The use of folic acid for the prevention of birth defects in Puerto Rico.

INTRODUCTION: The occurrence of neural tube defects (NTDs) varies by race/ethnicity, and the highest rates are among women of Hispanic ethnicity. Women of reproductive age are advised to use folic acid to prevent NTDs and other birth defects. Since 1994, Puerto Rico has had a campaign to promote the use of folic acid, and since 1998, enriched grain products have been fortified with folic acid. After fortification, the incidence of NTDs in the island decreased. The objective of this study was to assess the use of folic acid by women of reproductive age in Puerto Rico and determine factors associated with its use. METHODS: A self-administered questionnaire was answered by 964 women around the island. RESULTS: Folic acid consumption was reported by 30% of the participants, 21% reported consuming it at least 4 times per week, and only 14% consumed it the day before the survey. Knowledge about the recommendation for women to consume folic acid was reported by 97% of the participants. The use of folic acid was lower among women of lower education and lower social class. Women with higher education were 8.3 times more likely to consume folic acid. CONCLUSION: The folic acid campaign has improved women's knowledge about the recommendation for folic acid supplementation. Nevertheless, its use is lower than is needed to continue reducing the incidence of birth defects in Puerto Rico. Education and social class continue to be barriers to eliminating the disparities in the preconception health of our population.

Iron-deficiency anemia as presentation of pouchitis.

GOALS: This study sought to describe the percentage and cause of anemia in patients who underwent ileal pouch with anal anastomosis (IPAA) for ulcerative colitis (UC), and to compare the distribution of complications in patients with and without anemia, especially pouchitis, after IPAA. BACKGROUND: IPAA is the surgical procedure of choice for UC. Complications include pouchitis (40%), strictures (30%), small bowel obstruction (10%), pelvic sepsis (<5%), and urinary and sexual dysfunctions (<5%). Few studies have described the prevalence of anemia after IPAA, but no conclusive findings have been reported. STUDY: Patients who had undergone IPAA for UC were recruited from the UPR Inflammatory Bowel Disease Clinic and the Gastroenterology Research Unit. Demographic and medical data were obtained. Anemia was diagnosed using standard hematologic criteria. Serum iron, ferritin, transferrin, folate, vitamin B12, erythropoietin, total iron-binding capacity, reticulocyte count, peripheral smear, and bone marrow aspirate were evaluated in patients with anemia. Data analysis was performed with EPI Info version 6.4d. RESULTS: Iron-deficiency anemia was identified in 55.5% (10/18) of patients and pouchitis was found in 77% (14/18). All 10 patients with anemia had pouchitis, whereas only 4 of the 8 without anemia had pouchitis. In half of the anemic patients, pouchitis was asymptomatic. CONCLUSIONS: Iron-deficiency anemia may be a clinical presenting sign of pouchitis. Hemoglobin levels may be considered as surveillance tools for pouchitis in patients with IPAA.

Plasma ascorbate in a population of children: influence of age, gender, vitamin C intake, BMI and smoke exposure.

The objective of this study is to determine the influence of several personal and lifestyle factors on the levels of circulating vitamin C in a population of children. To accomplish this objective, blood samples were collected from 511 healthy children residing in the Greater San Juan area. The population was stratified into 4 percentile groups (approaching quartiles) according to plasma ascorbate levels from lowest to highest concentrations. Comparisons were made between percentile groups on the basis of age, gender, body mass index (BMI), dietary intake of vitamin C (corrected and uncorrected for energy intake) and exposure to environmental tobacco smoke (ETS). Smoke exposure was determined using urinary cotinine, which is a highly sensitive bioindicator for ETS. Dietary vitamin C was determined via one 24hr recall questionnaire. When all 4 percentile groups were used as a basis of comparison, no differences were noted for any of the factors between groups, however when comparing percentile group 1 (lowest blood ascorbate) to an aggregate value of percentile, groups 2-4, it was found that vitamin C intake (corrected for energy intake) paralleled blood values with a statistically significant association. Among personal and environmental factors only exposure to ETS showed a significant difference in blood levels between groups 2-4 and group 1. No differences between percentile groups were noted for age gender or BMI. These results emphasize that ETS is strongly associated with lowered blood ascorbate levels with the obvious implication of reduced antioxidant protection and increased risk of adverse health consequences.

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.

Influence of environmental tobacco smoke on vitamin C status in children.

BACKGROUND: It is known that vitamin C status is compromised in smokers. The vitamin C status of nonsmokers who are exposed to environmental tobacco smoke (ETS) is now being elucidated. OBJECTIVE: We assessed vitamin C status in children who were either exposed or not exposed to ETS, and we sought to associate changes in vitamin C status with the amount of ETS exposure. DESIGN: The study group included 512 children aged 2-12 y; 50% of them were exposed to ETS in the home because their parents smoked. Dietary intake of vitamin C, obtained with a 24-h recall questionnaire, and blood ascorbate concentrations were compared in the exposed and unexposed groups. Smoke exposure was assessed by measuring a biomarker, urinary cotinine. Age, sex, and body mass index were examined as potential correlates of vitamin C status in each exposure category. RESULTS: Plasma ascorbate concentrations were lower, by 3.2 micro mol/L on average, in ETS-exposed children than in unexposed children who consumed equivalent amounts of vitamin C; this was a highly significant difference (P = 0.002). This reduction in plasma ascorbate occurred even with very low exposure to ETS. CONCLUSIONS: ETS can reduce concentrations of ascorbate, an important blood antioxidant, even when the amount of smoke exposure is minimal. Children exposed to ETS should be encouraged to consume increased amounts of foods rich in vitamin C or should be given the equivalent amount of this vitamin as a supplement.

Plasma homocysteine concentrations in a population of rhesus monkeys (Macaca mulatta): reference ranges and accompanying plasma concentrations of folate and vitamin B12.

The circulating level of homocysteine (Hcy) is recognized as a major independent risk factor for cardiovascular disease in humans. Nonhuman primates are being investigated to see whether they will be accurate models for Hcy indicators of cardiovascular dysfunction. Normal reference values are available in humans for Hcy as classified by age, gender, ethnic origin, and biological factors, however similar information in nonhuman primates had not been published previously. The purpose of this report is to provide normal Hcy values in a large group of nonhuman primates in light of age, gender, and physiologic state (pregnancy and lactation) and to compare these values to the same parameters in humans to highlight similar and dissimilar trends. In addition, plasma levels of folic acid and vitamin B(12), which are determinants of Hcy status in humans, are presented. Samples obtained from a troop of 149 rhesus monkeys (Macaca mulatta) fed a high protein commercial diet were analyzed for Hcy by using high-performance liquid chromatography. Folate and vitamin B(12) levels were determined by using an autoanalyzer. Results (mean [95% confidence interval]) for the entire troop were: Hcy, 4.5 (4.2-4.9) micromol/L; folic acid, 8.6 (8.0-9.1) micromol/L; and vitamin B(12), 673 (611-741) pmol/L. Quantitative values are similar to published values for another species of wild-caught macaques. Similar to trends noted for humans, male monkeys had higher Hcy values than did female animals, pregnant animals had lower values than did nonpregnant ones, and Hcy levels were inversely proportional to plasma folate and vitamin B(12) concentrations. However, homocysteine levels in rhesus monkeys did not vary consistently with age, whereas they increase with age in humans.

CCR5 and beta-chemokines in HIV-1 infected children

The duration from initial infection with HIV-1 to CD4 lymphocyte depletion and progression to AIDS varies among infected individuals. Despite treatment with highly active antiretroviral therapy (HAART), patients still show different stages of disease progression. We examined the role of beta-chemokines and its receptor, CCR5 in HIV-1 infected children in order to define determinants of HIV progression among treated individuals. Population was divided in two groups: Group 1--Long Term Non Progressors (LTNP) includes 10 patients with B1-B2 CDC disease classification and with a less aggressive therapy (only 2 in HAART); Group 2--Rapid Progressors (RP) includes 9 patients with C3 disease classification. All the patients had a CCR5 wild type (wt) genotype indicating that they do not have the 32 base-pair deletion associated with slower progression. There was an increased production of MIP 1-beta in 8/10 LTNP but only in 4/9 Progressors (Paired t-test/Wilcoxon Sign test, p-value < 0.05). The change in the levels of MIP-1 beta after PHA stimulation was statistically significant in both groups. The levels of RANTES increased in LTNP and RP and the change of the levels after mitogen stimulation was statistically significant for both groups included. The production of RANTES and MIP-1 beta in response to stimulation between both groups was not statistically significant. The production of MIP-1 alpha was variable in both groups and the difference in the levels after mitogen stimulation between the groups was not statistically significant. These results suggest that beta-chemokines do not play an important role in HIV-1 progression in children undergoing HAART.

Surgical versus interventional procedures in patients with multivessel coronary artery disease

OBJECTIVE: This study examined the clinical characteristics, risk factors, indications and post-intervention complications of patients with multivessel coronary artery disease (CAD) submitted to either percutaneous transluminal coronary angioplasty (PTCA) and/or stent placement versus isolated coronary artery bypass grafting (CABG). BACKGROUND: Several studies have examined the relative safety and outcome of patients submitted to those interventional procedures compared to CABG. Limited information is available regarding that subject in Puerto Rico. METHODS: We performed a retrospective analysis of the clinical, angiographic, operative, interventional, post-operative and post-interventional data of patients submitted to those procedures in our institution from January 1998 to August 1998. There were 53 patients in the interventional group and 206 patients in the CAGB group. Comparison of quantitative variables by procedure was based on Student t test or Mann-Whitney-Wilcoxon test; categorical variables were compared using Pearson's chi-square or Fisher's exact test. RESULTS: There were no significant differences in age, body surface area, or cardiac risk factors. The most common pre-existing cardiovascular diagnosis was unstable angina. Three-vessel disease was the most common angiographic finding among CABG patients (61.7 percent). Two-vessel disease without left anterior descending coronary artery obstruction was significantly more common in the PTCA/Stent patients (58.5 percent). The vast majority (97.6 percent) of patients in the PTCA/Stent group and 52.4 percent of the CABG group had two-vessel intervention. A significantly higher frequency of complications occurred in the CABG group. However, the incidence of major complications, in both groups was not statistically different. Atrial arrhythmias were significantly more frequent in the CABG group. CONCLUSION: A larger prospective study should be conducted in order to corroborate these preliminary findings and seek effective solution to any identifiable problem.