Ponce Health Sciences University Scientific Journal
The Ponce Health Sciences University Scientific Journal (PHSU-SJ) is a multidisciplinary, online research journal based in Ponce, Puerto Rico. It is an open-access journal that aims to eliminate barriers and increase accessibility throughout the medical and academic community.
Authors retain copyright of their articles. All works are published under the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited.
Burnout, Well-being, and Distress Among Orthopaedic Surgeons in Puerto Rico
Physician burnout is a global concern, yet its prevalence among Puerto Rico’s surgeons remains underexplored. This study assesses burnout among orthopaedic surgeons working within the island’s strained healthcare system, marked by economic disparities, privatization, and physician exodus. A cross-sectional survey was conducted among 67 orthopaedic surgeons (over 60% of the island's workforce) and 27 romantic partners. The survey included the Maslach Burnout Inventory-Human Services Survey, General Health Questionnaire 12, and the Revised Dyadic Adjustment Scale. Burnout was identified in 28.4% of surgeons, with 58.2% reporting high emotional exhaustion and 37.3% high depersonalization. No respondents exhibited low personal accomplishment. The most frequently cited stressor was Puerto Rico's healthcare system, particularly health insurance restrictions (66.7%). Additionally, 25.4% of surgeons showed signs of mental health concerns, and 22.0% experienced relationship distress. While emotional exhaustion and depersonalization present as alarmingly high, resilience in personal accomplishment was notable. Interventions are needed to address systemic stressors while leveraging cultural factors that protect against burnout.
Copyright (c) 2025 Gabriel González-Díaz, Emil Varas-Rodríguez, Joshua Vivas, Francis Cedeño, Gerardo E. Rodríguez-Matias, Jerry Cruz, Hans Hess, Oscar Duyos (Author) https://creativecommons.org/licenses/by/4.0
Generative AI as a Tool for Enhancing ESL Students’ Understanding
Wilfredo De Jesus-Rojas, MD Ponce Health Sciences University Scientific Journal August 14, 2024 Dear Editor-in-Chief, As former ESL (English as a Second Language) students who have pursued science, technology, engineering and mathematics (STEM) fields and current researchers and instructors, we intimately understand the challenges faced by students adapting not just to a new language, but to the complex context in which that language is used in academic settings. Our experiences have given us unique insights into the difficulties ESL students encounter in higher education, particularly in STEM disciplines. <span data-ccp-props="{"201341983":0,"335559685":270,"335559737":2466,"335559738":240,"335559739":60,"335559740":228,"335572071":0,"335572072":0,"335572073":0,"335572075":0,"335572076":0,"335572077":0,"335572079":0,"335572080":0,"335572081":0,"335572083":0,"335572084":0,"335572085":0,"335572087":0,"335572088":0,"335572089":0,"469789798":"nil","469789802":"nil","469789806":"nil","469789810":"nil","469789814":"nil"}"> Research aligns with our personal observations. ESL students often struggle with academic language proficiency, which can severely impact their ability to understand complex materials and engage in academic discourse [1]. These students are also more likely to face higher attrition rates [2], with studies indicating that they are more likely to experience academic probation or drop out compared to their native English-speaking peers [3]. ESL students often encounter significant obstacles in accessing and understanding academic resources that are primarily available in English, which can impede their ability to fully engage with the material.<span data-ccp-props="{"201341983":0,"335559685":270,"335559737":2466,"335559738":240,"335559739":60,"335559740":228,"335572071":0,"335572072":0,"335572073":0,"335572075":0,"335572076":0,"335572077":0,"335572079":0,"335572080":0,"335572081":0,"335572083":0,"335572084":0,"335572085":0,"335572087":0,"335572088":0,"335572089":0,"469789798":"nil","469789802":"nil","469789806":"nil","469789810":"nil","469789814":"nil"}"> To illustrate the challenges and potential solutions, we would like to share an experience from Nelson's academic journey that led us to appreciate the potential of generative AI in ESL students' education. During his graduate studies, Nelson was enrolled in a rigorous Real Analysis course. Despite his best efforts, he found himself struggling to grasp the material. In a meeting with his then mentor, Prof. Doug Moupasiri, Nelson confessed his difficulties. Prof. Moupasiri asked a simple yet profound question: “What other books on the subject have you read?'' When Nelson admitted that he had only been using the assigned textbook, Prof. Moupasiri encouraged him to explore other authors' works. This advice—to seek out different perspectives—was a turning point in Nelson's academic career. By finding an author whose style resonated with him, he was able to understand concepts that had previously eluded him. This experience made us realize that sometimes, the issue is not with the subject itself but with how it is presented.<span data-ccp-props="{"201341983":0,"335559685":270,"335559737":2466,"335559738":240,"335559739":60,"335559740":228,"335572071":0,"335572072":0,"335572073":0,"335572075":0,"335572076":0,"335572077":0,"335572079":0,"335572080":0,"335572081":0,"335572083":0,"335572084":0,"335572085":0,"335572087":0,"335572088":0,"335572089":0,"469789798":"nil","469789802":"nil","469789806":"nil","469789810":"nil","469789814":"nil"}"> This is where we see a tremendous opportunity for generative Al tools to support students, particularly ESL students, in their learning journey. ESL students often benefit from different learning approaches, and findings show that they have positive perceptions of AI-based learning tools, appreciating their personalized learning paths and time-saving advantages [4]. As evidenced in recent studies [5], AI technologies are already being successfully used in medical education to provide real-time feedback on quizzes, assist in anatomy learning, and support the recognition and diagnosis of medical images. Additionally, a study performed in a medical school in Puerto Rico showed that integrating a course aimed to bridge the gaps in AI knowledge among participants resulted in more positive perceptions of AI. However, it also revealed a lack of practical experience with AI applications, emphasizing the need for better integration of AI into educational programs [6].<span data-ccp-props="{"201341983":0,"335559685":270,"335559737":2466,"335559738":240,"335559739":60,"335559740":228,"335572071":0,"335572072":0,"335572073":0,"335572075":0,"335572076":0,"335572077":0,"335572079":0,"335572080":0,"335572081":0,"335572083":0,"335572084":0,"335572085":0,"335572087":0,"335572088":0,"335572089":0,"469789798":"nil","469789802":"nil","469789806":"nil","469789810":"nil","469789814":"nil"}"> Initiatives aimed specifically at Hispanic students are demonstrating the value of incorporating AI literacy into their education, helping them critically evaluate and effectively use AI technologies across different contexts [7]. By equipping students with essential AI competencies, these programs foster not only academic success but also readiness for AI-rich environments at home and in the workplace. We believe extending such support to ESL students can enhance equitable access to education by providing adaptive and personalized learning paths that cater to specific language needs. Just as different authors can present the same subject in varying ways, generative AI can offer students alternative explanations, analogies, and examples that align more closely with their individual learning styles. This ability to reshape content makes generative AI particularly powerful for students at institutions in Puerto Rico and elsewhere, allowing them to bridge gaps in understanding through tailored explanations in their native language or more accessible rephrasing, ultimately making challenging subjects more comprehensible.<span data-ccp-props="{"201341983":0,"335559685":270,"335559737":2466,"335559738":240,"335559739":60,"335559740":228,"335572071":0,"335572072":0,"335572073":0,"335572075":0,"335572076":0,"335572077":0,"335572079":0,"335572080":0,"335572081":0,"335572083":0,"335572084":0,"335572085":0,"335572087":0,"335572088":0,"335572089":0,"469789798":"nil","469789802":"nil","469789806":"nil","469789810":"nil","469789814":"nil"}"> Generative AI is not just a tool for information retrieval but a companion in the learning process, helping students navigate complex subjects with a personalized approach that traditional methods may not always provide. The greatest value of generative AI as a tutor lies in its ability to customize learning experiences, tailoring them to fit the context and background of each student. As we continue to integrate AI into the educational landscape, it is our hope that we can leverage these tools to not only enhance learning but also to empower students to overcome the challenges that come with language barriers and different learning styles. Just as Nelson's mentor's advice reshaped his educational path, we believe encouraging the correct use of generative AI can play a similar role for many students, directly impacting academic outcomes.<span data-ccp-props="{"201341983":0,"335559685":270,"335559737":2466,"335559738":240,"335559739":60,"335559740":228,"335572071":0,"335572072":0,"335572073":0,"335572075":0,"335572076":0,"335572077":0,"335572079":0,"335572080":0,"335572081":0,"335572083":0,"335572084":0,"335572085":0,"335572087":0,"335572088":0,"335572089":0,"469789798":"nil","469789802":"nil","469789806":"nil","469789810":"nil","469789814":"nil"}"> We urge educators and administrators to consider the potential of generative AI as a powerful tool for addressing the unique challenges faced by ESL students and those from diverse backgrounds. By embracing this technology, we can create a more inclusive and effective learning environment that supports all students in reaching their full potential.<span data-ccp-props="{"201341983":0,"335559685":270,"335559737":2466,"335559738":240,"335559739":60,"335559740":228,"335572071":0,"335572072":0,"335572073":0,"335572075":0,"335572076":0,"335572077":0,"335572079":0,"335572080":0,"335572081":0,"335572083":0,"335572084":0,"335572085":0,"335572087":0,"335572088":0,"335572089":0,"469789798":"nil","469789802":"nil","469789806":"nil","469789810":"nil","469789814":"nil"}"> Sincerely, Nelson Colón Vargas, PhD and Marcos J. Ramos-Benitez, PhD<span data-ccp-props="{"201341983":0,"335551550":1,"335551620":1,"335559685":270,"335559737":2466,"335559740":228,"335572071":0,"335572072":0,"335572073":0,"335572075":0,"335572076":0,"335572077":0,"335572079":0,"335572080":0,"335572081":0,"335572083":0,"335572084":0,"335572085":0,"335572087":0,"335572088":0,"335572089":0,"469789798":"nil","469789802":"nil","469789806":"nil","469789810":"nil","469789814":"nil"}">
Copyright (c) 2025 Nelson Colón-Vargas, PhD, Marcos J. Ramos Benítez, PhD (Author) https://creativecommons.org/licenses/by/4.0
Sevelamer-induced Stercoral Ulceration in a Patient with End Stage Renal Disease
This is a case describing the sequence of stercoral ulceration leading to fecal impaction and subsequent feculent peritonitis in a patient with end-stage renal disease (ESRD). Analyzing the patient’s operative course and hospitalization illustrates the complex nature of ESRD and the associated circumstances leading to this patient’s death. Utilizing the patient’s imaging and pathology results concludes that medication resins such as sevelamer caused mucosal ulceration in her colon. These results emphasize current literature which describes the potential for gastrointestinal complications with use of sevelamer.
Copyright (c) 2025 Shruti Rai, Loren Bach (Author) https://creativecommons.org/licenses/by/4.0
Semaglutide and Tirzepatide: Revolutionary Therapies for Obesity and Type 2 Diabetes Mellitus Management
Obesity and Type 2 Diabetes Mellitus (T2DM) represent significant global health challenges, contributing to high morbidity and mortality due to a combination of lifestyle, dietary, and genetic factors. Traditional management strategies, including lifestyle modifications, pharmacotherapy, and bariatric surgery, often fail to achieve sustained weight loss and glycemic control or are overly invasive. This review explores the potential of semaglutide (a glucagon-like peptide-1 [GLP-1] receptor agonist) and tirzepatide (a dual GLP-1/glucose-dependent insulinotropic polypeptide [GIP] receptor agonist) as transformative therapies for obesity and T2DM management. These agents act by stimulating glucose-dependent insulin secretion, suppressing glucagon release, delaying gastric emptying, and reducing appetite, resulting in significant weight reduction and improved glycemic control. Tirzepatide further enhances these benefits through dual receptor activation, promoting fat oxidation and additional metabolic benefits. Clinical trials, such as the STEP and SURPASS programs, demonstrate that semaglutide and tirzepatide achieve weight loss of up to 20.9% of initial body weight, comparable to bariatric surgery, and HbA1c reductions exceeding 2%, surpassing the 0.5% to 2% reductions typically observed with other T2DM therapies. These agents also improve cardiometabolic health and quality of life. Both drugs are generally well-tolerated, with gastrointestinal issues being the most common side effects. These therapies redefine obesity and diabetes as treatable chronic conditions, transforming metabolic health management. This review examines their mechanisms of action, efficacy, and safety, underscoring their potential to revolutionize the approach to these conditions.
Copyright (c) 2025 James P. Torres-Pirela (Author) https://creativecommons.org/licenses/by/4.0
Robotically Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion (MIS-TLIF) Outcomes in the Aging Hispanic Population: A Retrospective Cohort Study
Minimally invasive techniques for lumbar spinal fusions have evolved significantly to treat lumbar spinal stenosis, degenerative spondylolisthesis, and many other complex conditions. This study evaluates the clinical outcomes of patients aged 65 and older who underwent minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with robotic assistance. In this single-surgeon single-institution retrospective cohort study, 72 patients aged 65 and older who underwent MIS-TLIF from 2018 to 2021 were analyzed. Patients had diagnoses of lumbar spinal stenosis, with or without degenerative spondylolisthesis. Clinical outcomes were assessed using the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) for back and lower extremities at baseline, and 6, 9, or 12 months postoperatively. The data was analyzed, and outcomes were compared using paired t-tests. Significant improvements in disability were observed postoperatively, with mean ODI scores decreasing from 46.4% to 9.3% (95% CI: -41.2, -33.1). In terms of pain intensity, mean VAS scores for back pain decreased from 8.0 to 3.5 (95% CI: -5.1, -3.9) and leg pain scores also decreased from 8.2 to 2.9 (95% CI: -5.9, -4.6). These changes indicate substantial clinical improvements (p < 0.001). This study substantiates the efficacy of MIS-TLIF in significantly improving pain relief and functional mobility among seniors with lumbar conditions. The substantial reductions in ODI and VAS scores highlight its clinical benefits potential to set a new standard of care. By offering a robotically assisted, minimally invasive alternative, this approach aligns with contemporary healthcare objectives of enhancing patient recovery while minimizing procedural risks and costs.
Copyright (c) 2025 Emil Varas-Rodríguez, Gabriel González-Díaz, Alexander Matos, Miguel Cartagena, Oscar Duyos (Author) https://creativecommons.org/licenses/by/4.0
Unraveling Leptin's Influence: Sleep Abnormalities in Obesity-Related Neurogenetics
The role of early-onset obesity-related genetic predisposition and leptin receptor variants have been previously studied. However, studies involving sleep-related disorders linked to a genetic predisposition, leading to obesity, and how leptin could play a role in sleep-related disorders have been limited. In this study, we explore a case of how leptin receptor variants could play a role in the relationship between obesity and sleep-related disorders. We present a case of a morbidly obese (BMI of 62.87 kg/m2) Puerto Rican teenage female with a past medical history of type 2 diabetes mellitus, hypothyroidism, essential primary hypertension, and obstructive sleep apnea (OSA), who was evaluated due to complications regarding sleeping difficulties, despite being on Continuous Positive Airway Pressure (CPAP) treatment. Genetic studies performed to assess the causes of obesity revealed BBS9 heterozygous gene for a sequence variant defined as c.396GC and heterozygous LEPR gene for a sequence variant defined as c.658GA, which has been associated with an increased predisposition to obesity. This case report emphasizes the value of genetic research in figuring out the root causes of obesity and its comorbidities, especially in cases of early-onset obesity and co-occurring disorders such as OSA. The discovery of genetic variations in LEPR and BBS9 genes offers crucial information on potential mechanisms underlying the clinical phenotype of the patient.
Copyright (c) 2025 José Colón-Soto, Bryan Vega-Sanabria, Roberto A. Cardona-Quiñones, Alexandra Balsalobre Vélez, Simón Carlo-Torres, MD, Jesús Meléndez-Montañez, MD, Wilfredo De Jesús-Rojas, MD, FAAP, MSc, ATSF (Author) https://creativecommons.org/licenses/by/4.0
Hermansky-Pudlak Syndrome: A Bilingual Assessment of Quality and Readability of Online Health Information
Hermansky-Pudlak Syndrome (HPS), characterized by oculocutaneous albinism and a bleeding diathesis, is an autosomal recessive disorder particularly found in Puerto Ricans. The highest prevalence is noted in the northwest of Puerto Rico, where one in 1,800 individuals are affected. Due to its complex presentation and treatment regimen, health information must ideally be accessible, understandable, and of high quality. We selected three keyword phrases in English and three in Spanish that describe the disease in layman’s terms and entered them as prompts in a Google search to simulate patient-initiated searches. The first 20 websites for each of the six terms were analyzed for quality and readability utilizing a DISCERN instrument questionnaire and an online readability test tool, respectively. The results for the English terms yielded a mean general reliability of 72.8%, with the quality and reliability of treatment information at a mean of 37.4%. The average grade level (AGL) recommended for the English sites was 14, with academic and private/commercial sites scoring 15 and 13, respectively. For the Spanish keywords, the general mean reliability was 65.8%, and the treatment information mean score was 27.4%. The recommended AGL for Spanish websites was 16. Although information on HPS is readily available, our analysis suggests that the complexity of the content may be high, with extreme variations in quality. This phenomenon was observed in both languages. Our results highlight the need to provide understandable, simple, and reliable quality information in both languages for educational purposes.
Copyright (c) 2025 Laura I. Ortiz-López, MD, Karla M. Santiago-Soltero, MD, Sofia Milosavljevic, BA, Krithika Nayudu, BA, Mihir K. Patil, BA, Goranit Sakunchotpanit, BS, Rhea Malik, TJ Hazen, BA, Stephanie Sánchez-Meléndez, MD, Vinod E. Nambudiri, MD, MBA (Author) https://creativecommons.org/licenses/by/4.0
Regional Disparities in COVID-19 Mortality Rates: An Analysis of the 2021 National Inpatient Sample
Amid the 2019 coronavirus (COVID-19) pandemic, regional disparities in outcomes were identified as crucial for an effective public health response. Regional variations in COVID-19 outcomes in the United States of America (USA) were studied in this retrospective cross-sectional analysis, with a focus on in-hospital mortality rates among COVID-19 patients with pneumonia or respiratory failure, using the 2021 National Inpatient Sample dataset. Patients aged ≥18 years with confirmed diagnoses of COVID-19 associated pneumonia or respiratory failure were included in the study. The association between hospital census regions and in-hospital mortality rates was examined using multivariate logistic regression, adjusting for demographic, clinical, and hospital characteristics. Significant disparities in regional COVID-19 outcomes in the USA were revealed by the results. Mortality rates in the COVID-19 study cohort ranged from 14% in the Midwest to 18% in the West. Adjusted significant differences were shown by regression analysis, with the West exhibiting up to 28% higher odds of death (odds ratio: 1.28, 95% confidence interval: 1.218–1.354, p<0.001) than the Midwest, the region with the lowest mortality. The importance of accounting for demographic, clinical, and contextual factors in understanding these disparities and addressing regional disparities to promote health equity during the ongoing pandemic was underscored by these substantial regional variations in COVID-19 mortality rates in the USA.
Copyright (c) 2025 José A. Acosta, MD, MBA, MPH (Author) https://creativecommons.org/licenses/by/4.0
Bridging gaps in healthcare: The journey of a student-run free clinic in Puerto Rico
Founding of Clínica del Sur: Disparities in healthcare access and affordability exacerbate the constraints presented by a complex socioeconomic landscape in Puerto Rico (PR). According to the U.S. Census Bureau, the median household income in PR is $24,112, and 41.7% of people live in poverty on the island [1]. While the U.S. Census Bureau states that just 5.1% of people in PR do not have healthcare coverage, the healthcare system in PR struggles with employee shortages and lack of federal funding [2]. This makes healthcare less accessible despite Puerto Ricans having health insurance. As the elderly population continues to grow to the point that the percentage of elderly people in PR is among the top ten globally, challenges arise in accessing healthcare with family members migrating to the U.S. [1]. In 2019, medical students at Ponce Health Sciences University (PHSU) sought out to address these healthcare disparities. Despite significant earthquakes and the COVID-19 pandemic, the Student-Run Free Clinic (SRFC) Clínica del Sur was born in 2022. The clinic serves as a reliable resource for underserved populations and an opportunity for preclinical health sciences students to gain clinical experience and conduct research. Since its founding, Clínica del Sur has been run by students in medicine, psychology, nursing, and public health. Since then, the clinic has expanded to offer dermatology, dental, and neurology services. Clínica del Sur strives to provide comprehensive care in these areas to best serve the needs of its community similar to the Student-Run Clinic of University of Texas Río Grande Valley School of Medicine, which treats patients who do not have access to primary care [3]. Other clinics such as Qlinic, an LGBTQIA+ clinic at Cornell University, focus on one area of healthcare such as behavioral therapy in mental healthcare [4]. As a member of the National Association of Free and Charitable Clinics (NAFC), Clínica del Sur has been funded by the following organizations: Americares, Direct Relief, Brother’s Brother Foundation, Fundación Intellectus, and Heart to Heart Foundation. Through this membership, the clinic has also received a grant from CeraVe, from which the Sun Protection Campaign was launched to raise awareness and provide education on sun protection. Equipment has been acquired through the grant to improve the clinic’s dermatology services. For example, many patients are lost to follow-up due to the complicated structure of the island's healthcare system. To relieve patients of this burden, the clinic acquired a camera to capture photos of areas of concern on the skin so that patients have the necessary information in their file for their referral for continued cost-free care. The clinic is also a member of the Society of Student-Run Free Clinics (SSRFC), through which it hopes to gain funding and networking opportunities.
Copyright (c) 2025 Brittany Hahney, MPH , Laura Domenech, MD (Author) https://creativecommons.org/licenses/by/4.0
Biomarkers for Prostate Cancer Aggressiveness in Puerto Rican Men: Analysis of Phospho-Rb S249, N-cadherin, β-catenin, and E-cadherin Expression in Prostate Biopsies
Prostate cancer (PCa) is the leading cause of cancer in Puerto Rican men and exhibits significant racial disparities globally. Although only 8% of cases invade beyond the prostate, predicting PCa aggressiveness is challenging. This study investigated the potential of the retinoblastoma tumor suppressor protein phosphorylated in Serine 249 (Phospho-Rb S249), N-cadherin, β-catenin, and E-cadherin as biomarkers for identifying aggressive PCa in Puerto Rican men. We hypothesized that the expression of these proteins could serve as biomarkers for identifying PCa tumors with potential to becoming aggressive in Puerto Rican men. Immunohistochemistry was performed on 23 biopsies from Puerto Rican men to evaluate the biomarkers’ expression, and correlation analyses examined associations with clinicopathological parameters. Results showed that Phospho-Rb S249 expression correlated positively with tumor size and positive cores in patients with Gleason scores ≥4+3. β-catenin was positively associated with tumor size and carcinoma percentage in Gleason scores >4+3. E-cadherin expression negatively correlated with grade group, indicating a protective role. In contrast, N-cadherin and β-catenin were more prominent in Gleason scores <3+4, hinting at their involvement in early epithelial-to-mesenchymal transition (EMT). A decision tree analysis identified N-cadherin expression as a key determinant for classifying PCa aggressiveness, with an 82% likelihood. These findings suggest N-cadherin as a biomarker for identifying PCa with the potential to become aggressive. While our study provides promising results, further validation in a larger patient cohort is needed to increase the robustness and reliability of our findings. Also, combining multiple biomarkers could further enhance the specificity of aggressive PCa detection.
Epitheliat-toMesenchymal Transition (EMT)
Copyright (c) 2025 Sheila M. Valle Cortés, Jaileene Pérez Morales, Mariely Nieves Plaza, Raymond Quiñones Alvarado, Gilberto Ruiz Deyá, Juan C. Santa Rosario, Pedro Santiago Cardona (Author) https://creativecommons.org/licenses/by/4.0