Quality of life two years after radical prostatectomy, prostate brachytherapy or external beam radiotherapy for clinically localised prostate cancer: the Catalan Institute of Oncology/Bellvitge Hospital experience

OBJECTIVE

The objective was to compare the short- and long-term impact of 3 different treatment modalities on health-related quality of life (HRQOL) in patients treated for localised prostate cancer at a single centre in Catalonia, Spain.

MATERIAL AND METHODS

This was a longitudinal, prospective study of 304 patients from a single centre in Catalonia, Spain. Patients underwent 1 of 3 treatment procedures: radical prostatectomy (114 patients), external beam radiation (134) or interstitial brachytherapy (56). HRQOL was assessed by both general and specific questionnaires, including the SF-36 health survey and the Expanded Prostate Cancer Index Composite (EPIC). Interviews were administered prior to treatment and at months 1, 3, 6, 12 and 24. One-way analysis of variance and generalised estimating equations models were constructed to assess between group differences in HRQOL.

RESULTS

After initial deterioration, HRQOL scores partially recovered, although significant differences between treatment groups persisted at two years. Worsening of urinary incontinence was especially marked for the radical prostatectomy group (11.45, p=0.005), while deterioration in the urinary irritative/obstructive domain was worse following brachytherapy treatment (4.76, p=0.025). Decline in sexual function was significantly greater for the radical prostatectomy group than for the brachytherapy group (18.74, p<0.001). No significant between-group differences were observed in bowel domain scores.

CONCLUSIONS

Quality of life 2 years after treatment for prostate cancer shows wide variability. Radical prostatectomy had the largest negative impact on the sexual and urinary incontinence domains. Differences between external radiation and brachytherapy were relatively small. Brachytherapy led to a moderate increase in urinary irritation compared to the other 2 groups.

Treatment persistence and compliance with a combination of calcium and vitamin D

INTRODUCTION

The persistence and compliance of patients in Spain with calcium and vitamin D supplementation are unknown, and thus the purpose of the present study was to determine the current figures.

METHODS

This was a multicenter, cross-sectional study. Throughout Spain, 1342 primary-care physicians and specialists were asked to recruit 7888 patients aged 45 years or over, who had been prescribed with a calcium and vitamin D combination (CaVitD) at least 1 year prior to the study. Data on biodemographics, the reason for prescription and fracture risk factors were collected. Persistence with treatment, reasons for discontinuation, and compliance among persistent patients were assessed and patients' profiles analyzed.

RESULTS

From the recruited sample, a total of 7624 patients were finally analyzed. Most subjects were postmenopausal (mean age 65.7 ± 9.4 years). The main reason for CaVitD prescription was osteoporosis (56.3%), started 2-5 years earlier. A family history of osteoporosis (41.4%) and previous fractures (40.7%) occurred frequently in the patients' clinical histories. At the study visit, 27.7% had discontinued CaVitD treatment, the main reason being fatigue due to the long-term treatment. Just 31.2% of persistent patients were adherent. Non-persistent patients were more likely to be smokers, alcohol consumers, have a long immobilization history, malabsorption syndrome and previous bone fractures.

CONCLUSIONS

Only two in ten patients effectively comply with CaVitD treatment after 1 year or more of its prescription.

Respiratory impedance during weaning from mechanical ventilation in a mixed population of critically ill patients

BACKGROUND

Worsening of respiratory mechanics during a spontaneous breathing trial (SBT) has been traditionally associated with weaning failure, although this finding is based on studies with chronic obstructive pulmonary disease patients only. The aim of our study was to assess the course of respiratory impedance non-invasively measured by forced oscillation technique (FOT) during a successful and failed SBT in a mixed population.

METHODS

Thirty-four weaning trials were reported in 29 consecutive mechanically ventilated patients with different causes of initiation of ventilation. During the SBT, the patient was breathing through a conventional T-piece connected to the tracheal tube. FOT (5 Hz, +/- 1 cm H(2)O, 30 s) was applied at 5, 10, 15, 20, 25, and 30 min. Respiratory resistance (Rrs) and reactance (Xrs) were computed from pressure and flow measurements. The frequency to tidal volume ratio f/V(t) was obtained from the flow signal. At the end of the trial, patients were divided into two groups: SBT success and failure.

RESULTS

Mixed model analysis showed no significant differences in Rrs and Xrs over the course of the SBT, or between the success (n=16) and the failure (n=18) groups. In contrast, f/V(t) was significantly (P<0.001) higher in the failure group.

CONCLUSIONS

Worsening of respiratory impedance measured by FOT is not a common finding during a failed SBT in a typically heterogeneous intensive care unit population of mechanically ventilated patients.

[Development of the CAT-Health, the first adaptive computerized test (CAT) for the evaluation health-related quality of life in Spain]

OBJECTIVES

To develop a Computerized Adaptive Test to obtain a generic measure of the patients' perceived health state.

METHODS

An experts' panel created a pool of five-alternative Likert format items, chosen among Health Related Quality of Life questionnaires validated in our country. That pool was applied to a pilot sample and later to another general sample of patients belonging to 7 Primary Health Centers in Asturias. Two response options were offered to the general sample: 1) on paper 2) on a touch panel. The Item Response Theory psychometric properties (discrimination, reliability and validity) were evaluated by means of the factorial analysis and other methods. The information function was analyzed and a study of simulation was developed.

RESULTS

A pool of 140 items was created. The requirements for the application of the IRT were verified by means of the factorial analysis. A selection of items was realized following the statistical criterion and the application of the IRT. The elimination of 35 articles resulted in a test composed by 105 items. Once the questionnaire was applied to the general sample, the parameters of the items were estimated again. The parameters invariance was verified once more and other 9 items were eliminated. The result was a definitive version of 96 items.

CONCLUSIONS

The Computerized Adaptive Test developed proves to be a fast and reliable tool to evaluate the Health Related Quality of Life generically. This test may imply a very important advance for the measurement of the results reported by the patients in the clinical practice.

Epidemiology, healthcare, resources, use and clinical features of different types of urticaria. Alergológica 2005

INTRODUCTION

In spite of the impact on quality of life, little attention has been given to chronic urticaria.

OBJECTIVE

To describe the morbidity and features of urticaria and compare the results with the other allergic diseases included in this study.

RESULTS

Urticaria is the fourth most prevalent condition after rhinitis, asthma and drug allergy. Despite this position, the number of patients who needed to visit emergency departments was higher (54.4%) than the rest of the sample (24.6%) (P < .001). The percentage of urticaria/angioedema patients with work absences was also higher than the rest of the sample suffering from other allergic conditions. We found significant differences in school performance between urticaria/angioedema children and children from of the rest of the sample (P = .029). Paired analysis identified significant differences in percentages of "bad school performance" for children suffering from urticaria/angioedema. Patients suffering from chronic urticaria scored in the lowest 25th percentile on physical impact. On psychological impact, urticaria patients scored below the 20th percentile of the general population. The general trend was to order extensive laboratory test for patients suffering from urticaria. In the present study, only one patient had a systemic disease, 13 patients had autoimmune and endocrine diseases often present with chronic urticaria. In spite of the insistence on the possible role of infections in chronic urticaria, in our study an infection could only be demonstrated in three patients.

CONCLUSION

Based on these results, we believe that urticaria is a disease with significant morbidity and involves heavy use of healthcare services and as such deserves more resources and attention.

From pollinosis to digestive allergy

Pollinosis is defined as the appearance of respiratory symptoms (rhinoconjunctivitis and/or asthma) as a result of the inhalation of pollen to which the individual is sensitized. Pollen allergy becomes all the more relevant on taking into account that it may be responsible for the development of plant food allergy, or may even constitute the direct cause of esophageal, gastric and/or intestinal inflammation in the context of a digestive allergic process. Pollen can act as a source of allergens that induce primary sensitization in the host as a result of inhalation, with secondary allergy to plant foods containing shared allergens via a cross-reactivity mechanism. The observed pattern of plant food allergy depends on the dietary habits of the population in a given geographical setting, and on the pollination found in that setting. Pollinosis may account for the greater or lesser prevalence of allergy to certain plant foods, and for the severity of the associated reactions. Beyond the digestive tract inflammation that may result from allergy to a given food, pollinosis is also intrinsically able to generate a clinically relevant or irrelevant Th2-mediated inflammatory response at digestive level, and may even give rise to eosinophilic esophagitis. Inter-relation with the airway may also extend to the digestive tract as a consequence of the systemic response that characterizes allergic disease.

Reference values for facilitating the interpretation of the ESPRINT-15 questionnaire (Spanish version)

OBJECTIVE

ESPRINT-15 is a specific, short-form instrument to measure health-related quality of life in adults suffering from allergic rhinitis. The aim of this study was to obtain reference values in order to improve its interpretability.

METHODS

ESPRINT-15 was administered to a representative sample of Spanish adults with allergic rhinitis. Means and percentiles were obtained, taking into account the kind of rhinitis (persistent/intermittent) and symptom severity (very mild/mild/moderate/severe).

RESULTS

A total of 2756 patients participated in the study. Mean (SD) scores were significantly lower (better) for men than for women (2.2 [1.4] vs 2.4 [1.4], P<.001, effect size [ES] is congruent to 0.15). Patients with intermittent rhinitis showed better scores than patients with persistent rhinitis (2.1 [1.4] vs. 2.5 [1.4], P<.001, ES is congruent to 0.21). Mean (SD) scores were higher (worse) when severity of symptoms increased, ranging from 0.9 (0.9) (very mild) to 3.7 (1.0) (severe) (ES is congruent to 1.0 between each consecutive group of symptom severity).

CONCLUSIONS

The magnitude of the differences found among groups of patients reinforces the usefulness of providing reference values stratified by gender, type of allergic rhinitis, and symptom severity. The percentiles obtained can be used in clinical practice to evaluate individual scores, and assign the patient to the corresponding reference group.

Allergic rhinitis and school performance

Allergic rhinitis is presently the most common chronic disorder in the pediatric population. It can affect sleep at night and cause daytime sleepiness, with school absenteeism, "presenteeism" or inattention, mood disturbances and psychosocial problems. All this in turn can contribute to reduce school performance. The correct treatment of allergic rhinitis can improve school performance, though the first generation antihistamines have unacceptable central and anticholinergic effects that can actually worsen the situation. The second generation antihistamines constitute the drug treatment of choice for allergic rhinitis in children. Vasoconstrictors should not be used in pediatric patients, due to their unpredictable pharmacokinetics and very narrow therapeutic margin. Intranasal corticoids could improve school performance in some patients, by reducing nose block or congestion, the nocturnal sleep disturbances, and daytime sleepiness. Concrete studies of the impact of chromones, anticholinergic agents, antileukotrienes and immunotherapy upon school performance are lacking.

Genetic aspects of allergic rhinitis

The development of allergic rhinitis entails a complex interaction between genetic predisposition and environmental exposure to different factors, of which the most important is the implicated allergen. There is a clear hereditary component in allergic rhinitis that has been well corroborated by segregation studies and investigations in twins. From the strictly genetic perspective, it is believed that the disease may be the result of the interaction of different genetic alterations, each of which would contribute a small defect. In recent years, considerable attention has focused on the genes that may be implicated in allergic rhinitis. A number of genomic searches have been made, yielding different chromosomal associations--the most repeated being those involving chromosomes 2, 3, 4 and 9. Single-nucleotide polymorphism studies involving genes encoding for molecules implicated in the pathogenesis of allergic rhinitis have also been made. Such molecules comprise chemokines and their receptors, interleukins and their receptors, eosinophil peroxidase and leukotrienes, among others.

Molecular diagnosis in allergology: application of the microarray technique

Recombinant and purified allergens are currently available for determining specific IgE targeted to different allergenic components. In this way it is possible to diagnose the sensitization profile of each individual patient. The microarray technique makes it possible to determine specific IgE against multiple allergens simultaneously in one same patient, with a minimum amount of serum, and even allows the determination of IgG and IgM against the same allergens in one same serum sample. Microarray procedures are being developed not only for the determination of antibodies but also for cell activation tests. In addition, microarray technology will help explain cross-reactions, and will facilitate the evaluation of subjects in which skin tests cannot be performed. These techniques will allow a great step forward in the development of immunotherapy specifically targeted to the sensitizations found in each individual patient, yielding especially hypoallergenic forms of great immunogenic capacity, and thus improving the safety and efficacy of immunotherapy. Lastly, microarrays will improve our understanding of the physiopathology of allergic diseases.

Stress and allergy

In recent years it has been seen that the nervous and immune systems regulate each other reciprocally, thus giving rise to a new field of study known as psychoneuroimmunology. Stress is defined as a general body response to initially threatening external or internal demands, involving the mobilization of physiological and psychological resources to deal with them. In other words, stress is characterized by an imbalance between body demands and the capacity of the body to cope with them. The persistence of such a situation gives rise to chronic stress, which is the subject of the present study, considering its repercussions upon different organs and systems, with special emphasis on the immune system and--within the latter--upon the implications in relation to allergic disease. Activation of the neuroendocrine and sympathetic systems through catecholamine and cortisol secretion exerts an influence upon the immune system, modifying the balance between Th1/Th2 response in favor of Th2 action. It is not possible to affirm that chronic stress is intrinsically able to cause allergy, though the evidence of different studies suggests than in genetically susceptible individuals, such stress may favor the appearance of allergic disease on one hand, and complicate the control of existing allergy on the other.

Allergic conjunctivitis and H1 antihistamines

Allergic conjunctivitis is the most common form of ophthalmological allergy. Eye symptoms are one of the main and most frequent reasons for consultation among patients with allergic rhinoconjunctivitis, which in turn is the most common reason for visiting the allergologist, according to the Alergológica 2005 study. Itching is the key symptom of allergic conjunctivitis, and its relief is the principal objective of the broad range of treatment options available. Topical antihistamines with multiple actions (mast cell stabilization, and antiinflammatory and antihistaminic actions) are probably the best treatment option, thanks to their rapid action, safety and convenience of use. However, oral antihistamines (preferentially second generation drugs) can also play an important role, since they are of established efficacy and offer adequate treatment of the nasal symptoms that tend to accompany the ocular manifestations of allergic rhinoconjunctivitis. Models of allergic conjunctivitis are useful for investigational purposes and for advancing our knowledge of allergic reactions. Advances in the study of the physiopathology of ocular allergy allow us to introduce new therapeutic options for the management of such allergic reactions, thanks to the findings derived from models of this kind. The present review provides an update to the published data on allergic conjunctivitis and the current role of both topical and ocular antihistamines in treating the disorder.

Component-resolved in vitro diagnosis in peach-allergic patients

BACKGROUND

The in vitro diagnosis of pollen-related food allergy presents low specificity and reproducibility with many conventional extracts. This can be improved using natural purified allergens, recombinant purified allergens, or both.

OBJECTIVE

We compared specific immunoglobulin (Ig) E determination (slgE), the basophil activation test (BAT), the histamine release test (HRT), and the cellular allergen stimulation test (CAST) using natural and recombinant allergens in the diagnosis of peach allergy.

METHODS

Thirty-two peach allergic patients were studied. Skin prick tests were performed with commercial peach and extract with Mal d 1, nPru p 3, and profilin (nPho d 2). slgE, BAT, CAST, and HRT were determined using rPru p 3, rMal d 3, rBet v 1, rMal d 1, and rMal d 4.

RESULTS

Agreement between the techniques was good with all the allergens, except HRT with rMal d 1 and rMal d 4. With rPru p 3, slgE, CAST, BAT, and HRT showed sensitivity values of 88%, 81%, 72%, and 69% and specificity values of 100%, 93%, 97%, and 83%, respectively. In patients with systemic symptoms or contact urticaria, the values were 100%, 85%, 81%, and 81%. In patients with oral allergy syndrome, sensitivity to profilins or homologues of Bet v 1 was detected in 100% of the cases by all the techniques, except by HRT with rMal d 1, which detected 66% of the cases.

CONCLUSIONS

The use of single allergens in the in vitro diagnosis of peach allergy by specific IgE determination, BAT, and CAST offers high specificity and sensitivity, with better results than the HRT.

Chronic urticaria: do urticaria nonexperts implement treatment guidelines? A survey of adherence to published guidelines by nonexperts

BACKGROUND

Guidelines including level of evidence and grade of recommendation were recently published for chronic urticaria (CU).

OBJECTIVES

To describe the therapeutic approach in patients with CU, and to depict how recent guidelines are implemented in the daily practice of management of CU.

METHODS

We performed a cross-sectional multicentre study through a questionnaire answered by 139 specialists. In total, 695 patients were evaluated, mean+/-SD age 42.3+/-15 years, 62.1% women. Of the patients, 168 were treated by an allergist, 473 by a dermatologist and in 54 cases the specialist was not stated. The drug prescribed was the main variable, and chi2 and Fisher's tests were utilized for the statistical analysis.

RESULTS

Nonsedating anti-H1 antihistamines taken regularly were the most common drugs prescribed, followed by nonsedating anti-H1 antihistamines taken as needed, corticosteroids, sedating antihistamines taken regularly, sedating antihistamines taken as needed, anti-H2 antihistamines, leukotriene antagonists, ciclosporin and doxepin. Nonsedating antihistamines plus corticosteroids was the most frequent drug combination prescribed. When comparing between allergists and dermatologists we found a positive and significant correlation only between prescription of cetirizine, dexchlorfeniramine, leukotriene antagonists and anti-H2 antihistamines and being treated by an allergist. A positive correlation was found with desloratadine and being seen by a dermatologist. We did not find any difference in CU management in the rest of the treatments studied.

CONCLUSIONS

It is surprising that a large amount of sedating antihistamines was prescribed. In many instances these were prescribed as needed. This fact could have a negative impact on urticaria control and patient satisfaction. It seems difficult for the nonexpert to differentiate between CU and any kind of physical urticaria.

Chronic ouabain treatment increases the contribution of nitric oxide to endothelium-dependent relaxation

The aim of this study was to analyze the contribution of nitric oxide, prostacyclin and endothelium-dependent hyperpolarizing factor to endothelium-dependent vasodilation induced by acetylcholine in rat aorta from control and ouabain-induced hypertensive rats. Preincubation with the nitric oxide synthase inhibitor N-omega-nitro-L-arginine methyl esther (L-NAME) inhibited the vasodilator response to acetylcholine in segments from both groups but to a greater extent in segments from ouabain-treated rats. Basal and acetylcholine-induced nitric oxide release were higher in segments from ouabain-treated rats. Preincubation with the prostacyclin synthesis inhibitor tranylcypromine or with the cyclooxygenase inhibitor indomethacin inhibited the vasodilator response to acetylcholine in aortic segments from both groups. The Ca2+-dependent potassium channel blocker charybdotoxin inhibited the vasodilator response to acetylcholine only in segments from control rats. These results indicate that hypertension induced by chronic ouabain treatment is accompanied by increased endothelial nitric oxide participation and impaired endothelium-dependent hyperpolarizing factor contribution in acetylcholine-induced relaxation. These effects might explain the lack of effect of ouabain treatment on acetylcholine responses in rat aorta.