Jorge Motta

Introducción: La multimorbilidad, definida como la coexistencia de dos o más condiciones crónicas en un individuo, ha surgido como un desafío significativo de salud pública a nivel mundial. La multimorbilidad se asocia con una disminución de la calidad de vida, un mayor uso de la atención médica y tasas más altas de mortalidad. Objetivo: Evaluar la prevalencia de multimorbilidad y posibles factores de riesgo en adultos mayores de Panamá. Materiales y Métodos: Utilizando datos de la Encuesta Nacional de Salud de Panamá (ENSPA) 2019, un estudio transversal, incluimos participantes que se dividieron en dos grupos: 40-59 años (n: 1,377; N: 250,354) y aquellos ≥ 60 años (n: 1,001; N: 213,624). Treinta y una morbilidades fueron auto reportadas; pero para la hipertensión, diabetes, obesidad y enfermedad renal crónica también se utilizaron mediciones objetivas (presión arterial, antropometría o pruebas de laboratorio). Se seleccionaron las variables demográficas mediante un análisis de la literatura actual usando un gráfico acíclico dirigido realizado por el modelo lenguaje de gran tamaño "Claude 3.5 Sonnet". La multimorbilidad se evaluó mediante modelos crudos y ajustados de regresión logística utilizando las variables sociodemográficas sugeridas que generan razones de momio (RM) con sus respectivos intervalos de confianza (IC) del 95%. Resultados: La prevalencia ponderada de multimorbilidad en participantes ≥ 60 años fue del 75,2% (IC del 95%: 70,9%-79,5%). Los participantes ≥ 60 años tienen mayor riesgo de desarrollar multimorbilidad (OR: 3,45; IC del 95%: 2,45-4,85) que los participantes de 40 a 59 años, al igual que las mujeres (OR: 2,38; IC del 95%: 1,74-2,35). El área indígena tuvo menor riesgo (OR: 0,21; IC del 95%: 0,12-0,37) que la urbana. Conclusiones: Este estudio describe la prevalencia de multimorbilidad en adultos mayores en Panamá. Identificar la multimorbilidad mejora la atención médica de los pacientes con un uso racional de los recursos.

Diabetes mellitus (DM) represents an important global burden of disease. In Panama, DM was investigated in 1 study utilizing questionnaires and in another using biomarkers, but at subnational level. Using data from a recent cross-sectional country-wide population-based study that included biomarkers, we estimated the prevalence of DM, its awareness, and control; evaluating possible risk factors. We used data from 4400 participants aged 18 years or older from the National Health Study of Panama (ENSPA) study conducted in 2019 at a national level. Weighted prevalence and 95% confidence intervals for DM, awareness, and control were estimated by sociodemographic factors, family history of DM, tobacco and alcohol use, nutritional status, and hypertension. Odds ratios (ORs) and 95% confidence intervals were calculated using logistic regression models to assess the possible risk factors associated with DM prevalence and awareness. We generated OR estimates by pooling ENSPA data with a previous regional study, prevalence of cardiovascular risk factors. The prevalence of DM was estimated to be 12.4% (10.9%–14.05%). In both men and women, age, family history of diabetes (OR in men: 4.0 ([2.4–6.7]; OR in women 3.5 [2.5–4.8]), and obesity (OR in men: 2.6 [1.4–5.1]; OR in women: 2.0 [0.9–4.5]) were associated with DM. Diagnosed and controlled hypertension was associated with DM only in women (OR: 2.1 [1.2–3.6]). DM awareness was estimated to be 62.6% (56.3%–68.9%). In both men and women, DM awareness was associated with age and a family history of diabetes (OR in men: 6.6 [2.4–18.4]; OR in women 1.9 ([1.1–3.6]). In women, having secondary education (OR: 1.9 [0.9–3.9]) and being diagnosed with uncontrolled hypertension (OR: 3.3 [1.2–9.5]) was also associated to DM awareness. Men in the ENSPA study were less likely to be aware of DM than those in the prevalence of cardiovascular risk factors (OR: 0.2 [0.0–0.7]). Less than half of the individuals diagnosed with DM had their condition controlled (39.6% [31.4%–47.8%]). This study revealed that the prevalence, awareness, and control of DM were similar to recent estimates reported in other Latin American countries. It also provides a baseline regarding DM and associated risk factors in Panama at a country-level knowledge that is essential for health policy development and useful in clinical practice.

Background: Recent estimates of hypertension in Panama remain unknown. We aim to describe the variation in prevalence and unawareness of hypertension in two Panamanian provinces using two different cross-sectional population-based studies and to investigate risk factors associated with hypertension unawareness. Methods: Data were derived from a sub-national study conducted in the provinces of Panama and Colon (PREFREC-2010 [2,733 participants]) and from a nationally representative study (ENSPA-2019), in which we restricted our analyses to the same provinces (4,653 participants). Individuals aged 30–75 years who had (a) self-reported history of hypertension or (b) blood pressure (BP) ≥140/90mmHg or (c) a combination or both were classified as hypertensive. Participants with BP≥140/90mmHg who denied a history of hypertension were considered unaware of the condition. Multivariable logistic regression models were used to estimate the association between risk factors and unawareness, expressed as odds ratios (OR) and 95% confidence interval (CI). Findings: In 2010, the prevalence and unawareness of hypertension in men were 51.6% (95% CI: 45.7–57.5) and 32.3% (25.4–40.1), respectively, and in women 46.0% (42.1–49.9) and 16.1% (12.6–20.4), respectively. In 2019, the prevalence and unawareness of hypertension in men were 46.5% (42.1–51.0) and 52.3% (45.9–58.6), and in women 42.1% (39.6–44.7) and 33.3% (29.8–37.0). Men (2010 and 2019), age <50 years (2010 and 2019), having no/primary education (2010), and living in a non-urban region (2019) were positively associated with hypertension unawareness, whereas obesity (2010), physical inactivity (2010), family history of hypertension (2019), and BP assessment in the year before study enrollment (2010 and 2019) were inversely associated with hypertension unawareness. Interpretation: Benefits of a decrease in the prevalence of hypertension are being undermined by an increase in hypertension unawareness. Actions should be encouraged to strengthen the implementation of the existing healthcare program for cardiovascular risk factor control.

Poor medication adherence is a public health concern leading to a large burden of cardiovascular disease among persons with hypertension. Using data from 3281 persons with diagnosed hypertension (N = 622,581) from the Panamanian National Health Survey (ENSPA) collected in 2019, we assessed the national prevalence of low-moderate medication adherence in hypertensive individuals using the 4-scale Morisky Medication Adherence Scale (4-MMAS) and identifying gender-specific associated factors. Multivariate logistic regression models were used to estimate the association between possible risk factors and low-moderate medication adherence with odds ratios (OR) and 95% confidence intervals (95% CI) stratified by gender. The national prevalence of low-moderate medication adherence was 78.2% (95% CI: 74.7–81.0%); in men it was 74.4% (95% CI: 67.5–80.3%) and in women it was 81.4% (78.4–84.0%). In women, low-moderate medication adherence was associated with living in indigenous area (OR: 5.15; 95% CI: 1.40–18.98), educational level (OR no formal education: 0.77, 95% CI 0.28–2.14; OR for primary education: 0.76, 95% CI 0.38–1.56; OR for secondary education: 0.90, 95% CI 0.48–1.70; Higher education as reference), increased BMI (normal as reference, OR for overweight: 1.35, 95% CI: 0.73–2.50, OR for obesity: 1.65, 95% CI: 0.90–3.03) and medical diagnosis of anxiety/depression (OR: 4.89, 95% CI: 1.36–17.49). However, in men, it was associated with having secondary education (OR: 2.94; 95% CI: 1.03–8.36), currently smoking (OR: 16.74, 95% CI: 1.83–152.70), taking antihypertensive medication with denial of hypertension diagnosis (OR: 4.35, 95% CI: 1.11–17.11) and having less than three annual check-ups (OR for no health check-ups: 2.97, 95% CI: 0.63–13.88; OR for 1–2 check-ups: 1.61, 95% CI: 0.78–3.32: three or more health check-ups: reference). Time since diagnosis was inversely associated with low-moderate adherence. This study assesses for the first time the national prevalence of low-moderate medication adherence among hypertensive individuals in Panama. Low-moderate medication adherence is an important public health issue that should be addressed to achieve blood pressure control in patients diagnosed with hypertension, taking into account gender-specific factors.

The Isthmus of Panama was a crossroads between North and South America during the continent’s first peopling (and subsequent movements) also playing a pivotal role during European colonization and the African slave trade. Previous analyses of uniparental systems revealed significant sex biases in the genetic history of Panamanians, as testified by the high proportions of Indigenous and sub-Saharan mitochondrial DNAs (mtDNAs) and by the prevalence of Western European/northern African Y chromosomes. Those studies were conducted on the general population without considering any self-reported ethnic affiliations. Here, we compared the mtDNA and Y-chromosome lineages of a new sample collection from 431 individuals (301 males and 130 females) belonging to either the general population, mixed groups, or one of five Indigenous groups currently living in Panama. We found different proportions of paternal and maternal lineages in the Indigenous groups testifying to pre-contact demographic events and genetic inputs (some dated to Pleistocene times) that created genetic structure. Then, while the local mitochondrial gene pool was marginally involved in post-contact admixtures, the Indigenous Y chromosomes were differentially replaced, mostly by lineages of western Eurasian origin. Finally, our new estimates of the sub-Saharan contribution, on a more accurately defined general population, reduce an apparent divergence between genetic and historical data.

Anthracyclines are highly effective anticancer medication prescribed for the treatment of breast cancer. Nevertheless, the use of anthracyclines as chemotherapeutic agents involves a risk for development of cardiac toxicity which may cause restrictive and dilated cardiomyopathy. Currently, genetic predisposition is not considered as a risk factor for cardiotoxicity associated to the use of anthracyclines. We report the case of a 37-years old Panamanian female patient diagnosed with breast cancer who developed clinical signs of severe heart failure after treatment with doxorubicin. A diagnosis of anthracycline induced cardiomyopathy was made and treatment was initiated accordingly. A whole exome sequencing study performed to the patient showed the presence of a missense mutation in LMNA gene, which codifies for lamin A/C. Our results points to a correlation between the LMNA variant and the anthracycline cardiotoxicity developed by the woman. Improvement of the clinical symptoms and the left ventricle ejection fraction was observed after proper treatment. This case report suggests for the first time a potential genetic predisposition for anthracyclines induced cardiomyopathy in patients with mutations in LMNA gene. Perhaps chemotherapies accelerate or deliver the “second-hit” in the development of DCM in patients with genetic mutations. More data is needed to understand the contribution of LMNA variants that predispose to DCM in patients receiving cardiotoxic therapies.

Objectives Central America is a region with an elevated burden of chronic kidney disease (CKD); however, the cost of treatment for end-stage renal disease (ESRD) remains an understudied area. This study aimed to investigate the direct costs associated with haemodialysis (HD) and peritoneal dialysis (PD) in public and private institutions in Panama in 2015, to perform a 5-year budget impact analysis and to calculate the years of life lost (YLL) due to CKD. Design A retrospective cost-analysis study using hospital costs and registry-based data. Setting Data on direct costs were derived from the public and private sectors from two institutions from Panama. Data on CKD-related mortality were obtained from the National Mortality Registry. Methods A budget impact analysis was performed from the payer perspective, and five scenarios were estimated, with the assumption that the mix of dialysis modality use shifts towards a greater use of PD over time. The YLL due to CKD was calculated using data recorded between 1 January 2015 and 31 December 2015. The linear method was utilised for the analyses with the population aged 20–77 years old. Results In 2015, the total costs for dialysis in the public sector ranged from ~US$7.9 million (PD) to US$62 million (HD). The estimated costs were higher in the scenario in which a decrease in PD was assumed. The average annual loss due to CKD was 25 501 808.40 US$-YLL. Conclusion ESRD represents a major challenge for Panama. Our results suggest that an increased use of PD might provide an opportunity to substantially lower overall ESRD treatment costs.

The aims of this study were to determine the geographic and time variation of social determinants of health (SDH) and cardiovascular disease (CVD) mortality in Panama from 2012 to 2016, and to identify which of the SDH has the strongest correlation with a socioeconomic index (SEI). We conducted an ecological study obtaining mortality from the National Mortality Register and socioeconomic variables derived from the National Household Survey (NHS). The International Classification of Diseases 10th revision codes I20–I25 and I60–I69 were used for ischemic heart disease (IHD) and stroke, respectively. Standardized age-adjusted mortality rates were calculated by direct method. Mortality rates and socioeconomic variables were evaluated together in a panel data model. A SEI was developed from factorial analysis by principal components with a polychoric correlation matrix. Provinces and regions were categorized in tertiles according to median value of the SEI score. The NHS evaluated an average of 15,919 households per year. The mean of age throughout the study period was 41 years. The average monthly income increased, from US$ (SD) 331.94 (5.38) in 2012, to 406.24 (5.81) in 2016, whereas the social security health coverage remained in a range of 57–58%. The mean number of school years was twelve. Significant geographical and temporal variations in social determinants and mortality rates were observed throughout the country. Colon, categorized in the middle tertile according to the SEI, presented higher IHD mortality rates. Darién (in the lowest SEI tertile) Colón and Herrera had higher stroke mortality rates. The SEI categorized indigenous territories in the lowest tertile. Total years of education was the strongest correlated variable with the SEI, when we excluded the population living in indigenous territories. However, when this population was included, social security coverage had the strongest correlation with the SEI. We observed geographical and temporal disparities in SDH and CVD mortality rates. Further epidemiological studies are warranted in the provinces of Colón, Darien, Herrera and Los Santos to explore in-depth the higher CVD mortality rates observed in these provinces.

Recent genome studies of modern and ancient samples have proposed that Native Americans derive from a subset of the Eurasian gene pool carried to America by an ancestral Beringian population, from which two well-differentiated components originated and subsequently mixed in different proportion during their spread in the Americas. To assess the timing, places of origin and extent of admixture between these components, we performed an analysis of the Y-chromosome haplogroup Q, which is the only Pan-American haplogroup and accounts for virtually all Native American Y chromosomes in Mesoamerica and South America. Our analyses of 1.5 Mb of 152 Y chromosomes, 34 re-sequenced in this work, support a “coastal and inland routes scenario” for the first entrance of modern humans in North America. We show a major phase of male population growth in the Americas after 15 thousand years ago (kya), followed by a period of constant population size from 8 to 3 kya, after which a secondary sign of growth was registered. The estimated dates of the first expansion in Mesoamerica and the Isthmo-Colombian Area, mainly revealed by haplogroup Q-Z780, suggest an entrance in South America prior to 15 kya. During the global constant population size phase, local South American hints of growth were registered by different Q-M848 sub-clades. These expansion events, which started during the Holocene with the improvement of climatic conditions, can be ascribed to multiple cultural changes rather than a steady population growth and a single cohesive culture diffusion as it occurred in Europe. We established and dated a detailed haplogroup Q phylogeny that provides new insights into the geographic distribution of its Eurasian and American branches in modern and ancient samples.

To estimate the prevalence of obesity in Panama and determine some risk factors and associated diseases in adults aged 18 years and older. A cross-sectional descriptive study was conducted in the provinces of Panama and Colon where 60.4 % of all Panamanians 18 years or older reside, by administering a survey regarding the consumption of protective and predisposing foods and assessing the development of obesity by measuring the weight, height, and waist circumference of 3590 people. A single-stage, probabilistic, and randomized sampling strategy employing multivariate stratification was used. Individuals with a body mass index ≥ 30 kg/m2 (men and women) were considered obese. Prevalence and descriptive analysis were conducted according to sex using Odds Ratio, with statistical significance set at a p value ≤ 0.05. The general prevalence of obesity was 27.1 % (30.9 % women and 18.3 % men). In women, obesity was associated with living in urban areas, being 40–59 years of age, being Afro-Panamanian, consuming beverages / foods rich in sugar, being physically inactive and having a family history of obesity. In men, obesity was associated with living in urban areas, consuming beverages/foods rich in sugar, and having a family history of obesity. Almost the totality of obese women (97.9 %), and 80.0 % of men with obesity had abdominal obesity according to the WHO classification. In both sexes, obesity was a risk factor associated to type 2 Diabetes Mellitus, hypertension, LDL values ≥ 100 mg/dL, and low HDL values ( 1.0; P < 0.05. Obesity represents a very serious threat to Panamanian public health. Our study confirms a direct association in Panama between excess weight, hypertension, type 2 Diabetes Mellitus, LDL values ≥ 100 mg/dL and low HDL values for women and men (<50 mg/dL and < 40 mg/dL, respectively). Intervention / treatment programs should be targeted, specially, to Afro-Panamanian women, whom are 40–59 years old, living in urban areas, and those having a family history of obesity.