[Pharmaceutical intervention on the therapeutic adherence in patients with chronic renal disease]

OBJECTIVES

To assess the therapeutic adherence in patients with stage 3-5 chronic renal disease (CRD), and evaluate whether pharmaceutical intervention improves medication adherence.

MATERIAL AND METHODS

A prospective uncontrolled before-after study (July 2008-March 2009) was carried out in the Pharmaceutical Care Unit of a tertiary hospital. Polymedicated patients >65 years with stage 3-5 CRD, and on treatment with erythropoietin. Infowin(®) program was used to provide written information during the interviews with patients, who signed the informed consent. The Haynes-Sackett and Morisky-Green questionnaires were used to assess the therapeutic adherence.

RESULTS

Of a total of 103 candidates, we asked 94 patients to participate, of whom 53 agreed; women 60.4%, mean age: 76.8 ± 6.9 years.

EXCLUSION CRITERIA

refusal to participate (19.5%), non-appearance of patient or usual caregiver (70.7%), and institutionalised patients (9.8%). Average number of drugs per patient: 10.8 ± 2.97. A total of 88.7% had no difficulty in taking medication (Haynes-Sackett) and 73.6% were considered compliant (Morisky-Green). Differences were observed when comparing both methods (P=.036). Patients with difficulty in taking medication were less compliant (45.6%). The Morisky-Green questionnaire was used for a second time on 78.6% of unreliable patients, and obtained a 45.5% increase in compliance, increasing the overall compliance to 87.8% (P=.00003). Fifty-two drug-related problems (DRP) were detected.

CONCLUSIONS

The initial compliance of patients with stage 3-5 CRD was was noteworthy. However, after pharmaceutical intervention there was a statistically significant improvement in adherence to therapy.

[Orbital lymphomas. Presentation of nine cases]

PURPOSE

To report nine cases of orbital lymphomas.

METHODS

We reviewed the clinical records of nine patients diagnosed with orbital lymphoma and performed a literature search related to this condition.

RESULTS

We present a series of five women and four males with orbital lymphoma involving the orbital region. In our cases, most patients presented concurrent extraorbital lymphoma when the orbital disease was first noticed (seven out of nine patients). We found three MALT lymphomas, two follicular lymphomas, two non-Hodgkin large B cell lymphomas, one low grade B cell lymphoma, and one mantle cell lymphoma. Eight patients were alive and one had died as a consequence of his lymphoma at the time this report was written.

CONCLUSIONS

An increase in the incidence of non-Hodgkin orbital lymphomas has been observed over the last three decades. The most common type in the orbital region is the MALT lymphoma. The clinical features observed in our series are similar to those reported in the literature. Since lymphomas are the most frequent malignant tumours in the orbit, usually with extraorbital involvement, and can be successfully treated in many cases, it is important for the ophthalmologist to be aware of this condition.

Stage, percentage of basophils at diagnosis, hematologic response within six months, cytogenetic response in the first year: the main prognostic variables affecting outcome in patients with chronic myeloid leukemia in chronic phase treated with interferon-alpha. Results of the CML89 trial of the Spanish Collaborative Group on interferon-alpha2a and CML

BACKGROUND AND OBJECTIVE

Interferon-a (IFN) is increasingly being used as the drug of choice in chronic myeloid leukemia patients. The main objectives of the study were to study the influence of the classic prognostic variables and response to IFN, and to assess the influence of this response on the course of the disease and survival.

DESIGN AND METHODS

Single arm, prospective, multicenter study, without a control group. Only Ph1-positive CML patients were included. The treatment scheme was biphasic: the patients first received standard chemotherapy and thereafter IFN-a2a was used as monotherapy, with a target dose of 9 MU/d/s.c.

RESULTS

Twenty-one centers in Spain enrolled 132 patients (72 men, 60 women). The median dose of IFN given was 5.8 MU/d, and the median treatment duration was 431 days (range: 18-2,597). Seventy-two percent of patients obtained a hematologic response in the first six months of IFN treatment. Genetic response was obtained in 47% of the patients, and the response was major or complete in 27% and 19%, respectively. The median time to obtain this response was 7, 9, and 18 months for minimal, partial and complete genetic response, respectively. Multivariant analysis showed that only a higher percentage of basophils at diagnosis was associated with a worse hematologic response at six months (p=0.001) (OR: 1.23) and with a worse cytogenetic response in the first year of IFN therapy (p=0.018) (OR: 1.4). Over an observation period of 8 years, 35.6% of the patients died, and 85 (64.4%) remained alive. With a median follow-up of 42 months (3.7-98), the 6-year projected probabilities of survival and transformation-free survival were 0.61+/-0.07 vs. 0.54+/-0.07, respectively. Patients with Kantarjian's stage 3 disease or in a high-risk Sokal group had lower probabilities of survival, but these systems did not adequately discriminate in our series. Obtaining a complete hematologic response in the first six months of IFN therapy was favorable in terms of overall survival (p=0.05; HR=0.33). Cox's analysis demonstrated that obtaining a cytogenetic response in the first year was independently associated with better overall survival (p=0.04; HR=0.19) and better transformation-free survival (p=0.0035; HR=0.11).

INTERPRETATION AND CONCLUSIONS

Nearly half of the patients obtained some degree of Philadelphia suppression, which was major in 27%, and complete in 19%. A higher percentage of basophils at diagnosis was the only variable associated with a lower probability of cytogenetic response. Obtaining a cytogenetic response during the first year of IFN treatment was a favorable and independent variable in terms of survival and transformation-free survival. Obtaining a major cytogenetic response during this period decreased the risk of transformation twenty times. Our results suggest that the effect of IFN on survival is independent of the classic prognostic variables.

Correlation and prognostic value of serum soluble ICAM-1, beta-2 microglobulin, and IL-2alphaR levels in non-Hodgkin's lymphoma

Serum levels of sICAM-1, sIL-2alphaR, and beta-2 microglobulin were measured in 63 patients with non-Hodgkin's lymphoma (NHL). The correlation between these serum markers as well as their relationship with NHL features and disease outcome were analyzed. Although in high-grade NHL sICAM-1 levels correlated with tumor mass, no correlation was found between sICAM-1 levels and tumor burden in low-grade NHL. When compared with sICAM-1 and beta-2 microglobulin, sIL-2alphaR showed the strongest correlation with the tumor burden. However, in multivariate analysis, including serum markers employed as continuous variables, the only parameteres which entered the regression model were beta-2 microglobulin (p=0.012) and sICAM-1 (p=0.019). In a dichotomized model, beta-2 microglobulin, aggressive histology, sICAM-1, age and number of nodal involved sites were found to be prognostically significant. Finally, by combining sICAM-1 and beta-2 microglobulin serum levels, a simple prognostic model useful for NHL was obtained.

Hydroxyurea-induced acute interstitial pneumonitis in a patient with essential thrombocythemia

Hydroxyurea is a drug widely used to control myeloproliferative disorders, due in part to its relative lack of severe side effects. We present a case of acute interstitial pneumonitis in a patient who was treated with hydroxyurea for essential thrombocythemia. The clinical course suggests that the interstitial pneumonitis was induced by hydroxyurea. This is the first case of hydroxyurea-induced acute interstitial pneumonitis reported in the literature.

Tumor burden and serum level of soluble CD25, CD8, CD23, CD54 and CD44 in non-Hodgkin's lymphoma

We studied the value of soluble CD25, CD8, CD23, CD54 and CD44 serum levels as tumor burden markers in lymphoma. Soluble CD25 compared with the others sCD and the usual serum factors (albumin, lactate dehydrogenase, beta 2-microglobulin, uric acid and C-reactive protein), showed the strongest correlation with the Ann Arbor stage and the number of affected localizations. sCD25 level is the most sensitive serum marker for tumor burden in lymphoma.

Familial myeloproliferative syndrome

Familial chronic myeloproliferative syndrome (CMS) was observed in five members from two different generations of the same kindred. Diagnosis included agnogenic myeloid metaplasia (case 1), polycythemia vera (case 2), and essential thrombocythemia (cases 3-5). Cases 1-3 were siblings, case 5 was the daughter of case 1, and case 4 was the cousin of cases 1, 3. Age at diagnosis ranged from 28 to 75 years, cases 1 and 3 were male, and the others were female. The diagnosis was made after an episode of cerebral thrombosis in one patient, during a study for headache and dizziness in another, and fortuitously in the three remainders. All patients had splenomegaly and varying degrees of thrombocytosis. The cytogenetic exam was normal in all four cases. A woman patient was treated with interferon during a pregnancy. Fetal growth was retarded, and the newborn showed bone and genital malformations. No environmental leukemogen factor was found. This familial case strengthens Dameshek's theory of a common pathogenesis of CMS and suggests a genetic and hereditary etiology.

[Histiocytic lymphoma and pulmonary fibrosis in a female patient with essential thrombocythemia]

The case of a patient with the diagnosis of essential thrombocythemia is presented. Following treatment with melphalan during three years the patient presented clinical and radiologic data of pulmonary fibrosis. Thoracotomy with lung biopsy histologically proving fibrosis was performed. The patient developed a true histiocytic lymphoma afterwards. The rarity of pulmonary fibrosis induced by melphalan and the exceptional association of essential thrombocythemia and histiocytic lymphoma is emphasized. The characteristics of the latter disease, diagnostic difficulties and possible treatment are commented upon.