Breast and Colorectal Cancer Screening Utilization after Hurricane María and the COVID-19 Pandemic in Puerto Rico.

Puerto Rico (PR) has faced environmental and public health challenges that could have significantly affected cancer screening access. Using administrative claims data from PR's Medicaid population, this study assessed trends in colorectal and breast cancer screening from 2016 to 2021, the impact of disasters in screening, and the absolute deficit in screening due to the pandemic. The monthly rates of claims were analyzed using Poisson regression. Significant reductions in breast and colorectal cancer screening utilization were observed. The colorectal cancer screening rate in 2017 was 77% lower a month after Hurricanes Irma and María [RRadj: 0.23; 95% CI: 0.20, 0.25] compared to the same time period in 2016. Breast cancer screening dropped 50% in November 2017 compared to November 2016 [RRadj: 0.50; 95% CI: 0.47, 0.54]. Prospectively, a recovery in utilization has been observed only for breast cancer screening. The results revealed that cancer screening utilization substantially declined after environmental disasters and the pandemic. These findings have potentially severe long-term implications for cancer health disparities and mortality in PR.

Effect of linagliptin plus insulin in comparison to insulin alone on metabolic control and prognosis in hospitalized patients with SARS-CoV-2 infection.

To evaluate the effect of the combination of linagliptin and insulin on metabolic control and prognosis in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hyperglycemia. A parallel double-blind randomized clinical trial including hospitalized patients with SARS-CoV-2 infection and hyperglycemia, randomized to receive 5 mg linagliptin + insulin (LI group) or insulin alone (I group) was performed. The main outcomes were the need for assisted mechanical ventilation and glucose levels during hospitalization. Subjects were screened for eligibility at hospital admission if they were not with assisted mechanical ventilation and presented hyperglycemia, and a total of 73 patients with SARS-CoV-2 infection and hyperglycemia were randomized to the LI group (n = 35) or I group (n = 38). The average hospital stay was 12 ± 1 vs 10 ± 1 days for the I and LI groups, respectively (p = 0.343). There were no baseline clinical differences between the study groups, but the percentage of males was higher in the LI group (26 vs 18, p = 0.030). The improvements in fasting and postprandial glucose levels were better in the LI group that the I group (122 ± 7 vs 149 ± 10, p = 0.033; and 137 ± 7 vs 173 ± 12, p = 0.017, respectively), and insulin requirements tended to be lower in the LI group than the I group. Three patients in the LI group and 12 in the I group required assisted mechanical ventilation (HR 0.258, CI 95% 0.092-0.719, p = 0.009); 2 patients in the LI group and 6 in the I group died after a follow-up of 30 days (p = 0.139). No major side effects were observed. The combination of linagliptin and insulin in hospitalized patients with SARS-CoV-2 infection and hyperglycemia reduced the relative risk of assisted mechanical ventilation by 74% and improved better pre and postprandial glucose levels with lower insulin requirements, and no higher risk of hypoglycemia.This study is registered at clinicaltrials.gov, number NCT04542213 on 09/03/2020.

Human papillomavirus vaccine initiation and up-to-date vaccine coverage for adolescents after the implementation of school-entry policy in Puerto Rico.

The human papillomavirus (HPV) vaccine has been proven effective in the prevention of infection with high-risk HPV types, which can lead to the development of six HPV-related cancers. Puerto Rico (PR) adopted a mandatory HPV vaccination school-entry policy that took effect in August 2018. While school-entry requirements are generally accepted as an effective approach for increasing vaccination rates, there are few studies that have documented their impact on improving HPV vaccination rates. The objective of this study was to evaluate the impact of the HPV school-entry policy in PR on HPV vaccine coverage. We used a pre-post natural experiment. The study population included adolescents registered in the PR Immunization Registry during 2008-2019. We calculated HPV vaccine initiation and up-to-date (UTD) vaccine coverage rates. We estimated age-standardized rates (ASR) and standardized rate ratio with 95%CI. Vaccine data corresponding to a total of 495,327 adolescents were included for analysis; 50.9% were male and 49.1% were females. After policy implementation, a marked increase in raw HPV vaccine initiation among 11- to 12-year-old adolescents was observed across years 2017 (a pre-policy year), 2018, and 2019 (58.3%, 76.3%, and 89.8%, respectively). UTD coverage also showed a moderate increase after policy implementation among 11- to 12-year-old adolescents. The gap between sexes in vaccine initiation and UTD coverage narrowed over time; the ASRs in 2019 showed an increase of 19% in initiation and 7% increase in UTD relative to 2017 for males and females combined (both significant at p<0.05). This study demonstrated evidence of improvement in HPV vaccination rates following implementation of the school-entry policy and a narrowed sex gap in vaccine rates over time in PR. Future analyses should assess how the policy continues to affect vaccine coverage in subsequent years and how the COVID-19 pandemic has impacted HPV vaccination uptake.

Sex disparities in the prevalence of physical function disabilities: a population-based study in a low-income community.

BACKGROUND: Functional disability continues to be a significant public health problem that increases older adults' vulnerability to experience a diminished quality of life, loss of independence, higher healthcare costs and health services utilization, and increased risks of mortality. Thus, we aimed to study the prevalence of functional disabilities by sex according to the types of daily living activities, controlling for specific sociodemographic variables among older Hispanics from low-income communities. METHODS: We used a cross-sectional epidemiological research design, considering a complex sampling design of households to interview adults ≥65 years living in low-income communities in Puerto Rico. Functional disability was measured by the PROMIS® Physical Function Short Form-20 T-score. The selected community was reported to have 5980 adult residents ≥65 years, according to the USA Census. The prevalence of functional disability was estimated using the logistic regression model, weighting by the effect of the sampling. Our estimated prevalence was compared between sexes using the prevalence ratio (PR), which was estimated with logistic regression models, controlling for age, income, number of chronic conditions, high and low impact of chronic conditions in functional disabilities, marital status, and sampling design. RESULTS: We recruited 211 older Hispanics from a randomly selected sample. Their mean age was 74.4 ± 7.1 years, with female predominance (57.3%). The overall estimated prevalence of physical function disability using T-score among females was 2.70 (95% CI: 1.4, 5.1) times the estimated prevalence of physical function disability among males. Women were more likely to report functional disabilities in instrumental activities of daily living, self-care activities, and functional mobility compared to males. However, sex differences were largely explained by the presence of musculoskeletal conditions of high impact in functional disability. CONCLUSIONS: The females in our study bear the greater burden of physical function disability in their adult age. Health policies, as well as future studies, should be targeted at reducing the burden of physical function disabilities in different types of daily activities through gender-sensitive disability self-management programs.

Chlamydia Trachomatis and Human Papillomavirus Serostatus in Puerto Rican Women.

OBJECTIVE: There is a high prevalence of human papillomavirus (HPV) infection in Puerto Rico, but little is known about the prevalence of Chlamydia trachomatis (CT) infection in healthy Puerto Rican women. Thus we aimed to evaluate the seroprevalence and association and the association between HPV and CT. METHODS: This was a secondary data analysis from a cross-sectional, populationbased, study of HPV infection in women aged 16-64 years in Puerto Rico (2010-2013). Enzyme-linked immunosorbent assays (ELISA) were used to detect serum antibodies to CT and HPV. Logistic regression models were used to estimate the odds ratio (OR) for the association between HPV and CT serostatus. RESULTS: The study included 524 women; mean age was 42 years. Overall, 97 (18.5%) women were CT-seropositive, 251 (47.0%) were HPV seropositive, and 57 (10.9%) had antibodies for both CT and HPV. Women who were CT-seropositive were more likely (p<0.05) to also be seropositive to any HPV type (ORadjusted: 1.7, IC 95% =1.1, 2.6), HPV 16/18 (ORadjusted: 1.6, IC 95% =1.0, 2.6) and HPV 6/11 (ORadjusted: 1.6, IC 95% =1.1, 2.6) than those CT-seronegative, after adjusting for possible confounding factors. CONCLUSION: Given the association between CT and HPV seropositivity, longitudinal studies to evaluate whether CT infection influences HPV incidence and persistence in this group are warranted.

The combination of linagliptin, metformin and lifestyle modification to prevent type 2 diabetes (PRELLIM). A randomized clinical trial.

BACKGROUND: Prediabetes is a highly prevalent health problem with a high risk of complications and progression to type 2 diabetes (T2D). The goals of this study were to evaluate the effect of the combination of lingaliptin + metformin + lifestyle on glucose tolerance, pancreatic ß-cell function and T2D incidence in patients with prediabetes. METHODS: A single center parallel double-blind randomized clinical trial with 24 months of follow-up in patients with impaired glucose tolerance plus two T2D risk factors which were randomized to linagliptin 5 mg + metformin 1700 mg daily + lifestyle (LM group) or metformin 1700 mg daily + lifestyle (M group). Primary outcomes were regression to normoglycemia and T2D incidence; glucose levels and pancreatic ß-cell function were secondary outcomes. RESULTS: Subjects were screened for eligibility by OGTT and 144 patients with prediabetes were randomized to LM group (n = 74) or M group (n = 70); 52 and 36 participants in the LM group and 52 and 27 participants in the M group, completed the 12 and 24 months of treatment, respectively; average follow-up was 17 ±â€¯6 and 18 ±â€¯7 months in M and LM group, respectively. Glucose levels during OGTT improved more in LM group. OGTT disposition index (DI) improved significantly better during the first months in LM group, increasing from 1·31 (95% CI: 1·14-1·49) to 2·41 (95% CI: 2.10-2.72) and to 2.07 (95% CI: 1.82-2.31) at 6 and 24 months in LM group vs from 1.21 (95% CI: 0.98-1.34) to 1.56 (95% CI: 1.17-1.95) and to 1.72 (95% CI: 1.45-1.98) at 6 and 24 months in M group (p < .05). T2D incidence was higher in M group in comparison to LM group (HR 4.0, 95% CI: 1.24-13.04, p = .020). The probability of achieving normoglycemia was higher in LM group (OR 3.26 CI 95% 1.55-6.84). No major side effects were observed during the study. CONCLUSIONS: The combination of linagliptin, metformin and lifestyle improved significantly glucose metabolism and pancreatic ß-cell function, and reduced T2D incidence in subjects with prediabetes as compared to metformin and lifestyle.

New Diagnoses among HIV+ Men and Women in Puerto Rico: Data from the HIV Surveillance System 2003-2014.

OBJECTIVE: Describe the age-standardized rates of new HIV diagnoses and compare sex and time disparities using data from the HIV/AIDS Surveillance System in Puerto Rico (PR). METHODS: The study comprises data of new HIV diagnoses of persons 13 years of age and older in PR reported from 2003-2014. Other variables included were age, sex, and health regions. We computed male to female ratio of new HIV diagnoses and assessed the trends in new HIV diagnoses using the annual percent change (APC) of the age-standardized rates (ASRs). The relative risk (RR) was estimated with 95% confidence intervals using Poisson regression models to assess the risk of new HIV diagnoses. RESULTS: The highest HIV diagnosis rates were observed in the metropolitan area. These rates decreased overall for both sexes for the periods 2007 onward. The risk of getting a new HIV diagnosis was significantly higher among males, ranging from an increased risk of more than 50% to almost 5-fold (p<0.05). Overall, a trend was observed in the 2011-2014 period were the risk increases as the age decreases. For the 13-24 age group, we observed a significant increased risk in new HIV diagnosis of 53% in the 2011-2014 period, when compared to 2003-2006 (p<0.05). CONCLUSION: Our findings suggest a shift in the risk of getting a HIV diagnosis from older to younger males. A possible explanation could be that HIV spread among young men that have sex with men might be increasing. Targeted prevention strategies should be implemented in this age group.

Human Papillomavirus Correlates With Histologic Anal High-Grade Squamous Intraepithelial Lesions in Hispanics With HIV.

OBJECTIVE: To estimate the magnitude of association between anal infection with high-risk human papilloma virus (HR-HPV) types and severity of biopsy-confirmed histopathological anal squamous intraepithelial lesions (SILs) among a clinic-based sample of HIV-infected adults in Puerto Rico. METHODS: This cross-sectional study analyzed data from medical records of adult patients who visited a specialized anal neoplasia clinic from June 2015 to December 2017 (n = 239); sociodemographics, behavioral risk factors, medical history, clinical data, and pathology reports were collected. The magnitude of association between anal HR-HPV and severity of anal SIL, adjusted for potential confounders, was assessed using a multinomial logistic model. RESULTS: A 78.7% of patients had anal HR-HPV infection, 43.9% had histopathological low-grade SIL (LSIL), and 37.7% had histopathological high-grade SIL (HSIL). The prevalence of anal HR-HPV infection was 63.6% among patients with no anal SIL, 70.5% for those with LSIL and 95.6% for those with HSIL. After adjusting for different predictors, patients with anal HR-HPV infection were more likely to have HSIL (odds ratio, 11.0; 95% confidence interval, 3.2-37.2) than those without anal HR-HPV infection, whereas no significant excess was observed for LSIL (odds ratio, 1.4; 95% confidence interval, 0.6-3.1). CONCLUSIONS: This study showed a strong association between anal HR-HPV infection and HSIL. Likewise, a high prevalence of anal HR-HPV infection and presence of anal SIL was observed among HIV-infected individuals. Our result highlights the importance of screening for anal HR-HPV infection and anal SIL and optimizing strategies for HPV vaccination in HIV-infected individuals.

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.

Association Between the Hypertriglyceridemic Waist Phenotype, Prediabetes, and Diabetes Mellitus Among Adults in Puerto Rico.

This study assessed the association of the hypertriglyceridemic waist (HTGW) phenotype with prediabetes and diabetes (DM) in a group of Hispanics. Analysis of a cross-sectional study of 858 adults residing in Puerto Rico that collected data on blood pressure, biochemical, and anthropometric measurements was performed. HTGW phenotype was defined as elevated triglycerides and elevated waist circumference. Prediabetes was defined as a fasting glucose of 100-125 mg/dL and DM as a fasting glucose ≥126 mg/dL or prior diagnosis. Prevalence of HTGW, prediabetes, and DM was 27.9, 38.0, and 21.6 %, respectively. Subjects with the HTGW phenotype had higher adjusted odds of prediabetes (POR 5.55; 95 % CI 3.38-9.13) and DM (POR 7.28; 95 % CI 3.63-14.63) compared to those without the phenotype. The association for prediabetes was stronger for women than among men. HTGW phenotype was strongly associated with prediabetes and DM, reinforcing the need to further assess its performance as a screening tool to identify at-risk individuals for cardiometabolic conditions.

Using a socioeconomic position index to assess disparities in cancer incidence and mortality, Puerto Rico, 1995-2004.

INTRODUCTION: Evaluation of the extent of socioeconomic inequalities in cancer incidence and mortality is essential to generate hypotheses in population health research and provides evidence for population-based strategies for comprehensive cancer control. The objective of this study was to create an area-based socioeconomic position (SEP) index to assess possible socioeconomic disparities in incidence and mortality of selected cancers in Puerto Rico. METHODS: Data for cancer incidence and mortality from 1995 to 2004 were obtained from the Puerto Rico Central Cancer Registry and the Puerto Rico Department of Health, and Puerto Rico socioeconomic data were obtained from the US Census 2000. We used principal component and factor analysis methods to construct the SEP index at the municipality level. We calculated age-adjusted incidence and mortality for each SEP area and used rate ratios to evaluate the differences by SEP. RESULTS: Incidence and mortality of cancer in Puerto Rico varied by SEP area. In general, the incidence and mortality for cancers of the esophagus and stomach were higher for municipalities with the lowest SEP; in contrast, rates for breast, colorectal, kidney, pancreas, prostate, and thyroid were higher for areas with the highest SEP. CONCLUSION: These results highlight cancer disparities in Puerto Rico by SEP level that warrant further research.

Incidence and mortality of the leading cancer types in Puerto Rico: 1987-2004.

BACKGROUND: Cancer remains one of the leading causes of morbidity and mortality worldwide and is the second cause of death in Puerto Rico (PR). This article describes the incidence and the mortality from cancer in PR for the period of 1987 to 2004. METHODS: We analyzed data from the PR Central Cancer Registry and the PR Demographic Registry from 1987-2004, for the leading cancer types in men and women in PR. Age-adjusted incidence and mortality rates were estimated by sex, municipality, health region and primary site and were age-standardized to the 2000 PR population. RESULTS: Incidence rates for overall cancer remained constant in men and increased in women (APC = 0.6%, p < 0.05), while mortality rates decreased (APC = -1.0%) for both sexes. A significant increase was observed in the cancer incidence rates for colorectal cancer in men, while in women, an increase in breast, colorectal, and corpus and uterus cancer was observed. Mortality rates decreased for most of the major cancers types in both sexes, except for colorectal cancer in men which showed a significant increase (p < 0.05). CONCLUSION: The most important cancer types in PR (prostate, breast, colorectal, and lung) for both incidence and mortality are susceptible to primary prevention (eliminating or reducing risk factors) or to secondary prevention (early diagnosis) strategies. Our results are essential for the development of cancer prevention and control strategies in the Island.

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.

Prevalence of chronic hepatitis C virus genotypes among patients between 21 to 65 years old in Puerto Rico.

OBJECTIVES: This is the first study done in Puerto Rico to estimate the prevalence of hepatitis C virus (HCV) genotype distribution in patients with chronic infection and to determine the statistical association between the genotype and variables such as age, sex, HCV risk factors, and viral load. METHODS: Chronic HCV infected patients diagnosed with ELISA, RIBA or PCR from 1990 to 2002 who were under follow up with members of the Puerto Rico Gastroenterological Association were asked to participate. Eligible patients were those without evidence of HIV or other viral hepatic infection; had no previous antiviral treatment or if previously treated, therapy ended at least six months prior to their participation in the study; had no history of organ transplant and were willing to participate. All study subjects completed a study questionnaire and had blood samples taken to determine HCV genotype and viral load. RESULTS: 500 patients were recruited. Most of the study subjects were males (68%); 70% were 45 to 65 years old. The principal reported risk factors were: surgeries (75.5%), drug use (46.8%), sexual relationships with intravenous/intranasal drug users (30.3%), blood transfusions (30.2%), multiple sex partners (28.9%), tattoos (22.0%), needle accidents (12.7%), and sexual relationships with an HCV infected partner (9.0%). Most patients had multiple risks factors for infection, only 3.4% (17/500) reported a single risk factor whereas 2.0% (10/500) reported none. 33% of the patients were previously treated (non-responders or relapsers) while 67% were naive. In general, 82% of the HCV patients had genotype 1, while 18% had non-1 genotypes. Among genotype 1 subtypes, genotype la (39.8 %) was more common than 1b (27%). The most common non-1 genotype was genotype 2 of which 2b represented 9.8% of the study population. Similar distribution was observed within the categories of the HCV risk factors, with the exception of those who reported sex with an infected partner (p=0.018), sex with multiple sexual partners (p=0.049) and IVDU (p=0.006). For patients in which the viral load was 2 million IU/ml or less, the genotype la (41%) predominates, followed by 1b (29%) and 1a/1b (9%); patients with viral load was greater than 2 million IU/ml, the genotypes distribution was 1a (38%), 1b (24%), and 2b (12%). After adjusting by type of patients (naive and treated), age and gender, no significant association (p<0.05) were found between two-categories of genotype (1 vs. non-1) and HCV risk factors. CONCLUSION: This cross-sectional epidemiological study demonstrated that the most frequent genotype found in Puerto Rican HCV infected patients is genotype 1. The principal risk factors associated in our population were: surgeries, drug use, blood transfusions, sexual relationships with IVDU, and multiple sex partners. The statistical evidence showed that the genotype distribution is not affected by the HCV risk factor, after adjusting by type of patients (naive and treated), age, gender or geographical area.

Breast cancer health promotion model for older Puerto Rican women: results of a pilot programme.

This article focuses on the development of a health promotion model programme for elderly Puerto Rican women intended to minimize barriers for early detection of breast cancer and to increase women's compliance with recommended guidelines. The programme was designed based on the findings of a national sample to assess knowledge, beliefs and practices of breast cancer early detection in Puerto Rican elderly women and their perceptions of barriers associated with non-compliance. It involves the combination of educational and environmental support for actions and conditions conducive to health behaviour and consists of the following components: (i) a culture- and cohort-sensitive health education programme for elderly women on breast cancer screening and assertive strategies for client-physician relationship; (ii) training for primary-care providers on current guidelines and barriers affecting compliance among older women in Puerto Rico; and (iii) coordination of necessary support services to facilitate access to clinical breast exams and mammograms. Programme implementation considers appropriate theories for health promotion and education in the older population. Evaluation measured progress in the plan implementation by assessing immediate products and long-term impact of the programme. Results of the pilot programme revealed a slight increase in knowledge and a significant decrease (p < 0.05) in beliefs after the health education sessions. Interventions in breast cancer early detection practices showed significant changes (p < 0.05) for mammogram and clinical breast examination. Different strategies must be combined to increase older women's compliance with breast cancer screening. Health system and access barriers to preventive care must be addressed.

Knowledge and beliefs of breast cancer among elderly women in Puerto Rico

This is the first national study of breast-cancer knowledge, beliefs, and early detection practices among elderly women (65+) in Puerto Rico. Cancer breast examination (CBE) was the most common early detection practice, followed by the mammogram, with breast self exam (BSE) a distant third. The primary reasons most often cited for never having a mammogram related to both personal and external factors: not having symptoms, negligence or forgetfulness, and not having a physician's referral. No statistically significant difference (p < 0.05) was found between knowledge and early detection practices. Conversely, beliefs had an impact on preventive behavior. Those who had less misconceptions were most likely to have had a CBE or a mammogram. Bivariate analysis demonstrated that age was associated with performing a BSE once or twice monthly, ever having a mammogram, and having a mammogram in the past two years. A higher socioeconomic status was associated to performing BSE and ever having had a mammogram. Education correlated positively to ever having a mammogram or having a mammogram in the two years prior to the interview. Factors that explained compliance with a mammogram in the last two years included referral from a physician, owning a car, and receiving information after menopause on breast cancer from a health care provider. A gynecological visit increased the probability of having had a mammogram during the last two years. Logistic regression determined that a referral from a physician was the most important factor for mammogram compliance when a combination of variables were considered.

Trends in diabetes mellitus mortality in Puerto Rico: 1980-1997

OBJECTIVE: To determine the characteristics and trends of diabetes mortality among the Puerto Rican population from 1980 through 1997. METHODS: Death certificates for Puerto Rican residents whose underlying cause of death was diabetes mellitus (ICD-9-250.0) were reviewed, and sociodemographic information was abstracted. The proportion mortality ratio (PMR) and 95 confidence intervals were calculated by gender, age group, educational level and period of time. Trend analysis in mortality was performed using a Poisson regression model. RESULTS: A total of 26,193 deaths (5.8) were primarily attributed to diabetes mellitus in the study period. Females accounted for 55.8 of all diabetes related deaths. Diabetes accounted for a higher proportion of deaths among persons aged 60-64 years (8.14), persons aged 65-74 (8.12), females (7.73) and those with 1-6 years of education (7.08). The PMR steadily increased from 4.55 in the 1980-85 period to 6.91 in the 1992-97 period. There was a higher mortality in male diabetic subjects aged < or = 64 than in females during the 18 year period. Between 1980 and 1991, females aged 65-74 had a higher mortality than males, however, mortality increased in males of the same age group during 1992-97. When the oldest age group (> or = 75) was examined, males had a higher mortality between 1986 and 1997, whereas females had a slightly higher rate between 1980 and 1985. CONCLUSIONS: Our results indicate that diabetes mortality has been markedly increasing in the Puerto Rican population, primarily in persons aged 65 years or more. Further analysis is needed to evaluate the determinants of mortality in diabetes.

Descripción del estado de salud y la capacidad funcional de la población de 65 años o más residente en la Región Universitaria de Salud de Puerto Rico / Description of health status and functional capacity of the 65-years-old and older population residing in the University Region of Health of Puerto Rico

This study intended to describe the health and functional status of the population 65 years and over resident in the Puerto Rico University Health Region (municipalities of Canóvanas, Loiza, Carolina and Trujillo Alto, Puerto Rico). Four ninety one hundred elderly subjects selected from a random sample of households, were interviewed. A questionnaire was designed to gather data of the following variables: health conditions, functional capacity, health services utilization, social support and preventive measures. Descriptive measures and chi-square were utilized for the statistical analysis. Findings revealed a population composed mostly of women with a higher prevalence of health conditions than their male counterparts. More than half of the sample report visual problems, arthritis or hypertension. Almost a quarter had diabetes mellitus. The prevalence of these conditions was higher in the age group over 75, with the exception of diabetes. Thirty percent of the sample was classified as functionally dependent, condition that increased with the subject's age. Findings evidence the need of an early assessment in this population in order to intervene with potentially modifiable factors to prevent future disability and improve quality of life of the aged.