize overweight
status of their child
“THROMBOCYTOSIS IN ILLICIT DRUGSEXPOSED NEWBORNS”
B) a reluctance to admit that their child is overweight
Thea Calderón MD, et al.
C) a lack of understanding of what “overweight”
means
1. The main causes of thrombocytosis in newborns
are:
A) infection and inflammation
D) all of the above
E) none of the above
B) Down syndrome
C) exposure to cephalosporin and illicit drugs
D) all of the above
5. In early childhood education to prevent obesity
includes:
A) proper nutrition with selection of low-fat
snacks
B) good exercise/activity habits
2. The most common cause of thrombocytosis in
neonates is:
A) infection or inflammatory process exposure
B) exposure to methadone during pregnancy
C) vitamin deficiencies
D) all of the above
3. The illicit drug most frequently associated with
thrombocytosis in the newborn is:
A) heroin
B) cocaine
C) methadone
D) marihuana
E) thinner
C) monitoring of television viewing
D) all of the above
E) a and b
From Article:
‘DEVELOPMENTAL SEX DISORDERS:
BRIEF REVIEW ON CURRENT ETHICAL
ASPECTS’
Nieves-Rivera et al.
6. Match accordingly the internal genitalia embryogenesis homologous:
A)
clitoris
___
penile shaft
B) labia majora
___
glans
C)
labia minora
___
scrotum
7. Chose the best answer: Among the urgent issues
of the current medical ethics are:
A) the doctor – hospital relationship
B) the hospital staff administration relationship
C) the patient – doctor relationship
D) all of the above
8. The goals of surgery in cases of developmental
sex disorders (DSD) are:
A) genital appearance compatible with gonads
B) unobstructed urinary emptying without incontinence or infections
63
B) 0.9NSS/D5W + 40mEq/Lt KCL at 1800mL/
M2/day
C) 0.33NSS + 20mEq/Lt KCL at 3000mL/M2/
day
D) 0.45NSS + 20mEq/Lt KCL at 3000mL/M2/
day
E) 0.45NSS/D5W + 20mEq/Lt KCL at 1500mL/
M2/day
12. The most feared complication of diabetic ketoacidosis is:
A) hypernatremia
C) good adult sexual and reproductive function
B) water intoxication
D) all of the above
C) brain edema
D) hyperglycemia
E) hyperkalemia
From the article:
“DIABETIC KETOACIDOSIS IN PEDIATRICS: MANAGEMENT UPDATE”
ANSWERS
1- (A)
(B)
(C)
(D)
(E)
2- (A)
(B)
(C)
(D)
(E)
3- (A)
(B)
(C)
(D)
(E)
4- (A)
(B)
(C)
(D)
(E)
5- (A)
(B)
(C)
(D)
(E)
6- (A)_______ (B)_______ (C) ________
C) vomiting, fever and hyperglycemia
7- (A)
(B)
(C)
(D)
(E)
D) high mortality rate even with adequate management.
8- (A)
(B)
(C)
(D)
(E)
9- (A)
(B)
(C)
(D)
(E)
E) hyperkalemia, hypoglycemia and hyponatremia.
10- (A)
(B)
(C)
(D)
(E)
11- (A)
(B)
(C)
(D)
(E)
12- (A)
(B)
(C)
(D)
(E)
Ricardo García-De Jesús MD
9. Diabetic ketoacidosis is characterized by:
A) hyperglycemia and vomiting.
B) moderate dehydration, metabolic acidosis, hyperglycemia and ketonuria.
10. Initial management of DKA includes all Except:
A) fluid bolus
B) blood glucose level
C) arterial or venous blood gas
D) regular insulin IV bolus
E) serum electrolytes
11. A 5 y/o boy with DKA and a weight of 20kg
has received 20ml/kg fluid bolus, and has already
voided. He is started on insulin drip at 0.1unit/kg/
hr. His dxt is 315. Which fluid regimen should
we start?
A) 0.9NSS/D5W + 20mEq/Lt KCL at 3000mL/
M2/day
Fill in the following information:
Name __________________________________
Licence No. _____________
Postal Adress_____________________________
________________________________________
Telephone _____________Fax _______________
Cut along the dotted lines, or print from our web
site (Scc. Educación), and send answers with check
for $20.00 payable to:
Asociacion Medica de Puerto Rico
PO Box 9387
San Juan, PR 00908-9387
Web site
64
Calendario de actividades de la AMPR
Todas las actividades pueden ser corroboradas en nuestro web site
18 de mayo
Municipio de Aibonito
9:00am a 2:00pm
27 de junio
Concierto lirico APTEL
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Cínicas Multifásicas
HIMA San Pablo - Bayamón
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7 de junio
Çlínicas Multifásicas
Santurce - Sede de la AMPR
9:00am a 2:00pm
11 de junio
Huracanes, cambio climático y
la epidemia del cólera en Puerto
Rico 1855-1856
Dr. Bernard Christenson
7:00pm
Sede de la AMPR
18 de junio
Cine - Dr. Bailey Ashford
Presenta: Dr. Norman
Maldonado
Sede de la AMPR
7:00pm
8 de julio
105 años del Boletin de la AMPR
y nuevo web site
7:00 pm
Sede de la AMPR
21 de junio
Curso CPR
Sede de la AMPR
1:00pm a 5:00pm
16 de julio
Conferencia: La Generación del
1930
en la Ciencia Puertorriqueña
Dr. José G Rigau Pérez
7:00 pm
Sede de la AMPR
2 de agosto
Clínica Multifásica & Centro
Unido
de Detallistas
9:00am a 12:00 am
Hotel El Conquistador - Fajardo
2 de agosto
Clínica de Salud Multifásica
Municipio de Trujillo Alto
- Oficina de Servicios al
Ciudadano.
9:00am a 2:00pm
Farmacia Caney - Bo. Las Cuevas
6 de agosto
Cine: Los muchachos de Paris
Dr. Justino del Valle
7:00pm
Sede de la AMPR
13 de agosto
Médicos inmigrantes siglo XIX
Ponce
Dra. Ivette Pérez Vega
7:00pm
Sede de la AMPR
15-17 de agosto
54th Convención del Distrito Este
AMPR
Embassy Suite Hotel Dorado del
Mar
23 agosto
Jornada Científica Geriatrics
update
1:00 pm a 5:00 pm - 4 hs. créditos
Sede de la AMPR
30 de agosto
Municipio de Caguas
Antiguo CDT
9:00 am a 2:00 pm
10 de setiembre
Dr. Agustín Stahl
Dr. Eduardo Rodríguez Vázquez
7:00pm
Sede de la AMPR
13 de setiembre
Clínica Multifásica
Municipio Mayagüez
9:00 am a 2:00 pm
27 de setiembre
Jornada Científica Vaccination
update
1:00pm a 5:00 pm - 4hs. créditos
Sede de la AMPR
4 de octubre
Jornada Científica Medical
Emergencies
1:00 pm a 5:00 pm
Sede de la AMPR
1 de noviembre
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update
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Sede de la AMPR
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Sede de la AMPR
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• Ave. Fernández juncos Núm. 1305 • PO Box 9387 • SANTURCE, Puerto Rico 00908-9387
• Tel 787-721-6969 • Fax: 787- 724-5208 • Email: [email protected]
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El “Boletín” se distribuye a todos los socios de la Asociación Médica de Puerto Rico como parte de su cuota
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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
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La publicación de los mismos no necesariamente implica
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Todo anuncio para ser publicado debe reunir las normas
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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 dentro del
contexto del artículo.
Todos los derechos reservados. El Boletín está totalmente
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Send address changes to:
Boletín / Asociación Médica de Puerto Rico
1305 Fernández Juncos Ave. P.O. Box 9387
San Juan, Puerto Rico 00908-9387
65
P.O. Box 9387
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Teléfono (787) 721-6969
SOLICITUD DE INGRESO
Nombre y apellidos (una letra de molde por casillero, deje un casillero vacío en los espacios)
Categoría de socio
ACTIVO
ACTIVO NO-RESIDENTE
INTERNO-RESIDENTE
ACTIVO ESPECIAL
Cuota $
Sociedad Médica Distrito
AFILIADO
ESTUDIANTE
PayPal transacción #
A la Junta de Directores:
Por la presente solicito ser admitido como socio de la Asociación Médica de Puerto Rico, para lo cual someto la siguiente información:
Dirección Postal:
Ciudad
Estado
Codigo postal
País
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Codigo postal
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Teléfono
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Teléfono
Dirección Oficina:
Horarios de Oficina
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PM
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PM
De:
a:
(
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Telefono celular
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PM
De:
a:
)
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Fax
Jueves
AM
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PM
De:
a:
Viernes
Sábados
AM
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PM
De:
a:
Marque los que
corresponda
AM
PM
AM
PM
De:
a:
@
Email
Seguro Social # (opcional)
Estado civil
Licencia #
Especialidad
DIA
MES
Fecha de nacimiento
Ciudad y pais
AÑO
Ciudadanía
Escuela de Medicina
Nombre de la madre
Afiliado
Desde
Hasta
MES
AÑO
Año de Graduación
Nombre del padre
Entrenamiento
Interno residente
Desde
Hasta
DIA
Nombre del conyuge
Estudiante
Fecha de graduación
DIA
DIA
MES
AÑO
MES
AÑO
Escuela de Medicina
Por favor responda las siguientes preguntas:
Ha sido convicto por alguna felonía en los últimos 5 años?
Ha sido su licencia para practicar la medicina limitada, suspendida o revocada, en cualquier jurisdicción, en los últimos 5 años?
Ha sido usted objeto de cualquier acción disciplinaria por cualquier Sociedad Médica o Junta de Hospital en los últimos 5 años?
Sí
No
Si ha contestado en afirmativa a cualquiera de estas preguntas, por favor añada una explicación completa en hoja aparte.
Entiendo que la convicción de una felonía o la limitación, suspensión o revocación de la licencia para practicar la medicina o acción disciplinaria por
cualquier Sociedad Médica o Junta de Hospital podrá, después de justo aviso y audiencia, resultar en la censura, suspensión o expulsión de un socio
activo o afiliado.
Certifico que la información arriba brindada es cierta y completa.
____de ____________________________de________
FIRMA DEL SOLICITANTE
USTED PUEDE OBTENER ESTE FORMULARIO, INSTRUCCIONES PARA MEMBRESÍA Y PAGO
CON TARJETA DE CRÉDITO O PAYPAL EN NUESTRO WEB SITE www.asociacionmedicapr.org
B LETÍN
• Instrucciones para los Autores*
• Instructions to Authors*
• Manuscrito
• Manuscripts
El “Boletín” acepta para su publicación artículos relativos a medicina y cirugía y las
ciencias afines. ¡Igualmente acepta artículos especiales y correspondencia que pudiera ser
de interés general para la profesión médica. Se urge a los autores se esfuercen en perseguir
claridad, brevedad, e ir a lo pertinente en sus manuscritos, no importa el tema o formato del
manuscrito.
El artículo, si se aceptara, será con la condición de que se publicara únicamente en la revista.
Para facilitar la labor de revisión de la junta Editora y la del impresor, se requiere de los
autores que sigan las siguientes instrucciones:
El manuscrito completo, incluyendo las leyendas y referencias deberán estar escritos en
maquinilla a doble espacio; por un sólo lado de cada página, en TRIPLICADO y con amplio
margen (ARTÍCULO DEBERÁ SER ACOMPAÑADO POR UN “CD”). En página separada
deberá incluirse lo siguiente: título, nombre de autor(es) y su grado (ej.: MD, FACP), ciudad
donde se hizo el trabajo, el hospital o institución académica, patrocinadores del estudio, y si
un artículo ha sido leído en alguna reunión o congreso, así debe hacerse constar como una
nota al calce.
El manuscrito debe comenzar con una breve introducción en la cual se especifique el
propósito del mismo. Las secciones principales (como por ejemplo: materiales y métodos)
deben identificarse con un encabezamiento en letras mayúsculas.
Artículos referentes a resultados de estudios clínicos o investigaciones de laboratorio deben
organizarse bajo los siguientes encabezamientos: introducción, Materiales y Métodos,
Resultados, Discusión, Resumen (en español e inglés), Reconocimiento y Referencias.
Artículos referentes a estudios de casos aislados deben organizarse en la siguiente forma:
Introducción, Materiales y Métodos si es aplicable,Observaciones del Caso, Discusión,
Resumen (en español e inglés), Reconocimientos y Referencias.
• Nomenclatura
Deben usarse los nombres genéricos de los medicamentos. Podrán usarse también los
nombres comerciales, entre paréntesis, si así se desea se usará con preferencia el sistema
métrico de pesos y medidas.
• Tablas
Las tablas deben aparecer en hojas separadas. Estas deben incluir el título, y el número de la
tabla debe estar en romano. Los símbolos de unidades deben limitarse al encabezamiento de
las columnas. Se deben omitir líneas verticales en la tabla. Se usará en las tablas el mismo
idioma en el cual está escrito el artículo. Deben limitarse las tablas a solo aquellas que
contribuyan al mejor entendimiento del manuscrito.
• Ilustraciones
Las fotografías y microfotografías se someterán como copias en papel de lustre, sin montar o
en transparencias. En el reverso de la figura debe aparecer el número de la figura (arábigo) y
el autor. Debe indicarse la parte superior de la ilustración.
• Resumen
Un abstracto no mayor de 150 palabras debe acompañar los manuscritos. Debe incluir los
puntos principales que ilustren la substancia del artículo y la exposición del problema,
métodos, resultados y conclusiones.
• Referencias
Las referencias deben ir numeradas sucesivamente de acuerdo a su aparición en el texto. Los
números deben aparecer en paréntesis al nivel de la línea u oración. Al final de cada artículo
las referencias deben aparecer en el orden numérico en que se citan en el texto. Deben
utilizarse solamente las abreviaturas para títulos de revistas científicas según indicadas en el
“Cumulative Index Medicus" que publica la Asociación Médica Americana.
Las referencias deben seguir el patrón que se describe a continuación.
1. Para artículos de revistas: Apellido(s) e iniciales del nombre del autor(es), título del
artículo, nombre de la revista, año, volumen, páginas. Por ejemplo: Villavicencio R: Soplos
inocentes en pediatría, Bol Asoc Méd P Rico 198 1; 73: 479-87. Si hay más de 7 autores,
incluir los primeros 3 y añadir et al.
2. Para citación de libros donde el autor(es) del capítulo citado es a su vez el (los) editor(es):
Apellido(s) e iniciales del autor(es), título del libro, número de edición, ciudad, casa editora,
año y página. Por ejemplo: Keith JD, Rowe RD, Vlad P: Heart disease in infancy and
childhood, 3d. Ed., New York, MacMillan, 1978: 789
3. Para citación de libros donde el editor(es) no es el autor(es) del capítulo citado se añade el
autor(es) del capítulo y el título del mismo. Por ejemplo: Olley PM: Cardiac arrythmias; In:
Keith ID, Rowe RD, Vlad P Eds. Heart disease in infancy and childhood,
3d Ed., New York, MacMillan, 1978: 275-301
• Cartas al Editor
Se publicarán a discreción de la Junta Editora. Deben estar escritas en maquinilla a doble
espacio, no deben ser mayores de 500 palabras, ni incluir más de cinco referencias.
(ARTÍCULO DEBERÁ SER ACOMPAÑADO POR UN “CD”)* Estas “Instrucciones para
los Autores` son de acuerdo a las normas establecidas por el Comité Internacional de Editores
de Revistas Médicas en sus `Requisitos Uniformes para Manuscritos Sometidos a Revistas
Bio-Médicas".
The “Buletín” will accept for publication contributions relating to the various areas of
medicine, surgery and allied medical sciences. Special articles and correspondence on
subjects of general interest to physicians will also be accepted. All material is accepted with
the understanding that is to be published solely in this journal.
All authors are urged to seek clarity, brevity, and pertinence in the manuscripts regardless
of subject or format.
In order to facilitate review of the article by the Editorial Board and the work of the printer,
the authors must conform with the following instructions:
The entire manuscript, including legends and references should be typewritten double
spaced in TRIPLICATE with ample margins (ARTICLES SHOULD BE ACCOMPANIED
WITH A ”CD”). A separate title page should include the following: title, authors and their
degrees (e.g. MD, FACP), city where the work was done, hospital or academic institutions,
acknowledgments of financial sponsors, and if the paper has been at a meeting the place and
date should be given.
The manuscripts should start with a brief introductory paragraph or paragraphs which
should state its purpose. The main sections (for example, Materials and Methods) should be
identified by heading in capital letters.
Articles reporting the results of clinical studies or laboratory investigation should be
organized under the following headings: Introduction, Materials and Methods, Result if
indicated, Discussion, Summary in English and Spanish, Acknowledgments if any, and
References.
• Nomenclature
Generic names of drugs should be used; trade names my also be given in parenthesis, if
desired, metric units of measurement should be used preferentially.
• Tables
These should be typed on separate sheets with the title and table number (Roman) centered.
Symbol for units should be confined lo the column headings. Vertical lines should be omitted.
The language used in the tables must be the same as that of the article. Include only those
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duplicate the text.
• Illustrations
Photographs and photomicrographs should be submitted as glossy prints (unmounted) or
slides. They should be labeled in the back with the name of the authors and figure number
(Arabic) and the top should be indicated. Legend to the figures should be typed on separate
sheet.
• Summary
An abstract not longer than 150 words should accompany all articles. It must include the
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results, and conclusions.
• References
These should be numbered serially as they appear in the text. The number should be enclosed
in parenthesis on the line or writing and not as superscript, numbers. At the end of the article
references should be listed in the numerical order in which they are first cited in the text. The
titles of journals should be abbreviated according to the style used in the "Cumulative Index
Medicus" published by the American Medical Association. The correct forms of references
are as given below:
1. For periodicals: Surname and initials of author(s), title of article, name of journal, year,
volume, pages. For example: Villavicencio R.: Soplos inocentes en pediatría. Bol Asoc Med
P Rico 198 1; 73: 479 87. If there are more than 7 authors list only 3 and add et al.
2. For books when the authors of the cited chapter is at the same time the editor: Surname
and initials of author(s), title, edition, city, publishing house, ~ear and page. For example:
Keith JD, Rowe RD, Vlad P: Heart disease in infancy and childhood, 3d Ed., New York,
MacMillan, 1978: 789
3. For chapter in book when the author of the chapter is not one of the Olley PM: Cardiac
arrythmias: In: Keith JD, Rowe RD, Vlad P. Eds. Heart disease in infancy and childhood, 3d
Ed. New York, MacMillan, 1978, 275-301
• Letters to the Editor
Will be published at the discretion of the Editorial Board. They should be typewritten doublespaced, should not exceed 500 words nor more than five references.
ARTICLES SHOULD BE ACCOMPANIED WITH A "CD" *The above 'Instructions to
Authors" are according to the format required by the international Committee of Medical
Journal Editors in its “Uniform Requirements for Manuscripts Submitted to Biomedical
Journals”.

ASOCIACIÓN MÉDICA DE PUERTO RICO Vol. 100 - Núm 2

Transcription

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