Factors Associated With Disease Damage in Puerto Ricans With Primary Sjögren Syndrome.

OBJECTIVE: The aim of this study was to determine the association of demographic parameters, clinical manifestations, disease activity, and pharmacologic therapy with disease damage in a group of Puerto Ricans with primary Sjögren syndrome (pSS). METHODS: A cross-sectional study was conducted in 100 Hispanics of Puerto Rico with pSS. Patients were 21 years or older and fulfilled the 2012 American College of Rheumatology classification criteria for pSS. Demographic factors, lifestyle behaviors, extraglandular manifestations, serologic tests, comorbidities, pharmacologic therapy, disease activity (per European League Against Rheumatism Sjögren Syndrome Disease Activity Index), and disease damage (per Sjögren Syndrome Disease Damage Index [SSDDI]) were assessed. Patients with disease damage (SSDDI ≥1) and without damage (SSDDI = 0) were compared using bivariate analysis and multivariate regression analysis adjusted for age, sex, and disease duration. RESULTS: The mean age of patients was 52.8 years; 94% were women. The mean disease duration was 5.9 years. Thirty-nine patients had disease damage. Disease damage was mainly attributed to pulmonary fibrosis and peripheral neuropathy. In the bivariate analysis, disease damage was associated with low C3 and C4, coronary artery disease, infections, and higher activity index and was more frequently treated corticosteroids and azathioprine. In the multivariate analysis, low C3, disease activity, and corticosteroid exposure retained significance. CONCLUSIONS: In this population of Puerto Ricans with pSS, C3 and C4 hypocomplementemia, coronary artery disease, infections, and exposure to corticosteroids and azathioprine were associated with damage accrual. Clinicians should be aware of these factors to identify those who may require close follow-up and early therapeutic intervention.

Effect of type of health insurance coverage on leukemia survival in adults in Puerto Rico.

OBJECTIVE: In Puerto Rico, leukemia is among the top 10 cancers in terms of incidence and mortality. The aim of the study described herein was to establish the overall leukemia survival rate in Puerto Rico and determine whether there are differences in leukemia survival by type of health insurance coverage. METHODS: Data for adult patients (aged > or = 20 years) diagnosed with leukemia were provided by the Puerto Rico Central Cancer Registry. The relative survival rates (1, 3, and 5 years) were estimated for leukemia patients (diagnosed from 2004 through 2006) by type of health insurance (government health plan [GHP] or non-government health plan [NGHP]). Relative survival is defined as observed survival in the cohort divided by expected survival in the cohort. A Poisson regression model was used to analyze the relative excess risk of death for both the GHP and the NGHP groups. RESULTS: A total of 516 leukemia patients were eligible for analysis. The overall survival rates of leukemia patients in PR for 1, 3, and 5 years after diagnosis were 55.8%, 40.5%, and 34.7%, respectively. Relative survival rates were lower for patients with GHP (1 year = 52.8%; 3 years = 36.4%; 5 years = 32.2%) than they were in people with NGHP (1 year = 57.5%; 3 years = 42.8%; 5 years = 36.1%). Among patients aged 65+ years, those with GHP had a 1.58-fold (95% CI: 1.11-2.27) higher risk of death than did those patients with NGHP. CONCLUSION: Several factors could explain the disparities observed in leukemia survival rates (as grouped by health insurance status) in PR. Some of them include differences in patterns of healthcare coverage, in delays in treatment, in quality of service, in risk factors, and co-morbidities present in the older population studied.

Increased Prevalence of Advanced Histologic Features in Small and Diminutive Polyps in Patients Undergoing Surveillance and Diagnostic Colonoscopy.

OBJECTIVE: Studies addressing small and diminutive polyps and their potential of harboring advanced histologic features (AH) are scarce in Hispanics. We aimed to determine the prevalence of AH in a cohort of Hispanics. METHODS: A retrospective review of medical records of patients who had a colonoscopy from 2005 through 2010. The data collected included demographics, indications, history (personal/family) of colon cancer and/or polyps, and polyp histology. Polyps with high-grade dysplasia, prominent villous component, adenocarcinoma or serrated were classified as having AH. RESULTS: The population comprised 1884 patients, and 3835 polyps were evaluated; 63.3% were diminutive (1-5 mm), 22.7% small (6-9 mm), and 13.9% large (≥10 mm). The prevalence of AH for small and diminutive polyps were 4.9% and 1.1%, respectively. Of the polyps with AH, 11.9% were diminutive and 19.6% small. Small polyps were 5.04 times more likely to harbor AH than were diminutive polyps. Distal rather than proximal polyps were more likely to harbor AH. Furthermore, AH was >7 times more common in small (6-9 mm) polyps identified during diagnostic or surveillance colonoscopies compared to screening colonoscopies. CONCLUSION: The prevalence of AH was significantly associated with size, location (distal), and procedure indication. Although diminutive polyps (<6 mm) were less likely to harbor AH, the risk for non-Hispanics was higher than previously reported. The "resect and discard" strategy for polyps ≤ 1 cm should be used with caution in ethnically diverse cohorts, as the risk for AH may be higher in Hispanics than in non-Hispanic Whites.

Diabetes self-care activities and perception and glycemic control in adult Puerto Rican residents with Type 2 Diabetes: The LLIPDS Study.

Background: Individuals with diabetes frequently have comorbid health conditions and suffer longer term complications. The control of blood glucose relies on diabetes management/self-care behaviors. Poor glycemic control, commonly encountered in underserved populations with type 2 diabetes (T2D) often results from inadequate diabetes self-care activities and/or perception. We aimed to assess the association between diabetes self-care activities/perception and glycemic control in adult Puerto Rican residents with T2D. Design and methods: We used a cross-sectional study design; our sample population was 260 individuals aged 40-65 years with T2D. We asked participants about their diabetes self-care over 8 weeks. High fasting blood glucose (≥130 mg/dL) and glycated hemoglobin (HbA1c; ≥7%) measures were defined. We estimated the strength of the following associations using logistic regression: each of three self-care activities and fasting glucose or HbA1c, adjusting for confounders. Results: Nearly 27% of the participants reported not checking their glucose levels, 7% did not take their medications as prescribed and 31% perceived their diabetes self-care as poor. Participants with less education perceived their diabetes self-care as poor more often than their counterparts (44% vs 25%; p = 0.003). Most participants had high glycemic levels (60%) or hbA1c levels (65%). Participants who perceived their diabetes self-care as poor had higher HbA1c levels than their counterparts (adj. odds ratio: 2.14, 95% CI (1.13, 4.08)). Conclusion: Poor diabetes self-care perception, possibly related to less education, likely explains poor glycemic control among adult Puerto Rican residents with T2D.

Sexually transmitted infections clinics as strategic venues for targeting high risk populations for HIV research and sexual health interventions.

Puerto Rico has one of the highest incidence rates of HIV in the U.S. Concurrent with increases in sexually transmitted infections (STI), an increasing share of the new infections in PR are associated with sexual transmission. Much of the available research on sexual risk in PR derives from STI/HIV surveillance data. There is limited social and epidemiological research on sexual risk in PR, particularly in hidden and often hard-to-reach populations at high risk. Despite the absence of substantial resources that most epidemiological studies require, a research collaboration was initiated in 2007 between researchers in the School of Public Health at the University of Puerto Rico and the Centro Latinoamericano de Enfermedades de Transmisión Sexual (CLETS), one of the largest publicly funded centers for STI/HIV screening and treatment in the San Juan metropolitan area. Structured as a case study in the development of community-based research collaborations, this paper describes the early history and development of the project, including formative research, recruitment and training of students, and evolution in the study design that contributed to the current configuration of the ongoing "Core" study. Preliminary data are presented, highlighting data from a number of subpopulations that may contribute to our understanding of the role of behavioral risk in the STI/HIV epidemics in PR. More generally, the paper may guide the development of similar collaboration elsewhere in the Caribbean where HIV risk is increasing but where resources for research in high risk settings and groups are scarce.

Clinical Manifestations and Outcomes in Disease-Modifying Antirheumatic Drug-Naive Adult Patients with Chronic Chikungunya Arthritis.

Most studies on chronic chikungunya virus (CHIKV) arthritis include patients treated with disease-modifying antirheumatic drugs (DMARDs), likely altering the expression of clinical manifestations and outcome. Therefore, we sought to evaluate the clinical features and correlates in DMARD-naive patients with chronic CHIKV arthritis. We conducted a case-control study in adult patients with serologically confirmed CHIKV infection in Puerto Rico. Demographic features, clinical manifestations, comorbidities, disease activity (per Clinical Disease Activity Index [CDAI]), functional status (per Health Assessment Questionnaire Disability Index [HAQ-DI]), and pharmacologic treatment were ascertained. Patients with and without chronic CHIKV arthritis were compared. Furthermore, a sub-analysis was performed among patients with chronic CHIKV who presented with mild disease activity versus moderate-to-high disease activity at study visit. In total, 61 patients were studied; 33 patients had chronic arthritis and 28 had resolved arthritis. Patients with chronic arthritis had significantly more diabetes mellitus, chronic back pain, and fever, tiredness, and myalgias on the acute phase. The mean (SD) HAQ score was 0.95 (0.56), and 57.6% had moderate-to-high disease activity. Patients with moderate-to-high disease activity had higher scores in overall HAQ-DI and HAQ-DI categories (dressing and grooming, arising, hygiene, reaching, and activities) than in those with mild activity. In conclusion, in this group of DMARD-naive patients with chronic CHIKV arthritis, nearly 58% had moderate-to-high disease activity and had substantial functional disability. Diabetes mellitus, chronic back pain, and some manifestations on acute infection were associated with chronic CHIKV arthritis.

Characterization of a subset of patients with primary Sjögren's syndrome initially presenting with C3 or C4 hypocomplementemia.

OBJECTIVE: This study aimed to determine the association of C3 and C4 hypocomplementemia at the diagnosis of primary Sjögren's syndrome (pSS) with clinical manifestations, disease activity, and disease damage. METHODS: A cross-sectional study was conducted in 94 Puerto Ricans with pSS. Patients were aged ≥21 years and met the 2012 American College of Rheumatology Classification Criteria for pSS. Demographic characteristics, health-related features, cumulative extraglandular manifestations, serologic tests at pSS diagnosis, comorbidities, disease activity (per European League Against Rheumatism Sjögren's Syndrome Disease Activity Index [ESSDAI]), disease damage (per Sjögren's Syndrome Disease Damage Index [SSDDI]), and pharmacologic therapy were determined. Serum C3 and C4 levels were measured at pSS diagnosis by immunoturbidimetry. Patients with and without hypocomplementemia were analyzed using bivariate and multivariate logistic regression analyses adjusted for age, sex, and disease duration. RESULTS: The mean age and disease duration of the study population were 52.4±12.4 years and 5.9±4.8 years, respectively; of the total study population, 94% were female. C3 and C4 hypocomplementemia were observed in 9.6% and 13.8% of the patients, respectively. In the multivariate analysis, C3 hypocomplementemia was associated with leukocytoclastic vasculitis, interstitial lung disease, higher SSDDI score, and exposure to rituximab. C4 hypocomplementemia was associated with leukocytoclastic vasculitis, interstitial lung disease, and higher ESSDAI and SSDDI scores. CONCLUSION: In this population of patients with pSS, low C3 and C4 levels at diagnosis were associated with extraglandular manifestations such as vasculitis and interstitial lung disease, as well as disease activity and damage accrual. These results suggest that complements C3 and C4 have clinical and prognostic value in patients with pSS.

Incident arterial vascular events in a cohort of Puerto Ricans with rheumatoid arthritis.

OBJECTIVE: The increased morbidity and mortality associated with cardiovascular events in patients with rheumatoid arthritis has been linked to traditional and nontraditional factors. However, these factors vary among different ethnicities. Few studies have described these features in Hispanic populations. Thus, we determined the clinical correlates of arterial vascular events in Hispanics from Puerto Rico. METHODS: A cross-sectional study was performed in a cohort of 405 Puerto Ricans with rheumatoid arthritis. Demographic parameters, health-related behaviors, clinical manifestations, disease activity (per Disease Activity Score 28), functional status (per Health Assessment Questionnaire), comorbidities, and pharmacotherapy were compared in patients with and without incident arterial vascular events. The latter was defined as the occurrence of myocardial infarction, angina pectoris, vascular procedures for coronary artery disease, stroke, or peripheral artery disease. Study groups were analyzed using bivariate and multivariate analyses. RESULTS: Of the total study population, 87.2% were woman. The mean age at study visit was 56.1 ± 13.9 years, and the mean disease duration was 15.0 ± 13.2 years. Arterial vascular events occurred in 43 patients (10.6%). In the multivariate analysis adjusted for age and sex, arterial hypertension, dyslipidemia, metabolic syndrome, extra-articular manifestations, higher Health Assessment Questionnaire score, and number of hospitalizations were associated with arterial cardiovascular events. CONCLUSION: In this cohort of Puerto Ricans with rheumatoid arthritis, traditional and nontraditional factors, particularly extra-articular manifestations and functional disability, were associated with arterial vascular events. Awareness of these associations may help to implement clinical strategies in this group of rheumatoid arthritis patients at risk of arterial vascular events.

Scientometric analysis of the Puerto Rico Clinical and Translational Research Consortium (PRCTRC) research publications, 2010-2018.

We analyzed the publication productivity supported by the Puerto Rico Consortium for Clinical and Translational Research (PRCTRC) using the structured process of scientometrics. The objective of this study was to evaluate the impact of the research and collaborations as presented in publications. Manuscripts published from 2010 to 2018 and that had the PRCTRC award number and a PMCID number were retrieved from the Science Citation Index database. Scientometric indicators included h-index (HI), average citation (AC), collaboration coefficient (CC), collaboration index (CI), and degree of collaboration (DC) analysis, and relative citation ratio (RCR) was done with Web of Science Platform, iCite, and Stata software. Joinpoint Trend Analysis Software was used to calculate the annual percent change (APC). From 2010 to 2018, 341 publications were identified with an average of 38 publications per year and a total of 3569 citations excluding self-citations. A significant growth (APC: 17.76%, P < 0.05) of scientific production was observed. The overall HI was 31, and the AC per item was 11.04. The overall CC was 0.82, the CI was 8.59, and the DC was 99.1%. This study demonstrates a statistically significant increase in the PRCTRC scientific production. Results allow for the assessment of the progress resulting from the provided support and to plan further strategies accordingly.

Cesarean delivery as a barrier for breastfeeding initiation: the Puerto Rican experience.

The study's objective was to examine the relationship between cesarean section delivery and the initiation of breastfeeding in a representative sample of 1695 Puerto Rican women aged 15 to 49 years, who delivered their last healthy singleton child in Puerto Rico between 1990 and 1996. Secondary analysis of data collected in the population-based cross-sectional study Puerto Rico Reproductive Health Survey was performed. Bivariate and multivariate logistic regression analyses were used to examine the crude and covariate adjusted association between type of childbirth and initiation of breastfeeding. Overall, 36% of all births were performed by cesarean section, while initiation of breastfeeding was achieved by 61.5% of the women. Cesarean section was negatively related to breastfeeding initiation in multivariable logistic regression models (odds ratio=.64; 95% CI=0.51-0.81) after controlling for confounding variables. Intervention programs that aim to promote breastfeeding and that provide special assistance to women undergoing this procedure should be developed.

Long-Term Outcomes in Puerto Ricans with Rheumatoid Arthritis (RA) Receiving Early Treatment with Disease-Modifying Anti-Rheumatic Drugs using the American College of Rheumatology Definition of Early RA.

BACKGROUND: Early treatment of rheumatoid arthritis (RA) results in better long-term outcomes. However, the optimal therapeutic window has not been clearly established. OBJECTIVE: To determine the clinical outcome of Puerto Ricans with RA receiving early treatment with conventional and/or biologic disease-modifying anti-rheumatic drugs (DMARDs) based on the American College of Rheumatology (ACR) definition of early RA. METHODS: A cross-sectional study was performed in a cohort of Puerto Ricans with RA. Demographic features, clinical manifestations, disease activity, functional status, and pharmacotherapy were determined. Early treatment was defined as the initiation of DMARDs (conventional and/or biologic) in less than 6 months from the onset of symptoms attributable to RA. Patients who received early (< 6months) and late (≥6 months) treatments were compared using bivariate and multivariate analyses. RESULTS: The cohort comprised 387 RA patients. The mean age at study visit was 56.0 years. The mean disease duration was 14.9 years and 337 (87.0%) patients were women. One hundred and twenty one (31.3%) patients received early treatment. In the multivariate analysis adjusted for age and sex, early treatment was associated with better functional status, lower probability of joint deformities, intra-articular injections and joint replacement surgeries, and lower scores in the physician's assessments of global health, functional impairment and physical damage of patients. CONCLUSION: Using the ACR definition of early RA, this group of patients treated with DMARDs within 6 months of disease had better long-term outcomes with less physical damage and functional impairment.

Reversal of pentylenetetrazole-altered swimming and neural activity-regulated gene expression in zebrafish larvae by valproic acid and valerian extract.

RATIONALE: Ethnopharmacology has documented hundreds of psychoactive plants awaiting exploitation for drug discovery. A robust and inexpensive in vivo system allowing systematic screening would be critical to exploiting this knowledge. OBJECTIVE: The objective of this study was to establish a cheap and accurate screening method which can be used for testing psychoactive efficacy of complex mixtures of unknown composition, like plant crude extracts. METHODS: We used automated recording of zebrafish larval swimming behavior during light vs. dark periods which we reproducibly altered with an anxiogenic compound, pentylenetetrazole (PTZ). First, we reversed this PTZ-altered swimming by co-treatment with a well-defined synthetic anxiolytic drug, valproic acid (VPA). Next, we aimed at reversing it by adding crude root extracts of Valeriana officinalis (Val) from which VPA was originally derived. Finally, we assessed how expression of neural activity-regulated genes (c-fos, npas4a, and bdnf) known to be upregulated by PTZ treatment was affected in the presence of Val. RESULTS: Both VPA and Val significantly reversed the PTZ-altered swimming behaviors. Noticeably, Val at higher doses was affecting swimming independently of the presence of PTZ. A strong regulation of all three neural-activity genes was observed in Val-treated larvae which fully supported the behavioral results. CONCLUSIONS: We demonstrated in a combined behavioral-molecular approach the strong psychoactivity of a natural extract of unknown composition made from V. officinalis. Our results highlight the efficacy and sensitivity of such an approach, therefore offering a novel in vivo screening system amenable to high-throughput testing of promising ethnobotanical candidates.