Short- and mid-term outcomes in systemic lupus erythematosus patients presenting with disease exacerbation after SARS-CoV-2 mRNA vaccination: A cohort study from Puerto Rico.

OBJECTIVE: To determine if SARS-CoV-2 mRNA vaccination has an impact on the clinical course of systemic lupus erythematosus (SLE). METHODS: Puerto Ricans with SLE who received mRNA COVID-19 vaccines were studied. Demographic parameters, clinical manifestations, disease activity (per Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), disease damage (per Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index), emergency room visits, hospitalizations, and pharmacologic therapy were determined. Baseline variables (prior to vaccination) were compared between patients with and without exacerbation after SARS-CoV-2 vaccination. Among those with exacerbation, clinical outcomes were determined up to 1 year after vaccination. RESULTS: Of the entire cohort (n = 247), 14 (5.7%) had post-vaccination exacerbations. Photosensitivity, oral ulcers, anti-Ro antibodies, higher SLEDAI score, and corticosteroids exposure were associated with post-vaccination flares. Among those with post-vaccination flares, 10 (71.4%) had major organ involvement. No significant differences were observed for mean SLEDAI scores, emergency room visits, hospitalizations, disease damage, and exposure to immunosuppressive drugs before and after SARS-CoV-2 mRNA vaccination. At 12 months of follow-up, all patients were fully controlled without evidence of active disease. CONCLUSION: In our group of SLE patients, 5.7% had a disease flare after SARS-CoV-2 mRNA vaccination. Most had exacerbations involving major organs/systems. Mucocutaneous manifestations, anti-Ro antibodies, disease activity, and corticosteroids were associated with flares. Awareness of these factors and the possibility of a major lupus flare after vaccination with COVD-19 vaccines is critical to provide timely and effective therapy.

Recidivism at the puerto rico trauma hospital.

PURPOSE: Although trauma represents a leading cause of morbidity and mortality worldwide, there is limited and heterogeneous evidence regarding trauma recidivism and its outcomes. This analysis determined the rate and independent risk factors of trauma recidivism and compared the first and second injury episode among recidivists. METHODS: An IRB-approved retrospective cohort study was performed with data from the Puerto Rico Trauma Hospital Registry. Bivariate analyses were done using Pearson's Chi squared, Wilcoxon rank-sum, McNemar, Stuart-Maxwell or Wilcoxon signed-rank tests, as appropriate. Independent predictors for recidivism were determined through a logistic regression model. Statistical significance was set at p < 0.05. RESULTS: 24,650 patients were admitted to the hospital during 2000-2017. Recidivism rate was 14 per 1,000 patients discharged alive. Males and individuals aged 15-24 years old were 3.88 (95% CI: 2.21-6.80) and 3.80 (95% CI: 2.24-6.46) times more likely to be recidivists, respectively. Contrariwise, an ISS [Formula: see text] 25 [adjusted odds ratio (AOR) = 0.44; 95% CI: 0.28-0.68] and a GCS [Formula: see text] 8 (AOR = 0.56; 95% CI 0.34-0.92) were protective factors. Furthermore, recidivists exhibited less in-hospital mortality than their non-recidivist counterparts (7.2% vs. 10.7%; p = 0.045). For recidivists, the median (interquartile range) time to reinjury was 42 (59) months; and the second injury episode was more severe than the first one, as the proportion of patients with ISS [Formula: see text] 25 increased (7.9% vs. 14.1%; p = 0.022). CONCLUSION: The independent predictors of trauma recidivism and the median time to reinjury identified in this study provide valuable information to the development of prevention strategies aimed at reducing the burden of injury.

The effect of the lockdown executive order during the COVID-19 pandemic in recent trauma admissions in Puerto Rico.

BACKGROUND: The COVID-19 pandemic led to world-wide restrictions on social activities to curb the spread of this disease. Very little is known about the impact of these restrictions on trauma centers. Our objective was to determine the effect of the pandemic-associated lockdown on trauma admissions, patient's demographics, mechanisms of injury, injury severity, and outcomes in the Puerto Rico Trauma Hospital. METHODS: An IRB-approved quasi-experimental study was performed to assess the impact of the restrictions by comparing trauma admissions during the lockdown (March 15, 2020 - June 15, 2020) with a control period (same period in 2017-2019). Comparisons were done using the Pearson's chi-square test, Fisher exact test, or Mann-Whitney U test, as appropriate. A negative binomial model was fitted to estimate the incidence rate ratio for overall admissions among pre-lockdown and during-lockdown periods. Statistical significance was set at p < 0.05. RESULTS: A total of 308 subjects were admitted during the quarter of study for 2017; 323, for 2018; 347, for 2019; and 150, for 2020. The median (interquartile range) age of patients rose significantly from 40 (33) years to 49 (30) years (p < 0.001) for the lockdown period compared to the historical period. Almost all mechanisms of injury (i.e., motor vehicle accident, assault, pedestrian, burn, suicide attempt, other) had a slight non-significant reduction in the percentage of patients presenting with an injury. Instead, falls experienced an increase during the lockdown period (18.9% vs. 26.7%; p = 0.026). Moreover, the proportion of severe cases decreased, as measured by an injury severity score (ISS) > 15 (37.3% vs. 26.8%; p = 0.014); while there were no differences in the median hospital length of stay and the mortality rate between the comparison groups. Finally, the decrease in overall admissions registered during the lockdown accounts for a 59% (IRR 0.41; 95% CI 0.31-0.54) change compared to the pre-lockdown period, when controlling for sex, age, mechanism of injury, and ISS. CONCLUSIONS: Following periods of social isolation and curfews, trauma centers can expect drastic reductions in their overall patient volume with associated changes in trauma patterns. Our findings will help inform new interventions and improve healthcare preparedness for future or similar circumstances.

Epidemiology of traumatic falls after Hurricane Maria in Puerto Rico.

BACKGROUND: Hurricanes are among the most devastating natural disasters, playing a significant role in public health. Currently, the epidemiology of fall-related injuries after the occurrence of a tropical storm is not well described. This study aims to compare the demographical patterns, clinical profile, hospital course, and costs of patients admitted to the Puerto Rico Trauma Hospital before and after Hurricane Maria. METHODS: A retrospective study was performed to compare fall-related injuries after the hurricane (September 20, 2017 - January 20, 2018) with a control period (same period in 2014-2016). Comparison between the groups was done using chi-square, Mann-Whitney test, and logistical regression. RESULTS: After the hurricane, there was an increase in the proportion of fall-related admissions in subjects aged 40-64 years (39.2% vs. 50.6%) and a decrease among those aged 18-39 years (16.0% vs. 5.9%), when compared with the previous years. A greater proportion of patients presented with work related injuries (3.9% vs. 9.4%). No significant differences were identified for sex, Glasgow Coma Scale, Injury Severity Score, and hospital outcomes (hospital and intensive care unit days, mechanical ventilation, and mortality). Intracranial injuries were marginally higher post-Maria (p = 0.06). In multivariate analysis, during the post-Maria period, an increased risk of fall-related injuries was observed among subjects ≥40 years (OR: 3.20) and injuries related to recovery work (OR: 2.64) (p < 0.05). CONCLUSIONS: Our study shows that there is an increased risk of fall-related injuries among middle-aged individuals after a hurricane, causing significant changes in epidemiology. This study helps to elucidate the health consequences of falls and, in doing so, improves healthcare preparedness, interventions, and planning for future natural disasters.

Unveiling the Natural History of Category 4 Tropical Cyclones: The Puerto Rico Trauma Hospital Experience after Hurricane Maria.

OBJECTIVES: The hazardous environmental conditions hurricanes create might increase injury incidence almost 7 times. Therefore, a cohort study was performed at the Puerto Rico Trauma Hospital to compare morbidity and mortality patterns of patients after Hurricane Maria with a control period. METHODS: Admissions from September 20, 2017, through January 20, 2018, constituted the post-Maria period (473 patients); the corresponding months of the previous year comprised the pre-Maria period (439 patients). Comparisons were done using Pearson's chi-square or Mann-Whitney U-tests, as appropriate. A logistic regression was performed to assess the association between mortality and the study period. RESULTS: Postlandfall admissions among patients aged 40-64 y increased by 6.6%, while among subjects between ages 18 and 39 y dropped by 7.0% (P = 0.03). Falls, gunshots, and burns were the injury mechanisms that varied the most across the exposure period. The median Injury Severity Score (13 vs 12; P = 0.05) and the frequency of Glasgow Coma Scale scores ≤8 (17.1% vs 10.9%; P = 0.03) were higher among poststorm patients. Moreover, a 2-fold (odds ratio = 1.93; 95% CI: 1.07-3.47) increase in mortality was observed after Maria, when adjusting for covariates. CONCLUSIONS: Following a hurricane, trauma centers might expect an older population, with more severe injuries and a 2-fold increased mortality risk.

Association of soluble TREM-like transcript-1 with clinical features and patient reported outcomes in systemic lupus erythematosus.

OBJECTIVE: The soluble triggering receptor expressed on myeloid cells (TREM-1)-like transcript 1 (sTLT-1) has a modulatory effect on the activation of TREM-1. We compared plasma sTLT-1 levels between patients with systemic lupus erythematosus (SLE) and healthy individuals and determined the association between sTLT-1 levels and clinical features and patient-reported outcomes (PROs) among patients with lupus. METHODS: An unmatched case-control study was conducted in 46 patients with SLE and 28 healthy subjects. sTLT-1 plasma levels were determined using enzyme-linked immunosorbent assay. Demographic factors, SLE manifestations, comorbidities, pharmacologic profile, disease activity (per SLAM-R), damage accrual, and PROs (as per Lupus Patient-Reported Outcome [LupusPRO]) were studied. RESULTS: Patients with SLE were found to have lower sTLT-1 levels compared with healthy individuals (9.0±7.2 vs. 18.6±22.3 pg/mL, p=0.008). Among patients with SLE, higher sTLT-1 levels were found in those taking corticosteroids (11.1±8.8 vs. 6.9±4.6 pg/mL, p=0.014). Significant correlations were found for the cognition (r=-0.442, p=0.027) and desires/goals (r=0.435, p=0.030) domains of LupusPRO. A tendency was observed between sTLT-1 levels and the SLAM-R (r=-0.278, p=0.064) and the lupus symptoms (r=-0.388, p=0.055) and physical health (r=-0.382, p=0.060) domains of LupusPRO. CONCLUSION: Compared with healthy individuals, sTLT-1 levels were significantly lower in patients with SLE. Among patients with SLE, correlations were observed for some domains of LupusPRO. Given that sTLT-1 has anti-inflammatory properties, the deficiency of this protein could play an important role in the pathogenesis of SLE.

Patient-reported outcome measures in a population of medically indigent patients with systemic lupus erythematosus in Puerto Rico.

OBJECTIVE: To determine patient-reported outcomes measures in indigent patients with systemic lupus erythematosus receiving their healthcare through the Puerto Rico government managed care system and compare these measures with non-indigent patients treated in a private fee-for-service setting. METHODS: A cross-sectional study was conducted in a cohort of 98 Puerto Ricans with systemic lupus erythematosus. Patients from the public group (n = 40) were treated in a university-based specialized systemic lupus erythematosus clinic and the private group (n = 58) in a community-based rheumatology practice. Demographic and clinical features and patient-reported outcomes measures per LupusPRO instrument were determined. LupusPRO captures quality-of-life measures in 12 domains. Differences among study groups were examined using chi-square, Fisher's exact, t-tests, and the Wilcoxon signed-rank test. RESULTS: The mean (standard deviation) age of the study population was 44.9 (12.0) years; 94 (95.9%) were women. Patients in the public setting were younger and were more likely to have renal disease and elevated anti-double-stranded DNA antibodies, and being treated with azathioprine and cyclophosphamide. Patients from the public sector were more likely to have better quality-of-life measures in the LupusPRO domains of pain/vitality and coping. No significant differences were observed for the domains of lupus symptoms, physical health, emotional health, body image, cognition, procreation, lupus medications, desires/goals, social support, and satisfaction with medical care. CONCLUSION: Despite having a lower socioeconomic status and worse clinical status, systemic lupus erythematosus patients from the public sector had equal or better patient-reported outcomes measures than those treated in the private setting. This favorable outcome may be associated with the comprehensive healthcare received by these patients in a specialized lupus clinic.

Usefulness of the culturally adapted oxygen-cost diagram in the assessment of dyspnea in Puerto Rico.

OBJECTIVE: Breathlessness is a common and disabling symptom of pulmonary disease. Measuring its severity is recommended as such measurements can be helpful in both clinical and research settings. The oxygen-cost diagram (OCD) and the Medical Research Council (MRC) dyspnea scale were developed in English to measure severity of dyspnea. These scales were previously translated to Spanish and adapted for use in a Hispanic population. The objective of this study is to assess the psychometric properties of these scales. We propose the scales correlate well with measures of physiological impairment. METHODS: Subjects having pulmonary disease rated their perceptions of dyspnea using the scales, performed a spirometry test, and did a 6-min walk. Spearman correlation coefficients (p) were used to correlate dyspnea scores with spirometric parameters and distance walked (6MWD). RESULTS: Sixty-six patients having stable asthma (n = 36), chronic obstructive pulmonary disease (n = 19), or interstitial lung disease (n = 11) participated in the study. OCD scores showed a significant correlation with FEV1 (p = 0.41; p < 0.01), FEV1% (p = 0.36; p < 0.01), FVC (p = 0.44; p < 0.01), and FVC% (p = 0.37; p < 0.01) in the study population. The OCD scores were highly correlated with 6MWD (p = 0.59, p < 0.01). The MRC dyspnea scale showed significant inverse correlation with FEV1 (p = -0.34; p < 0.01) and 6MWD (p = -0.33; p < 0.05), but the correlations were weaker compared to the correlations with the OCD scale. CONCLUSION: The severity of breathlessness as measured by the adapted Spanish OCD showed a moderate to high correlation with spirometric parameters and 6MWD; therefore, the adapted OCD should prove to be useful in Puerto Rico.

Pharmacogenetic association study of warfarin safety endpoints in Puerto Ricans.

OBJECTIVE: This study was intended to determine the incidence rate of warfarin-related adverse events (e.g., bleeding) in Puerto Ricans and whether a genetic association between warfarin pharmacogenes and any of these adverse events was observed over the initiation period (i.e., the first 90 days of therapy). METHODS: We conducted an observational, retrospective cohort study of pharmacogenetic association in 122 warfarin-treated, male, Puerto Rican patients (69.9 +/- 9.6 years) from the Veterans Affair Caribbean Healthcare System (VACHS) who consented to participate. Genotyping was performed using the CYP2C9 and VKORC1 assays by Luminex. Event-free survival curves were estimated using the Kaplan-Meier method and analyzed by log-rank test. Cox regression models were constructed and hazard ratios (HR) calculated. RESULTS: Carriers of functional CYP2C9 and VKORC1 polymorphisms demonstrated a higher incidence rate of multiple adverse events (i.e., 5.2 vs. 1.0 cases per 100 patient-months; RR = 4.8, p = 0.12) than did wild types. A significant association was observed between multiple adverse events and carrier status (HR = 2.5; 95% CI: 1.0-6.3, p = 0.04). However, no significant associations between genotypes and individual outcomes over the first 90 days of therapy were found. CONCLUSION: The association of CYP2C9 and VKORC1 genotypes and risks for adverse events due to exposure to warfarin was examined for the first time in Puerto Ricans. Despite a lack of association with individual events in this study population, our findings revealed a potential utility of genotyping for the prevention of multiple adverse events during warfarin therapy.

Association of the use of statins with disease activity and functional status in Puerto Ricans with rheumatoid arthritis.

OBJECTIVE: Statins, which appear to have anti-inflammatory and immunomodulatory effects, may benefit patients with rheumatoid arthritis (RA). Our study sought to determine the association of statins use with disease activity and functional status in a group of patients with RA. METHODS: A cross-sectional study was performed in 209 Puerto Ricans with RA (per the 1987 classification criteria of the American College of Rheumatology). Demographic features, lifestyle-related behaviors, disease activity (per Disease Activity Score 28), comorbid conditions, functional status (per Health Assessment Questionnaire), pharmacologic therapy, and patients' and physicians' global assessments using visual analogue scales, were determined. Data were examined using univariate, bivariate, and multiple logistic regression analyses. RESULTS: The mean (standard deviation [SD]) age of the study population at study visit was 56.8 (13.5) years (range: 24-86 years); 175 patients (83.7%) were women. The mean (SD) disease duration was 10.4 (9.5) years (range: 0.0-44.0 years). Thirty-two (15.3%) patients were using statins at study visit, and 36 (17.2%) had used statins in the past. In the multivariable analysis, the current use of statins was associated with higher functional status (odds ratio 0.42, 95% confidence interval 0.22-0.80) than was nonuse, after adjusting for age, disease duration, arterial hypertension, coronary artery disease, and dyslipidemia. No association between either current or past use of statins and disease activity was found. CONCLUSION: In this group of RA patients, the current use of statins was associated with a higher functional status; conversely, no association was found between statins use and disease activity. However, larger and longitudinal studies are required to confirm these findings.

Factors associated with regional rheumatic pain disorders in a population of Puerto Ricans with diabetes mellitus.

The aim of the study was to determine the prevalence and factors associated with bursitis/tendonitis disorders in Puerto Ricans with diabetes mellitus (DM). A cross-sectional study was performed in 202 adult Puerto Ricans (100 DM patients and 102 non-diabetic subjects). For each participant, a complete medical history and a musculoskeletal exam were systematically performed. Socio-demographic parameters, health-related behaviors, comorbidities, and pharmacotherapy were determined for all subjects. For DM patients, disease duration, glycemic control, and DM long-term complications were also examined. Multivariate logistic regression analyses were used to determine the factors associated with bursitis/tendonitis disorders. The mean (SD) age for DM patients and non-diabetic controls were 53.3 (12.9) and 50.0 (13.1) years; 64.0 and 64.7 % of DM patients and controls were females, respectively. Overall, the prevalence of bursitis/tendonitis was higher in DM patients than among non-diabetics (59.0 % vs. 29.4 %, p < 0.01). In multivariate analyses, DM patients had 2.47 (95 % CI 1.05, 5.84) the odds of having bursitis/tendonitis as compared to non-diabetics. Specifically, DM patients had a higher frequency of flexor tenosynovitis, De Quervain's tenosynovitis, lateral epicondylitis, medial epicondylitis, trochanteric bursitis, and anserine bursitis than non-diabetic subjects (p < 0.05). Among DM patients, multivariate analyses showed that those with bursitis/tendonitis were more likely to be female [OR (95 % CI) 4.55 (1.42, 14.55)] and have peripheral vascular disease [OR (95 % CI) 8.48 (1.71, 41.93)]. In conclusion, bursitis/tendonitis disorders were common in this population of Hispanics with DM. Among DM patients, bursitis/tendonitis disorders were more frequent in women and those with long-term complications such as peripheral vascular disease.

Pediatric Risk, Injury, Failure, Loss, End-Stage renal disease score identifies acute kidney injury and predicts mortality in critically ill children: a prospective study.

OBJECTIVES: To determine whether Pediatric Risk, Injury, Failure, Loss, End-Stage renal disease (pRIFLE) criteria serve to characterize the pattern of acute kidney injury in critically ill pediatric patients. To identify if pRIFLE score will predict morbidity and mortality in our patient's cohort. DESIGN: Prospective cohort. SETTING: Multidisciplinary, tertiary care, ten-bed PICU. PATIENTS: A total of 266 patients admitted to PICU from November 2009 to November 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The incidence of acute kidney injury in the PICU was 27.4%, of which 83.5% presented within 72 hours of admission to the PICU. Patients with acute kidney injury were younger; weighed less; were more likely to be on fluid overload greater than or equal to 10%; and were more likely to be on inotropic support, diuretics, or aminoglycosides. No difference in gender, use of other nephrotoxins, or mechanical ventilation was observed. Fluid overload greater than or equal to 10% was an independent predictor of morbidity and mortality. In multivariate analysis, acute kidney injury and failure categories, as defined by pRIFLE, predicted mortality, hospital length of stay, and PICU length of stay. CONCLUSIONS: In this cohort of critically ill pediatric patients, acute kidney injury identified by pRIFLE and fluid overload greater than or equal to 10% predicted increased morbidity and mortality. Implementation of pRIFLE scoring and close monitoring of fluid overload upon admission may help develop early interventions to prevent and treat acute kidney injury in critically ill children.

Association of hand or knee osteoarthritis with diabetes mellitus in a population of Hispanics from Puerto Rico.

BACKGROUND: Although a higher prevalence of osteoarthritis (OA) has been reported among diabetes mellitus (DM) patients, inconsistencies and limitations of observational studies have precluded a conclusive association. OBJECTIVE: The objective of this study was to evaluate the association of hand or knee OA with DM in a population of Hispanics from Puerto Rico. METHODS: A cross-sectional study was performed in 202 subjects (100 adult DM patients as per the National Diabetes Data Group Classification and 102 nondiabetic subjects). Osteoarthritis of hand and knee was ascertained using the American College of Rheumatology classification criteria. Sociodemographic characteristics, health-related behaviors, comorbidities, pharmacotherapy, and DM clinical manifestations were determined. Multivariable logistic regression was used to evaluate the association of DM with hand or knee OA and to evaluate factors associated with hand or knee OA among DM patients. RESULTS: The mean (SD) age for DM patients was 51.6 (13.1) years; 64.0% were females. The mean (SD) DM duration was 11.0 (10.4) years. The prevalence of OA in patients with DM and nondiabetic subjects was 49.0% and 26.5%, respectively (P < 0.01). In the multivariable analysis, patients with DM had 2.18 the odds of having OA when compared with nondiabetic subjects (95% confidence interval [CI], 1.12-4.24). In a subanalysis among DM patients, female patients were more likely to have hand or knee OA (odds ratio [95% CI], 5.06 [1.66-15.66]), whereas patients who did not use insulin alone for DM therapy were more likely to have OA (odds ratio [95% CI], 4.44 [1.22-16.12]). CONCLUSIONS: In this population of Hispanics from Puerto Rico, DM patients were more likely to have OA of hands or knees than were nondiabetic subjects. This association was retained in multivariable models accounting for established risk factors for OA. Among DM patients, females were at greater risk for OA, whereas the use of insulin was negatively associated.

Rectal adenocarcinoma: proposal for a model based on pretreatment prognostic factors.

OBJECTIVE: Currently the choice of chemotherapy regimen in rectal cancer is made prior to surgery in contrast to colon cancer where it is made postoperatively after the pathological stage has been determined. If we could identify which are the important pretreatment prognostic factors in rectal cancer, we could then target those patients with unfavorable features to investigate potentially more effective preoperative chemotherapy regimens aimed at those with unfavorable features. The present study aimed to determine pre-treatment prognostic factors that are associated with an unfavorable outcome. METHODS: A retrospective review of 99 rectal cancer patients operated at the Auxilio Mutuo Hospital, San Juan, Puerto Rico, and the San Pablo Hospital, Bayamón, Puerto Rico was done. Socio-demographic, clinical and treatment data were collected. RESULTS: Of the 99 cases, 54% were males. The mean age +/- standard deviation was 62.2 +/- 10.4. In age-adjusted Cox model, male gender (HR [95%CI]: 3.32 [1.09-10.13]), mucinous carcinoma (HR [95% CI]: 3.67 [1.25-10.77]), and clinical stages II & III (HR [95%CI]: 8.19 [1.08-62.08]) were predictors of poor prognosis. In the multivariate age-adjusted analysis, a tendency towards a poorer prognosis was observed for male patients (HR: 2.60), carcinoembryonic antigen level > or =5 ng/ml (HR: 2.55), mucinous carcinoma (HR: 2.96), and clinical stages II & III (HR: 4.96), although results were not statistically significant (p > 0.05). CONCLUSION: Although current therapeutic results are relatively favorable with preoperative 5-fluorouracil and radiotherapy, future clinical trials should address the management of those cases with adverse pretreatment prognostic factors so that they can be treated with potentially more effective albeit more toxic chemotherapy regimens.

The association of body mass index and perforation of the appendix in Puerto Rican children.

OBJECTIVE: Puerto Rico Department of Health lacks data on appendicitis since 1996. We inquired about factors influencing perforation. METHODS: Retrospective study of risk factors among Puerto Rican children with appendicitis from 2002-2008. RESULTS: One hundred and seventy records were reviewed. Appendiceal perforation = 38%. Median age was 10 years. Risk factors for perforation were age younger than five years, onset of symptoms more than 36 hours previously, public insurance, more than two examiners, and public hospital. Obese patients had a tendency to present with perforation (OR: 1.5 (0.6-3.5)). In the multivariate analysis, the only variables that remained significant were age younger than five years (OR: 10.2 (2.2-46.7)), and onset of symptoms more than 36 hours previously (OR: 5.9 (2.3-14.7)). CONCLUSION: Age younger than five years and onset of symptoms more than 36 hours previously were associated with perforation of the appendix. Body mass index for age percentile greater than the 95th had a tendency to present with perforation.

Outcome and predictors of kidney disease progression in Puerto Ricans with systemic lupus erythematosus initially presenting with mild renal involvement.

OBJECTIVES: The aims of this study were to determine the outcomes and predictors of renal disease progression in Puerto Ricans with systemic lupus erythematosus (SLE) initially presenting mild renal involvement. METHODS: A retrospective cohort of 61 patients with SLE (per American College of Rheumatology classification) with mild renal involvement was studied. Mild renal disease was defined as glomerular filtration rate (GFR) of 90 mL/min or higher in the presence of proteinuria (>0.25 g/d, but <3.5 g/d), hematuria, and/or urinary cellular casts. Demographic parameters, clinical manifestations, serologic markers, comorbidities, pharmacologic treatments, disease activity, and damage accrual were determined at onset of renal disease. Factors associated with renal disease progression were evaluated using recurrent event survival analysis. RESULTS: Of 61 patients, 55 (90.2%) were women. The mean (SD) age at renal onset was 29 (11.2) years, and the mean (SD) follow-up period was 5.1 (3.4) years. Thirty-eight patients had a decline in GFR. Thirty-two had a mild decline (GFR = 60-89 mL/min), 5 developed moderate to severe renal insufficiency (GFR = 15-59 mL/min), and 1 evolved to end-stage renal disease (GFR < 15 mL/min). In the Cox model, low C4 levels and proteinuria greater than 0.5 g/d were associated with an earlier decline in GFR. CONCLUSIONS: Most Puerto Rican patients with SLE initially presenting with mild renal involvement had a decrease in GFR after an average of 5 years of kidney disease, although most had a mild dysfunction. Low C4 levels and proteinuria were predictors of an earlier decline in GFR. We emphasize that awareness of these factors may contribute to early identification of individuals at risk for renal deterioration.

Candidemia distribution, associated risk factors, and attributed mortality at a university-based medical center.

Candida is the fourth most common cause of nosocomial bloodstream infections (BSI), being Candida albicans the most common species. This study evaluated the distribution of Candida spp isolates at a tertiary care medical center. The associated factors and outcome of patients with candidemia at the Puerto Rico Medical Center (PRMC) were evaluated. Laboratory data from May 2005 to April 2006 was reviewed. Blood cultures reported as positive for Candida spp were identified and records were reviewed. Two hundred and four blood cultures were reported with Candida spp, corresponding to 85 different episodes of candidemia in 82 patients: 3 patients presented more than one candidemia episode with two different Candida spp. In seventy-two percent (61/85) of candidemia episodes, the organism isolated was a non-albicans Candida, being C. parapsilosis the most common species isolated with 49% (42/85). Sixty five records were evaluated; of which 45 cases were reviewed (20 cases were excluded from the study due to incomplete information). The predominant factors identified were being on broad spectrum antibiotics 95.6% (43/45), central catheter placement 97.8% (44/45), mechanical ventilation 64.4% (29/45), and urinary catheter placement 73.3% (33/45). The mortality among the reviewed cases was 48.9% (22/45).