Boletín de la Asociación Médica de Puerto Rico
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In the last few decades cardiac rehabilitation has evolved dramatically. It consists of a multidisciplinary approach for secondary prevention and rehabilitation treatment after an individual has sustained a cardiac event. A key principle for successful cardiac rehabilitation management is the modification of risk factors which have been demonstrated to have a significant impact on overall mortality and morbidity outcomes. This article summarizes some of the evidence that supports modification of risk factors through the use of cardiac rehabilitation.
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The population of pregnant women with valvular heart disease represents a unique patient group with increased risk for adverse outcomes. The significant hemodynamic changes that occur during pregnancy can mimic symptoms of congestive heart failure. Furthermore, many patients with valvular heart disease are first recognized during pregnancy. ⋯ Low molecular weight heparin is not recommended to be administered to pregnant patients with mechanical prosthetic valves unless anti-Xa levels are monitored 4 to 6 h after administration. Aspirin at low doses, 81-325 mg has been proposed to reduce the risk of thrombosis. At this moment, optimal antithrombotic therapy in pregnant women with mechanical valves cannot be definitively recommended due to lack of properly designed studies.
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Comparative Study
Methadone: an effective alternative to morphine for pain relief in cancer patients.
Pain management is a central issue in the care of cancer patients in hospice services. Morphine is at present the first line opioid recommended. But when morphine is used in large doses, especially in renal patients, an active metabolite of morphine, morphine-6-glucoronide, may cause delirium and myoclonus and sometimes antagonize the analgesic effect of morphine. ⋯ Methadone was found to be as effective as morphine, transdermal fentanyl and common combinations of other opioids in controlling the types of cancer pain presented by patients in a hospice in the Northwestern Region of Puerto Rico. The use of methadone on elderly patients with cancer pain as first line therapy is growing in European and North-American hospices. Hospitals should add methadone to their therapeutic armamentarium and physicians should develop skills to use this long acting opioid.
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Calcific uremic arteriolopathy is a rare and devastating disorder characterized by diffuse calcification of medium size arterioles and occasionally affects patients with chronic kidney disease. A 62-year-old woman with diabetes mellitus, arterial hypertension and moderate to severe chronic kidney disease was admitted to the hospital with multiple, non painful, necrotic, hemorrhagic and purulent chronic open wounds ranging from 1 cm to 3 cm of diameter in the medial and posterior aspects of both lower extremities. ⋯ Biopsy of a one of the lesions showed fat necrosis and extensive dystrophic calcific deposits in the subcutaneous fat and the wall of small arterioles, consistent with systemic calcific uremic arteriolopathy. Once the lesions ulcerate and grow proximally survival is unlikely.
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Liver involvement in systemic lupus erythematosus (SLE) is infrequent. The coexistence of SLE and autoimmune hepatitis is rare (1.3-1.7%). We report a case of a 27 year old female with no history of systemic illnesses or alcohol abuse that presented with acute hepatitis with jaundice, abdominal pain, and increased liver function tests. ⋯ She was started on prednisone 40 mg with mild improvement of symptoms and transaminase values, but when azathioprine 100 mg was added a marked improvement in liver function tests was observed. After a year in azathioprine she remained with SLE in remission. To our knowledge this is the third reported case and the first in the Western Hemisphere of jaundice as the initial presentation of SLE.