Showing papers in "Puerto Rico Health Sciences Journal in 2013"

Physical activity and its associations with sociodemographic characteristics, dietary patterns, and perceived academic stress in students attending college in Puerto Rico.

Abstract: Objective: The academic environment usually generates stress in students. Increasing physical activity (PA) is one of the stress-coping strategies for students; however, students usually reduce their PA while enrolled in college. Objective: To determine the association between PA, self-perceived academic load and stress, and dietary patterns in students attending college in Puerto Rico. Methods: A proportional stratified sample of 275 students from UPR-MSC completed a self-administered questionnaire on socioeconomic status, academic load and stress, body composition, dietary patterns, and PA. Chi² was used to assess the association between variables. Results: Most of the participants were female (68%), were aged 21 to 30 years (88%), and had low annual household incomes ($0-$24,999) (43%). Women reported higher levels of stress (p 0.05). Conclusion: Most students reported sedentary lifestyles during periods of greater stress. High level of stress were positively associated with a light PA level. [P R Health Sci J 2013;1:44-50]

Dietary patterns and their association with sociodemographic characteristics and perceived academic stress of college students in Puerto Rico.

Abstract: Objective: University students face academic responsibilities that may produce stress, which may lead to changes in dietary patterns (DPs). These changed patterns can become dysfunctional, often resulting in a negative impact on the health of the stressed student. Little is known about DPs in college students in Puerto Rico (PR). The purpose of this study was to describe the DPs of college students in PR and the association of these patterns with socio-demographic characteristics and perceived academic stress. Methods: This retrospective epidemiological study investigated self-reported DPs in a representative sample of 275 college students, in relation to socio-demographic characteristics, body composition (BC), and perceived academic stress; a Diet Quality Index was developed using the USDA Food Patterns for 2010 to determine whether their DPs were adequate or inadequate. Results: Most of the participating students were female (67.6%), ranged from 21 to 30 years old (88%), lived in low household incomes (42.7%), and had healthy weights (56.4%). Most of the students perceived the stress levels as being moderate (60.7%). Most had diets that were below the dietary recommendations for grains, fruits, vegetables, dairy products, and protein, whereas fat consumption was adequate. Overall, most had inadequate DPs (62%). DP was significantly associated with age (p<0.05); older students had better DPs than did younger students. In terms of the different schools (p<0.05), those students from the School of Medicine and those from the School of Public Health had better DPs than did the students from the other schools. DP was not associated with income, gender, BMI, stress level, or course load. Conclusion: The majority of the students had inadequate DPs, which inadequacy was associated with both the age of the student and the school that he or she attended. [P R Health Sci J 2013;1:36-43]

Knowledge of and attitudes toward organ donation: a survey of medical students in Puerto Rico.

Abstract: Objective: The increasing demand for organ transplants exceeds the organ donation rate. Addressing this discrepancy is challenging for organ procurement agencies and health professionals involved in the care of patients in dire need of organs. Research suggests that health-care professionals’ knowledge of, attitudes toward, and behavior in terms of organ donation and transplantation are deciding variables in promoting organ donation. In Puerto Rico, there is a lack of information regarding medical student’s knowledge of and/or attitudes toward organ donation, a lack that our study was designed to address. Methods: Two hundred thirty participants (98 first-year, 45 second-year, and 87 third-year medical students) completed a questionnaire consisting of 55 questions; 10 questions assessed knowledge and 20, attitudes about organ and tissue donation. The remaining questions inquired after demographic information, history of blood donation, and educational experience. Results: In terms of their knowledge about organ donation, the participating students had a mean score of 6.29 on a 10-point scale—with 10 being the highest possible knowledge score—and 45.7% of them scored 7 or more. These data also showed that participants had a positive attitude toward organ donation (44.9; range 14 to 56), with approximately 72% having a favorable view. However, while 40% of the participating students stated their intentions to donate their organs, only 23% of them had donor cards. Conclusion: We determined that medical students have a positive attitude towards organ donation. However, a substantial lack of knowledge of organ donation among our subjects is a barrier to their taking the necessary measures to become active donors. Our data highlight the need to incorporate educational programs to increase knowledge and awareness regarding organ donation and the transplantation process.

Caffeinated-beverage consumption and its association with socio-demographic characteristics and self-perceived academic stress in first and second year students at the University of Puerto Rico Medical Sciences Campus (UPR-MSC).

Abstract: Objective: To determine the association between caffeinated-beverage consumption, self-perceived academic load, and self-perceived stress levels in first and second year students at UPR-MSC. Methods: A descriptive epidemiological study was performed using a selfadministered anonymous questionnaire given to a representative stratified sample of 275 students. Questions included information regarding socio-demographic characteristics, academic load and stress indicators, and caffeinated-beverage consumption. Chi 2 was used to assess the associations between these variables. Results: Most participants were women (68%), aged 21-30 years (88%), with low annual household incomes (43%). Most perceived their academic loads as being heavy (68%), and most perceived their academic stress levels as being moderate (37%). Academic load was significantly correlated with stress level (p<0.001). About 88% of the participants reported consuming caffeinated beverages; of those, 87% drank soft drinks, 83% drank coffee, 56% drank hot chocolate, 40% drank tea, and 29% drank energy drinks, all of which were—according to the participants (54%)—used mainly to stay awake. Soft drinks and coffee intake increased in periods of high stress, and many (49%) reported that these beverages were useful for coping with stress. Energy drinks, in particular, were consumed more often by men compared to women (p<0.05). None of these beverages were significantly associated with academic stress or load. Conclusion: Consuming caffeinated beverages is a popular practice among participants in this sample, with soft drinks and coffee being the ones that are the most frequently consumed. No associations were found between the consumption of caffeinated beverages and academic stress or load. [P R Health Sci J 2013;2: 95-100] Key words: College students, Academic load, Academic stress, Caffeinated beverages

Behavioral Correlates of Fruit and Vegetable Intake in Puerto Rico: Results from the Health Information National Trends Survey

Abstract: Objective: A diet high in fruit and vegetables (FV) is associated with a decreased risk for chronic diseases, such as cancer. Limited information exists regarding the factors associated with FV intake in persons living in Puerto Rico. The objective of this study was to examine sociodemographic, behavioral, and health belief factors associated with dietary habits in Puerto Rico. Methods: Secondary data analysis of adults aged 18 years and older from the Puerto Rico Health Information National Trends Survey (HINTS-PR) conducted in 2009. Multivariate logistic regression models were used to identify factors associated with meeting the established recommendations for FV consumption. Results: Only 14.5% of the adults in Puerto Rico met the recommendations for daily FV intake, and the vast majority (90.9%) were unaware of current recommendations. Bivariate analyses demonstrated that being obese, having lower than a high school education, and not knowing the recommendations were significantly associated with not meeting these recommendations. In the multivariate logistic regression analysis, being obese (OR = 3.77; 95% CI = 1.41-10.08) and not being aware of the current dietary recommendations (OR = 9.26; 95% CI = 3.77-22.73) continued to be significantly associated with not meeting the FV intake recommendations. Conclusion: The Puerto Rican population is far from meeting FV consumption recommendations, with prevalence estimates of consumption that are below the US median. Low FV intake might put the population in Puerto Rico at increased risk of developing cancer as well as a number of other chronic diseases that are secondary both to improper nutrition and to obesity.

Thyroid dysfunction in an adult female population: A population-based study of Latin American Vertebral Osteoporosis Study (LAVOS) - Puerto Rico site.

Abstract: Objective: To determine the prevalence of hypothyroidism in an adult female population in Puerto Rico and to determine the relationship between hypothyroidism, bone mineral density and vertebral and non-vertebral fractures in this population. Methods: Data from the 400 subjects’ database of the Latin American Vertebral Osteoporosis Study (LA VOS), Puerto Rico site was reviewed. Patient’s medical history, anthropometric data, current medications, laboratories, and DXA results was extracted. Subjects with thyroid dysfunction were identified based on their previous medical history and levels of TSH. Bone Mineral Density was classified using the World Health Organization criteria. Crude prevalence of thyroid dysfunction were estimated with a confidence of 95% and weighted by the population distribution by age, according to the distribution by age group in the 2000 census. Bone mineral densities and prevalence of vertebral and non-vertebral fractures were compared among the groups. Results: The weighted prevalence of hyperthyroidism in this population was 0.0043% (95% CI : -0.0021%, 0.0107%). The weighted prevalence of hypothyroidism was 24.2% (95% CI : 19.9%, 28.4%). Increased prevalence of hypothyroidism was found in participants 70 years or older. The mean BMD at spine, hip and femoral neck was similar among the groups. No difference in the proportion of participants with vertebral and non-vertebral fractures was found among the groups. Conclusion: Our study found a high prevalence of hypothyroidism among adult postmenopausal females in Puerto Rico. No association between hypothyroidism and decreased bone mineral densities, vertebral or non-vertebral fractures was found in this population.

Association between obesity and symptoms of depression of adults in Puerto Rico.

Abstract: Objective: This study was aimed at determining the prevalence of overweight; of class 1 and class 2/3 obesity; and of the symptoms of depression in adults in Puerto Rico The study also evaluated the relationship between the symptoms of depression and weight status Methods: The sample for this study consists of 6,025 adults (3,851 females and 2,174 males) who lived in Puerto Rico at the time of and who participated in either the 2006 or the 2010 BRFSS Results: In this sample 700% of the respondents were either overweight or obese About 396% of them were considered overweight, while 181% were obese class 1 and 123% were obese class 2 or 3 When compared by gender, the prevalence rate of overweight was higher for males (469%) than it was for females (355%), but females (141%) had a higher rate of class 2/3 obesity than did males (92%) There were no significant gender-based differences in the class 1 (BMI between 30 and 35) obesity group According to the study’s findings, depression symptoms and class 1 obesity are not strongly associated A positive relationship between depression and weight was found only in women with class 2/3 obesity (BMI>35) Conclusion: In summary, the results of this study show that depressive symptoms are associated with obesity, and this correlation seems to be more significant in women, especially those with severe obesity, less education, and lower incomes Findings point to the existence of a high risk of comorbid obesity and depression of adults in Puerto Rico

Alcohol consumption and smoking and their associations with socio-demographic characteristics, dietary patterns, and perceived academic stress in Puerto Rican college students.

Abstract: Objective: College students often use different strategies, such as consuming alcohol and smoking, to cope with stress. We examined the associations between self-perceived academic stress, alcohol consumption, smoking, and dietary patterns in graduate students. Methods: A representative stratified sample of 275 students from each school of the Medical Science Campus of the University of Puerto Rico (UPR-MSC) completed a 48-item questionnaire that solicited the following: socio demographic data, estimates of self-perceived stress, estimates of the frequency of alcohol consumption and the type(s) of alcohol consumed, details regarding smoking habits, and information associated with diet (i.e., dietary patterns). Fisher’s exact test and the Chi2 test were used to assess the associations between the different study variables. Results: Only 3% were considered smokers (defined as > 1 cigarettes per day), with the greatest number of smokers among those aged 21-30 y (p 0 drink/day), with a higher proportion found among women (63.5%), among those aged 21-30 years (90.6%), and among those with a low or moderate household income (p 0.05). Most subjects classified as drinkers reported that alcohol consumption was not (in their experience) an effective strategy for the management of stress (81%). Conclusion: Alcohol consumption was only associated with academic stress. No associations were found between smoking habits and academic stress/load and dietary patterns.

Child maltreatment in Puerto Rico: findings from the 2010 National Child Abuse and Neglect Data System.

Abstract: OBJECTIVE: Child maltreatment can have long-term adverse effects. Quantifying the scope and characteristics of child maltreatment is necessary for effective prevention in Puerto Rico. METHODS: The National Child Abuse and Neglect Data System Child File contains all the reports of child maltreatment from the United States (US) and Puerto Rico. A child maltreatment victim is defined as a child whose maltreatment was substantiated or indicated by the local child protective agency. We compared reporting and victimization rates and reporting sources in Puerto Rico, with those in the US and examined characteristics of child maltreatment in Puerto Rico. RESULTS: During 2006-2010, a total of 31,849-40,712 cases of child maltreatment were reported annually in Puerto Rico. Victimization rates are consistently higher in Puerto Rico than in the US (10.7/1,000-14.8/1,000 in Puerto Rico vs. 10.1/1,000-12.1/1,000 in the US), despite consistently lower reporting rates. In 2010, victimization rates were highest among children aged 1-6 years. In Puerto Rico, neglect is the most common form of maltreatment, followed by emotional abuse; however, the majority of victims suffered multiple types of abuse. Reporting was more commonly anonymous in Puerto Rico (29.8%) than in the US (9.4%) and less commonly provided by professionals in Puerto Rico (37.2%) than in the US (58.7%). CONCLUSION: We identified a high prevalence of child maltreatment in Puerto Rico. A lower reporting rate, higher victimization rate, and substantial percentage of anonymous reporting indicate potential underreporting of child maltreatment in Puerto Rico. Increasing the awareness and training professionals for improved child maltreatment identification could help alleviate the problem of underreporting. Language: en

Anal Cancer Incidence and Mortality in Puerto Rico

Abstract: Objective: Anal cancer is a rare tumor that is associated with oncogenic HPV genotypes. This study aims to compare the age-standardized rates (ASRs) of anal cancer incidence and mortality in men and women living in Puerto Rico (PR) with those of non-Hispanic whites (NHW), non-Hispanic blacks (NHB), and Hispanics (USH) living in the continental United States (US). Methods: ASRs were calculated based on cancer data that came from the PR Cancer Central Registry and from the Surveillance, Epidemiology, and End Results (SEER) program. The age-specific relative risks (RR) and 95% Confidence Interval (95% CI) were estimated using Poisson regression models. Results: Comparing the period of 2001 to 2004 to that of 1992 to 1996, the incidence of anal cancer increased among NHW, NHB, and PR men. In females, an increase in the incidence was observed for all racial groups except for Puerto Rican women. When evaluating findings by age groups, Puerto Rican men younger than 60 years old had a 20% higher incidence of anal cancer than did USH men of the same age strata (RR: 2.20; 95% CI = 1.48-3.29). However, Puerto Rican females had a lower incidence of anal cancer than NHW and NHB women. An increased percent change in mortality was observed only in NHW and NHB men. A decreasing trend was observed in all racial/ethnic groups except for NHW women. Conclusion: Our results support the notion that there are racial/ethnic differences in anal cancer incidence and mortality, with potential disparities among men and women in PR compared with USH men and women. Given the increasing incidence trends in anal cancer, particularly among PR, NHW, and NHB men, further investigation is needed to better elucidate screening practices that can aid in the prevention of anal cancer.

Correlates of colorectal cancer screening among Hispanics: Results from the 2008 Puerto Rico behavioral risk factor surveillance system survey.

Abstract: Objective: Colorectal cancer (CRC) is the second most commonly diagnosed cancer in Puerto Rico (PR). Given the lack of information on cancer screening behavior, we identified factors associated with CRC screening among adults aged ≥ 50 years in PR. Methods: Age-eligible adults who participated in the PR- Behavioral Risk Factor Surveillance System (BRFSS) in 2008 were included in the analysis (n=2,920). Weighted prevalence of fecal occult blood test (FOBT) within two years and of Sigmoidoscopy/Colonoscopy examination within five years before the interview were estimated, and logistic regression models were used to assess factors associated with these CRC screening practices. Results: Overall, 8.2% (95% CI 7.1%-9.3%) of the participants had had the FOBT within the past two years, 39.8% (95% CI 37.7%-41.9%) had sigmoidoscopy/colonoscopy examination within 5 years, and 46.7% (95% CI= 44.5%-48.8%) had ever had any type of CRC screening. Factors positively associated to CRC screening in multivariable analyses included older age, higher education, and having had a routine check-up in the past year. Gender, body mass index, and other relevant covariates evaluated were not associated to screening behavior. Conclusion: Prevalence of CRC screening in PR during 2008 was below the goals established by Healthy People 2010 (50.0%) and 2020 (70.5%). We provide the first population-based estimates of CRC screening prevalence and correlates in a US predominantly Hispanic population. Low adherence to CRC screening may result in late stage at diagnosis and poorer disease outcomes. Public health efforts should focus on the promotion of CRC screening and early detection.

Non-medical Use of Prescription Drugs and its Association with Socio-demographic Characteristics, Dietary Pattern, and Perceived Academic Load and Stress in College Students in Puerto Rico

Abstract: Objective: Stress can have deleterious effects on health and academic performance. Common stress-relieving activities among college students include the non-medical use of prescription drugs (NMUPD). The aim of this study was to determine the associations between self-perceived academic load and stress, NMUPD (stimulants, depressants, and sleeping medication), and dietary pattern in college students in PR. Methods: A questionnaire to evaluate academic load and stress, NMUPD, and dietary pattern was used on a representative sample of 275 first- and second-year students from one campus. Results: In total, 27.6% reported NMUPD in the past 6 months, with higher use among students aged 21-30 years (93.4%) than in those aged 31-53 years (6.6%; p=0.062). Those with high levels of stress had higher NMUPD (42.1%) than did those with low (26.3%) or moderate (31.6%) stress levels, after controlling for age and sex (p=0.03). Among those who reported NMUPD over the previous 6 months, 74% reported that such use was effective as a coping strategy, and 35% reported that it helped them to improve academic performance. Although no significant association was found between NMUPD and dietary pattern, 57% of the participants reported that their appetites decreased when they engaged in NMUPD. Conclusion: To our knowledge, this is the first study that has associated selfperceived academic load and stress, NMUPD, and dietary pattern among college students in Puerto Rico. NMUPD’s prevalence was 27.6%, which prevalence appeared to be higher in students aged 21-30 years than in those of any other age. High levels of stress were significantly related to high NMUPD in this sample.

La salud en Puerto Rico en el siglo XX

Abstract: The evolution in physical condition, life expectancy at birth, and access to preventive and curative services rapidly improved the quality of life of Puerto Ricans in the twentieth century. The population quadrupled to almost 4 million inhabitants and the crude mortality rate fell from 38 per thousand in 1900 to 7.7 per thousand in 1997, with its most dramatic change (18.6 to 6.7) occurring from 1941 to 1960. The great promoters of health were the general increase in socioeconomic level, improvements in infrastructure, and vaccines; its great scourges were infectious diseases (from hookworm to AIDS) and social dislocations, such as the war of 1917 (accompanied by epidemics and hunger) or the present war between illicit drug distributors. This article summarizes the events in the century related to health and its political and economic contexts, the developments in public health structures and health care, professional education, volunteer organizations, campaigns against infectious diseases, chronic causes of mortality, and environmental problems. Bringing the capacity to defend public health to the level of sophistication available for clinical care is one of the vital challenges of the twenty-first century for Puerto Rico.

Incidence, in-hospital case-fatality rates, and management practices in Puerto Ricans hospitalized with acute myocardial infarction.

Abstract: Objective: There are extremely limited data on minority populations, especially Hispanics, describing the clinical epidemiology of acute coronary disease. The aim of this study is to examine the incidence rate of acute myocardial infarction (AMI), in-hospital case-fatality rate (CFR), and management practices among residents of greater San Juan (Puerto Rico) who were hospitalized with an initial AMI. Methods: Our trained study staff reviewed and independently validated the medical records of patients who had been hospitalized with possible AMI at any of the twelve hospitals located in greater San Juan during calendar year 2007. Results: The incidence rate (# per 100,000 population) of 1,415 patients hospitalized with AMI increased with advancing age and were significantly higher for older patients for men (198) than they were for women (134). The average age of the study population was 64 years, and women comprised 45% of the study sample. Evidencebased cardiac therapies, e.g., aspirin, beta blockers, ACE inhibitors/angiotensin receptor blockers, and statins, were used with 60% of the hospitalized patients, and women were less likely than men to have received these therapies (59% vs. 65%) or to have undergone interventional cardiac procedures (47% vs. 59%) (p<0.05). The in-hospital CFR increased with advancing age and were higher for women (8.6%) than they were for men (6.0%) (p<0.05). Conclusion: Efforts are needed to reduce the magnitude of AMI, enhance the use of evidence-based cardiac therapies, reduce possible gender disparities, and improve the short-term prognoses of Puerto Rican patients hospitalized with an initial AMI. [P R Health Sci J 2013;3:138-145]

Assessment of the National School Lunch Program in a Subset of Schools in San Juan, Puerto Rico: Participants vs. Non-Participants

Abstract: Objective: Extensive evaluations of the national school lunch program (NSLP) have been carried out on the U.S. mainland. Puerto Rico, a commonwealth of the U.S. is a participant in this program, but has never been included in assessment studies. Herein, we present assessment information and compare results with comparable mainland studies. Methods: Multiple 24-hr recall questionnaires were administered to groups of participating (P) and non-participating (NP) children in the lunch program at 3 educational levels. Comparisons were made for children within the study as well as between comparable children in mainland studies for total intake of several macro and micro nutrients, contribution of the lunch to the total daily intake and adherence to U.S. Recommended Dietary Allowances (RDA’s) or to Dietary Reference Intakes (DRI’s) including acceptable macronutrient distribution ranges (AMDR’s). Results: Target intakes were met by P for % of the RDA of energy from protein, for all water soluble vitamins, iron, zinc and cholesterol. P did not achieve target intakes for total energy, energy from carbohydrates and fat nor for fat soluble vitamins, calcium, magnesium, phosphorus, potassium and fiber. Recommended levels were exceeded for sodium, total fat and saturated fat. Comparing P vs NP, the vast majority of both groups fell within AMDR recommendations for macronutrients but not all micronutrients. Conclusion: For the most part, our results parallel those obtained in the National sample however, results suggest that P in the lunch program in Puerto Rico have a healthier intake of several nutrients than NP students. The unique feature of this study is that it is the first assessment of the NSLP in a completely Hispanic population.

Cervical human papillomavirus infection in a sample of Hispanic women living in Puerto Rico: comparison with cervical cytology reports.

Abstract: Objective: Persistent infection with high-risk (HR ) HPV is a necessary risk factor for the development of cervical cancer. Information on HPV infection is limited in Puerto Rico. This study determined the distribution of HPV types and the association of HR - HPV types with cervical pathology in a clinic-based sample of women in PR. Methods: Data from 92 female participants aged 18 to 34 years and recruited from the University of Puerto Rico-Gynecology Clinic, were analyzed. Cervical cytology was performed. HPV testing was performed using L1 consensus primer PCR with MY09/MY11 primers and typed by dot-blot hybridization. Logistic regression modeling was used to determine the crude and covariate adjusted association between HR -HPV and cervical pathology. Results: Twenty percent (n=18) of the patients had abnormal cytology, 45.7% (n=42) were HPV positive, and 30.4% (n=28) were HR HPV-positive. Women infected with HR -risk HPV types were 7.9 (95% CI = 2.5-25.5) times more likely to have abnormal cytology as compared to women without HR infection when adjusted by age and age at first sexual intercourse. Conclusion: The burden of HPV infection was high, and, as expected, HR HPVs were strongly associated with dysplasia. A population-based study is needed to estimate HPV prevalence and its association with related malignancies in our population. This will be of great value in determining disease burden and will increase awareness of the HPV vaccination in our population.

Homo sapiens as physician and patient: a view from Darwinian medicine.

Abstract: Medicine’s cardinal diagnostic and therapeutic resource is the clinical encounter. Over the last two centuries and particularly over the last five decades the function of the clinical encounter has been eroded to the point of near irrelevance because of the atomized and atomizing influence of technology and microspecialization. Meanwhile, over the past five decades the exceptionalist view of Homo sapiens inherent in the social and religious traditions of the West has similarly undergone radical changes. H. sapiens is now best understood as a microecosystem integrated into a much broader ecosystem: the biosphere. That human microecosystem is composed of constituents derived from the archaeal, bacterial, and eukaryan domains via endosymbiotic, commensalistic and mutualistic interactions. This amalgamation of 100 trillion cells and viral elements is regulated by a composite genome aggregated over the 3.8 billion years of evolutionary history of organic life. No component of H. sapiens or its genome can be identified as irreducibly and exclusively human. H. sapiens’ humanity is an emergent property of the microecosystem. Ironically as H. sapiens is viewed by evolutionary science in a highly integrated manner medicine approaches it as a balkanized, deaggregated entity through the eye of 150 different specialties. To effectively address the needs of H sapiens in its role as patient by the same species in its role as physician the disparate views must be harmonized. Here I review some conceptual elements that would assist a physician in addressing the needs of the patient in integrum, as a microecosystem, by the former address the latter as a historical gestalt being. The optimal way to recover the harmony between patient and physician is through a revitalization of the clinical encounter via an ecological and Darwinian epistemology.

Anaphylaxis diagnosis and treatment at an emergency department in Puerto Rico

Abstract: Objective: Anaphylaxis is a severe, potentially life-threatening systemic allergic reaction. Most cases of anaphylaxis are encountered and managed at Emergency Departments (ED). We aimed to evaluate all cases of anaphylaxis and of acute allergic reactions presenting to the ED of the Veterans Affairs Caribbean Healthcare System (VACHS) to assess each patient’s presentation, the possible cause of that individual’s allergic reaction or anaphylaxis, and the treatment or treatments that that person received. Methods: We conducted a retrospective review of all of the cases seen at the ED from July 2007 through July 2009 in which a diagnosis of either anaphylaxis (ICD-9-CM 995.0) or allergic reaction (ICD-9-CM 995.3) was made. We reviewed the diagnosis of each case using the anaphylaxis guidelines and compared the presentations, causes, treatments, and outcomes of patients with recognized or unrecognized anaphylaxis. Results: The study included 135 adults. Six patients (4.4%) were diagnosed with anaphylaxis and 129 patients (95.6%) were found to have been suffering from allergic reactions. Among the patients diagnosed with allergic reactions, 25 (23%) met the diagnostic criteria for anaphylaxis but were not recognized as having experienced it. The most common causes for anaphylaxis were food (41.9%), medication (38.7%), and insect bites or stings (12.9%); in 12.9% of the cases, a cause could not be determined. There were no statistically significant differences between groups in terms of demographics, causes, or symptoms. Significant differences were found in patient vital signs upon ED arrival. There was under-treatment, particularly among subjects with unrecognized anaphylaxis. Only 67% of recognized and 4% of unrecognized anaphylaxis were treated with epinephrine (p<0.001). It was more likely for subjects whose anaphylaxis was recognized to be admitted than was the case for patients whose anaphylaxis went unrecognized or who were merely suffering from allergic reactions (p<0.001). Conclusion: Anaphylaxis is under diagnosed and under-treated in ED patients receiving care at the VACHS. There is a need to improve anaphylaxis recognition and treatment in the ED setting and, in addition, to better identify barriers to optimal health care.

HIV and Syphilis Infection among Men attending a Sexually Transmitted Infection Clinic in Puerto Rico

Abstract: Sexually transmitted infections (STIs) are a significant public health problem worldwide (1). A disproportionate burden of HIV is carried by Puerto Ricans as compared to the general US population and the overall Hispanic US population (2). As of December 2010, the Puerto Rico HIV/AIDS Surveillance System reported 43,682 cases of HIV infection in PR, and ranked 4th among US states and territories reporting the highest number of diagnosis of HIV infection among adults and adolescents in 2010. (3). Disparities in HIV infection may be correlated with social determinants of health, such as poverty, high rates of illicit drug use, and complex patterns of risky sexual behavior (4). Social and epidemiological data suggest that the high prevalence of HIV in PR is concentrated among vulnerable and underserved populations. High-risk sexual practices in these populations compound the problem by increasing the rate of disease transmission. Furthermore, the lack of screening in these populations, in terms of long-term health problems associated with HIV, creates an even larger disparity between these populations and those with adequate access to medical care (5). In addition, the incidence of syphilis is increasing worldwide (6). Syphilis is highly infectious but easily curable in its early stages. If untreated, it can lead to serious long-term complications, including neurological problems, cardiovascular disease, organ damage, and even death (7). In the US, the rate of primary and secondary syphilis decreased throughout the 1990s, and in 2000 it reached an all-time low (8). However, in the past 8 years the syphilis incidence rate in the US, as well as that in PR, has been increasing, primarily among men (9). Additionally, the disparity in syphilis infection rates between males and females has grown consistently throughout this period (10). For example, in PR, the rates of syphilis among males and females were almost equivalent in 2001, but by 2008 it was estimated that the rate was six times higher among males (10). It is suggested that this disparity may in part be due to the increasing incidence rate of syphilis in men who have sex with other men (MSM) (11). Because of the reported increase in syphilis rates among men and given that the presence of syphilis increases susceptibility to HIV transmission (12), it is important to make every effort to curb the spread of syphilis and, thus, HIV infection, particularly in high-risk populations. In order to better understand the characteristics and behaviors associated with syphilis and HIV infection among high-risk men attending an STI clinic in PR, our aim was twofold: 1) to describe the proportion of individuals infected with HIV and syphilis and 2) to investigate the correlates of HIV and syphilis infection among the men who attended an urban STI clinic in PR from 2009 to 2010.

Small Cell Neuroendocrine Carcinoma of Rectum with Associated Paraneoplastic Syndrome: A Case Report

Abstract: Neuroendocrine carcinomas of the colon and rectum comprise fewer than 1% of all colorectal cancers. These aggressive tumors generally have a poor prognosis compared to that associated with colorectal adenocarcinoma. We describe herein the case of a 68-year-old female presenting with a bleeding rectal mass involving the anal canal, which case was associated with hyponatremia due to inappropriate serum levels of antidiuretic hormone. The histopathological examination was consistent with a small-cell neuroendocrine tumor. She was treated with combination chemotherapy and radiation therapy. The Syndrome of Inappropriate Antidiuretic Hormone (SIADH) was managed with vasopressin antagonists. After the completion of therapy, endoscopic ultrasound revealed evidence of residual disease, for which she underwent an abdominoperineal resection (APR). The patient died 4 months later of disease progression. To our knowledge, this is the first report of a small-cell neuroendocrine tumor involving the rectum and anal canal that presented with the paraneoplastic syndrome, SIADH.

Social support and its association with sociodemographic characteristics, dietary patterns, and perceived academic stress among college students in Puerto Rico.

Abstract: Objective: The objective of the present study was to determine the association between social support, dietary pattern, and academic stress among college students in Puerto Rico, based on their socio-demographic characteristics. Methods: This was a retrospective, descriptive, epidemiological study that used a stratified sample of 275 college students. The data collection was done by means of a self-administered instrument. Results: Most of the participating students were female (67.6%), ranged in age from 21 to 30 years (88%), and had health weights (56.4%); a large minority, 42.7%, lived in homes having low annual incomes. Most of the participating students perceived their academic loads as being heavy (68.2%) and their total academic stress levels as being moderate (60.7%). Most of the students had moderate levels of social support (61.5%). Social support was significantly associated with age (p = 0.04), in that young students had high levels of social support; with the school being attended (p = 0.01), in that students from the School of Dental Medicine had high levels of social support’ and with perceived academic load (p = 0.02). Social support was significantly associated with age (p = 0.04), in that the younger students had higher levels of social support than did their older counterparts; with the school being attended (p = 0.01), in that students from the School of Medicine had higher levels of social support than did the students from the other schools; and with perceived academic load (p = 0.02). Conclusion: There were associations between social support and age, school, and perceived academic load, but there were no such associations between social support and either level of academic stress or dietary pattern.

Predisposing Factors for Acute Kidney Injury in Hispanic Patients Treated with Diuretics for Decompensated Heart Failure

Abstract: Objective: In patients with congestive heart failure (CHF), use of loop diuretic therapy may result in acute kidney insufficiency (AKI). We assessed the factors that contributed to the development of AKI in patients with CHF treated with loop diuretics in a sample of patients who attended the Cardiovascular Center of Puerto Rico and the Caribbean (CCPRC). Methods: Medical records of 236 patients admitted between: January 1, 2008 to December 31, 2008 with the diagnosis of CHF were reviewed. Diagnosis of CHF based on symptoms and signs was confirmed by echocardiography. Twenty six (26) patients with significant valvular disease and four (4) patients who did not receive diuretics during hospitalization were excluded. Hospital course was observed until diuretic therapy was discontinued or patient was discharged. AKI was defined as a 25% increase in serum creatinine level after the start of diuretic therapy. The study sample was categorized in two groups: patients who developed AKI and those who did not. Variables associated with AKI (p 80 mg/dl) and history of diabetes mellitus were significantly (p<0.05) associated with AKI. Conclusion: Analysis of data shows that increased doses of diuretic therapy and history of diabetes mellitus were significantly associated with AKI in patients with CHF. This study highlights the importance of monitoring the doses of diuretic therapy during hospitalization, in this group of patients. [P R Health Sci J 2013;2:63-67]

Dentogingival complex: dimension based on biotypes.

Abstract: Objective: Estimate the DGC dimensions and determine whether the DGC dimension varies by gingival biotype. Methods: A cross sectional study was performed in the Undergraduate and Prosthodontic Graduate Program clinics of the School of Dental Medicine, University of Puerto Rico from August 2011 to April 2012. A total of 53 participants who needed restorative crowns in their teeth were recruited. Prior to crown preparation, the gingiva was classified as having a thin, mixed or thick biotype, according to transparency, using a standardized 15 UNC Hu-Friedy® periodontal probe. The DGC dimension was measured by transulcus probing. Descriptive statistics were calculated in mesial, medial, and distal sites by phenotypes. Differences between and within the sites’ DGC dimension mean were determined using a Friedman test. The level of significance was 0.05. Results: Mean DGC dimensions, in millimeters, for all sites measured were: 3.09 (95% CI: 2.91-3.27), 3.40 (95% CI: 3.18-3.62), 2.70 (95% CI: 2.51-2.89), and 3.17 (95% CI: 2.94-3.41) in mesial, medial, and distal sites, respectively. In thick, mixed, and thin biotypes the mesial sites showed greater DGC dimension means than the medial and distal (p<0.05) sites. Mean DGC dimension was greater for the thin compared to mixed and thick biotypes at mesial, medial and distal sites (p<0.001). Nevertheless, the thick biotype presented the smallest DGC mean dimensions compared to mixed and thin biotypes at the same sites. Conclusion: The DGC dimensions in all sites were similar to those reported in the literature. DGC dimensions are different for thin, mixed and thick gingival biotypes.

Pediatric dentistry workforce in Puerto Rico: results of a 2011 survey.

Abstract: Objective: Determine the socio-demographic and educational characteristics of and develop a profile of practice for Pediatric Dentists (PDs) in Puerto Rico. Methods: A 34-item questionnaire assessing 3 dimensions: socio-demographic and education, practice profile, and level of satisfaction/desire to relocate, was developed and pre-tested for comprehensiveness, validity, and reliability. Data were collected through telephone interviews by a calibrated interviewer, entered and tabulated using Excel® (Microsoft Office 2010) and exported to SPSS v. 17 (SPSS Inc., Chicago, IL). Descriptive statistical analyses were conducted. Results: Eighty percent (80%) of all of the licensed PDs in PR participated in our study. The typical PD in PR has been in practice for 19 years, is 48 years old, and spends 31 hours/week providing clinical care. Female PDs, who comprise 70% of the PD workforce, devote more time to clinical and managerial activities than do their male counterparts. Seventy-three percent (73%) of the current PD workforce will be retiring within the next 20 years and 70% are solo-practitioners. Most PDs (65%) participate in the government-subsidized dental insurance program “Mi Salud,” which represents as much as 48% of their income. PDs beginning or ending their careers were more likely to be participating providers for “Mi Salud” than were those in mid-career. Conclusion: In evaluating the adequacy of the pediatric dentistry workforce in Puerto Rico, the socio-demographic information of the PDs and the characteristics of their practices must be taken into account. These variables must be examined in relation to epidemiological indicators as well as environmental factors, including the comprehensiveness of dental benefits and the adequacy of reimbursement levels by third-party payers, which when inadequate may lead to decreased access to care.

Achievement of National Clinical Practice Recommendations among those in the Puerto Rican Population with Diabetes Mellitus

Abstract: Objective: To analyze glycemic control among patients with diabetes mellitus (DM) in Puerto Rico (PR) using the 2011 American Diabetes Association (ADA) recommendations and glycemic goals as standards. We also explored other factors that are related to glycemic control. Methods: Glycemic data were obtained from 600 adults with DM from 5 different regions in PR. The patient’s health insurance coverage, type of health care provider, type of diabetes treatment, gender, age, physical activity, weight, degree of hypertension and degree and type of dyslipidemia comorbidities (when one or both were applicable), and disease duration were variables of interest. Univariate and bivariate analyses were conducted to describe the population and determine the statistical differences in the glycemic control of the subjects. Results: Fewer than half of the participants achieved the ADA-recommended levels for HbA1c (37.3%) and blood pressure (34%). However, relatively more participants met the goals for high-density lipoprotein cholesterol (51.7%), low-density lipoprotein cholesterol (59.9%), and triglycerides (61.5%). The percentage of participants reaching the HbA1c, blood pressure, and low-density lipoprotein cholesterol goals at the same time was 9.9%. Patients with private health insurance achieved better glycemic control than did patients in the public managed healthcare system. Half of the population presented simultaneous hypertension, dyslipidemia, and DM comorbidities. Only 50% of the participants were physically active. Conclusion: In the sample population, glycemic control levels and blood pressure levels in adults with DM were far from the ADA-recommended standards. Physical activity levels, type of medical insurance, and type of DM medical treatment were the main modifiable factors associated with the goal of attaining glycemic control. Barriers that limit the achievement of this goal should be analyzed in more detail to improve the medical care for people with DM.

Pulmonary Hemorrhage in a Patient initially presenting with Discoid Lupus

Abstract: As a cutaneous variant of lupus erythematosus, discoid lupus erythematosus (DLE) is thought to have a good prognosis; however, the involvement of internal organs with a transition to systemic disease may occur The progression from DLE to systemic lupus erythematosus has been reported in up to 28% of patients This progression to systemic disease has been associated with a benign course Herein, we report the case of a 31-year-old woman with a 10-year history of discoid lupus, now presenting with dyspnea and pleuritic chest pain of 1 month's duration A significant drop in hemoglobin and hematocrit levels was observed in association with leukopenia, lymphopenia, a positive ANA, and hypocomplementemia Chest radiography and computed tomography revealed bilateral infiltrates An open lung biopsy confirmed the presence of intra-alveolar hemorrhage Based on the results of the tests and analyses detailed herein, a diagnosis of pulmonary hemorrhage secondary to systemic lupus erythematosus was made To our knowledge, pulmonary hemorrhage as the initial manifestation of the systemic involvement of discoid lupus has not been reported before

Heart tumors in Puerto Rico de novo atrial fibrillation as clinical presentation in a subgroup of patients.

Abstract: Objective: Primary cardiac tumors are rare neoplasms in humans, of which the most common is the atrial Myxoma. The objective of this study was to find the incidence of these tumors at the Heart Center of Puerto Rico and the Caribbean. Methods: This study was approved by the Institutional Review Board of the Medical Sciences Campus University of Puerto Rico to review the records at the Heart Center of patients with heart tumors in the last 14 years. Results: The sample consists of 55 patients (78.9% were females and 24.1% were male) with a median age of 52 years. Sixty-five percent of patients lived in rural areas. Clinical presentations included shortness of breath (43.1%), chest pain (37.9%), asymptomatic (25%), palpitations (20.7%), neurologic symptoms (10.3%) and dizziness (6.9%). Electrocardiographic findings included normal sinus rhythm (53.4%), non-specific ST-T changes (32.8%), sinus tachycardia (20.7%), left atrial enlargement (10.3%) and atrial fibrillation (8.6%). A subgroup presenting with atrial fibrillation prior to diagnosis had left atrial myxoma. The tumors found, in descending order of frequency are: left atrial myxoma, right atrial myxoma, papillary fibroelastoma, hamartoma, lipoma and rhabdomyoma. We found a correlation between large left atrial myxoma and atrial fibrillation. Conclusion: The most frequent heart tumor was atrial myxoma. The larger myxomas were associated with atrial fibrillation.

Acquired Segmental Neuromas

Abstract: Neuromas are benign hyperplastic proliferations of normal peripheral nerve components. These can be associated with some genodermatoses, namely Cowden syndrome and multiple endocrine neoplasia (MEN) 2B, especially when numerous lesions are present. Given the potential for malignancy (such as breast cancer, pheochromocytoma, and thyroid cancer) associated with these syndromes, other features indicative of either syndrome should be evaluated in patients presenting with multiple cutaneous neuromas. The evaluation should include a thorough family history and complete physical, dermatologic, and ophthalmologic exams as well as thyroid studies. We report, herein, the case of an 8-year-old female with cutaneous neuromas distributed segmentally with no other associated finding suggestive of an underlying syndrome.

Challenges in critical care medicine: an overview of Puerto Rico's intensive care units.

Abstract: Objective: Puerto Rico (PR) has undergone rapid changes during the last decades. Some of these involve the health care system and the delivery of care to the critically ill patient. With this in mind, we investigated how the intensive care units throughout our island’s hospitals are organized so that we could establish a profile of the adult intensive care units (ICU) in PR. Methods: From January 1, 2010 through April 30, 2010, questionnaires were distributed by e-mail or fax to every hospital that maintained a critical care unit. The questionnaires asked for such details as the structure of the unit; whether is use on an open or closed model; the number of beds in the unit; the total number of faculty members in the unit; the credentials of the unit’s medical faculty and nursing staff; whether critical care service was available, and the different people in-charge of the unit during the day and at night. Results: A total of 33 questionnaires were distributed, of which 19 were collected and analyzed. Among the IC U directors who responded, the predominant specialty was cardiology. Surprisingly, only 26% of the hospitals had critical care specialists. In most of the institutions, an internist or a primary care physician was on site during the day, this individual directly supervised patients and had decision making authority. At night, however, patients were managed by supervising nurse with limited ability to medically identified patient complications , though primary care physician was always available by phone if a critical decision needed to be made. Some of the units used protocols as part of their medical management armamentarium. Conclusion: Although only a small percentage of the island’s IC Us participated in our project, the study’s findings serve as evidence of the need to re-evaluate the delivery of care to the critically ill population.