Climate change, heat, and mortality in the tropical urban area of San Juan, Puerto Rico.

Extreme heat episodes are becoming more common worldwide, including in tropical areas of Australia, India, and Puerto Rico. Higher frequency, duration, and intensity of extreme heat episodes are triggering public health issues in most mid-latitude and continental cities. With urbanization, land use and land cover have affected local climate directly and indirectly encouraging the Urban Heat Island effect with potential impacts on heat-related morbidity and mortality among urban populations. However, this association is not completely understood in tropical islands such as Puerto Rico. The present study examines the effects of heat in two municipalities (San Juan and Bayamón) within the San Juan metropolitan area on overall and cause-specific mortality among the population between 2009 and 2013. The number of daily deaths attributed to selected causes (cardiovascular disease, hypertension, diabetes, stroke, chronic lower respiratory disease, pneumonia, and kidney disease) coded and classified according to the Tenth Revision of the International Classification of Diseases was analyzed. The relations between elevated air surface temperatures on cause-specific mortality were modeled. Separate Poisson regression models were fitted to explain the total number of deaths as a function of daily maximum and minimum temperatures, while adjusting for seasonal patterns. Results show a significant increase in the effect of high temperatures on mortality, during the summers of 2012 and 2013. Stroke (relative risk = 16.80, 95% CI 6.81-41.4) and cardiovascular diseases (relative risk = 16.63, 95% CI 10.47-26.42) were the primary causes of death most associated with elevated summer temperatures. Better understanding of how these heat events affect the health of the population will provide a useful tool for decision makers to address and mitigate the effects of the increasing temperatures on public health. The enhanced temperature forecast may be a crucial component in decision making during the National Weather Service Heat Watches, Advisories, and Warning process.

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

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

Type 2 diabetes mellitus and colorectal neoplasia risk in Hispanics: a case-control study.

AIMS: There is inconclusive evidence regarding the potential link between diabetes mellitus (DM) and colorectal cancer (CRC). Associations between type 2 DM and colorectal neoplasia (CRN; colorectal cancer and/or adenomas) have not been well studied in Hispanics, an ethnic minority at high risk for type 2 DM. This study aims to assess the association between type 2 DM and CRN in Hispanics. METHODS: Hispanics with incident CRN and colonoscopy-negative controls from 2005 to 2009 were evaluated. Diagnosis of type 2 DM was established by previous medical diagnosis and/or use of DM treatments. Unconditional logistic regression was performed to estimate odds ratios for the association between type 2 DM and CRN. RESULTS: A total of 451 participants (mean age 61.1±11.9years, 59.6 % men) were evaluated (218 with incident CRC, 77 with colorectal adenomas, and 156 colonoscopy-negative controls). The prevalence of type 2 DM in this study was 25.1%. After adjusting for potential confounding variables, women with type 2 DM were 2.74 (95% CI: 0.94-7.99) times more likely to have CRN and 4.83 times more likely to present with proximal colonic CRN (95% CI: 1.25-18.58) than women without type 2 DM. No statistically significant associations were found between type 2 DM and CRN among men. CONCLUSIONS: An increased odds for CRN and proximal location of CRN was observed among Hispanic women with type 2 DM. Since DM is a highly prevalent disease in this population, adherence to routine CRC screening is of outmost importance.

Demographics, clinical characteristics, IFNL3- and IFNL4- polymorphisms in a cohort of hepatitis C patients from Puerto Rico.

OBJECTIVE: To describe the risk factors for infection, complications, treatment received and response in Puerto Ricans with HCV attending gastroenterology clinics at UPR-MSC, and the prevalence of single nucleotide polymorphisms (SNPs) in IFNL3 and IFNL4 in this population. METHODS: After consent, demographic and medical data were obtained and blood samples were drawn from each patient. The QIAamp Blood-Maxi Kit was employed for DNA extraction. The TaqMan allelic discrimination assay was employed for SNP genotyping. HCV-RNA was measured by branched-chain DNA assay. Frequency distributions were used to describe the study population and the prevalence of SNPs. The UPR Medical Sciences Campus IRB approved the study. RESULTS: Of 259 patients recruited, 64% were men. Genotype 1was found in 112/136 (82%). Of 150 subjects treated, 19% had sustained virological response (SVR), 40% received treatment with pegylated interferon plus ribavirin. The SNP frequencies (n = 239) of IFNL3 locus rs12979860 were 27% (C/C), 50% (C/T), and 23% (T/T), and for rs8099917 were 46% (T/T), 47% (T/G), and 7% (G/G). SNP frequencies of IFNL4 locus ss469415590 were 26% (TT/TT), 48% (TT/ΔG), and 26% (ΔG/ΔG). CONCLUSION: HCV-infected Hispanics in our sample (all of which were Puerto Rican) were shown to have a low SVR rate of 19%. The demographic characteristics were similar to those of other study groups in the US, except for the annual income. Genotype-1 was the most prevalent in those patients with known HCV genotypes. This study group showed significant differences with frequencies observed in other populations. Lower frequencies of the favorable genotypes were found in our group compared with the populations having European and Asian ancestry.

Socio-demographic, behavioral, and health correlates of nutrition transition dietary indicators in San Juan, Puerto Rico / Correlatos sociodemográficos, conductuales y de salud de los indicadores alimentarios de transición nutricional en San Juan, Puerto Rico

OBJECTIVE: To identify socio-demographic, behavioral, and health-related correlates of food preferences in Puerto Rico that will help determine Caribbean-region populations vulnerable to nutrition transition. METHODS: Data from a cross-sectional study of a representative sample of 858 adults residing in the San Juan Metropolitan Area of Puerto Rico were analyzed. Multivariable ordinal logistic regressions were used to model the frequency of consumption of 1) fruits and vegetables, 2) tubers/starchy root vegetables, 3) fried foods, and 4) Western-style fast foods as a function of socio-demographic, behavioral, and health-related characteristics. RESULTS: Higher frequency of consumption of fruits and vegetables was associated with being physically active and older and having a medium to high level of education, whereas intake of tubers was associated with being older, having a low income, not using government insurance, and having elevated levels of triglycerides. Frequency of consumption of fast food was associated with younger age, higher income, 12-15 years of formal education, and a higher body mass index (BMI), whereas frequency of consumption of fried food was associated with being younger and male, not being a smoker, and having elevated levels of fasting blood glucose. CONCLUSIONS: The results indicate a nutrition transition in Puerto Rico with health consequences for the Caribbean region. The characteristics of this nutrition transition seem to be determined by income, education, and age, but may also be dictated by access to various food groups. These results set the stage for needed investigation of environmental and individual-level factors that could shape patterns in food consumption.

OBJETIVO: Determinar los correlatos sociodemográficos, conductuales y relacionados con la salud de las preferencias alimentarias en Puerto Rico a fin de ayudar a determinar las poblaciones vulnerables con respecto a la transición nutricional en el Caribe. MÉTODOS: Se analizaron datos procedentes de un estudio transversal de una muestra representativa de 858 adultos que residen en el área metropolitana de San Juan, en Puerto Rico. Se usaron regresiones logísticas ordinales con múltiples variables para modelar la frecuencia de consumo de 1) frutas y verduras, 2) tubérculos feculentos, 3) alimentos fritos y 4) comida rápida de estilo occidental, como una función de las características sociodemográficas, conductuales y relacionadas con la salud. RESULTADOS: Se asoció una mayor frecuencia de consumo de frutas y verduras con un comportamiento físicamente activo y mayor edad, al igual que un nivel de escolaridad de medio a alto, mientras que la ingesta de tubérculos se asoció a una edad mayor, ingresos bajos, no usar el seguro del gobierno y niveles elevados de triglicéridos. La frecuencia de consumo de comida rápida se asoció con una edad menor, ingresos más altos, de 12 a 15 años de educación formal y un índice de masa corporal mayor, mientras que la frecuencia del consumo de alimentos fritos se asoció con una edad más joven y el sexo masculino, no fumar y niveles elevados de glucemia en ayunas. CONCLUSIONES: Los resultados indican una transición nutricional en Puerto Rico con consecuencias para la salud en el Caribe. Las características de esta transición nutricional parecen estar determinadas por los ingresos, la escolaridad y la edad, pero también podrían estar determinadas por el acceso a diversos grupos alimentarios. Estos resultados establecen las condiciones necesarias para la investigación de los factores ambientales e individuales que podrían configurar los modelos de consumo de alimentos.

Socio-demographic, behavioral, and health correlates of nutrition transition dietary indicators in San Juan, Puerto Rico.

OBJECTIVE: To identify socio-demographic, behavioral, and health-related correlates of food preferences in Puerto Rico that will help determine Caribbean-region populations vulnerable to nutrition transition. METHODS: Data from a cross-sectional study of a representative sample of 858 adults residing in the San Juan Metropolitan Area of Puerto Rico were analyzed. Multivariable ordinal logistic regressions were used to model the frequency of consumption of 1) fruits and vegetables, 2) tubers/starchy root vegetables, 3) fried foods, and 4) Western-style fast foods as a function of socio-demographic, behavioral, and health-related characteristics. RESULTS: Higher frequency of consumption of fruits and vegetables was associated with being physically active and older and having a medium to high level of education, whereas intake of tubers was associated with being older, having a low income, not using government insurance, and having elevated levels of triglycerides. Frequency of consumption of fast food was associated with younger age, higher income, 12-15 years of formal education, and a higher body mass index (BMI), whereas frequency of consumption of fried food was associated with being younger and male, not being a smoker, and having elevated levels of fasting blood glucose. CONCLUSIONS: The results indicate a nutrition transition in Puerto Rico with health consequences for the Caribbean region. The characteristics of this nutrition transition seem to be determined by income, education, and age, but may also be dictated by access to various food groups. These results set the stage for needed investigation of environmental and individual-level factors that could shape patterns in food consumption.

Type 2 diabetes mellitus among youth in Puerto Rico, 2003.

AIMS: To describe the clinical characteristics, and estimate the prevalence of type 2 diabetes mellitus among Puerto Rican youth, 1995-2003. METHODS: All patients aged less than 20 years with a confirmed diagnosis of type 2 diabetes were identified from pediatric endocrinologists' medical practices. Medical records of each patient were reviewed to confirm the diagnosis, classify the type of diabetes, and gather sociodemographic and clinical characteristics. From 1995 to 2003 a total of 32,444 records were reviewed. A total of 2,800 children with diabetes were identified, of which 2,702 were type 1 and 93 type 2; typel/type 2 ratio was 29:1. Frequency distributions were obtained for categorical variables, and summary measures (mean +/- standard deviation) for quantitative measure were computed. RESULTS: Mean age at first visit was 14 years. The majority of cases were females (69%), for a female/ male ratio of 2.2:1. 78.5% had a family history of the disease, 74.2% were overweight, and 48% had acanthosis nigricans. 64.5% of the cases were receiving some type of hypoglycemic therapy. 18.5% of the cases had severe hypertension while 17.5% had cholesterol levels considered at increased risk (e"200). The overall prevalence was 13.5 per 100,000 population. CONCLUSIONS: This study is the first that describes the frequency and clinical presentation of type 2 diabetes in children and adolescents in a sample of Puerto Ricans. Further investigations must be conducted to obtain a more precise estimate of the burden of type 2 diabetes in youth and to raise awareness of this condition among health care professionals.

Health disparities between diabetic patients under private and public health coverage in Puerto Rico, 2000.

OBJECTIVE: To examine health disparities between diabetic patients receiving services in private and public health sectors. METHODS: Insureds with service claims for diabetes (ICD-9 250-259) from two private insurance companies and two public health groups were selected. Personnel of the participant insurance companies were responsible for identifying medical claims that met the study inclusion criteria and providing the information in a computerized database file. RESULTS: Overall prevalence was 4.9%. Prevalence in the public sector (5.8%) was higher than that of the private sector (3.7%) (p < 0.0001). The overall prevalence among females of the public sector was nearly twice (6.3%) the prevalence in the private sector (3.3%) (p < 0.0001). The prevalence of the majority of services analyzed was larger in the public sector. However, prevalence of specific services (glucose and glycosilated hemoglobin tests) was larger in the private sector. Differences between sectors in the prevalence of complications were also observed. Prevalence and service utilization also varied by age and sex in both sectors. CONCLUSIONS: Significant difference exists in the prevalence of diabetes and health service utilization between the private and the public sector.

Prevalence and associated factors of diabetes mellitus in Puerto Rican adults: behavioral risk factor surveillance system, 1999

OBJECTIVE: To estimate the self-reported weighted prevalence of diabetes mellitus among different population subgroups and determine associated factors in Puerto Rico. METHODS: Data gathered from the Behavioral Risk Factor Surveillance Survey (BRFSS) during 1999 was analyzed. RESULTS: The weighted prevalence in Puerto Rico in 1999 was 9.6 (95 CI: 8.5-10.7), highest than reported nationally. It was higher among individuals with increasing age, female sex, decreasing annual income, decreasing educational attainment, being non-employed, having a health care coverage, high blood pressure, high blood cholesterol, and increasing body mass index. Health behaviors and co-morbid conditions significantly associated with diabetes among individuals aged less than 65 years were high blood pressure, high blood cholesterol, obesity and low educational attainment. However, the only significant characteristic associated with diabetes in individuals aged 65 years or more was female sex. Analysis of the data gathered in the diabetes module revealed that nearly 35 were using insulin, 57.4 were using insulin once a day, 14.4 self-monitored their blood glucose one to three times per day, 18.3 reported they have heard of the glycosylated hemoglobin test, and of these, 71.8 had their test performed between one and six times within the past year. Nearly 42 reported their feet were checked and 54.1 had a dilated eye examination last year. CONCLUSION: The high prevalence of diabetes in Puerto Rico underscores the need for developing integrated management strategies for improving quality of diabetes care.

The public health burden of diabetes: a comprehensive review

The review of several diabetes epidemiological studies confirms that diabetes is one of the most prevalent non-communicable diseases globally, and it is the fourth or fifth leading cause of death in most developed countries. Diabetes prevalence ranges from nearly 0 in New Guinea to 50 in the Indians of Arizona. No modifiable risk factors have been clearly established in persons with type 1 diabetes, but major environmental determinants have been suggested. Impaired glucose tolerance, gestational diabetes, insulin resistance, obesity and lack of physical activity have been consistently identified as risk factors for type 2 diabetes. The prevalence of diabetes increases with age, but a sex-specific tendency has not been consistent. In addition, the prevalence of diabetes is higher in African-Americans and Hispanics when compared to other ethnic groups. Diabetes affects almost all organs of the body and is the leading cause of blindness and amputations of legs, imposing both clinical and economic costs to patients and society.

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

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

Natural history and incidence of premature thelarche in Puerto Rican girls aged 6 months to 8 years diagnosed between 1990 and 1995

OBJECTIVE: To describe the natural history and estimate the incidence of premature thelarche in girls aged 6 months to 8 years living in Puerto Rico and diagnosed between 1990 and 1995. BACKGROUND: In the 1970s and 1980s, several pediatric endocrinologists, based on their clinical experience, acknowledged a dramatic increase in the number of cases of precocious sexual development in Puerto Rico. In 1987, the Puerto Rico Health Department developed the Registry of Premature Thelarche and Precocious Sexual Development, which began to operate in 1989. Data regarding the long-term outcomes of girls diagnosed with premature thelarche are insufficient. Knowledge about the natural history of this condition is relevant for predicting the long-term prognosis and therapeutic management of the affected population. METHODS: Of 2,716 cases of precocious sexual development reported to the Premature Thelarche and Precocious Sexual Development Registry, 1,916 (70.5) were premature thelarche. The clinical characteristics and evolution during follow-up of premature thelarche cases were described and compared by age group at diagnosis. RESULTS: Incidences were 6.2 and 1.62 per 1,000 live births for girls aged < 2 years and 2 to 8 years, respectively. These estimates were 10 and 15 times higher than those reported in Olmsted, MN. When the average change in mammary tissue diameter during follow-up was evaluated, a slight reduction in girls aged < 2 years was observed; however, it remained constant for girls aged 2 to 8 years. CONCLUSIONS: The results of this study underscore the need to continue an active search of premature thelarche cases and to perform analytical investigations of precocious sexual development to expand the understanding of the etiology of this important public health problem.

Componentes básicos para el desarrollo de propuestas de investigación en las ciencias de la salud / Basic components in the development of research proposals in health sciences

Any investigation in the health sciences should have a plan or proposal to answer a specific research question. This document, designed for persons preparing for or already pursuing a research project, describes the conceptual framework related with a research proposal, from the study design until its implementation. The objective of this document is to summarize different theoretical aspects that should be considered in a research project, including pertinent references that might be used to deepen the discussion. First, a series of definitions related to the scientific method are presented and then the processes to carry out a research proposal including common epidemiologic designs are illustrated. In addition, a series of research questions that can serve as a guide to perform a critical analysis of published papers are included. Finally, an interdisciplinary group integrated by health professionals with the clinical expertise and health professionals with the necessary skills in biostatistics and epidemiology to undertake a sound scientific research is recommended.

An Epidemiologicaql review of tuberculosis in the Puerto Rican population

Past and recent developments related with tuberculosis (TB) epidemiology in the island were reviewed. Characteristics of the disease such as surveillance, incidence, mortality and the relation of TB with HIV infection were included. TB remains an important public health problem in Puerto Rico and in the Americas, particularly, in HIV-infected patients. From 1981 through 1998, a total of 1,000 AIDS/TB cases has been reported in the island accounting for 4.4 percent of the total of AIDS cases. 82 percent of the AIDS/TB cases were males. The incidence was highest among injecting drug users (IDUs) infected with HIV. The overall incidence of TB in recent years seems to reach a plateau. By the contrary, AIDS/TB cases have been increasing. However, problems of under-reporting must be taken into consideration when analyzing morbidity trends. Adequate and innovative solutions to maintain TB control in the community must be promptly implemented

Clinical findings in patients submitte to cardiac catheterization and coronary angiography at the Cardiovascular Center of Puerto Rico and the Caribbean: a pilot study

OBJECTIVE: This study examined the demographic characteristics, cardiac risk factors, angiographic findings, and complications of patients undergoing coronary angiography. BACKGROUND: There is growing evidence of coronary angiography safety, however, limited data is available concerning the value of this procedure in the Puerto Rican population. METHODS: We retrospectively reviewed the medical records of 322 patients submitted to this procedure at the Cardiovascular Center of Puerto Rico and the Caribbean over a three-month period during 1995. Comparisons of means were based on Student's t-test; comparisons of proportions were based on Pearson's Chi-Square test. RESULTS: Mean age was 60.4 +/- 10.6 years (Range: 20-86); 57.1 per cent were males. Stable angina (p < 0.001) and atypical chest pain (p = 0.014) were more frequent in females. Smoking history (p < 0.0001), left ventricular dysfunction (p = 0.003), angina post-myocardial infarction (p < 0.001), and myocardial infarction (p < 0.025) were more frequent in males. The most frequent angiographic findings were two-vessel disease (24.2 per cent), normal coronary angiogram (21.2 per cent), and non-obstructive disease (16.9 per cent). In patients with angiographic evidence of coronary artery disease, hypertension (69.8 per cent), diabetes mellitus (41.3 per cent), and hypercholesterolemia (37 per cent) were the predominant risk factors. Thirty-four percent of patients had left ventricular dysfunction. The majority of patients (86 per cent) met American College of Cardiology/American Heart Association Class I.