Sexual activity as a risk factor for hepatitis C in Puerto Rico.

BACKGROUND: Hepatitis C (HCV) is a blood born infection that affects millions of people worldwide. Although IV drug use (IVDU) and blood transfusions have been clearly defined as transmission risk factors for HCV, the role of sexual transmission is still not clearly defined. AIMS: To define the role of sexual transmission among Puerto Ricans HCV+ patients, and to determine if there is an association between sexual, and non-sexual risk factors, genotypes and viral load. METHODS: A cross-sectional epidemiological IRB approved study was performed among patients with HCV+ enrolled from Nov-2001 to May-2002. The Puerto Rico Gastroenterology Association sponsored this study. Five hundred subjects completed a risk-factor study questionnaire. Blood samples were drawn to determine HCV genotype and viral load. RESULTS: A male predominance was found (68%). Most patients (70%) were between 45-65 years old. The most common genotype was 1 (82%). Reported sexual risk factors were: sex with a drug user (30.3%), multiple sexual partners (>10) (28.9%), sex with an HCV infected partner (9.0%), and homosexuality (8.3%). Most common non-sexual risk factors were: blood transfusion (30.2%) and intravenous drug use (IVDU) (46.8%). Illicit drug users (IDU) reported having sex at a younger age (15.5 y/o), than those non-IDU (18.9 y/o) p=0.015. IDU reported both, a higher frequency of homosexual encounters than non-IDU (10.8% vs. 1.5%) p<0.0001, as well as having sex with another IDU (47.8% vs. 11.3%) p<0.0001. Those patients who reported sex with an HCV infected partner and were non-IDU had fewer partners than those who were IDU (1-2 vs. >20 partners) p<0.001. As a group, homosexuals had sex at a younger age, had multiple partners (> 20) and a higher proportion of sex with IVDU. After adjusting for age, gender, and risk factors, no significant association was found between genotype and sexual variables. The difference noted between groups in viral load had no statistical significance. CONCLUSIONS: Our data supports that sexual risk factors are common in HCV infected patients. High risk sexual practices such as early sexual intercourse, homosexuality and multiple sexual partners are the most common in patients with hepatitis C with use of illicit drugs as a risk factor also. The role of sexual transmission in this group cannot be clearly established. No significant relationship was found between genotype, viral load and sexual transmission. Patients with illegal drug use (IDU) showed significant difference from non users in regard to the age of the first sexual intercourse, the number of sexual partners and the practice of sex with other illicit drug users or partners of the same sex. When parenteral transmission is excluded, practicing sex with a HCV infected partner was the only identified risk factor in 6.5% of the studied population.

Hepatocellular carcinoma: ten years experience among veterans in Puerto Rico.

PURPOSE: The aim of our study is to determine the characteristics of hepatocellular carcinoma (HCC) as well as risk factors, demographics, survival rates and the use of diagnostic and therapeutic modalities among veteran patients in Puerto Rico. METHODS: A retrospective study of 114 patients with Hispanic background and biopsy-proven HCC diagnosed at the VA Caribbean Healthcare System from 1992 to 2002 was performed. Demographics data, Child-Turcotte-Pugh (CTP) score, presence of cirrhosis, viral serology, alcohol and/or other liver diseases history, diagnostic modalities, lesion size, therapy, and overall survival were examined. RESULTS: The mean age was 66.6 years old. 82% had known underlying cirrhosis. 60% had alcoholic liver disease (ALD), 33% positive serology for hepatitis C (HCV) and 21% both. 5.3% had chronic hepatitis B virus (HBV) infection. Additional causes were not present. CTP classification was: A (42%), B (44%) and C (14%). Abdominal CT scan demonstrated most of the lesions, while ultrasound only 57%. Alfa-fetoprotein was diagnostic in 32%. Mean survival was 10.3 months, better for those with CTP score A. Only 42% of the patients received any kind of therapy. CONCLUSIONS: ALD is the principal underlying liver disease in our HCC patients, closely followed by chronic HCV infection. Less than half of our patients received treatment mainly due to advanced disease for which the over survival was less than a year. HCC continues to be a dreadful disease with poor prognosis for which aggressive screening should be considered for all patients with cirrhosis and advanced liver disease regardless of the cause.

Malignant tumors of the small intestine.

SUMMARY: Malignant tumors of the small bowel are unusual and account for only 1% to 5% of all gastrointestinal tract malignancies. Thirteen cases of malignant tumors of the small bowel identified at the VAMC in Puerto Rico from January 1999 to September 2001 and a review of the literature are presented. The mean age of our cases was 67 (range: 45-78). Vague abdominal pain, nausea, vomiting, and melena were the most frequently reported symptoms. The average time from first symptoms to diagnosis was 3.2 months. A positive test for occult blood or hypochromic microcytic anemia was invariably present. Hyperbilirubinemia and increased alkaline phosphatase were warning signs that allowed earlier diagnosis in patients with duodenal tumors. Fifty-four percent of the lesions were detected by endoscopic examination while 46% relied on radiographic studies. Eleven had carcinomas and two malignant gastrointestinal stromal tumors. Neither carcinoids nor lymphomas were identified. Our report of thirteen cases of malignant small bowel tumors is unusual and exhibits differences with the previously reported data. The cases were identified in a limited Hispanic population in a short period of time. Aggressive evaluation and a high suspicion of these malignancies should be entertained whenever subtle symptoms and unexplained gastrointestinal blood loss are assessed.