Maribel Campos

Periodontal Disease, Hypertension, and Blood Pressure Among Older Adults in Puerto Rico

BACKGROUND Current scientific evidence addressing the relationship between periodontitis and hypertension is limited to studies producing inconsistent results. METHODS All participants of an ongoing representative cohort of Puerto Rican elderly who were ≥70 years old and residing in the San Juan metropolitan area were invited to this cross-sectional study. Periodontal probing depth (PD) and attachment loss (AL) were summarized using the Centers for Disease Control and Prevention and the American Academy of Periodontology definition for severe periodontitis (≥2 teeth with AL ≥6 mm and ≥1 tooth with PD ≥5 mm). Three repeated blood pressure (BP) measurements taken were averaged using a standardized auscultatory method. Information on hypertension history, use of antihypertensive medications, and potential confounders (age, sex, smoking, heavy and binge drinking, diabetes, use of preventive dental services, flossing, body mass index, consumption of fruits, vegetables, whole wheat bread, and high-fiber cereal) was collected during in-person interviews. High BP was defined as average systolic BP ≥140 mm Hg or diastolic ≥90 mm Hg. Multivariate logistic regression models were used to study the relationship between severe periodontitis, hypertension history, and high BP. RESULTS The study population comprised 182 adults. In multivariate analysis, there was no association between severe periodontitis and hypertension history (odds ratio [OR] = 0.99; 95% confidence interval [CI]: 0.40 to 2.48). Severe periodontitis was associated with high BP, with OR of 2.93 (95% CI: 1.25 to 6.84), after adjusting for age, sex, smoking, and binge drinking. This association was stronger when restricted to those with hypertension or taking antihypertensive medications: OR = 4.20 (95% CI: 1.28 to 13.80). CONCLUSION The results of this study suggest that periodontitis may contribute to poor BP control among older adults.

Congenital EWS/pPNET presenting as a neck mass.

To the Editor: Ewing sarcoma and peripheral primitive neuroectodermal tumor (EWS/pPNET) belong to the same group of tumors collectively termed Ewing sarcoma family of tumors (ESFT). These tumors are characterized by the same molecular translocations and immunophenotyping [1]. They are blue round cell sarcomas with varying degree of neuroectodermal differentiation [2]. EWS/pPNET are tumors that usually affect adolescents or young adults and rarely occur in newborns. The most common locations are the chest wall, abdomen, and extremities [3]. The median age at diagnosis is 14– 22 years, with 70–80% of cases presenting at or before 20 years of age. In the series of Coffin and Dehner, they constituted 4% of pediatric soft tissue tumors. Only 14% of cases occur in children younger than 5 years of age [4]. Thirteen cases of congenital pPNET have been reported in the English literature and none of them had arisen in the neck area [5–7]. A 36 weeks pregnant woman was referred to our institution due to prenatal diagnosis of a rapidly growing mass protruding from the right side of the neck of the fetus. At birth, a lobulated mass, with active bleeding through a laceration which occurred during C-section, was seen protruding from the infant’s neck. A gauze packing was placed in an attempt to control the bleeding. However, in spite of multiple interventions, the patient died 14 hr after birth. The autopsy revealed a mass measuring 13 cm 10 cm 7 cm and weighing 400 g arising from the soft tissues of the neck without involvement of any other structure (Fig. 1). Microscopically, the tumor cells were uniform and small with clear cytoplasm and round nucleus containing fine chromatin. Rosettes were easily seen (Supplementary Fig. 2). Immunostain for MIC 2 (CD-99, O13) showed intense membranous immunoreaction. LCA, desmin, chromogranin, S-100, NSE, and GFAP were negative. The diagnosis of EWS/pPNET was established. Cytogenetic studies were not performed. There was no evidence of metastatic disease. Congenital masses of the neck are often benign. Congenital malignant tumors are rare, accounting for 0.5–2% of all childhood malignancies [5,6]. The differential diagnosis of congenital neck masses includes teratoma, neuroblastoma, rhabdomyosarcoma, hemangioma, vascular, and lymphatic malformations. Immunohistochemistry and molecular/genetic studies are fundamental in the differential diagnosis. MIC2 is a highly reliable marker for the ESFT; however, the use of a panel of antibodies is necessary because the expression of the MIC2 is not entirely restricted to the ESFT [4,8]. The majority of tumors in the Ewing sarcoma family express either a t(11;22)(q24;q12), t(21;22)(q22;q12), or t(7;22)(p22;q12) translocations [2,4,9]. ESFT are highly aggressive malignancies with a grisly prognosis. Although rare in that location, they should be considered in the differential diagnosis of malignant tumors of the neck area in the neonatal period.

Phase I Randomized Study of a Tetravalent Dengue Purified Inactivated Vaccine in Healthy Adults from Puerto Rico

Abstract. The safety and immunogenicity of four adjuvanted formulations of an investigational tetravalent dengue purified inactivated vaccine (DPIV) were evaluated in a predominantly dengue-primed population in Puerto Rico. In this placebo-controlled, randomized, observer-blind, phase I trial, 100 healthy adults were randomized 1:1:1:1:1 to receive DPIV at Day (D)0 and D28 (1 μg per dengue virus [DENV] type 1–4 adjuvanted with either alum, AS01E or AS03B, or 4 μg per DENV type adjuvanted with alum) or saline placebo. Functional antibody responses were assessed using a microneutralization assay at D56, Month (M)7, and M13. All DPIV formulations were well tolerated and no safety signals were identified through M13. The M13 according-to-protocol (ATP) immunogenicity cohort included 83 participants. The ATP analysis of immunogenicity was performed only on the 78 subjects seropositive for ≥ 1 DENV type at baseline: 69 tetravalent, three trivalent, two bivalent, and four monovalent. In all DPIV groups, geometric mean antibody titers (GMTs) increased from D0 to D56 and waned modestly through M13, while remaining well above prevaccination levels. The 4 μg + alum and the AS01E- and AS03B-adjuvanted formulations were highly immunogenic, with M13-neutralizing antibody GMTs against all four DENV types above 1,000. M13/D0 GMT ratios were highest in the 1 μg + AS03B group (ranging 3.2–3.7 depending on the DENV type). These results encourage continued clinical development of DPIV (ClinicalTrials.gov: NCT01702857).

Multi-site trial using short mobile messages (SMS) to improve infant weight in low-income minorities: Development, implementation, lessons learned and future applications

Childhood obesity is a significant public health problem, with the overall prevalence of obesity in children higher than the Healthy People 2020 goal of 14.5%.1 Obesity in childhood is associated with a number of health risks, including chronic disease.2 Weight gain above the recommendation in infancy increases risk of obesity in later life,3,4 particularly during the first 6 months due to the metabolic programming occurring at this stage.5 There is higher prevalence of excessive weight gain in Hispanic (14.8%) and Native Hawaiian (11.4%) infants compared to any other group (Blacks 8.7% and Whites 8.4%).6 Given the high rates of obesity in disadvantaged groups,7 interventions early in life are particularly important in these populations. Appropriate feeding practices in infancy are key in preventing excess weight gain in at-risk groups.8 Exclusive breastfeeding for the first 6 months is protective against excessive early infant gain and later obesity.5 However, Hispanic mothers are less likely to practice exclusive breastfeeding than White or Black mothers,9 and in Native Hawaiians, duration of exclusive breastfeeding through the first 6 months is lower (20%) compared to Whites (26.8%).10 Timing of introduction of complementary foods, as well as food quality and quantity, are also important for obesity prevention.11,12 Infant feeding practices such as early introduction of solid foods has been shown to be associated with excessive weight gain.13,14 While there have been a number of studies on obesity prevention interventions for children under 2 years of age, results have been mixed. A recent systematic review of interventions to prevent obesity in socioeconomically disadvantaged children (0–5 years) revealed that of the 6 studies identified that recruited children before age 2 with anthropometric outcomes, only 1 had a small effect on BMI.15 The authors note that most studies use intensive face-to-face interventions, and that future research should explore the feasibility, acceptability and effectiveness of low-cost delivery modes such as use of mobile phone based interventions.15 According to data collected from July to December 2016 through the National Health Interview Survey, 66.3% of adults considered “poor” according to the U.S. Census Bureau’s poverty thresholds lived in wireless-only households.16 Common components of face-to-face interventions, such as education and skills training, support, and peer interaction, have been shown to be equally successful in comparable interventions using mobile devices and web-based methods.17 Further, traditional strategies such as self-monitoring, positive reinforcement, and immediate feedback have been successful in promoting behavioral change in past studies using short mobile messages (SMS).18,19 The use of SMS has shown tremendous potential to reach new mothers, particularly those with fewer resources.20,21 Interventions using SMS may increase participant retention rates19,22,23 and may be cost effective, sustained over time and embedded into programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The objectives of this paper are: (a) to describe development and implementation of an intervention seeking to test weekly SMS sent to parents/caregivers of infants to improve feeding practices and prevent excessive weight gain in infants in WIC in Hawai’i (HI) and Puerto Rico (PR), (b) to determine acceptability of the intervention, and (c) to report lessons learned from implementing this intervention. Results of the intervention regarding effect on infant feeding practices and weight will be published elsewhere.

Association between within-visit systolic blood pressure variability and development of pre-diabetes and diabetes among overweight/obese individuals

Short-term blood pressure variability is associated with pre-diabetes/diabetes cross-sectionally, but there are no longitudinal studies evaluating this association. The objective of this study is to evaluate the association between within-visit systolic and diastolic blood pressure variability and development of pre-diabetes/diabetes longitudinally. The study was conducted among eligible participants from the San Juan Overweight Adults Longitudinal Study (SOALS), who completed the 3-year follow-up exam. Participants were Hispanics, 40–65 years of age, and free of diabetes at baseline. Within-visit systolic and diastolic blood pressure variability was defined as the maximum difference between three measures, taken a few minutes apart, of systolic and diastolic blood pressure, respectively. Diabetes progression was defined as development of pre-diabetes/diabetes over the follow-up period. We computed multivariate incidence rate ratios adjusting for baseline age, gender, smoking, physical activity, waist circumference, and hypertension status. Participants with systolic blood pressure variability ≥10 mmHg compared to those with <10 mmHg, showed higher progression to pre-diabetes/diabetes (RR = 1.77, 95% CI: 1.30–2.42). The association persisted among never smokers. Diastolic blood pressure variability ≥10 mmHg (compared to <10 mmHg) did not show an association with diabetes status progression (RR = 1.20, 95% CI: 0.71–2.01). Additional adjustment of baseline glycemia, C-reactive protein, and lipids (reported dyslipidemia or baseline HDL or triglycerides) did not change the estimates. Systolic blood pressure variability may be a novel independent risk factor and an early predictor for diabetes, which can be easily incorporated into a single routine outpatient visit at none to minimal additional cost.

Effect of a Multi-Site Trial using Short Message Service (SMS) on Infant Feeding Practices and Weight Gain in Low-Income Minorities

ABSTRACT Objective: To test the effects of weekly SMS for improving infant feeding practices and infant weight. Methods: This was a multi-site randomized clinical trial in a convenience sample of 202 caregivers of healthy term infants 0–2 months participating in the WIC program in Puerto Rico and Hawaii. Participants were randomized to receive SMS about infants general health issues (control) or SMS for improving feeding practices (intervention) for four months. Weight, length and infant feeding practices were assessed at baseline and four months later. Results: A total of 170 participants completed the study (n = 86 control and n = 84 intervention). Baseline characteristics were similar between groups. At the end, exclusive breastfeeding rates were similar between groups (67.4% control and 59.1% intervention). Introduction of other foods and beverages, addition of foods to the bottle, placing infants to sleep with milk bottles, caregivers method and response to feeding infants and distractions while feeding infants were similar between groups. Also, weight status or rate of weight gain was similar between groups. Conclusion: There were no significant improvements in feeding practices or in weight with the intervention. The timeline of the messages in relation to the targeted behavior may have affected the effectiveness of the intervention. Earlier dissemination of messages, higher level of intensity, longer intervention, additional contacts and inclusion of other caregivers may be needed to achieve the desired effects.

A Semi-Quantitative Food Frequency Questionnaire Validated in Hispanic Infants and Toddlers Aged 0 to 24 Months

BACKGROUND There are limited validated food frequency questionnaires (FFQs) for infants and toddlers, most of which were evaluated in Europe or Oceania, and the ones available for use in the United States have important limitations. OBJECTIVE Our aim was to assess the validity of an FFQ developed for infants and toddlers. DESIGN A semi-quantitative FFQ was developed that included 52 food items, their sources, and portion sizes. The FFQ inquired about diets over the previous 7 days. Its validity was assessed in a cross-sectional study. Participants completed the FFQ, followed by a 24-hour recall on two occasions with 1 week between data collection. PARTICIPANTS/SETTING A total of 296 caregivers of infants and toddlers aged 0 to 24 months enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children, Puerto Rico. MAIN OUTCOME MEASURES Intake of nutrients and food groups were averaged for the two FFQs and the two 24-hour food recalls, and adjusted for energy intake. STATISTICAL ANALYSES PERFORMED Spearman correlations were performed for intakes of energy, nutrients, and foods between administrations and between instruments. Correlation coefficients were de-attenuated to account for variation in the 24-hour recalls. RESULTS A total of 241 participants completed the study. Intake of all nutrients and foods were significantly correlated between FFQs and 24-hour recalls and between the means of FFQs and 24-hour food recalls. The de-attenuated correlation for nutrients between the FFQs and 24-hour recalls ranged from 0.26 (folate) to 0.77 (energy), with a mean correlation of 0.53. The de-attenuated correlation for food groups between the FFQs and 24-hour recalls ranged from 0.28 (sweets) to 0.80 (breast milk), with a mean correlation of 0.55. When analyses were restricted to those consuming foods other than breast milk or formula (n=186), results were similar. CONCLUSIONS This semi-quantitative FFQ is a tool that offers reasonably valid rankings for intake of energy, nutrients, foods, and food groups in this sample of infants and toddlers.