Dominican Hospital

Predictive genetic testing for Huntington’s Disease, a fatal and progressive neurodegenerative disorder with no cure, can lead to a multitude of favorable and unfavorable responses, impacts, and experiences. Utilizing many qualitative studies, participants’ reactions to their gene-positive test results were categorized into the opposing psychological states of motivation vs. hopelessness. Key milestones of adulthood, such as education and career, romantic and familial relationships, reproductive choices, and financial investments, were used as metrics for the two categories. By studying the psychological well-being of at-risk individuals for Huntington’s, this literature review also argues for the use and improvement of long-term, tailored genetic counseling.

Este trabajo utiliza técnicas cuantitativas de la economía de la salud para ofrecer herramientas que permitan evaluar la costo-efectividad de la financiación de nuevas tecnologías (incluyendo procedimientos y medicamentos) que resulten en un mayor bienestar y salud del país. Específicamente, se desarrolla una metodología para la estimación del umbral de costo efectividad (UCE) del sistema de salud pública de Republica Dominicana. Dado que el UCE mide el nivel de gasto en el sistema de salud que se estima necesario para ganar un año de vida ajustado por calidad de vida (AVAC) o alguna medida análoga de resultado en salud, este valor ofrece un criterio para determinar si la financiación de una nueva tecnología es costo-efectivo. Dada una restricción presupuestal, si el valor por AVAC de una nueva tecnología es superior al UCE, su adopción proporcionaría beneficios de salud inferiores a las tecnologías que se desplazarían. Usando técnicas econométricas este estudio estima el UCE para la República Dominicana en $85,928 pesos dominicanos (DOP), con intervalos de confianza de $40,720 y $131,140 DOP lo cual equivale a al 26% del PIB per cápita en el año 2016 ($331,253 pesos dominicanos) con un intervalo de confianza de 12,3% y 39,6% del PIB per cápita respectivamente. Estos resultados son robustos a muchas especificaciones econométricas y/o medidas alternativas de resultados en salud.

Paragangliomas are neuroendocrine tumors of the autonomic nervous system that are variably clinically functional and have a potential for metastasis. Up to 40% occur in the setting of a hereditary syndrome, most commonly due to germline mutations in succinate dehydrogenase (SDHx) genes. Immunohistochemically, paragangliomas are characteristically GATA3-positive and cytokeratin-negative, with loss of SDHB expression in most hereditary cases. In contrast, the rare paragangliomas arising in the cauda equina (CEP) or filum terminale region have been shown to be hormonally silent, clinically indolent, and have variable keratin expression, suggesting these tumors may represent a separate pathologic entity. We retrospectively evaluated 17 CEPs from 11 male and 6 female patients with a median age of 38years (range 21-82), none with a family history of neuroendocrine neoplasia. Six of the 17 tumors demonstrated prominent gangliocytic or ganglioneuromatous differentiation. By immunohistochemistry, none of the CEPs showed GATA3 positivity or loss of SDHB staining; all 17 CEPs were cytokeratin positive. Genome-wide DNA methylation profiling was performed on 12 of the tumors and compared with publicly available genome-wide DNA methylation data. Clustering analysis showed that CEPs form a distinct epigenetic group, separate from paragangliomas of extraspinal sites, pheochromocytomas, and other neuroendocrine neoplasms. Copy number analysis revealed diploid genomes in the vast majority of CEPs, whereas extraspinal paragangliomas were mostly aneuploid with recurrent trisomy 1q and monosomies of 1p, 3, and 11, none of which were present in the cohort of CEP. Together, these findings indicate that CEPs likely represent a distinct entity. Future genomic studies are needed to further elucidate the molecular pathogenesis of these tumors.

Structural inequalities in the U.S. work environment place most immigrants in low paying, high-risk jobs. Understanding how work experiences and influence the health of different immigrant populations is essential to address disparities. This article explores how Brazilian and Dominican immigrants feel about their experiences working in the U.S. and how the relationship between work and culture might impact their health. In partnership with the Dominican Development Center and the Brazilian Worker Center, we held five cultural conversations (CCs) with Brazilians (n = 48) and five with Dominicans (n = 40). CCs are participatory, unstructured groups facilitated by representatives from or embedded in the community. Brazilian immigrants focused on physical health and the American Dream while Dominicans immigrants emphasized concerns about the influence of work on mental health. Dominicans’ longer tenure in the U.S. and differences in how Brazilians and Dominicans are racialized in the region might account for the variation in perspectives between groups. Future studies should further investigate the relationship between health and how immigrants’ work lives are shaped by culture, race and immigrant status.

More than 90% of all fatal mushroom poisonings worldwide are due to amatoxin containing species that grow abundantly in Europe, South Asia, and the Indian subcontinent. Many cases have also been reported in North America. Initial symptoms of abdominal cramps, vomiting, and a severe cholera-like diarrhea generally do not manifest until at least six to eight hours following ingestion and can be followed by renal and hepatic failure. Outcomes range from complete recovery to fulminant organ failure and death which can sometimes be averted by liver transplant. There are no controlled clinical studies available due to ethical reasons, but uncontrolled trials and case reports describe successful treatment with intravenous silibinin (Legalon® SIL). In nearly 1,500 documented cases, the overall mortality in patients treated with Legalon® SIL is less than 10% in comparison to more than 20% when using penicillin or a combination of silibinin and penicillin. Silibinin, a proven antioxidative and anti-inflammatory acting flavonolignan isolated from milk thistle extracts, has been shown to interact with specific hepatic transport proteins blocking cellular amatoxin re-uptake and thus interrupting enterohepatic circulation of the toxin. The addition of intravenous silibinin to aggressive intravenous fluid management serves to arrest and allow reversal of the manifestation of fulminant hepatic failure, even in severely poisoned patients. These findings together with the available clinical experience justify the use of silibinin as Legalon® SIL in Amanita poisoning cases.

Conventional analysis of vascular prevention trials assigns equal weight to disparate vascular events in a composite end point at variance with the public's perception of their differential impact on health outcome. This study sought to apply the disability-adjusted life-year (DALY) metric to differential weighting individual vascular end points in trial analyses. DALY values for the most common major end points in vascular prevention trials (nonfatal myocardial infarction, nonfatal stroke, and vascular death), were derived by using World Health Organization Global Burden of Disease Project methodology. The standardized DALYs for each event were applied to recent major primary and secondary vascular prevention trials and to hypothetical model trials. Standardized DALYs lost were 7.63 for nonfatal stroke, 5.14 for nonfatal myocardial infarction, and 11.59 for vascular death. In the published trials analyses, the direction of treatment effects was consistent between DALY and standard event analysis, but the rank order of treatment effect changed for 10 of 18 trials. The DALY analysis also permitted derivation of number-needed-to-treat values to gain 1 DALY: 2.1 for anticoagulation in atrial fibrillation, 2.7 for carotid endarterectomy in symptomatic stenosis, and 4.7 for clopidogrel added to aspirin in acute coronary syndrome. Hypothetical trial analyses demonstrated that the DALY metric more finely discriminates treatment effects. Compared with a nonfatal myocardial infarction, a nonfatal stroke causes a 1.48-fold greater loss and vascular death a 2.25-fold greater loss of DALY. DALY analysis integrates these valuations in a summary metric reflecting the net impact of therapy on patient and societal health, complementing conventional end point analyses.

Objectives: To demonstrate that an autosensing function provided by a new dual-chamber pacemaker selects an appropriate sensing threshold setting in the atrium and ventricle. Methods: All patients were implanted with a Talent Model 233 DR dualchamber pacemaker (ELA Medical), activating an algorithm that automatically measures the sensing threshold in each chamber and adjusts it accordingly. A variety of marketed atria1 and ventricular pacing and sensing leads were used. At pre-discharge, one month and three months, autosensing threshold measurements were compared to manual sensing threshold measurements. When pacing occurs, the algorithm drives the sensing threshold toward a preset minimum to make the pacemaker as sensitive as possible to ensure sensing when intrinsic rhythm reemerges. Two different analyses were therefore performed: with and without pacing. Population: The study population consisted of 34 patients (18 F, mean age 74 y.). Primary indications for implant were: sinus node dysfunction (45.5%), AV block (24.2%), bradycardia-tachycardia syndrome (21.2%), chronotropic incompetence (9.1%), vase-vagal or carotid-sinus syndrome (3.0%).