Hepatitis C in Puerto Rico: a time for public health action

Studies investigating the seroprevalence of HCV infection have been carried out in diverse populations, showing an estimated worldwide prevalence of 3%. A seroprevalence survey conducted among randomly selected non-institutionalized adults aged 21-64 years in San Juan, Puerto Rico in 2001-2002 revealed that 6.3% were positive for HCV antibodies. These data suggest that Puerto Ricans are burdened with a significantly greater prevalence of HCV infection compared to the general United States population aged 20-69 years (0.9%-4.3%). This article illustrates data from different sources that taken together establish the need to start addressing HCV infection in Puerto Rico with prompt and decisive public health actions. Some of these include (1) establish hepatitis C prevention as a priority for state and municipal public health authorities, (2) raise awareness and educate target populations about HCV transmission and prevention, (3) increase clinician awareness of the HCV reporting system and the epidemiology and management of hepatitis C, (4) increase availability of diagnosis and treatment facilities, (5) increase access to effective drug treatment services, and (6) develop appropriate control measures to help reduce continued transmission in correctional settings.

Hepatocellular carcinoma at the University of Puerto Rico Liver Transplant Clinic

The aim of this study was to determine the prevalence of hepatocellular carcinoma (HCC) in our liver transplant clinic, and describe the risk factors, predictors and treatment outcomes of primary liver cancer. METHODS: 459 of 469 records of patients attending the UPR Liver Transplant Clinic from September 1999 to January 2005 were reviewed. Frequency distributions were computed to describe the study group. RESULTS: 35 patients (7%) were included. 33 patients were diagnosed during the pre-transplant evaluation and 2 were diagnosed in the explant. Mean age at diagnosis in males was 54.5 years and 61.3 years in females. The main cause of liver disease was hepatitis C plus ethanolism in 42.9% (15 cases). The frequency of HCC in patients with a BMI > or = 25 Kg/m2 was more than twice that of patients with a BMI < 25 Kg/m2. Predominant presenting symptoms were ascites (40%), abdominal pain and jaundice (25%). Normal alpha-fetoprotein was found in 25%. 76% had a MELD score < 20. Treatment modalities included trans-arterial embolization (TAE/TACE) (49%), conservative treatment (34%), liver transplant (OLT, 23%), partial resection (9%) and systemic chemotherapy (3%). Eight patients underwent OLT and one developed primary graft failure, needing a second transplant. Two had T1N0M0 score, with a 100% survival at 2 yrs, and 6 patients had a T2N0M0 score, 5 of which underwent TAE before OLT, with an overall survival of 67%. Partial resection had an overall survival of 66%. CONCLUSIONS: The population of our clinic is similar in gender and age distribution, etiology of chronic liver disease, and clinical presentation of HCC to other studies previously described. The treatment outcomes and mortality rates compare with those observed in the literature.

Infliximab in Hispanics: characterization of response to infliximab in an ethnic minority with Crohn's disease

PURPOSE: The incidence and prevalence of Crohn's disease (CD) varies geographically and with racial/ ethnic background. The highest frequency of occurrence is in North America and Northern Europe. Incidence is highest among Caucasians, lower in blacks and Hispanics, and lowest in Asians. However in the mid-1980s and 1990s, the incidence and prevalence increased in continental Europe, the Middle East, the Pacific Rim, Africa, and Latin America. An increase in the incidence of CD has been noted in Puerto Rico, although our population differs genetically from other described CD populations. A study in our population showed lower prevalence of ASCA and no NOD2 in our CD patients. Infliximab, a TNFa antibody, is effective in refractory inflammatory CD and in fistulizing disease. Since limited data exists regarding CD in Hispanics, the fastest growing minority group in the United States, we designed this retrospective study with patients treated with infliximab at our institution. We wanted to determine if the response to infliximab in genetically admixed Hispanics differed from that previously reported. METHODS: Baseline characteristics, infusion related information and clinical response was abstracted from medical records. Clinical response was classified as complete response, partial response, and nonresponse. RESULTS: The study included 15 patients treated for refractory inflammatory disease, 9 for fistulizing disease, and 11 for both. The positive response rate was 83%(29/35) and the non response rate was 17%(6/35). Overall the patients with complete, partial, and no response were 13/35(37%), 16/35(46%), and 6/ 35(17%), respectively. No statistically significant association was found between response and disease location. Significant association was found between response and fistula type (p = 0.02). Steroid withdrawal was possible in 21/31 patients (68%). In terms of safety, 9/35 patients (26 %) suffered an adverse reaction, 4 patients required therapy discontinuation. CONCLUSION: This study suggests that infliximab has similar global response, allowance of steroid withdrawal and safety in Hispanics as in other populations. Ethnicity does not seem to influence response rate to infliximab.

Crohn's disease associated to chordoma: a case report

Crohn's disease is an inflammatory bowel disease characterized by remissions and exacerbations. Immunosuppressants are frequently used to induce and maintain remission in these patients. The use of the immunomodulator azathioprine has been associated to malignancies. Chordomas are rare, locally aggressive tumors arising from remnants of the notochord. A specific trigger for this tumor has not been identified and association to any medication has not been reported. The purpose of this report is to present the first case reported in the literature of Crohn's disease associated to a chordoma. The patient to be presented was on azathioprine therapy, among other medications. A review of literature revealed that Crohn's disease and chordoma have abnormalities in chromosomes 1 and 10. Inflammatory bowel disease and chordoma also have abnormalities in chromosomal regions 1p, 3p, and 7q. Despite these findings, a direct genetic relationship between these diseases is speculative.

Improving access to liver transplantation: the University of Puerto Rico experience

Liver transplantation is the only treatment for end-stage liver disease. It is costly, difficult, and not performed in Puerto Rico. For these reasons, it has been a limited option for Puerto Ricans with advanced cirrhosis, especially for those with no medical insurance to cover for the procedure. In an effort to improve access to the procedure and offer this chance of life to more Puerto Ricans facing death from complications of advanced liver disease, the Gastroenterology and Liver Diseases Division of the University of Puerto Rico, in collaboration with LifeLink Transplant Institute in Tampa, Florida and the Office of Catastrophic Funds of the Commonwealth of Puerto Rico, opened a clinic for liver transplant evaluation at the Medical Sciences Campus. The purpose of this clinic is to coordinate the pre-transplant evaluation of candidates for this therapy, provide the evaluation by the transplant surgeon in Puerto Rico, expedite the process in seriously ill patients, and offer post-transplant follow-up upon the patient's return to Puerto Rico. The purpose of this article is to describe the experience in this clinic from 1999 to 2003. One hundred ninety-three patients were seen from September 1999 to January 2003. The most common causes for liver disease were hepatitis C and alcohol, alone or in combination. One hundred thirty four were accepted as candidates for evaluation. Of these, 63 had completed the process, 33 were listed for transplantation and 21 had been transplanted by January 2003. Neither education level, marital status, health insurance nor Child score were associated with successful outcome. This clinic offers Puerto Ricans, especially those with limited resources, with a viable access to liver transplantation.

Response to combination therapy of interferon alfa-2b plus ribavirin in Hispanics with chronic hepatitis C

OBJECTIVE: To evaluate the response rate of Hispanics with chronic hepatitis C to combination therapy of interferon alfa-2b plus ribavirin and to assess its adverse events. BACKGROUND: Hepatitis C virus may lead to chronic infection and multiple complications. Response to combination therapy of interferon plus ribavirin has been studied in many populations. African Americans have been found to have a lower response rate than Caucasians. However, little data exist for Hispanics. METHODS: Hispanic patients from Puerto Rico with chronic hepatitis C were eligible for the study between November 1997 and February 2000. The Institutional Review Boards of the participating institutions approved the study. Written informed consents were obtained. Combination therapy was given for 48 weeks and patients were followed for 24 weeks after treatment. Analysis of response to therapy was performed in an intention-to-treat basis. RESULTS: The most frequent adverse event was anemia (89%), associated to ribavirin. Sustained response was 23% for naive patients, 45% for relapsers, and 8% for non-responders to previous interferon monotherapy (p < 0.001). Data to analyze response was not available in 27% of patients. Hispanic patients had a low response rate to combination therapy. CONCLUSIONS: Response rates to combination therapy for Hispanic naive and previously non-responder patients are lower than in other reported populations. This may be due to a high prevalence of genotype 1 in Puerto Rico, which is associated to poor response. The higher response rate of relapsers, similar to those reported previously, was expected since these patients showed a previous response to interferon monotherapy. Ethnic factors may play a role in the response to therapy and should be further studied to determine proper treatment strategies for this population.

A government sponsored clinic for the evaluation and treatment of chronic hepatitis C in an underinsured population in Puerto Rico

BACKGROUND: Chronic hepatitis C (CHC) is a major health problem in Puerto Rico (PR). More than 50% of the population is insured by a government-sponsored managed care system that does not cover treatment for CHC. Lack of access to treatment will result in an increase in end-stage liver disease with its high socioeconomic impact in the future. In an attempt to identify strategies for the treatment of CHC in the publicly insured population, the PR Health Department and the University of Puerto Rico (UPR) Gastroenterology (GI) Division have developed a pilot clinic for the evaluation and treatment of CHC. METHODS: UPR and the PR Health Department negotiated a fee per patient to include all medical care and follow-up laboratories. Viral studies were covered by a grant to the Health Department. Medications were bought at a discount price by the government and dispensed at a government pharmacy. The Health Department allocated funds for 200 patients with government insurance. A dedicated clinic was established at the UPR, staffed by an internist under the supervision of the GI faculty. Patients with a positive HCVab were referred to this clinic. The public insurance covered the CBC, liver tests, metabolic panel, TSH, HBsAg, HIV, ultrasound and liver biopsy, which were required prior to evaluation for possible treatment. In the initial visit, patients underwent a medical evaluation, including assessment of suitability for therapy and counseling. Those deemed to be candidates who still needed a liver biopsy had it performed by the GI staff. Genotype and viral titers were ordered after the decision on treatment had been made. The clinic physician prescribed pegylated interferon and ribavirin, which were dispensed by the government pharmacy. Instruction on proper drug administration was given. Clinic visits were scheduled for 1, 3, 6 and 12 months but also allowed on demand. Laboratory tests were done at the clinic and reviewed by the physician expediently to monitor...

Epidemiology of hepatitis C infection and its public health implications in Puerto Rico

Hepatitis C infection is the most common chronic blood-borne pathogen in the United States associated with liver cirrhosis and hepatocellular carcinoma and is the leading reason for liver transplantation. It has been estimated that hepatitis C infection may lead to a substantial health and economic burden over the next 10 to 20 years. The prevalence of hepatitis C virus (HCV) infection varies worldwide, with an estimated overall prevalence of 3%. However, the only available data of hepatitis C in the general population of Puerto Rico suggest an elevated prevalence of hepatitis C infection in the municipality of San Juan (6.3%) in comparison with estimates for the adult population residing in the United States (0.9%-3.9%). Much of the inter-region variability in the prevalence of hepatitis C can be attributable to the frequency and extent to which different risk factors have contributed to the transmission of the virus. Established risk factors for infection include injection drug use, transfusion of blood and solid organ transplantation from infected donors prior to July 1992 and blood clotting products before 1987, occupational injury, vertical transmission, sex with an HCV infected partner, and multiple sexual partners. Other potential exposures for infection that have been investigated in epidemiologic studies include history of intranasal cocaine use, sharing of contaminated equipment and personal care items, tattooing, body piercing, imprisonment, acupuncture, and use of contaminated healthcare instruments. The high incidence of AIDS in Puerto Rico and the large prevalence observed in Puerto Rican inmates and in adults residing in the municipality of San Juan indicate that HCV infection is an emerging public health concern. From a public health perspective, potential targets for intervention to decrease the spread of HCV infection, ongoing surveillance, increased clinician awareness of disease reporting systems and the epidemiology and management...

Folic acid supplementation does not prevent ribavirin-induced anemia

Treatment of chronic hepatitis C consists of inteferon plus ribavirin. The major adverse effect of ribavirin is hemolytic anemia, a complication that limits therapy. Folic acid supplementation is used to improve erythropoiesis in chronic hemolytic anemia. The aim of this study was to evaluate the effectiveness of folic acid supplementation in the prevention of ribavirin-induced anemia in patients being treated for hepatitis C. Twenty one patients enrolled in treatment protocols for hepatitis C received folic acid 1 mg daily and 22 did not. Groups were similar in age, gender, ribavirin dose and baseline hemoglobin. Folic acid supplementation had no effect in the decrease in hemoglobin or the measured parameters of hemolysis. No difference between males and females was noted for hemoglobin decrease or lowest hemoglobin levels. In our study, folic acid showed no beneficial effect in the prevention of ribavirin-induced anemia.

Prevalence of inflammatory bowel disease in an insured population in Puerto Rico during 1996

OBJECTIVES: Limited data exists about Inflammatory Bowel Disease (IBD) in Hispanic populations. The aims of the present study were to estimate overall and specific prevalence of IBD (Crohn's disease and ulcerative colitis) and to describe the characteristics of a group of patients from the University of Puerto Rico's IBD Registry. METHODS: To estimate the prevalence of IBD, computerized records of all physician billing and hospital discharges from a major health insurer in Puerto Rico and classified with ICD-9-CM codes 555.0-555.9 (Crohn's disease) and 556.0-556.9 (ulcerative colitis) during 1996 were searched. Prevalence was estimated by age group, sex, and type of insurance. To describe demographic and selected clinical information from patients with IBD, data gathered in the University of Puerto Rico's IBD Registry from 1995 through 2000 was analyzed. RESULTS: Out of 802,726 insured individuals, 332 had a diagnosis of Crohn's disease, 499 of ulcerative colitis and 21 had both diagnoses. The estimated prevalence per 100,000 was 41.4 for Crohn's disease, 62.2 for ulcerative colitis, and 106.1 cases per 100,000 for IBD. Peak prevalence of Crohn's disease occurred among the age groups 50-59 years and > or = 60 years, and the overall female:male prevalence ratio of Crohn's disease was 1.13 (95 per cent CI: 0.91-1.42). Ulcerative colitis was most prevalent among insured individuals aged 50-59 years and 40-49 years. The prevalence of ulcerative colitis was significantly higher among females than among males, with an overall prevalence ratio of 1.42 (95 per cent CI: 1.18-1.71). Of 342 patients participating in the IBD Registry, 155 (45.3 per cent) had Crohn's disease and 187 (54.7 per cent) had ulcerative colitis. Among patients diagnosed with Crohn's disease, 51.6 per cent were females, the mean age was 35.2 +/- 18.3 years, and 18.1 per cent had a family history of IBD. More than half (57.8 per cent) of patients with ulcerative colitis were females, the mean age was 42.6 +/- 17 years, and 17.1 per cent had a family history of IBD. CONCLUSIONS: The estimated prevalence of IBD in this insured population in Puerto Rico places it among the middle-range of that reported for other countries. Additional studies must be conducted in Puerto Rico in order to confirm the observed findings. Population-based epidemiologic studies aimed at estimating the burden of IBD in Hispanic populations in the United States and Latin America are essential for health care planning.

Prevention of recurrent esophageal bleeding and survival in patients with alcoholic cirrhosis: a randomized study

OBJECTIVES: To compare endoscopic sclerotherapy, propranolol and distal splenorenal shunt in the prevention of rebleeding esophageal varices and mortality in alcoholic cirrhotics. METHODS: Forty-three alcoholic cirrhotics that had bled from esophageal varices were randomized to sclerotherapy (13), shunt (15) or propranolol(15). Outcomes measured were rebleeding from varices and death. RESULTS: There was no significant difference between the three treatment groups in relation to rebleeding rate or death. Continued alcohol consumption did not influence outcome. CONCLUSIONS: All three therapies were equally effective in preventing rebleeding from varices

Immunological distrubance in West and Lennox-Gastaut syndromes.

Investigamos a imunidade humoral e celular em 18 pacientes com sindrome de West, 12 com sindrome de Lennox-Gastaut e 19 controles. Os exames realizados foram os seguintes: percentagem de linfocitos T e B no sangue periferico, niveis sericos de IgG, IgA e IgM, sensibilizacao cutanea com o DNCB, PHA intra dermica, teste de inibicao e migracao de leucocitos e transformacao blastica de linfocitos em presenca de PHA. Detectamos deficiencia de imunidade celular em 28 criancas (18 com sindrome de West e 10 com sindrome de Lennox-Gastaut) e baixos niveis de imunoglobulinas em apenas 6. A depressao imunitaria mostrou-se mais intensa nas criancas que apresentam sindrome de West.nas 6. A depressao imunitaria mostrou-s