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AIM: To determine the expression of neurokinin-1 receptor (NK-1R), phosphorylated epidermal growth factor receptor (pEGFR), cyclooxygenase-2 (Cox-2), and vitamin D receptor (VDR) in normal, inflammatory bowel disease (IBD), and colorectal neoplasia tissues from Puerto Ricans. METHODS: Tissues from patients with IBD, colitis-associated colorectal cancer (CAC), sporadic dysplasia, and sporadic colorectal cancer (CRC), as well as normal controls, were identified at several centers in Puerto Rico. Archival formalin-fixed, paraffin-embedded tissues were de-identified and processed by immunohistochemistry for NK-1R, pEGFR, Cox-2, and VDR. Pictures of representative areas of each tissues diagnosis were taken and scored by three observers using a 4-point scale that assessed intensity of staining. Tissues with CAC were further analyzed by photographing representative areas of IBD and the different grades of dysplasia, in addition to the areas of cancer, within each tissue. Differences in the average age between the five patient groups were assessed with one-way analysis of variance and Tukey-Kramer multiple comparisons test. The mean scores for normal tissues and tissues with IBD, dysplasia, CRC, and CAC were calculated and statistically compared using one-way analysis of variance and Dunnett’s multiple comparisons test. Correlations between protein expression patterns were analyzed with the Pearson’s product-moment correlation coefficient. Data are presented as mean ± SE. RESULTS: On average, patients with IBD were younger (34.60 ± 5.81) than normal (63.20 ± 6.13, P < 0.01), sporadic dysplasia (68.80 ± 4.42, P < 0.01), sporadic cancer (74.80 ± 4.91, P < 0.001), and CAC (57.50 ± 5.11, P < 0.05) patients. NK-1R in cancer tissue (sporadic CRC, 1.73 ± 0.34; CAC, 1.57 ± 0.53) and sporadic dysplasia (2.00 ± 0.45) were higher than in normal tissues (0.73 ± 0.19). pEGFR was significantly increased in sporadic CRC (1.53 ± 0.43) and CAC (2.25 ± 0.47) when compared to normal tissue (0.07 ± 0.25, P < 0.05, P < 0.001, respectively). Cox-2 was significantly increased in sporadic colorectal cancer (2.20 ± 0.23 vs 0.80 ± 0.37 for normal tissues, P < 0.05). In comparison to normal (2.80 ± 0.13) and CAC (2.50 ± 0.33) tissues, VDR was significantly decreased in sporadic dysplasia (0.00 ± 0.00, P < 0.001 vs normal, P < 0.001 vs CAC) and sporadic CRC (0.47 ± 0.23, P < 0.001 vs normal, P < 0.001 vs CAC). VDR levels negatively correlated with NK-1R (r = -0.48) and pEGFR (r = -0.56) in normal, IBD, sporadic dysplasia and sporadic CRC tissue, but not in CAC. CONCLUSION: Immunohistochemical NK-1R and pEGFR positivity with VDR negativity can be used to identify areas of sporadic colorectal neoplasia. VDR immunoreactivity can distinguish CAC from sporadic cancer.

Hepatocellular carcinoma (HCC), the most common type of liver cancer, is becoming a healthcare burden for Puerto Rico and, in particular, for those clinics that specialize in liver disease. It is our hypothesis that liver transplantation, the most effective curative option for unresectable tumors, is underutilized. We describe in detail the outcomes of liver transplants for HCC in Puerto Ricans referred to a major liver transplant center in the USA.Thirty-two Puerto Rican HCC patients receiving transplants (from January 1, 1997, through July of 2012) at Tampa General Hospital are described. Recurrence rates were calculated, and the Kaplan-Meier estimator was used for survival analysis.The proportion of transplants performed for HCC in our Puerto Rican patients was only 12% (p = 0.05). Disease-free survival at 1, 3, and 5 years was 93.7%, 83%, and 78.8%, respectively. Patient survival at 1, 3, and 5 years was 96.7%, 75%, and 67%, respectively. Sixty-nine percent of the 32 patients were alive at the mean follow-up of 56 months. The recurrence rate from 2002 to the present is 14%.This study provides the most comprehensive report detailing the relative benefits of utilizing liver transplantation as a curative option for Puerto Ricans with hepatocellular carcinoma. It also incorporates the first comprehensive review of the available literature of liver cancer in Puerto Rico. Survival and recurrence rates were comparable to published results. In Puerto Rico, liver transplantation for HCC patients has been underutilized. In order to improve outcomes over the next 2 decades, it is imperative that the healthcare system in Puerto Rico handle the burden of this disease using liver transplantation, locoregional therapies, and newer treatments for hepatitis C and HCC.

Producción Científica, En este trabajo presentamos una propuesta de innovación docente desde la Didáctica de las Ciencias Sociales que se imparte en las aulas universitarias del Grado de Primaria basada en la aplicación de la metodología de Aprendizaje Basado en Problemas (ABP). Después de comentar brevemente el contexto teórico en el que se enmarca y, condicionados por éste, los objetivos que nos planteamos alcanzar, se detallan los elementos que definen nuestra propuesta explicando el planteamiento del proyecto que pedimos a los alumnos, los criterios de calidad y el seguimiento del mismo, para pasar después al análisis y valoración de los resultados preliminares de su desarrollo, en los que apoyaremos nuestras primeras conclusiones., In this paper we present a proposal for teaching innovation from the Didacticof Social Sciences that is taught in university classrooms Grade Primary Education basedon the application of the methodology of Problem Based Learning (PBL). After discussingbriefly the theoretical context in which it occurs and, conditional on this, the goals we wishto achieve, we detail the elements that define our proposal explaining the project approachthat we ask to students, quality criteria and their follow-up. Then we move on to the analysisand evaluation of the preliminary results of its development, which will support our initial findings.

Resumen Objetivos Conocer el grado de conocimientos sobre el cancer, la percepcion de riesgo y el estado emocional de las personas con historia familiar de cancer de mama y cancer colorrectal que acuden a una unidad de consejo genetico (UCG). Metodo Estudio transversal descriptivo sobre una muestra de 128 personas que acudieron por primera vez a la UCG del Institut Catala d’Oncologia de Barcelona con sospecha de predisposicion hereditaria al cancer de mama y/o cancer colorrectal. Resultados Las personas del estudio demostraron tener pocos conocimientos respecto al cancer; desde un minimo de 0 hasta un maximo de 100 puntos, la puntuacion que obtuvieron fue de 36,9 (desviacion estandar = 21,8). Obtuvieron mejores puntuaciones las personas con mayor educacion, y quienes poseian menor informacion presentaban un mayor grado de ansiedad (p Conclusiones Existe una importante falta de informacion y sobrestimacion del riesgo de presentar cancer en la poblacion catalana que acude a una UCG. Estas variables pueden actuar como barreras que impidan a estas personas de riesgo incorporarse a programas de cribado.

Las enfermeras oncológicas tienen que afrontar los retos del cuidado oncológico dentro de una expectativa de calidad asistencial. La investigación de enfermería oncológica es necesaria para dar respuesta a problemas actuales o potenciales de los pacientes con cáncer. Además, el cuidado profesional de las enfermeras requiere la integración de la investigación como actividad fundamental, bien participando en proyectos de investigación o bien utilizando los resultados de la evidencia empírica en la práctica asistencial. Este trabajo presenta la estrategia para potenciar la investigación de enfermería centrándose en cuatro aspectos: Obtención de más financiación, aumento de la productividad científica, mejora de la diseminación de los resultados y potenciación del consumo de los resultados publicados por las enfermeras asistenciales.Oncology nurses have to COPE with the demands of the cancer within a reference framework of quality care. Oncology nursing research is needed to respond to actual or potential cancer patient problems. Besides, professional nursing care requires research as a fundamental activity. All nurses have to participate in research as generators of knowledge by participating in nursing research or as consumers of research results in focusing in four targeted aspects: Greater funding directed towards nursing research, increased production of clinical research, improved dissemination, enhanced consumption of research publications by clinicians.

To describe the profile of the average organ non-donor, compare it to that of the average donor, and identify characteristics that predict the likelihood that a given individual will be a non-donor.The charts of 397 consenting potential organ donors of LifeLink of Puerto Rico from 2009 through 2011 were reviewed. Data regarding gender, age, BMI, the presence of diabetes, hypertension and/or kidney injury, death from cerebrovascular accident, and smoking were collected.Of the 397 charts reviewed, 283 were from donors, 96 were from non-donors, and 18 were excluded from the analysis. When compared to donors, non-donors were found more frequently to be 60 years old or older, diabetic, hypertensive, or obese; to have suffered from kidney injury, to have smoked and to have died of a cerebrovascular accident. On multivariate analysis, age, diabetes, kidney injury and smoking remained significant. However, after adjusting for age, only smoking and death from cerebrovascular accident remained statistically associated to non-donor status.Although being over 60 years old, having smoked and dying from a cerebrovascular accident were characteristics found significantly more frequently in non-donors, these characteristics were also present in some donors. Therefore, a careful evaluation of each potential donor is still mandatory to avoid the loss of transplantable organs.

The Puerto Rico population may be modeled as an admixed population with contributions from three continents: Sub-Saharan Africa, Ancient America, and Europe. Extending the study of the genetics of inflammatory bowel disease (IBD) to an admixed population such as Puerto Rico has the potential to shed light on IBD genes identified in studies of European populations, find new genes contributing to IBD susceptibility, and provide basic information on IBD for the care of US patients of Puerto Rican and Latino descent. In order to study the association between immune-related genes and Crohn’s disease (CD) and ulcerative colitis (UC) in Puerto Rico, we genotyped 1159 Puerto Rican cases, controls, and family members with the ImmunoChip. We also genotyped 832 subjects from the Human Genome Diversity Panel to provide data for estimation of global and local continental ancestry. Association of SNPs was tested by logistic regression corrected for global continental descent and family structure. We observed the association between Crohn’s disease and NOD2 (rs17313265, 0.28 in CD, 0.19 in controls, OR 1.5, p = 9×10−6) and IL23R (rs11209026, 0.026 in CD, 0.0.071 in controls, OR 0.4, p = 3.8×10−4). The haplotype structure of both regions resembled that reported for European populations and “local” continental ancestry of the IL23R gene was almost entirely of European descent. We also observed suggestive evidence for the association of the BAZ1A promoter SNP with CD (rs1200332, 0.45 in CD, 0.35 in controls, OR 1.5, p = 2×10−6). Our estimate of continental ancestry surrounding this SNP suggested an origin in Ancient America for this putative susceptibility region. Our observations underscored the great difference between global continental ancestry and local continental ancestry at the level of the individual gene, particularly for immune-related loci.

The increasing demand for organ transplants exceeds the organ donation rate. Addressing this discrepancy is challenging for organ procurement agencies and health professionals involved in the care of patients in dire need of organs. Research suggests that health-care professionals' knowledge of, attitudes toward, and behavior in terms of organ donation and transplantation are deciding variables in promoting organ donation. In Puerto Rico, there is a lack of information regarding medical student's knowledge of and/or attitudes toward organ donation, a lack that our study was designed to address.Two hundred thirty participants (98 first-year, 45 second-year, and 87 third-year medical students) completed a questionnaire consisting of 55 questions; 10 questions assessed knowledge and 20, attitudes about organ and tissue donation. The remaining questions inquired after demographic information, history of blood donation, and educational experience.In terms of their knowledge about organ donation, the participating students had a mean score of 6.29 on a 10-point scale-with 10 being the highest possible knowledge score-and 45.7% of them scored 7 or more. These data also showed that participants had a positive attitude toward organ donation (44.9; range 14 to 56), with approximately 72% having a favorable view. However, while 40% of the participating students stated their intentions to donate their organs, only 23% of them had donor cards.We determined that medical students have a positive attitude towards organ donation. However, a substantial lack of knowledge of organ donation among our subjects is a barrier to their taking the necessary measures to become active donors. Our data highlight the need to incorporate educational programs to increase knowledge and awareness regarding organ donation and the transplantation process.

The evaluation of the Quality of Experience (QoE) for data services over wireless technologies is currently a hot topic. In this paper we present service performance evaluation method that is able to estimate both the Quality of Service (QoS) and QoE for different data services over cellular networks. This method is based on specific performance indicators that are evaluated at each layer of the terminal’s protocol stack following a bottom-up process from the physical layer up to the application layer. Then, specific utility functions for each data service are used to map QoS into QoE in terms of Mean Opinion Score (MOS). Three different data services (web, YouTube and voice over IP) have been evaluated over a typical LTE network scenario. Performance results show that the MOS is largely affected by the radio level performance (error rate, throughput and delay), so proper protocols’ configuration critical to achieve a desired service quality.

Ink disease caused by the fungus Phytophthora cinnamomi Rands is a major threat to the sustainability of chestnut ecosystems in northern Portugal. Not only soil factors and host resistance but also management practices can influence the occurrence of this disease. Total soil porosity was measured in chestnut groves affected by the ink disease and in healthy ones, at 2 or 3 depth zones. The orchards were located either in mid-slope position or at the foot of the slope. The purpose of the work was to investigate whether or not the occurrence of ink disease would be related with the presence of a plough pan and with the topographical position of the stand. The areas covered by pores with Ø>3O µm (po30) and by pores with Ø>5OO µm (po500) were directly quantified on soil thin sections using micromorphological and image analysis techniques. This method was chosen because routine methods fail to detect soil porosity differences in the soils with a clear plough pan. The results show that low absolute total porosity does not directly influence the health status of the orchards. However, the presence of a layer with reduced porosity at 20-35 cm clearly affects the occurrence of ink disease. This plough pan strongly hinders root development and soil aeration and thus makes the trees more sensitive to the attack of Phytophthora cinnamomi. The plough pans observed were more pronounced in the foot-slope than in the mid-slope soils. Former studies have shown that lowland groves are also more intensively affected by ink and that there is a close relationship between the number of tillage operations and the incidence of the disease. This study evidences the relationship between the occurrence of Phytophthora root disease and the presence of a plough pan, which in turn depends on the location of the stand on the slope. From a methodological point of view it stresses the importance of micromorphological and image analysis techniques to directly determine total soil porosity and to provide complementary and more accurate data than the indirect methods commonly used for quantifying soil porosity., La maladie de l’encre (Phytophthora cinnamomi Rands) constitue une des grandes menaces pour le maintien des châtaigneraies cultivées du Nord du Portugal. L’occurence de cette maladie est influencée par des facteurs pédologiques, la résistance de la plante et les pratiques agricoles. L’objectif principal de l’étude est de vérifier si la présence de la maladie est liée à l’existence d’une semelle de labour dans les sols et/ou à la position topographique de la châtaigneraie. Ainsi, la porosité totale du sol a été mesurée à 2 ou 3 profondeurs dans des châtaigneraies attaquées par le champignon et dans des châtaigneraies saines. Les châtaigneraies étudiées sont localisées en mi-pente ou en bas-fonds. Nous avons directement mesuré, en lames minces de sols par des techniques micromorphologiques et d’analyse d’images, les surfaces couvertes par des pores de diamètre supérieur à 30 pm et par des pores de diamètre supérieur a 500 pm. Cette technique a été choisie car les méthodes de routine n’ont pas permis de détecter des variations de porosité à différentes profondeurs, même dans les sols avec une semelle de labour très prononcée. Les résultats indiquent qu’une porosité totale plus basse n’a pas d’influence directe sur l’état de santé des châtaigneraies. D’autre part, la présence dans les sols d’une couche compactée, entre 20-35 cm de profondeur, est clairement associée à l’occurrence de la maladie. Cette semelle de labour restreint le développement des racines et l’aération du sol ; de ce fait, les arbres deviennent plus sensibles à l’attaque du Phytophthora. Les semelles de labour sont plus prononcées dans les sols des châtaigneraies en bas-fonds que dans les sols des châtaigneraies en mi-pente. Des études précédentes ont montré que les châtaigneraies en bas-fonds sont aussi plus fortement attaquées par la maladie de l’encre et qu’il existe une relation directe entre le nombre d’opérations de labour et le taux d’incidence de la maladie. Cette étude met en évidence la relation entre la maladie de l’encre sur des châtaigniers et la présence d’une semelle de labour dans les sols, qui, à son tour est reliée à la position topographique de la châtaigneraie. Sur le plan méthodologique, l’étude souligne l’importance de l’utilisation des techniques micromorphologiques et de l’analyse d’images pour mesurer directement la porosité totale du sol et pour fournir des résultats plus précis que ceux obtenus par les méthodes indirectes de quantification de la porosité du sol., Marcelino Vera de Melo, Torres Nuria Esther Hurtado, Portela Ester, Martins A. Soil physical properties and the occurrence of chestnut ink disease : a micromorphological study. In: Ecologia mediterranea, tome 26,2000. pp. 129-135.

En este texto Santana Bonilla hace un análisis del surgimiento y evolución del concepto de calidad total y cómo este es insertado desde la empresa en las instituciones educativas; considerando que la calidad es la satisfacción de las necesidades y expectativas de los clientes. Aborda además cómo la Gestión de la Calidad Total (GCT) es exportada del sector privado al sector estatal de educación, incluso sin tener resultados fehacientes que demuestren sus potencialidades reales. Partiendo de un análisis de diferentes autores que tratan la temática tanto desde el punto de vista productivo como educativo, Santana Bonilla reconoce la incoherencia, aun presente, entre ambos conceptos en los diferentes ámbitos, aunque centra más sus argumentos en la esfera económico-productiva, dejando el sector educacional un tanto sin fundamentar.

Evaluation of ethnic and racial patterns of Inflammatory Bowel Disease (IBD) has demonstrated a higher incidence of IBD in Jews, and lower rates in blacks and Hispanics when compared to whites. There is limited data describing incidence and prevalence among Hispanics, the fastest growing minority in the United States.To estimate the prevalence of IBD computerized records of all physicians billing and hospital discharges classified with ICD-9-CM IBD related codes were searched. Prevalence was estimated by age group, sex, and type of insurance (commercial versus government-sponsored managed care).Of 1,248,993 insured individuals in 2005, 186 had a diagnosis of Crohn's disease and 291 of ulcerative colitis. The estimated prevalence per 100,000 was 14.9 for Crohn's disease, 23.3 for ulcerative colitis, and 38.2 cases for IBD. The most significant difference was found when comparing insurance type, with a total IBD prevalence rate of 61.75 cases among commercial versus 14.36 cases among government-sponsored insured.The prevalence of IBD in this insured population in Puerto Rico places it among the highest described in a Hispanic population. Given the continued rise in prevalence of IBD and the limited studies describing the epidemiology of IBD in Hispanics, further studies which may provide important clues to the etiology of the disease as well as valuable information for appropriate health care planning are important.

Among the challenges that Puerto Rico transplant patients face are a lack of social support that would enable them to move away from Puerto Rico, the difficulty of obtaining insurance coverage, and limitations imposed by language barriers. These factors may lead to reduced access to liver transplantation, which is a form of healthcare disparity. The objective of the study is to describe a group of Puerto Rican liver transplant candidates for the first time and to determine whether the above-named factors limit the possibilities of these candidates to be listed for transplant.Using non-public databases from the referral and the transplant center, we performed a retrospective analysis of the medical records of patients who had been evaluated for liver transplant candidacy. Candidates (137) from the Liver Transplant Clinic at the University of Puerto Rico School of Medicine pre-evaluated for transplant candidacy during the period of 2002 to 2008 were selected.Records from 86 men and 51 women were reviewed. The most predominant etiologies of liver disease were hepatitis C virus (36%), a combination of etiologies (26%), alcoholic liver disease (16%), and cryptogenic cirrhosis (10%). While social support and history of psychiatric disorders did not affect listing, private insurance increased the odds of being enlisted for liver transplant (OR = 2.97) 195%CI: 1.067-8.242) (p0.05).Access to private insurance increases the possibility of patient's being enlisted for liver transplantation. Recommendations for overcoming the gap in access to transplants by patients without private insurance are discussed.

There is limited data describing Inflammatory Bowel Disease (IBD) among Hispanics. In Puerto Rico, three studies have been conducted that estimate the prevalence of this disease. Although still rare, these studies coincide that IBD has increased during the last decades. This study aims to describe the IBD surgical resections received in the Pathology Laboratory of the Puerto Rico Medical Center (PRMC) in two periods: 1966-82 and 2002-2008.A retrospective review of the Surgical Pathology reports was done. A total of 133 reports complied with the inclusion criteria for IBD out of a total of 314,493 pathologies evaluated. For purposes of comparison, the data was grouped into 3 time periods: 1966-1973, 1974-1982 and 2002-08.The number of IBD cases per 100,000 pathologies for the period 1966-73 was 15.1, for the period 1974-82 was 19.1 and for the period 2002-08 was 125.0. The number of IBD resections increased 87.9% when comparing years 1966-73 with 2002-2008, with similar increases in Ulcerative Colitis and Crohn's Disease. Although this result was not statistically significant (p0.05), a higher proportion of IBD patients had an IBD resection at a younger age in the 2002-2008 time period. A change in the sex profile of the patients was also identified; the majority of cases (75%) were females in the years 1966-1973 while 50.6% were males in 2002-2008.Our results confirm an increase in IBD surgical resections at the PRMC. Although not significant, a higher proportion of incident cases are occurring among younger age groups and the distribution of incident cases has become similar between males and females in recent years.

Purpose: The aim of the present study was to describe sexual health in Spain according to three important indicators of the World Health Organization definition and explore the influence of socioeconomic factors. Methods: We performed a population-based cross-sectional study of sexually active people aged 16-44 years residing in Spain in 2009 (2365 women and 2532 men). Three main aspects of sexual health were explored: sexual satisfaction, safe sex, and sexual abuse. The independent variables explored were age, age at first intercourse, reason for first intercourse, type of partner, level of education, country of origin, religiousness, parity, and social class. Bivariate and multivariate logistic regression models were fitted. Results: Both men and women were quite satisfied with their sexual life, their first sexual intercourse, and their sexual relationships during the previous year. Most participants had practiced safe sex both at first intercourse and during the previous year. Levels of sexual abuse were similar to those in other developed countries. People of disadvantaged socioeconomic position have less satisfying, more unsafe, and more abusive sexual relationships. Women experienced more sexual abuse and had less satisfaction at their first intercourse. Conclusions: The state of sexual health in Spain is relatively good. However, we observed inequalities according to gender and socioeconomic position. This study was funded by the Ministry of Health, Social Policy and Equality of Spain (TI-EXT005-2/2) and the Ministry of Economy and Knowledge of the Generalitat of Catalonia, Spain (BE-DGR 2009).

Aims: To describe gender- and social class-related inequalities in sexual satisfaction and analyze their relationship with self-perceived health status. Methods: This population-based, cross-sectional study included 7384 sexually active people aged 16 years and over residing in Spain in 2009 (3951 men and 3433 women). The explanatory variables were gender, age, social class, share in performing domestic tasks, spend time looking after oneself, collaborate economically in supporting the family, caring for children, self-perceived health status, and the desire to increase or decrease frequency of having sexual relations. Bivariate and multivariate logistic regression models were fitted. Results: Among women, sexual satisfaction declines progressively after age 45. Sexual satisfaction is 1.7 times higher among women who look after themselves and who feel good compared with those who do not. The odds of wanting to increase sex is 3.3 times higher for women who are satisfied compared with women who desire a lower frequency of sexual intercourses; and good perceived health was associated with sexual satisfaction. In satisfied men, the corresponding odds is 1.9 times that of men desiring to reduce their frequency of sex. Conclusions: Gender and social class inequalities are found in sexual satisfaction. This is associated with perceived health status, adding evidence in support of the World Health Organization definition of sexual health. Supported by a contract of consultation and technical assistance for the exploitation of data from the 2009 SNSHS, Ministry of Health, Social Policy and Equality (Women’s Health Observatory) and CIBERESP (2010).

Diabetes mellitus (DM) has been proposed as a risk factor for both chronic liver disease (CLD) and for hepatocellular carcinoma (HCC); however, studies among Hispanics are limited. Puerto Rico (PR) has a high prevalence of DM (13%), supporting the need for a better understanding of the public health implications associated with DM in this population. We assessed the association of DM with CLD and with HCC in a population of Puerto Rican adults with health insurance.The study sample consisted of 1,040,025 individuals, agedor = 18 years, all covered by the government-run healthcare program in PR, in 2002. The ICD-9 codes for DM, CLD, and HCC were obtained in order to determine the prevalence of these conditions. Logistic regression models were used to determine the association of DM with CLD and with HCC, after adjusting for covariates.The prevalence of DM was higher in patients with CLD (17%) and those with HCC (18%) than it was in patients without either of these conditions (8% and 7%, respectively). Among women, those with DM were significantly more likely to have CLD than were those without DM (POR: 35-49 yrs: 3.26, 95% CI = 2.12, 5.00; POR: 50-64 yrs: 2.10, 95% CI = 1.63, 2.71; POR:or = 65 yrs: 2.33, 95% CI = 1.67, 3.25). Among men, those with DM were more likely to have CLD than were those without DM; this association was significant among males aged 50-64 (POR: 1.30, 95% CI = 1.03-1.63) and those agedor = 65 yrs (POR: 1.94, 95% CI = 1.35-2.80).Consistent with other studies, we observed a strong association of DM with CLD and HCC. In order to reduce the burden of these conditions in PR, research and public health efforts should be concentrated on gaining a better understanding of these associations.

Although primary prevention of HAV and HBV can be achieved through vaccination, the burden of HCV can only be reduced through behavioral interventions to reduce its risk factors. This study evaluated knowledge regarding transmission, clinical manifestations and prevention of viral hepatitis in Puerto Rico. We assessed the level of knowledge about HAV (six questions), HBV (12 questions) and HCV (eight questions) among non-institutionalized Puerto Rican adults aged 21–64 years. Demographic characteristics and self-reported knowledge of these infections were determined through a face-to-face interview. A mean knowledge score was computed by summing correct responses to each scale. Mean knowledge scores according to demographics were compared using ANOVA or the Kruskal–Wallis test. Mean knowledge scores for HAV, HBV and HCV infections were 2.6 ± 1.5, 6.1 ± 2.4, and 3.6 ± 1.1, respectively. For HAV and HBV infections, the mean knowledge score significantly (P < 0.05) increased with age, level of counseling received and number of sources of information. However, for HCV infection the mean knowledge score significantly increased with decreasing age, increased educational level and increased annual family income. Contrary to HBV, a higher HAV and HCV knowledge score was observed among individuals with history of vaccination for HAV and HBV, seropositive status for HAV and HCV, and history of drug use. A sizeable proportion of adults in this study demonstrated an inadequate level of knowledge, especially about transmission routes. Health education must be focused on transmission and prevention methods, including the availability of a vaccine for HAV and HBV, especially among those with chronic liver disease.

Esophageal variceal bleeding is a frequent complication in patients with chronic liver disease. There is no published study that evaluates the management of this complication in Puerto Rico. Our study describes the management of patients with esophageal varices admitted to the emergency room of the Puerto Rico Medical Center from January 2002 to December 2004. Seventy-four patients were included, 50% of which presented stigmata of recent bleeding from esophageal varices. In patients who presented stigmata of recent esophageal variceal bleeding, larger varices were identified (65% vs. 27% p = 0.002). Significant bleeding and banding of esophageal varices was most common in patients with stigmata of recent bleed. Octreotide infusion and prophylactic antibiotics were received by the vast majority. The management of esophageal variceal bleeding in our institution is compliant with the American Association for the Study of Liver Diseases guidelines.

Treatment of hepatitis C virus (HCV) with interferon-based therapy has been shown to be less effective in Hispanics when compared to other populations. A pilot clinic was established at the University of Puerto Rico for the treatment of HCV in the government-insured population. The aim of this study was to describe the outcomes and treatment response to pegylated interferon and ribavirin in treatment-naive patients enrolled at this government-sponsored clinic.A retrospective analysis was undertaken to investigate the treatment outcomes with weight based peg-interferon-alpha-2b and ribavirin in patients with chronic HCV enrolled in the pilot clinic during 2003-2005. Descriptive statistics were reported. Continuous variables were summarized as means and standard deviations. Frequency distributions and percents were used for categorical variables. Statistical analysis was performed using STATA.A total of 155 patients (105 males and 50 females) with mean age of 42 years started treatment; 79 (51%) patients had HCV genotype 1. Completion of treatment was achieved by 59 patients (38.1%), of whom end of treatment response (ETR) was observed in 30 (50.9%), representing 19.4% of the intention-to-treat population (ITT). Sustained viral response (SVR) was achieved in 17 (28.8%) patients who completed treatment, resulting in 11% (17/155) SVR by ITT. The only significant predictor of SVR was treatment onset within 5 years of the diagnosis of HCV (p = 0.026). Although no association was found between HCV genotype and SVR (p = 0.192), those patients with HCV genotypes 2 and 3 were more likely to complete treatment (p = 0.009).SVR to pegylated interferon and ribavirin seems to be lower than expected in our population. The high rate of incomplete treatment surpasses previously reported rates in U.S. Latinos and Caucasians. Further studies should explore reasons for lower response and higher treatment discontinuation in our population.

The prevalence of inflammatory bowel disease [IBD, Crohn's disease (CD) and ulcerative colitis (UC)] in Puerto Rico has increased significantly in recent years. Experience with these diseases outside of a referral center is limited. A registry for IBD, created by the University of Puerto Rico (UPR) Center for IBD, has collected data from subjects all over the island for 15 years. We analyzed the medication profiles and IBD-related surgeries of the registrants in order to characterize the therapies used and to identify any trends in disease severity.This descriptive study reports on the medication profiles of 507 individuals with IBD (1995 to 2007). Descriptive statistics related to gender, diagnosis, pharmacological therapies (aminosalicylates, steroids, immune modulators, and anti-TNF antibodies), and IBD-related surgical interventions (as indicators of disease severity) are presented.The study included 256 females and 251 men. There were 241 patients with UC (48%) and 266 patients with CD (52%). The great majority of them had received aminosalicylates and steroids. Biological agents and immune modulators were less commonly used, generally in IBD patients who had undergone surgical procedures. Steroid use was almost equivalent in both IBD populations despite a trend towards greater steroid use both in UC patients with colectomies and in nonsurgical CD patients.Aminosalicylates and steroids are the mainstays of medical treatment for IBD in Puerto Rico. The use of biological agents and immune modulators appears to be limited to severe disease. A prospective analysis to detect changes in prescribing practices, as a step-down approach becomes more prevalent, is needed.

Impaired neutrophil function has been proposed in the pathogenesis of Inflammatory Bowel Disease. Failure to control the response to bacteria and bacterial products triggers the inflammatory cascade. Genetic disorders of neutrophil dysfunction exhibit gastrointestinal manifestations similar to Crohn's disease. Treatments that enhance neutrophil and macrophage function with colony-stimulating factors have been successful in these conditions. Some studies using sargramostin in patients with Crohn's disease have suggested a beneficial effect in disease activity, including fistulizing disease. The goal of the study was to evaluate the safety and efficacy of sargramostin in patients with fistulizing Crohn's disease who had not responded to conventional therapy or had developed adverse reaction to infliximab requiring discontinuation of the drug.Patients with fistulizing Crohn's disease who had failed conventional therapy were recruited. Sargramostin 6 microg/kg subcutaneously daily for 8 weeks was prescribed. Follow-up included clinical evaluation, exam of the fistulas, laboratories, CDAI score, adverse events, compliance with therapy, quality of life assessment, and baseline and post-treatment abdomino-pelvic MRI.Three patients were enrolled. There were 4 perianal, 7 enterocutaneous and multiple enteroenteric fistulas. Two completed 8 weeks of treatment and 1 was discontinued at week 5 for a hypersensitivity reaction. Sargramostin was ineffective in all three.The small number of patients and the severity of their disease do not allow any conclusions about the drug effectiveness. Placebo-controlled studies, perhaps with less complicated patients, are needed to define a role, if any, of this therapy in fistulizing Crohn's disease.

The Behavioral Risk Factor Surveillance System (BRFSS) collects data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries, and preventable infectious diseases that affect the adult population in all states and territories in the US. The BRFSS is currently the only survey conducted annually in Puerto Rico in the population aged 18 years and older; however, prevalence estimates are based on self-reports and therefore are subject to reporting errors. Although surveillance data are useful for the purpose of evaluation, program planning and health policy, surveys that collect biological specimens and clinical data provide a more accurate assessment of prevalence and a comprehensive picture of disease distribution and their risk factors. This article summarizes the methodology employed in a population-based study to estimate the seroprevalence of hepatitis C and other viral infections in Puerto Rico and shows the feasibility of combining different modes of data collection in population-based surveys that collect biologic specimens.

Este trabajo analiza la influencia que ejerce la distancia institucional entre el país de la matriz y el de la subsidiaria sobre la estandarización en el desempeño medioambiental en la empresa multinacional. La distancia institucional es analizada considerando tres dimensiones ampliamente aceptadas en el marco de la teoría institucional: regulatoria, cognitiva y normativa. Bajo la perspectiva institucional de las organizaciones observamos que, mientras que una elevada distancia institucional en términos regulatorios favorece el que dichas empresas cuenten con desempeños medioambientales diferenciados suficientes a las peculiaridades de cada entorno en el que la empresa se ubica, una elevada distancia institucional en términos cognitivos y normativos contribuirá positivamente a que las empresas estandaricen su desempeño medioambiental en todas sus ubicaciones, con independencia de los países donde estén ubicadas. Este último hecho viene motivado por un fortalecimiento del perfil institucional interno de dichas empresas. In this paper we analyze the influence that the environmental institutional distance between countries has on the degree of environmental performance’s similarity within the multinational enterprise (MNE). We break down the institutional distance between the host and the home country into distances in relation to the regulatory, cognitive, and normative dimensions of institutions. Building upon the institutional approach, we show that not all the national institutional dimensions have the same influence on the environmental performance’s similarity within MNES. Whereas a high regulatory distance between countries leads MNEs' units to have a different environmental performance according to each country’s legal requirements, the cognitive and normative distances encourage these firms to standardize their environmental performance, independent of the countries where their units are based. Este trabajo ha sido parcialmente cofinanciado por diversas becas de investigación concedidas por el Ministerio de Ciencia e Innovación y por el Proyecto de Excelencia con código P06-SEJ-2356 de la Consejería de Innovación, Ciencia y Empresa de la Junta de Andalucía.

The residents of Puerto Rico (PR) had limited access to liver transplantation (LTx) prior to 1996. LTx remains locally unavailable and success rates for LTx for patients from PR have never been published. The outcome of the first 100 LTx recipients from PR transplanted at our center is analyzed.100 consecutive patients transplanted between 3/1997 and 1/2005 were evaluated.Hepatitis C was the indication for LTx in 44%. Overall patient survival at 1, 3 and 5 yrs was: 94.0%, 81.4% and 75.7%, respectively, while for hepatitis C, it was 90%, 73% and 73%, respectively. At mean follow up of 44 mo., 80% of patients were alive (66% HCV were alive vs 91% non HCV, p0.01).Access to LTx in Puerto Rico has dramatically improved since 1996. The government-sponsored fund has provided access to indigent patients. Decreased survival in this minority population was not observed at 1, 3 and 5 years. Long-term survival was most affected by recurrence of HCV.

Blacks and Hispanics in the United States (US) have the lowest survival rates of hepatocellular carcinoma (HCC), mainly associated to the presence of advanced disease at diagnosis when intervention is least beneficial. This study compared the survival distribution and relative survival of HCC in Puerto Rico (PR) during 1988-1992 and 1998-2002.All HCC cases in the PR Central Cancer Registry database for 1988-1992 (n = 306) and 1998-2002 (n = 333) were identified. Patient characteristics and clinical variables were compared between study periods. Survival by age at diagnosis, sex, tumor stage and treatment was estimated using the Kaplan-Meier method, and survival curves were compared using the Wilcoxon test. A Cox proportional hazards model was employed to assess the effect of period of diagnosis on survival, after adjusting for confounders. One- and three-year survival rates were also calculated.Patients diagnosed during 1998-2002 (median: 3.08 months, 95% CI: 2.30-4.16) had a longer observed survival than those diagnosed from 1988-1992 (median: 1.80 months, 95% CI: 1.44-2.52). A significant interaction was observed between the variables age and period of diagnosis, where only among persons agedor = 60 years the risk of HCC death was lower (sex-adjusted HR = 0.72; 95% CI: 0.59-0.88) in patients diagnosed during 1998-2002 as compared to those diagnosed during 1988-1992. The overall one- and three-year relative survival during 1998-2002 was approximately 6% (22.4% vs. 16.6%) and 2% higher (9.0% vs. 6.7%) respectively, as compared to 1988-1992.We observed a temporal improvement in the survival of HCC in PR during the last decade. However, this survival is inferior to the one observed in the US population. Further studies are needed to identify factors that explain these disparities.

Phenotype characteristics of inflammatory bowel disease (IBD) may differ significantly among ethnic subpopulations. The aim of this study was to characterize the IBD phenotype in French Canadians, the most prominent founder population in North America.Using well-characterized phenotype data in the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)-IBD Genetics Consortium repository on patients with IBD, we compared phenotypic characteristics of 202 French Canadians with those of 1,287 other Caucasian patients. These included diagnosis, anatomical location, disease behavior, extraintestinal manifestations, surgical history, and family history of IBD.French-Canadian patients with Crohn's disease (CD) were less likely to have stricturing disease (11 vs. 21%, P=0.005; odds ratio (OR): 0.45, 95% confidence interval (95% CI): 0.24-0.85). Using a stringent definition of ethnicity (three out of four grandparents being French Canadians, as opposed to self-report, n=148), French Canadians had a tendency toward developing fistulizing CD (37 vs. 28%, P=0.07), and there was an increased prevalence of sacroiliitis among those with IBD (4 vs. 2%, P=0.045). Among French Canadians, the numbers of current smokers in CD (40 vs. 25%, P=0.006) and former smokers in ulcerative colitis (UC) (35 vs. 20%, P=0.03) were significantly higher. The prevalence of one of the three main variants of nucleotide-binding oligomerization domain containing 2 (NOD2) single-nucleotide polymorphisms (SNPs) among French-Canadian CD patients was 43.2%. The 3020insC SNP correlated with small bowel disease in French Canadians (25 [corrected] vs. 0%, P=0.006).French Canadians show an IBD phenotype profile distinct from other Caucasian IBD populations, with an accentuated association between smoking status and IBD. This unique profile may have implications regarding the need for a different approach to the management of IBD in this population.

Limited information about the epidemiology of hepatitis C virus (HCV) infection is available in hemodialysis patients in Puerto Rico. We assessed the factors associated to the prevalence of antibodies to HCV (anti-HCV) among patients receiving hemodialysis in eight dialysis centers in Puerto Rico.A systematic sampling design was employed to select a sample of 150 hemodialysis patients (30 anti-HCV+ and 120 anti-HCV-) 21 years and older during 2005. A total of 110 (81.5%) from 135 eligible patients completed a face-to-face interview that gathered data on demographics, and self-reported risk behaviors followed by a clinical record review. Variables that were marginally or significantly associated with the prevalence of anti-HCV (p0.10) in the bivariate analyses were considered for inclusion into the multiple logistic regression model to estimate the adjusted prevalence odds ratio (POR).Bivariate analysis revealed that age (POR(C) = 3.65, p = 0.05), blood transfusions prior to 1992 (POR(C) = 5.13, p = 0.05), tattooing practices (POR(C) = 13.29, p = 0.04), and illegal drug use (POR(C) = 4.53, p = 0.01) were associated with anti-HCV. Multivariate analysis revealed that blood transfusions prior to 1992 (POR(A) = 11.05; p = 0.04) remained significantly associated with anti-HCV after adjusting for age, tattooing practices, illegal drug use and dialysis center. Age (POR(A) = 5.40; p = 0.06) was marginally associated with anti-HCV after adjusting for blood transfusions prior to 1992, tattooing practices, illegal drug use and dialysis center.The present study showed that the profile of risk factors for the hemodialysis population was similar to the profile of risk factors reported in the general population.

The risk of developing cancer in the ileal pouch of patients with surgery for ulcerative colitis has not been defined. Dysplasia in the pouch is quite rare. Although some suggest pouch surveillance based on previous histological assessments, there are no guidelines for surveillance of these patients. The aim of our study was to investigate that risk and identify time intervals for ileoanal pouch surveillance. Endoscopy and biopsies of the ileal pouch were performed at 3, 6, and/or 12 months after ileal pouch-anal anastomosis (IPAA) became functional. Biopsies were evaluated by two pathologists using Riddel’s criteria. Interim data analysis using descriptive statistics is reported. Thirty-eight patients have entered the study. Average patient age at 3, 6, and 12 months of surveillance was 39.1, 36.8, and 39.1 years, respectively. Average disease duration was 8.2 years. Ten of 38 cases (26%) had colonic dysplasia prior to surgery. Dysplasia within the pouch was reported in one patient 6 months after IPAA became functional. This patient demonstrated no dysplasia at 12 months or statistical divergence by age, duration of disease or history of colonic dysplasia prior to IPAA. No subgroup of patients with dysplasia was identified to calculate cumulative risk or perform comparative statistical analysis. A study with longer follow-up after IPAA should precede any attempt to recommend routine surveillance. However, the finding of dysplasia early after surgery underscores the importance of early pouch surveillance in our population, at least until definite predisposing variables are identified.

We report a case of a 49 year-old male who had undergone liver transplant due to hepatitis C, Laennec's cirrhosis, and hepatocellular carcinoma, and was treated with etanercept for recalcitrant generalized psoriasis. Clearance of psoriasis was achieved without any adverse effects or complications of his current conditions.

In our environment, care of the dependent elderly is usually provided by family members, thereby ensuring autonomy and avoiding institutionalization of the dependent adult. Thirty-three percent of Spanish caregivers have acknowledged the importance of acquiring the knowledge and skills necessary for daily care. Consequently, several interventions have been developed by health professionals from distinct disciplines.The purpose of this study was to systematically review and evaluate the efficacy of published interventions for the caregivers of dependent elderly individuals.We conducted a systematic review of the literature on interventions in the caregivers of the dependent elderly (older than 65 years old) published between 1996 and 2006. The inclusion criteria included controlled clinical trials with outcome measures related to effectiveness in reducing caregiver burden, anxiety and depression. Our search yielded 15 reports.The interventions produced statistically significant reductions in burden (40%), anxiety (50%) and depression (90%). Interventions requiring active participation by caregivers and those based on cognitive-behavioral therapy were more effective than those focused on knowledge acquisition.Due to the heterogeneity of caregiving interventions, evaluation of both the clinical and statistical significance of these interventions is essential. Reducing the chronic stress experienced by caregivers is difficult to achieve. Consequently, future experimental designs should take into account the needs reported by caregivers as well as promote active participation.

Recent studies have used dense markers to examine the human genome in ancestrally homogeneous populations for hallmarks of selection. No genomewide studies have focused on recently admixed groups--populations that have experienced admixing among continentally divided ancestral populations within the past 200-500 years. New World admixed populations are unique in that they represent the sudden confluence of geographically diverged genomes with novel environmental challenges. Here, we present a novel approach for studying selection by examining the genomewide distribution of ancestry in the genetically admixed Puerto Ricans. We find strong statistical evidence of recent selection in three chromosomal regions, including the human leukocyte antigen region on chromosome 6p, chromosome 8q, and chromosome 11q. Two of these regions harbor genes for olfactory receptors. Interestingly, all three regions exhibit deficiencies in the European-ancestry proportion.

Organ transplantation as a substitute for diseased organs in end-stage organ failure has led to a worldwide increase in this treatment modality, but donation has not kept pace with the demand, despite scientific, social, and government efforts. For many years, Hispanic donation in Puerto Rico was meager and lagged behind major centers in North America and Europe. Studies signaled mostly cultural factors in this limited donation. We report a 16-fold increase in organ donation with the development of a formal procurement organization tailored to a local culture. Methods. The 30-year, 1400-transplant experience of the Puerto Rico Transplant Center was divided in three periods: 1977 through 1893, the latter signaling the approval of a transplant law; 1984 through 1995, signaling the commencement of a formal organ procurement organization; and 1996 through 2006. The subset of 2001 to 2006 was used in an additional calculation against 1984 to 1995. Results. The comparison of the mean deceased donors from 1984 to 1995 with 1998 to 2006 shows a 12-fold increase; and the last 6 years versus 1984 to 1995, a 16.8-fold increase. Conclusion. Cultural and educational obstacles in a given country may be overridden by aggressive administrative and educational approaches and strategic planning tailored to local realities, with improvement in organ transplantation.

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.

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.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.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 BMIor = 25 Kg/m2 was more than twice that of patients with a BMI25 Kg/m2. Predominant presenting symptoms were ascites (40%), abdominal pain and jaundice (25%). Normal alpha-fetoprotein was found in 25%. 76% had a MELD score20. 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%.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.

The authors carried out a systematic search in main data bases and a methodological content review by paired authors about selected publications. The authors reviewed and analyzed 332 articles about informal caretakers and they chose 182 which complied with their selection criteria. The profile for informal caretakers of persons aged over 65 in Spain is identified as well as the type of care he/she provides. It is worth highlighting the introduction of a new factor in caretaking for the elderly during recent years at a national Spanish level, and since the 1990s on an international level: paid non-professional immigrant caretakers. This phenomenon makes the different traits which ethnic minority caretakers have reflect on the dynamics and the results of this study.

Background: The NIDDK IBD Genetics Consortium (IBDGC) collects DNA and phenotypic data from inflammatory bowel disease (IBD) subjects to provide a resource for genetic studies. No previous studies have been performed on the reliability and validity of phenotypic determinations in either Crohn's disease (CD) or ulcerative colitis (UC) using primary records. Our aim was to determine the reliability and validity of these phenotypic assessments. Methods: The de-identified records of 30 IBD patients were reviewed by 2 phenotypers per center using a standard protocol for phenotypic assessment. Each phenotyper evaluated 10 charts on 2 occasions 5 months apart. Reliability was expressed as the kappa (κ) statistic. Performance characteristics were determined by comparison to a consensus-derived “gold standard” and by generation of receiver operating characteristic (ROC) curves. Results: Agreement for diagnosis was excellent (κ = 0.82; 95% confidence interval [CI]: 0.71–0.92). Agreement for CD location was good for jejunal, ileal, colorectal, and perianal disease with κ between 0.60 and 0.74 but was fair for esophagogastroduodenal (κ = 0.36). Agreement for UC extent (κ = 0.67; 95% CI: 0.48–0.85), and CD behavior (κ = 0.67; 95% CI: 0.49–0.83) were very good. Area under the ROC curves was greater than 0.84 for diagnosis, CD behavior, UC extent, and ileal and colonic CD location. Conclusions: IBD phenotype classification using a standard protocol exhibited very good to excellent inter- and intrarater agreement and validity. This study highlights the importance of standard protocols in generating reliable and valid phenotypic assessments. The data will facilitate estimates of phenotyping misclassification rates that should be considered when making inferences from IBD genotype–phenotype studies. (Inflamm Bowel Dis 2007)