Calidad de vida en personas con depresión y comorbilidad física desde una perspectiva de género

ObjetivoEl objetivo del estudio es describir la percepción de la calidad de vida relacionada con la salud de personas con depresión y comorbilidad física bajo una perspectiva de género. Se incluyeron 380 individuos mayores de 49 años con, al menos, una patología de las siguientes: diabetes, enfermedad obstructiva pulmonar crónica y cardiopatía isquémica, reclutadas en 31 equipos de atención primaria de Cataluña. La calidad de vida se midió con la escala EuroQol (EQ-5D). Además, se recogieron variables sociodemográficas, gravedad de depresión, índice de privación económica y ámbito de residencia. Se evaluó la relación ajustada entre el sexo y las dimensiones de calidad de vida, mediante una regresión logística multivariante.ResultadosEl 81,3% fueron mujeres; la media de edad fue de 68,4 años (DE: 8,8), La media de la escala visual analógica fue de 57,8 (DE: 17,4) en hombres y 55,8 (DE: 18,6) en mujeres. La media del EQ-Health Index fue de 0,74 (DE: 0,17) en hombres y 0,65 (DE: 0,21) en mujeres (p = 0,001). La probabilidad de presentar problemas en las dimensiones del EQ-5D mostró el sexo como factor de más peso (mujer = 1/hombre = 0) en: autocuidado OR: 2,29 (IC 95% 1,04 a 5,07) y actividades cotidianas OR: 3,09 (IC 95% 1,67 a 5,71). La movilidad se asoció con la edad OR: 1,87 (IC 95% 1,22 a 2,86), el ámbito de residencia con el dolor OR: 2,51 (IC 95% 1,18 a 5,34) y el Beck Depression Inventory (BDI) con la ansiedad/depresión OR: 4,77 (IC 95% 1,77 a 12,88).ConclusiónLa percepción en la calidad de vida de las mujeres con depresión y comorbilidad física es inferior a la de los hombres, siendo en ambos casos inferior a la de población general.Palabras clave: Calidad de vida, Depresión, Comorbilidad física, Género, Atención Primaria     

Intensive chemotherapy (high-dose CHOP/ESHAP regimen) followed by autologous stem-cell transplantation in previously untreated patients with peripheral T-cell lymphoma

Aim: To analyze toxicity, response and outcome of a phase IItrial with intensive chemotherapy plus autologous stem-celltransplantation (ASCT) for young patients with peripheral T-celllymphoma (PTCL). Patients and methods: Forty-one patients [30 males and 11 females,median age 47 years] consecutively diagnosed with PTCL receivedthree courses of high-dose cyclophosphamide 2000 mg/m²/day,adriamycin 90 mg/m²/day, vincristine and prednisone alternatingwith three courses of etoposide, cisplatin, cytarabine and prednisone.Responders were submitted to ASCT. Results: Sixty-eight percent of patients received the plannedtreatment. After chemotherapy, 20 patients reached completeresponse (CR), 4 partial response and 17 failed. ASCT was carriedout in 17 of 24 candidates due to lack of mobilization (threecases), toxicity (two), early relapse and patient decision (oneeach). CR rate after treatment was 51%. With a median follow-upof 3.2 years, 5 of 21 CR patients relapsed and 2 died in CRdue to secondary neoplasms. Four-year progression-free survivalwas 30%. Twenty-two patients have died, with a 4-year overallsurvival of 39%. International Prognostic Index was the mainvariable predicting survival. No differences were seen amongthe 24 candidates according to whether or not they underwentASCT. Conclusion: This intensive regimen resulted in moderate CR rate,with manageable toxicity in PTCL. The contribution of ASCT inpreventing relapse is debatable. Novel strategies to increaseCR warrant investigation. Key words: autologous stem-cell transplantation, peripheral T-cell lymphoma, prognosis Received for publication January 7, 2008. Accepted for publication January 9, 2008.     

Gene-expression profiling and not immunophenotypic algorithms predicts prognosis in patients with diffuse large B-cell lymphoma treated with immunochemotherapy

Diffuse large B-cell lymphomas (DLBCLs) can be divided into germinal-center B cell-like (GCB) and activated-B cell-like (ABC) subtypes by gene-expression profiling (GEP), with the latter showing a poorer outcome. Although this classification can be mimicked by different immunostaining algorithms, their reliability is the object of controversy. We constructed tissue microarrays with samples of 157 DLBCL patients homogeneously treated with immunochemotherapy to apply the following algorithms: Colomo (MUM1/IRF4, CD10, and BCL6 antigens), Hans (CD10, BCL6, and MUM1/IRF4), Muris (CD10 and MUM1/IRF4 plus BCL2), Choi (GCET1, MUM1/IRF4, CD10, FOXP1, and BCL6), and Tally (CD10, GCET1, MUM1/IRF4, FOXP1, and LMO2). GEP information was available in 62 cases. The proportion of misclassified cases by immunohistochemistry compared with GEP was higher when defining the GCB subset: 41%, 48%, 30%, 60%, and 40% for Colomo, Hans, Muris, Choi, and Tally, respectively. Whereas the GEP groups showed significantly different 5-year progression-free survival (76% vs 31% for GCB and activated DLBCL) and overall survival (80% vs 45%), none of the immunostaining algorithms was able to retain the prognostic impact of the groups (GCB vs non-GCB). In conclusion, stratification based on immunostaining algorithms should be used with caution in guiding therapy, even in clinical trials.     

Treating COPD in chronic patients in a primary-care setting

The aging of the populations in Western countries entails an increase in chronic diseases, which becomes evident with the triad of age, comorbidities and polymedication. chronic obstructive pulmonary disease represents one of the most important causes of morbidity and mortality, with a prevalence in Spain of 10.2% in the population aged 40 to 80. In recent years, it has come to be defined not only as an obstructive pulmonary disease, but also as a systemic disease. Some aspects stand out in its management: smoking, the main risk factor, even though avoidable, is an important health problem; very important levels of underdiagnosis and little diagnostic accuracy, with inadequate use of spirometry; chronic patient profile; exacerbations that affect survival and cause repeated hospitalizations; mobilization of numerous health-care resources; need to propose integral care (health-care education, rehabilitation, promotion of self-care and patient involvement in decision-making).     

Augmentation of fluoxetine's antidepressant action by pindolol: analysis of clinical, pharmacokinetic, and methodologic factors

In a controlled trial, the beta-adrenoceptor/5-hydroxytryptamine-1A (5-HT1A) receptor antagonist pindolol accelerated and enhanced the antidepressant effect of fluoxetine. The median times to sustained response (> or = 50% reduction of baseline severity maintained until endpoint) were 19 days for fluoxetine plus pindolol (N = 55) and 29 days for fluoxetine plus placebo (N = 56) (p = 0.01). The response rate at endpoint was 16% greater in patients treated with the combination. The plasma concentration of pindolol remained stable between 3 days (first blood sampling) and 6 weeks. Mean values were approximately 26 nM, a concentration higher than the Ki of (-)pindolol for human 5-HT1A autoreceptors (11 nM). Plasma fluoxetine and norfluoxetine concentrations increased steadily until the fourth week of treatment. Fluoxetine concentrations were lower in patients receiving the combination (p = 0.043), but there was no significant relationship to the clinical response in either group. A reanalysis of the data using a survival analysis revealed that significant differences in the time to sustained response between both groups would have also been detected (1) in a 2-week trial, (2) without a placebo lead-in phase, and (3) with less frequent visits. However, the use of "response" instead of "sustained response" as measure of clinically relevant change would have greatly diminished the difference between treatment arms (p = 0.08 instead of p = 0.01). This emphasizes the need of using stringent outcome criteria in antidepressant drug trials. A comparison of the data of all sustained responders (N = 27) in the fluoxetine-plus-placebo group with the first 27 responders in the fluoxetine-plus-pindolol group (of a total of 38) revealed a highly significant difference in the time to sustained response (18 and 10 days, respectively; p = 0.0002). This indicates that the faster response in the fluoxetine-plus-pindolol group is not a result of the greater proportion of responders.     

Ethical questions concerning newborn genetic screening

Newborn screening is a public health strategy used to identify certain diseases in the first days of life and, therefore, facilitate early treatment before the onset of symptoms. The decision of which diseases should be included in a screening goes beyond the medical perspective, including reasons for public health and health economics. There are a number of characteristics to include a disease in the screening, such as that the disorder must be a significant health problem, the natural history of the disease must be well known, a feasible and accurate test must be available, there must be a treatment that is most effective when applied before the onset of clinical symptoms and a health system must be in place that is capable of performing the procedure and subsequent monitoring. Currently, newborn screening programs are currently based on the use of biochemical markers that detect metabolites, hormones or proteins, but recently, the availability of new technology has allowed the possibility of a genetic screening. In addition to technical problems, the possibility of neonatal screening also presents a number of ethical problems. We identified and discussed six areas of particular concern: type of illness, overdiagnosis or overtreatment, information management and informed consent, data confidentiality and protection, justice and legal regulation.