Use of Medicare services by elderly residents of Puerto Rico

OBJECTIVES: We describe hospitalization rates among Medicare beneficiaries resident in Puerto Rico compared to beneficiaries in the mainland U.S., in 1999. METHODS: A cross-sectional analysis using Medicare Denominator and hospitalization files. RESULTS: The rate ratio (PR/U.S.) of age, gender-adjusted hospitalizations among elderly Medicare beneficiaries with Part A coverage was 0.78, compared with 0.92 among beneficiaries with both Part A and Part B coverage. Among the latter, the rate ratios were 0.78 for surgical admissions, 1.08 for low-variation medical conditions, and 0.97 for high variation medical conditions. They were higher for younger elderly beneficiaries. CONCLUSIONS: Rates of hospitalization in Puerto Rico may be lower, the same or exceed those of the mainland U.S. depending on the age of the beneficiary and the type of hospitalization.

CsA-based post-graft immunosuppression: the main factor for improving outcome of allografted patients with acquired aplastic anemia. A retrospective survey by the Spanish Group of Hematopoietic Transplantation.

A retrospective multicenter study was performed to assess the clinical results in patients with acquired aplastic anemia (AA) allografted over a 19 year period and to identify prognostic factors influencing survival. From April 1978 to December 1997, 176 patients were transplanted. Records from 160 receiving related matched bone marrow transplantation (BMT) were reviewed. Fifty-two percent of the patients were older than 20 years, 5% older than 40; 6.3% were untransfused at BMT and 56.2% had received prior treatments. Conditioning regimens were with chemotherapy in 43.7% of the procedures and with additional irradiation in 56.3%. Graft-versus-host disease (GVHD) prophylaxis was based on cyclosporin A (CsA) in 58.1% of the patients while methotrexate (MTX) was administered to 41.9%. Transplantation earlier on, a longer interval from diagnosis to BMT, GVHD prophylaxis with MTX, graft failure/rejection and acute severe GVHD were adverse factors for survival. The use of CsA emerged as the main factor for the improvement, inducing a significant decrease in graft failure/rejection rate and severe acute GVHD when compared with MTX alone. Radiation-containing regimens decreased the graft failure/rejection rate without improving survival due to the increased risk of acute GVHD. Age and number of transfusions pretransplant did not influence outcome. Survival achieved since 1991 is 79.79%, and graft failure and acute severe GVHD rates are 6.0% and 11.8%, respectively. In conclusion, CsA-based post-graft immunosuppression has been crucial in achieving improved survival in patients with acquired AA up to 40 years of age. Regardless of CsA use, further improvement in survival was apparent with time, probably due to better skills in patient care.

Allogeneic peripheral blood stem cell transplantation with reduced-intensity conditioning: results of a prospective multicentre study.

Reduced-intensity conditioning (RIC) regimens for allogeneic haematopoietic stem cell transplantation (SCT) have been shown to lead to engraftment of donor stem cells without the severe extra-haematological toxicities of traditional myeloablative transplants. Between December 1998 and December 2000, 76 patients underwent a RIC peripheral blood SCT in a prospective multicentre study. The median age was 53 years, and 57 patients were beyond the early phase of their disease. The conditioning regimens consisted of fludarabine (150 mg/m2) plus melphalan (140 mg/m2) or busulphan (10 mg/kg). Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin A plus short-course methotrexate. The preparative regimens were well tolerated. All patients experienced severe pancytopenia, but haematological recovery was prompt in all but two cases (early deaths). The 100-d probability of developing grade II-IV acute GVHD was 32% (10% grade III-IV), and the 1-year probability of developing chronic extensive GVHD was 43%. Early complete donor chimaerism was observed in 52/68 patients, and 16 evaluable patients were in complete chimaerism 1 year post transplant. With a median follow-up of 283 d (355 in 48 survivors), the 1-year probability of transplant-related mortality was 20%, and the 1-year overall and progression-free survivals were 60% and 55% respectively. In conclusion, RIC regimens lead to low early toxicity after allografting, with stable donor haematopoietic engraftment, with an apparent low risk of acute GVHD. Chronic GVHD, however, develops in a significant proportion of patients.

Predictors of adverse events after percutaneous transluminal coronary angioplasty in a group of Hispanic patients.

OBJECTIVE: To identify predictors of adverse events after PTCA during hospitalization and after hospital discharge in a private hospital in Puerto Rico. BACKGROUND: A review of the literature shows limited information about predictors of adverse events associated to percutaneous transluminal coronary angioplasty (PTCA) in Hispanic patients. METHODS: This is a non-concurrent prospective study. Baseline variables were analyzed using multivariate logistic regression to identify predictors of adverse events. Data were collected from medical charts and telephone reports from referring physicians. RESULTS: Data from 197 subjects undergoing PTCA were analyzed for this study. Median age of patients was 65 years, and 62.9% of patients were male. Angiographic success rate was 81.6%. A total of 8.1% of patients had at least one in-hospital adverse event, and 39.8% had at least one adverse event after hospital discharge. After multivariate analysis, a statistically significant association was found between the presence of at least one lesion with residual stenosis of 50% or greater and the risk of developing adverse events in-hospital (RO 11.75; 95% CI 4.32-31.97). A marginally significant association was found between family history of heart disease (RO 2.75; 95% CI 0.93-8.11) and the risk of adverse events during hospitalization. Family history of heart disease (RO 1.41; 95% CI 0.98-2.04) and the presence of at least one lesion with residual stenosis of 50% or greater (RO 2.87; 95% CI 0.82-10.01) showed marginally significant associations with increased risk for adverse events after discharge. CONCLUSIONS: These findings suggest that the presence of at least one lesion with residual stenosis of 50% or greater and family history of heart disease may be risk factors for adverse events after PTCA during hospitalization and after discharge.

[Description of health status and functional capacity of the 65-year-old and older population residing in the University Region of Health of Puerto Rico]. / 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.

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.

Prevalence of tuberculin reactivity and risk factors for the development of active tuberculosis upon admission to a nursing home.

A total of 118 nursing home admissions were studied to determine the prevalence of M. tuberculosis infection and the prevalence of risk factors for the development of active tuberculosis. The overall prevalence of positive tests was 22.5%. The most prevalent risk factors for development of active tuberculosis were diabetes mellitus (42.4%), being more than 10% below ideal body weight (41.5%), and alcohol abuse (12.7%). Thirty-four percent of admissions had albumin levels below 3.5 g/dl. No associations were found when logistic regression was used to determine the impact of age and poor nutritional status on the prevalence of positive PPD tests on admission. These results show a substantial difference between the prevalence of positive PPD tests found upon nursing home admissions (22.5%) and the prevalence found previously among residents in the same in nursing home (42.9%).

Prevalence of tuberculin reactivity and prevalence of risk factors for the development of active tuberculosis in a nursing home in Puerto Rico.

A total of 91 nursing home patients were evaluated to determine the prevalence of tuberculous infection and the prevalence of risk factors for active TB in those with positive tuberculin reactions. Overall prevalence rate for positive PPD was 42.9%. No association was found between prevalence of positive PPD and time since admission to the nursing home. The most prevalent risk factors for active TB among PPD positive patients were diabetes mellitus (38.5%), being 10% below ideal body weight (25.6%), chest X ray with fibrotic changes (13.2%), and carcinoma of oropharynx (5.1%). Twenty-one patients (53.8% of patients with positive test) met criteria for prophylactic treatment with isoniazid. This study detected a high prevalence of positive PPD reactions in this nursing home population and a high prevalence of risk factors for the development of active TB in the group with positive reaction to PPD. Due to the high risk for the development of active tuberculosis in this population, aggressive screening and preventive therapy are mandatory.

Prevalence of cognitive and functional impairment in an elderly Puerto Rican population.

Data from the Gurabo census of the elderly, 1987-1988 (n = 1890) were analyzed to determine the prevalence rates for cognitive and functional impairment in that population. Besides socio-demographic questions, the census questionnaire included the Short Portable Mental Status Questionnaire to determine cognitive dysfunction, and the modified Katz Scale to detect functional impairment. The overall prevalence rates were 18.5% and 18.4% for cognitive and functional dysfunction respectively. After multiple logistic regression analysis, cognitive impairment was found to be associated with poor education (OR = 4.0, CI = 2.31-6.93), older age (OR = 2.67, C.I. = 2.00-3.58), functional decline (OR = 2.44, C.I. = 1.83-3.25), female sex (OR = 1.82, C.I. = 1.39-2.40) and low income (OR = 1.49, C.I. = 113-1.98). Functional impairment was found to be associated with cognitive dysfunction (OR = 2.45, C.I. = 1.84-3.27) and older age (OR = 2.08, C.I.-1.59 = 2,72). These findings suggest that a substantial proportion of the elderly in Puerto Rico may require assistance to deal with the consequences of these impairments.

Salt and gastric cancer: a case-control study in Puerto Rico.

A total of 136 incident intestinal type gastric cancer cases and 151 age-comparable population controls were interviewed in Puerto Rico about their dietary habits with special emphasis on dietary salt consumption. All interviews were conducted at home using a quantitative dietary frequency instrument. The weekly intake of foods was estimated from the reported frequency of consumption and portion size according to a food model. The dietary salt exposure was estimated from the intake of nine selected food items which are highly salted food items commonly consumed in Puerto Rico. A strong (odds ratio [OR] = 3.34) and statistically significant (P < 0.001) unadjusted difference was found between cases and controls regarding dietary salt exposure. A statistically significant dose response for the index of salt exposure and gastric cancer was also found. The association remained positive and statistically significant after simultaneously adjusting for the confounding effects of sex, education and cigarette smoking.

[The sociodemographic profile and physical growth patterns of pediatric patients with the acquired immunodeficiency syndrome followed at the San Juan City Hospital: 1986-1990]. / Perfil sociodemográfico y medidas del crecimiento físico en pacientes pediátricos con el síndrome de inmunodeficiencia adquirida seguidos en el Hospital Municipal de San Juan: 1986-1990.

Between September 1989 and August 1990, Puerto Rico was ranked third in the number of pediatric AIDS cases in the United States. The highest number of pediatric AIDS cases has been identified in high risk metropolitan areas. AIDS usually affects children of mothers with history of intravenous drug user. This work attempts to describe the sociodemographic profile and physical growth pattern of the pediatric aids cases followed at the San Juan Aids Institute between the years 1986 and 1990. The sample consist of 40 living patients diagnosed as AIDS cases. Ninety percent of the cases acquired the disease by perinatal transmission. Intravenous drug use by the mother was the most common risk factor identified (67.5% of the cases). Forty two percent of the mothers were not legally married. Seventy percent of the children were born after the 38th week of gestation with an average weight of 2,954 grams and average height of 50.9 centimeters. Upon classification in any P2 categories (according to CDC criteria for children under 13 years of age), 67.7% of the cases were below the 50th. percentile of weight and 86.9% of the cases were below the 50th. percentile of height.

Differences in patient mix: a partial explantation for the excessive Medicare mortality observed in some Puerto Rican hospitals.

Data from a census in a Puerto Rican community were used to retrospectively compare patients admitted to government hospitals in terms of demographic variables, mental status and functional status in the community prior to admission. A total of 268 patients admitted to a hospital at least once during the study period were identified. Patients admitted to government hospitals were poorer, less educated, less functional and had a higher level of mental impairment. However, in comparison to private hospitals, stratified analysis showed consistently higher in-hospital mortality rates among patients admitted to government hospitals when other variables were taken into account.

Increased alanine aminotransferase (ALT-SGPT) activity in Puerto Rican blood donors.

Data was obtained from 4189 volunteer blood donation records in two hospital-based blood banks in Puerto Rico to determine whether Hispanics have higher serum alanine aminotransferase (ALT-SGPT) activity than donors from other racial-ethnic groups. The overall mean value of ALT-SGPT in the study population was 36.84 u/l (range 1-910, standard deviation 37.8). When the logarithm of ALT-SGPT (log ALT) was calculated for all subjects, the overall, mean for log ALT was 1.47 (range 1-2.96, standard deviation 0.27). Analysis of each blood bank's donation records at two different time periods showed a consistently high ALT-SGPT activity even when donations positive for hepatitis B surface antigen or other serologic markers were excluded. Though the causal factor of this finding is not clear, non-infectious environmental such as alcohol consumption should be considered as a probable explanation.

[A model of experimental acute pancreatitis in the conscious rat]. / Modelo de pancreatitis aguda experimental en la rata consciente.

We describe an experimental model of acute pancreatitis in conscious rats, based on biliary reflux; sodium deoxycholate was injected while maintaining the common duct (biliary and pancreatic) temporally occluded. A progressive increase of serum amylase, cardiac rate and hematocrit value, as well as a decrease of plasma proteins are characteristic of this experimental model. Blood pressure was maintained until shortly before death, which occurred after 85 minutes. This is a simple model, reliable and reproducible, which requires minimal surgical manipulation.

[Digestive hemorrhage secondary to segmental portal hypertension: an infrequent cause of hemorrhage]. / Hemorragia digestiva secundaria a hipertensión portal segmentaria: una causa de hemorragia poco frecuente.

Isolated obstruction of the splenic vein leads to the appearance of a relatively uncommon form of portal hypertension, the diagnosis of which depends on a high rate of awareness, and it can be successfully treated by splenectomy. A case is described of segmental portal hypertension, with special emphasis on the difficulty of its diagnosis and the measures used. Therapeutic possibilities are commented.

[The aging person in Gurabo: a bio-psychosocial profile of the aging person in a community in Puerto Rico]. / El envejeciente de Gurabo: un perfil biosicosocial del envejeciente en una comunidad de Puerto Rico.

The Department of Family Medicine of the University of Puerto Rico Medicine School performed a census of the inhabitants 60 years and older in the community of Gurabo. A total of 1,890 elderly were interviewed 51% were female and 49% male. Sixty percent were married and twenty-five percent were widowed. Eighty two percent still lived within a family setting and only seventeen percent lived alone 86% owned their own home despite ninety percent reporting incomes below $400.00 per month. Ninety five percent have access to medical services but 63% receive services in multiples sites. Eighteen percent were functionally impaired, fourteen percent intellectually impaired and five percent had impairment in both areas. Preliminary data show that the latter group had an annual mortality rate of 15% compared to only 3.6% and 1.3% respectively in the other two group. We concluded that: 1) functional and mental impairment are indicators of increased mortality. 2) although access to health care is not a problem this health care is episodic and interrupted being provided in multiple different sites.

An outbreak of acute infectious nonbacterial gastroenteritis in a high school in Maryland.

An outbreak of acute infectious nonbacterial gastroenteritis (AING) occurred in a high school in Maryland in 1984. Thirty-six percent of students surveyed met the case definition of gastroenteritis, as did 24 percent of school employees. Eating lunch in the cafeteria on January 30 was significantly associated with illness. After controlling for other food items consumed during the January 30 lunch, only the sandwiches were significantly associated with illness, but the source of the contamination was not identified. Four of 17 serum pairs from sick students and none of the 8 serum pairs from exposed controls (a nonsignificant difference) showed at least a 4-fold rise in antibody titre to Norwalk virus between acute- and convalescent-phase specimens. This outbreak of AING is believed to be the first to implicate epidemiologically sandwiches as vehicles of transmission. The outbreak highlights the need for investigators to look for a viral etiology in gastroenteritis outbreaks.