Implementing a pharmacogenomic-driven algorithm to guide antiplatelet therapy among Caribbean Hispanics: a non-randomised clinical trial.

OBJECTIVES: To assess whether genotype-guided selection of oral antiplatelet drugs using a clinical decision support (CDS) algorithm reduces the rate of major adverse cardiovascular and cerebrovascular events (MACCEs) among Caribbean Hispanic patients, after 6 months. DESIGN: An open-label, multicentre, non-randomised clinical trial. SETTING: Eight secondary and tertiary care hospitals (public and private) in Puerto Rico. PARTICIPANTS: 300 Caribbean Hispanic patients on clopidogrel, both genders, underwent percutaneous coronary intervention (PCI) for acute coronary syndromes, stable ischaemic heart disease and documented extracardiac vascular diseases. INTERVENTIONS: Patients were separated into standard-of-care (SoC) and genotype-guided (pharmacogenetic (PGx)-CDS) groups (150 each) and stratified by risk scores. Risk scores were calculated based on a previously developed CDS risk prediction algorithm designed to make actionable treatment recommendations for each patient. Individual platelet function, genotypes, clinical and demographic data were included. Ticagrelor was recommended for patients with a high-risk score ≥2 in the PGx-CDS group only, the rest were kept or de-escalated to clopidogrel. The intervention took place within 3-5 days after PCI. Adherence medication score was also measured. PRIMARY AND SECONDARY OUTCOMES: The occurrence rate of MACCEs (primary) and bleeding episodes (secondary). Statistical associations between patient time free of events and predictor variables (ie, treatment groups, risk scores) were tested using Kaplan-Meier survival analyses and Cox proportional-hazards regression models. RESULTS: The genotype-guided group had a clinically lower but not significantly different risk of MACCEs compared with the SoC group (8.7% vs 10.7%, p=0.56; HR=0.56). Among high-risk score patients, genotype-driven guidance of antiplatelet therapy showed superiority over SoC in reducing MACCE incidence 6 months postcoronary stenting (adjusted HR=0.104; p< 0.0001). CONCLUSIONS: The potential benefit of implementing our PGx-CDS algorithm to significantly reduce the incidence rate of MACCEs in post-PCI Caribbean Hispanic patients on clopidogrel was observed exclusively among high-risk patients, with apparently no evident effect in other patient groups. TRIAL REGISTRATION NUMBER: NCT03419325.

Dr. Manuel Martinez-Maldonado: A Pioneer in Renal Therapeutics and Mentor to a Generation of Minority Physician-Scientists.

Dr. Manuel Martinez-Maldonado is a distinguished Puerto Rican internist, nephrologist, physician-scientist, mentor, and prolific writer whose leadership in academic and clinical settings has significantly advanced the fields of nephrology, renal physiology and pharmacology, fluids and electrolyte metabolism, calcium metabolism, hypertension research, and medical education. His research on electrolyte imbalances has led to innovative hypercalcemia treatments, notably furosemide with IV fluid therapy. This is an approach that, combined with pharmacotherapy using calcitonin and bisphosphonates, became the standard practice for managing hypercalcemia until specific therapies became available. His nephrology research team and laboratory in the San Juan VA (Veterans Affairs) Medical Center and the Medical School of the University of Puerto Rico were internationally renowned. Throughout his career, he fostered a culture of mentorship while spearheading superb clinical teaching and research initiatives. His transformative tenures at several institutions, including Baylor College of Medicine; the University of Puerto Rico-Medical Sciences Campus; the VA medical centers in Atlanta, Houston, and San Juan; Emory University; Oregon Health Sciences University; Ponce School of Medicine; and the University of Louisville School of Medicine demonstrate his lasting contributions to medical science and education. His interdisciplinary approach, advocacy for kidney and clinical research, and contributions to understanding the renin-angiotensin system and the role of sodium-potassium-activated adenosine triphosphatase in renal concentration mechanisms illustrate his enduring impact on renal physiology and human health.

Treatment-related Problems and Countermeasures for Patients Undergoing Maintenance Hemodialysis Following Tropical Cyclones: A Scoping Review.

BACKGROUND: Patients undergoing maintenance hemodialysis face heightened vulnerability during disasters like tropical cyclones, yet there is sparse research on their treatment-related challenges and countermeasures. This scoping review aims to highlight the issues maintenance hemodialysis patients encounter following tropical cyclones. METHODS: A systematic scoping review of 19 articles from 2000 to 2023 was conducted, evaluating eligibility against predefined criteria. RESULTS: Hemodialysis patients encounter substantial challenges during and after tropical cyclones in the United States, Puerto Rico, Australia, and Taiwan. Thematic analysis identified 3 themes related to "challenges" (Hemodialysis health-related challenges, socially relevant challenges, and challenges of management inefficiencies). "Recommendations" comprised 4 themes and 4 phases across the "mitigation phase" (fortifying healthcare infrastructure and mobilizing community-focused risk mitigation initiatives), "preparedness" (emergency plan development, training, and patient education), "response" (activation of emergency plans and providing emergency healthcare services), and "recovery" (intersectoral collaboration for recovery and rebuilding). CONCLUSION: This scoping review underscores challenges confronted by patients undergoing maintenance hemodialysis post-tropical cyclones, highlighting the urgent need for targeted strategies to ensure the continuity of dialysis care during and after such disasters.

Understanding Barriers and Facilitators to Disaster Preparedness in Federally Qualified Health Centers in the United States: A Mixed Methods Study.

OBJECTIVE: Severe weather events exacerbate existing health disparities due to poorly managed non-communicable diseases (NCDs). Our objective is to understand the experiences of staff, providers, and administrators (employees) of Federally Qualified Health Centers (FQHCs) in Puerto Rico and the US Virgin Islands (USVI) in providing care to patients living with NCDs in the setting of recent climate-related extreme events. METHODS: We used a convergent mixed-methods study design. A quantitative survey was distributed to employees at 2 FQHCs in Puerto Rico and the USVI, assessing experience with disasters, knowledge of disaster preparedness, the relevance of NCDs, and perceived gaps. Qualitative in-depth interviews explored their experience providing care for NCDs during recent disasters. Quantitative and qualitative data were merged using a narrative approach. RESULTS: Through the integration of quantitative and qualitative data, we recognize: (1) significant gaps in confidence and preparedness of employees with a need for more training; (2) challenges faced by persons with multiple NCDs, especially cardiovascular and mental health disorders; and (3) most clinicians do not discuss disaster preparedness with patients but recognize their important role in community resilience. CONCLUSION: With these results, we recommend strengthening the capacity of FQHCs to address the needs of their patients with NCDs in disasters.

Leptospirosis Outbreak in Aftermath of Hurricane Fiona - Puerto Rico, 2022.

Leptospirosis, an acute bacterial zoonotic disease, is endemic in Puerto Rico. Infection in approximately 10%-15% of patients with clinical disease progresses to severe, potentially fatal illness. Increased incidence has been associated with flooding in endemic areas around the world. In 2022, Hurricane Fiona, a Category 1 hurricane, made landfall and inundated Puerto Rico with heavy rainfall and severe flooding, increasing the risk for a leptospirosis outbreak. In response, the Puerto Rico Department of Health (PRDH) changed guidelines to make leptospirosis cases reportable within 24 hours, centralized the case investigation management system, and provided training and messaging to health care providers. To evaluate changes in risk for leptospirosis after Hurricane Fiona to that before the storm, the increase in cases was quantified, and patient characteristics and geographic distribution were compared. During the 15 weeks after Hurricane Fiona, 156 patients experienced signs and symptoms of leptospirosis and had a specimen with a positive laboratory result reported to PRDH. The mean weekly number of cases during this period was 10.4, which is 3.6 as high as the weekly number of cases during the previous 37 weeks (2.9). After Hurricane Fiona, the proportion of cases indicating exposure to potentially contaminated water increased from 11% to 35%, and the number of persons receiving testing increased; these factors likely led to the resulting overall surge in reported cases. Robust surveillance combined with outreach to health care providers after flooding events can improve leptospirosis case identification, inform clinicians considering early initiation of treatment, and guide public messaging to avoid wading, swimming, or any contact with potentially contaminated floodwaters.

A deep-sea isopod that consumes Sargassum sinking from the ocean's surface.

Most deep-ocean life relies on organic carbon from the surface ocean. While settling primary production rapidly attenuates in the water column, pulses of organic material can be quickly transported to depth in the form of food falls. One example of fresh material that can reach great depths across the tropical Atlantic Ocean and Caribbean Sea is the pelagic macroalgae Sargassum. However, little is known about the deep-ocean organisms able to use this food source. Here, we encountered the isopod Bathyopsurus nybelini at depths 5002-6288 m in the Puerto Rico Trench and Mid-Cayman Spreading Center using the Deep Submergence Vehicle Alvin. In most of the 32 observations, the isopods carried fronds of Sargassum. Through an integrative suite of morphological, DNA sequencing, and microbiological approaches, we show that this species is adapted to feed on Sargassum by using a specialized swimming stroke, having serrated and grinding mouthparts, and containing a gut microbiome that provides a dietary contribution through the degradation of macroalgal polysaccharides and fixing nitrogen. The isopod's physiological, morphological, and ecological adaptations demonstrate that vertical deposition of Sargassum is a direct trophic link between the surface and deep ocean and that some deep-sea organisms are poised to use this material.

Social and Health-related Changes in Hispanic Cancer Patients during the COVID-19 Lockdown.

OBJECTIVE: The current study aimed to explore changes in health-related behaviors and social practices in Hispanic cancer patients during a government-mandated lockdown and their relationship to sociodemographic and clinical characteristics. METHODS: Secondary analyses were conducted on data gathered by a longitudinal cohort study to describe the unmet needs of Hispanic cancer patients living in Puerto Rico exposed to Hurricane Maria in 2017, earthquakes in 2020, and COVID-19. However, our study solely focuses on the data from the COVID-19 pandemic period. RESULTS: Most participants were women (n = 72) with breast cancer (81.2%). Participants exhibited changes in religious practices (60%), physical activity (58.4%), and sedentary behavior (50%); 31.4% experienced changes in eating habits and sleeping patterns. Responses to the study questionnaire involved staying connected with family (85.5%) through phone calls (78.2%); 69.9% of the participants reported observing shifts in the family dynamics. A strong majority endorsed the government-imposed isolation measures (95.6%). Patients not undergoing treatment were likelier (r = -0.324; P = .010) to support the measures. Finally, younger patients experienced more work-related changes (r = -0.288; P = .017) and were less inclined (r = -0.293; P = .011) to find the isolation measures appropriate. CONCLUSION: This paper describes the lockdown related changes in health and social behaviors sustained by cancer patients, changes which could potentially impact their overall health and health-related quality of life. Our results fill an existing gap in our findings and contribute to understanding the experiences of cancer patients (in particular, Hispanic patients) during the COVID-19 pandemic.

Self-perception of Genital Appearance following a Vaginal Delivery, C-section and Nulliparous Women in a Hispanic Population in Puerto Rico.

OBJECTIVE: Childbirth is considered to be both beautiful and traumatic. Following a vaginal delivery, some women express discontent with the appearance of their genitalia on social media and/or websites. This study explored how some women perceived their genitalia, post childbirth. Three groups were compared: women with a vaginal delivery, those with a cesarean-section, and those who had never given birth. METHODS: After the study received approval from the institutional review board, 224 female participants living in Puerto Rico and aged 21 to 42 years completed a questionnaire about their genital self-image. RESULTS: Approximately 51% (n = 115) of the participants had never given birth; the others had given birth via C-section 23% (n = 51) or vaginally 26% (n = 58). In all 3 groups, 84% felt positive about their genitals, 79% expressed their satisfaction with the appearance of their genitals and 84%, with their size; 81% were not ashamed of their genitals. CONCLUSION: Logistic regression found no significant difference in genital self-perception between delivery groups or nulliparous women. The adjusted odds ratios for positive genital image varied slightly between delivery methods but were not statistically significant (ranging from 0.65 to 1.11 for vaginal deliveries, and 0.42 to 1.00 for C-sections; P > .05). This suggests that the method of delivery does not have a significant impact on women's genital self-perception. However, for the 21% with negative perceptions, targeted support is essential; for those struggling with their self-image after childbirth, our results can inform support services to address concerns.

Maternal Mental Health in Latinx/Hispanic Women after COVID-19 Pandemic.

The recent COVID-19 global emergency may have ripple effects on mental health of many people worldwide. This is especially true for populations like birthing and postpartum women where many changes to daily routines, access to medical care, work-related routines and socialization were experienced. This brief report presents data from an ongoing cohort study aiming to describe maternal mental health during the pandemic T12 (March 2020 to April 2021) with post-pandemic T2 (May 2022 to May 2023) of mothers followed in Puerto Rico. 47 out of 100 mothers have been recalled and assessed with psychosocial interviews (COPE-IUS) and assessments of anxiety (GAD-7) and depression (PHQ-9). Paired t-test revealed mean scores of depressions (PHQ-9) were significantly higher for T2 with a mean of 6.35 and a range of 4.4+/- than for T1 where mean was 5.15 (+/- 2.9), t=-1.954, df=45, p < .05. Similarly, anxiety scores (GAD-7) were significantly higher in T2 6.67 (4.2) than for T1 5.35 (3.7), t=-1.8, df=45, p < .05. Also, COPE-IUS Post-pandemic psychosocial interview results evidence that 80% of mothers do not feel the COVID-19 pandemic is a significant stressor at T2 and are able to maintain routine activities with no social distancing measures. However, reports of loneliness, sadness, worry, and fear continue to be present. Our findings point to the need to further identify other contributing factors to the deterioration of maternal mental health during the perinatal/peripartum period (pregnancy, birth, and postpartum) in Puerto Rico. Possibly the effects of repeated adversity that has been present in the island (multiple environmental stressors, history of traumatic experiences, and constant hardships) may all have cumulative impact over maternal mental health during the perinatal/peripartum period.

A Bayesian Projection of the Total Fertility Rate of Puerto Rico: 2020-2050.

OBJECTIVE: The abrupt decline in the Total Fertility Rate (TFR) of Puerto Rico to 0.9 children per woman, well below the replacement level of 2.1 children per woman, makes the prospect of a sustained population decline a real possibility. Population projections produced by the United States Census Bureau and the United Nations Population Division show that the island population may decline from 3.8 millions in 2000 to slightly above 2 million by 2050, a dramatic population decline of 47% in 50 years. Both population projections assume that all countries with a TFR below replacement level could eventually increase toward or oscillate to 2.1 children per woman and have Puerto Rico's TFR approaching 1.5 by 2050. This assumption has been widely criticized as unrealistic and not supported by evidence. The main objective of our research is to provide an alternative fertility projection for Puerto Rico by 2050 that has more realistic assumptions. METHODS: Our methodology is based on the Bayesian Hierarchical Probabilistic Theory used by the United Nations to incorporate a way to measure the uncertainty and to estimate the projection parameters. We modified the assumptions used by the United Nations by considering 17 countries with TFR similar to Puerto Rico. RESULTS: By 2050, Puerto Rico may have a TFR of 1.1 bounded by a 95% credibility interval (0.56,1.77). CONCLUSION: Under this scenario Puerto Rico can expect to have a larger population decline than that projected by the Census Bureau and the United Nations.

Direct-Acting Antiviral Therapy in Patients with Chronic Hepatitis C Shows Liver Fibrosis Regression on Three Noninvasive Tests: A Puerto Rican Cohort.

OBJECTIVE: Direct-acting antiviral (DAA) drugs have resulted in high rates of virological cure in chronic hepatitis C (CHC)-infected patients. We used noninvasive tests to assess fibrosis in subjects who had been cured with DAA. METHODS: Retrospective data collection (2014-2019) from the medical record of CHC patients at the hepatology clinic was performed. Subjects co-infected with HIV and hepatitis B, post-liver transplant, and lost to follow-up were excluded. We evaluated fibrosis at baseline and 1 year after completing therapy using vibration-controlled transient elastography (VCTE), fibrosis-4 (FIB-4), and aspartate aminotransferase-toplatelet ratio index (APRI) scores. RESULTS: With 210 medical records reviewed, 41 were included. The mean age was 62.8 years; 61% were men. Significant fibrosis regression was observed 1-year post-treatment using 3 noninvasive methods: VCTE, APRI, and FIB-4 score. Prior to treatment, 46% of the patients had advanced fibrosis compared to 25% 1 year after treatment. The VCTE scores of 4 subjects (with body mass indices [BMIs] > 30) indicated a worsening of fibrosis. We did not find a statistically significant association between BMI and VCTE, FIB-4, or APRI score. CONCLUSION: In most CHC patients, DAA therapy leads to liver fibrosis regression. Obesity may play an important role in the worsening of hepatic fibrosis or the absence of fibrosis regression.

Hypergammaglobulinemia D and Periodic Fever Syndrome (HIDS) in a 3-year-old Patient from Puerto Rico.

Mevalonate kinase deficiency is a rare autosomal recessive disease caused by mutations in the mevalonate kinase gene (MVK). Depending on the mutations, a patient with this deficiency can exhibit any one of a spectrum of rare autoinflammatory diseases, such as hypergammaglobulinemia D (hyper-IgD) with periodic fever syndrome and mevalonic aciduria. To date, approximately 300 cases with mutations in the MVK gene have been reported worldwide. Herein, we present a 3-year-old female from Puerto Rico with a history of fever, arthralgia, and skin lesions since her first month of age and who, upon genetic workup, was confirmed to have compound heterozygous mutations in the MVK gene. Given her medical history and the results of her genetic testing, she was diagnosed with hyper-IgD with periodic fever syndrome. She will be treated with canakinumab, an interleukin-1ß antagonist, after receiving the varicella and measles-mumps-rubella (MMR) vaccines.

First Report of Cacao Mild Mosaic Virus Associated with Cacao (Theobroma cacao) in Hawai'i, USA.

Cacao, Theobroma cacao, is an important tropical agricultural crop and the key ingredient of chocolate, which has an international trade value of $103 billion/year (Marelli et al. 2019). Cacao mild mosaic virus (CaMMV) is a badnavirus that causes mild symptoms compared with some of the closely related species of Cacao swollen shoot virus (CSSV), the latter of which are currently only found in West Africa (Marelli et al. 2019; Ullah et al. 2021). CaMMV was recently found in symptomatic commercial cacao trees in Mayagüez, Puerto Rico (Puig et al. 2020), and subsequently detected in a USDA ARS (Agricultural Research Service) quarantine greenhouse in Miami, FL (Puig 2021). The USDA ARS germplasm repository in Hilo, Hawai'i, USA serves as a backup collection for Puerto Rico's cacao germplasm, and field trials have been established from cacao germplasm from Miami to evaluate select varieties. To determine if CaMMV is present in the collection in Hilo, greenhouse and field accessions were tested. Using an optimized sampling and PCR protocol established by Puig (2021), three young cacao petioles per tree or seedling were collected and pooled, and DNA was extracted using the NucleoSpin Plant II commercial kit (Macherey-Nagel, Düren, Germany) following the manufacturer's instructions. Samples were molecularly identified via end point PCR, gel electrophoresis, and Sanger sequencing. PCR amplification of CaMMV using the virus-specific primer set Mia-1396F (5'-ACCGTGTCTAYCAGCACTGGA-3') and Mia-1667R (5'-GACCACCGTCAGCCAGAC-3') produced 289 bp amplicons. Of 230 plants sampled, 26 CaMMV positive detections were discovered in greenhouse and field plantings in Hilo. Most CaMMV+ plants contained some form of leaf chlorosis (96.2%). The sequenced PCR products from Hawai'i were deposited in GenBank (accession nos. OQ692890-OQ692891) and showed 99.2% nucleotide identity to CaMMV accessions from Puerto Rico (MW052520; n = 23) and 98.1% nucleotide identity to CaMMV accessions from Florida, USA (MZ409692; n = 3) in BLASTn analysis. For species-level confirmation, the RT-RNase H domain was amplified from 9 isolates using CaMMV-specific primers (Mia5385F, 5'-AGGACAACGGCTTTCTTGGT-3'/Mia6616R, 5'-GAGACTAACTTGGTTAGGGCT-3'), sequenced, and deposited in GenBank (accession nos. PP997461-PP997462). Sequences matched most closely to GenBank isolates from Puerto Rico (MT253659; 98.0%; n = 7) and Trinidad and Tobago (NC_033738; 97.1%; n = 2). CaMMV, previously known as cacao Trinidad virus A, was first reported in 1943 and was associated with 7 to 33% yield reduction, loss of vigor, and tree decline (Posnette 1944; Swarbrick 1961). CaMMV is known to exist in the Americas and was most recently detected in Brazil and Indonesia (Kandito et al. 2022; Ramos­Sobrinho et al. 2021). To the best of our knowledge, this is the first report of CaMMV infecting cacao in Hawai'i. The cacao industry continues to expand in Hawai'i, and cultivation occurs on at least four of the main islands including Hawai'i Island, O'ahu, Maui, and Kaua'i. To develop disease management strategies, further investigation is needed to define CaMMV symptomology, and determine the distribution and effect this virus has on production in Hawai'i. In the meantime, cacao will be screened regardless of visible symptomology to maintain pathogen-free accessions and avoid the transfer of virus-containing germplasm.

Recent cervical cancer incidence, stage at diagnosis, and mortality trends in Puerto Rico, 2001-2019.

BACKGROUND: Cervical cancer incidence is rising in Puerto Rico (PR). Whether the increase is real or reflective of increased diagnostic scrutiny remains unclear. METHODS: Using data from the PR Central Cancer Registry for 2001-2019, we estimated trends of hysterectomy-corrected cervical cancer incidence and mortality rates, overall, and by stage at diagnosis and age. RESULTS: Overall, cervical cancer incidence (per 100,000) increased 1.6%/year (95% CI, -0.5% to 3.8%) from 12.5 to 15.3, with a prominent increase in distant-stage disease (4.5%/year [95% CI, 1.6% to 8.0%]), particularly among screening age eligible (25-64-year-old) women (5.8%/year [95% CI, 2.1% to 10.6%]). Mortality rates in this age-group remained stable during the study period. CONCLUSIONS: Increased occurrence of distant-stage disease among screening-eligible women is troubling and may reflect a real increase. Future research is needed to elucidate the factors underlying these trends. Improved prevention is also an urgent priority to reverse the rising cervical cancer incidence in PR.

Puerto Rican physician's recommendations to mitigate medical migration from Puerto Rico to the mainland United States.

Puerto Rico (PR) is a United States (US) territory with a history of colonial violence, poverty, and government corruption. Due to these sociopolitical factors and natural disasters (e.g., hurricanes and earthquakes), there has been a sharp increase in PR residents migrating to the mainland US. Local media and professional health organizations focus on the impact of medical migration on the PR health system (e.g., health personnel shortages and long waiting periods for critical care). According to the PR College of Physicians and Surgeons, 365-500 physicians have left annually since 2014, which represents a crisis of access to health services. However, few studies have focused on ways to mitigate medical migration from PR to the US mainland. This article describes the recommendations provided by migrating and non-migrating Puerto Rican Physicians (PRPs) to mitigate medical migration from PR to the US mainland. We focus on qualitative data from a mixed-methods NIH-funded study (1R01MD014188) to explore factors that motivate or mitigate migration among migrating (n = 26) and non-migrating (n = 24) PRPs. Interviews were analyzed following thematic analysis guidelines. Results show the following themes: 1) strategies to retain early-career medical residents living in PR; 2) recommendations for local government on future health policy; and 3) work environment initiatives for health institutions to mitigate physician migration. Findings suggest multilevel efforts are required to mitigate medical migration in PR.

Levels of Telehealth Use, Perceived Usefulness, and Ease of Use in Behavioral Healthcare Organizations After the COVID-19 Pandemic.

The use of telehealth in behavioral healthcare increased significantly since the start of the COVID-19 pandemic and remains high even as a return to in-person care is now feasible. The use of telehealth is a promising strategy to increase access to behavioral healthcare for underserved and all populations. Identifying opportunities to improve the provision of telehealth is vital to ensuring access. An online survey about the current use of, and attitudes toward, telehealth was conducted by five Mental Health Technology Transfer Center (MHTTC) regional centers and the MHTTC Network Coordinating Office. The national MHTTC network provides training and technical assistance, to support the behavioral health workforce to implement evidence-based treatments. Three hundred and sixty-five respondents from 43 states and Puerto Rico participated. The majority of respondents were clinical providers (69.3%). Nearly all (n = 311) respondents reported providing at least one telehealth service at their organization, but the number and type of services varied substantially. Respondents had positive views of both video-based and phone-based services, but most had some preference for video-based telehealth services. Other services, including text message reminders, medication services, and mobile apps for treatment or recovery, were offered via telehealth by ~ 50% or fewer of respondents' organizations. Many organizations have areas where they could expand their telehealth use, allowing them to extend the reach of their services and increase access for populations that experience barriers to service access, though organizational barriers may still prevent this.

Trends in hospital capacity and utilization in Puerto Rico by health regions, 2010-2020.

Like many under resourced, island communities, most of the municipalities in Puerto Rico are medically underserved. However, there is limited information about changes in hospital capacity and any regional disparities in availability of hospital services in Puerto Rico, especially given the multiple public health emergencies the island has faced in recent years (e.g. hurricanes, earthquakes, and COVID-19). This study described the trends in hospital capacity and utilization for the Island of Puerto Rico and by health regions from 2010 to 2020. We analyzed the 2021-22 Area Health Resource File (AHRF) and aggregated the data by seven health regions, which are groupings of municipalities defined by the Puerto Rico Department of Health. Ten-year estimates for hospital utilization were adjusted for population size by health region. During the more recent five-year period, there were decreases in hospitals, hospital beds, and surgeries, which represent a shift from the earlier five-year period. Over the 10 years of the study period, there was an overall decrease in population-adjusted measures of hospital utilization on the island of Puerto Rico-despite multiple disasters that would, theoretically, increase need for health care services. We also found variation in hospital capacity and utilization by health regions indicating the rate of change was not uniform across Puerto Rico. The capacity of Puerto Rico's hospital system has shrunk over the past decade which may pose a challenge when responding to recurrent major public health emergencies, especially within specific health regions.

Colonial shadows: Exploring coloniality of being among Puerto Rican immigrants in the United States.

Coloniality, or the enduring legacy of domination and White supremacy stemming from colonization, manifests across power dynamics, knowledge systems, and personal identity. This study investigated the coloniality of being of 12 Puerto Rican adults living in the United States. We explored their perceptions of the self, other Puerto Ricans, Puerto Rican cultural patterns, and self-aspirations. Using consensual qualitative research, six domains emerged from the data, including (a) self-identity, (b) Puerto Rican pride, (c) other Puerto Ricans, (d) Puerto Rican dependency, (e) Puerto Ricans and work, and (f) reasons for migrating or staying in Puerto Rico. Results portrayed colonial power dynamics' profound and complicated mark on different aspects of the participants' individual and collective selves. Participants' language and narratives also conveyed ruptures between participants and other Puerto Ricans. Findings from our study help expand our understanding of Puerto Ricans' lived experiences of colonization, a group that still experiences the occupation and domination of its land and people. Our article also discusses the clinical and theoretical implications of this work, particularly as it pertains to Puerto Rican identity formation. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

First report of leaf spot caused by Paramyrothecium roridum on Coffea arabica in Hawai'i, USA.

During the 2022-2023 season, the harvested coffee crop in Hawai'i (Coffea arabica) was valued at $57.1 million (USDA NASS 2023). In September 2022, coffee leaf samples with foliar leaf spots affecting the Kona Typica variety were collected from Honaunau, Hawai'i, incidence <10%. The symptoms were circular, necrotic leaf spots with yellow margins, which merged, resulting in complete leaf blade coverage and subsequent leaf drop. Sporodochia were present on the abaxial leaf surface. Symptomatic leaf tissue was disinfected in 10% bleach solution for 60 seconds and chlorotic leaf tissue from the spot margins were excised and placed onto water agar and potato dextrose agar (PDA; Difco, USA). After a 7-day incubation period, pure cultures with white aerial mycelium having sporodochia arranged in concentric rings with olivaceous to black conidial masses were isolated. The conidia were aseptate, hyaline, smooth, cylindrical with rounded ends, measuring 5.1 to 6.8 µm long and 1.7 to 2.3 µm wide (n=50). Based on symptomology and cultural/morphological characteristics (Huaman-Pilco et al. 2023; Lombard et al. 2016; Pelayo-Sanchez et al. 2017), the isolates were initially identified as Paramyrothecium roridum (Tode) L. Lombard & Crous, comb. nov. (syn. Myrothecium roridum Tode). Fungal identification of isolate P22-81-2 was further confirmed using BLAST analysis of bulk sequenced PCR products of the ribosomal DNA internal transcribed spacer (ITS) region (White et al. 1990), ß-tubulin (ßtub), RNA polymerase II (RPB2), and calmodulin genes (Lombard et al., 2016; Huaman-Pilco et al., 2023). The gene sequences (GenBank accession nos. PP211198, PQ192517-19) were >98.4% identical to the P. roridum type specimen (CBS 357.89). A multilocus maximum likelihood phylogenetic analysis incorporating sequence data from previous relevant studies (Lombard et al., 2016; Pinruan et al. 2022) confirmed species identification. To prove pathogenicity, four, 26-month-old Kona Typica variety seedlings were foliar inoculated with a 1 X 106 conidia/ml suspension using a perfume atomizer. An additional four plants were inoculated in a similar manner with sterile water which served as controls. All plants were sprayed to drip on both the upper and lower leaf surfaces and incubated in a clear plastic bag to keep the humidity levels between 90 to 100% for 48 hours at 24°C. After 48 hours, the plants were removed from the bags, placed on a greenhouse bench, and observed weekly for symptom development. Within seven days light brown sunken spots had developed on all inoculated plants. The spots continued to enlarge having a dark distinct margin, light tan center, chlorotic halo, and formed concentric rings, which were identical to the original diseased samples. Leaf spots were not present on any of the control plants. The test was conducted twice. A fungus was consistently reisolated from the leaf spot margins of inoculated plants and morphologically (PDA) and molecularly (ITS, ßtub, RPB2, calmodulin) identified as P. roridum, thus fulfilling Koch's Postulates. To the best of our knowledge, this is the first report of P. roridum causing leafspots on C. arabica plants in Hawai'i. This pathogen has been reported on coffee in other parts of the world including Colombia, Costa Rica, Guatemala, Puerto Rico, and Mexico (USDA Fungus-Host Database). Under the right conditions, P. roridum has the potential to cause leafspots and defoliation resulting in economic losses for coffee growers in Hawai'i.

Non-Linkage to Care and Non-Viral Suppression among Hispanic/Latino Persons by Birthplace and Social Vulnerability-United States, 2021.

BACKGROUND: Assessing individual- and community-level factors may help to explain differences among Hispanic/Latino adults with diagnosed HIV not linked to care and without viral suppression in the United States. METHODS: We analyzed CDC's National HIV Surveillance System data among Hispanic/Latino persons aged ≥ 18 years with HIV diagnosed during 2021 in 47 states and the District of Columbia and linked cases via census tracts to the CDC/ATSDR's Social Vulnerability Index (SVI). Adjusted prevalence ratios and 95% confidence intervals for non-linkage to care and non-viral suppression were estimated using Poisson regression model. RESULTS: Among 5,056 Hispanic/Latino adults with HIV diagnosed in 2021, 51.5% were born in the United States, 17.3% in Mexico, 9.2% in Central America, 11.1% in South America, 1.8% in Puerto Rico, 6.8% in Cuba, and 2.4% in the Caribbean. Compared with U.S.-born Hispanic/Latino adults, those born in Mexico and South America had a lower prevalence of non-linkage to care. Hispanic/Latino adults born in Mexico, South America, and the Caribbean (excluding Puerto Rico and Cuba) had a lower prevalence of non-viral suppression, compared with those born in the United States. No significant differences were observed among SVI quartiles for either care outcome. CONCLUSION: This study aimed to challenge the narrow perspective on HIV care outcomes by examining the impact of birthplace and social vulnerability among Hispanic/Latino adults. To increase HIV care and prevention among Hispanic/Latino persons, research must evaluate health disparities within the group, and efforts are needed to better understand and tailor interventions within the diverse Hispanic/Latino population.