Reflexiones sobre la aplicación de la "Ley Trans” en la atención sanitaria / Reflections on the application of the “trans law” in health care

En este artículo se reflexiona sobre la reciente ley aprobada por el Congreso de los Diputados conocida como Ley 4/2023 para la igualdad real y efectiva de las personas trans y para la garantía de los derechos de las personas LGTBI (BOE-A-2023-5366, 2023). Se analizan inicialmente los artículos que más polémica han causado en el ámbito social, que son los relativos a la rectificación registral (Art. 43-51), y posteriormente los que hacen referencia directa o indirectamente a aspectos sanitarios; 1) el que prohíbe de métodos, programas o las llamadas terapias de conversión (Art. 17), 2) los que definen cómo debe ser en términos generales la atención sanitaria (Art. 56-59), y 3) finalmente el único artículo que menciona a los menores (Art 70). Se comenta que el término utilizado de persona trans, al englobar un amplio abanico de diversidades sexuales, variantes y expresiones de género, incluye tanto a personas que necesitan una atención médica como a otras que no. Se plantea que la rectificación registral acorde con esta ley 2023 al no precisar ningún requisito para su inscripción, ofrece menos garantías que la legislación ya existente de marzo 2007. Se considera que las directrices de la nueva ley se están traduciendo en una toma de decisiones por parte del usuario sin disponer de una valoración o diagnóstico por el equipo de profesionales que atienden el caso. Se destaca que la ley no incluye ninguna referencia a la atención por salud mental. Y en conjunto, se concluye que el texto aprobado, en el ámbito sanitario, puede mermar la calidad de la asistencia integral, sobre todo en menores, o personas con identidades complejas, dudosas, o con comorbilidades, que pueden generar discrepancia entre el criterio del profesional y la opinión del usuario.(AU)

Glucocorticoid Receptors, Brain-Derived Neurotrophic Factor, Serotonin and Dopamine Neurotransmission are Associated with Interferon-Induced Depression.

BACKGROUND: The role of inflammation in mood disorders has received increased attention. There is substantial evidence that cytokine therapies, such as interferon alpha (IFN-alpha), can induce depressive symptoms. Indeed, proinflammatory cytokines change brain function in several ways, such as altering neurotransmitters, the glucocorticoid axis, and apoptotic mechanisms. This study aimed to evaluate the impact on mood of initiating IFN-alpha and ribavirin treatment in a cohort of patients with chronic hepatitis C. We investigated clinical, personality, and functional genetic variants associated with cytokine-induced depression. METHODS: We recruited 344 Caucasian outpatients with chronic hepatitis C, initiating IFN-alpha and ribavirin therapy. All patients were euthymic at baseline according to DSM-IV-R criteria. Patients were assessed at baseline and 4, 12, 24, and 48 weeks after treatment initiation using the Patient Health Questionnaire (PHQ), the Hospital Anxiety and Depression Scale (HADS), and the Temperament and Character Inventory (TCI). We genotyped several functional polymorphisms of interleukin-28 (IL28B), indoleamine 2,3-dioxygenase (IDO-1), serotonin receptor-1A (HTR1A), catechol-O-methyl transferase (COMT), glucocorticoid receptors (GCR1 and GCR2), brain-derived neurotrophic factor (BDNF), and FK506 binding protein 5 (FKBP5) genes. A survival analysis was performed, and the Cox proportional hazards model was used for the multivariate analysis. RESULTS: The cumulative incidence of depression was 0.35 at week 24 and 0.46 at week 48. The genotypic distributions were in Hardy-Weinberg equilibrium. Older age (p = 0.018, hazard ratio [HR] per 5 years = 1.21), presence of depression history (p = 0.0001, HR = 2.38), and subthreshold depressive symptoms at baseline (p = 0.005, HR = 1.13) increased the risk of IFN-induced depression. So too did TCI personality traits, with high scores on fatigability (p = 0.0037, HR = 1.17), impulsiveness (p = 0.0200 HR = 1.14), disorderliness (p = 0.0339, HR = 1.11), and low scores on extravagance (p = 0.0040, HR = 0.85). An interaction between HTR1A and COMT genes was found. Patients carrying the G allele of HTR1A plus the Met substitution of the COMT polymorphism had a greater risk for depression during antiviral treatment (HR = 3.83) than patients with the CC (HTR1A) and Met allele (COMT) genotypes. Patients carrying the HTR1A CC genotype and the COMT Val/Val genotype (HR = 3.25) had a higher risk of depression than patients with the G allele (HTR1A) and the Val/Val genotype. Moreover, functional variants of the GCR1 (GG genotype: p = 0.0436, HR = 1.88) and BDNF genes (Val/Val genotype: p = 0.0453, HR = 0.55) were associated with depression. CONCLUSIONS: The results of the study support the theory that IFN-induced depression is associated with a complex pathophysiological background, including serotonergic and dopaminergic neurotransmission as well as glucocorticoid and neurotrophic factors. These findings may help to improve the management of patients on antiviral treatment and broaden our understanding of the pathogenesis of mood disorders.

Demanda de atención sanitaria en las unidades de identidad de género de Andalucía y Cataluña durante la década 2000 a 2009 / The demand for health care services in the gender identity units of Andalusia and Catalonia during the period of 2000 to 2009

Objetivo. Evaluar de forma comparada la demanda de atención sanitaria pública en dos unidades de trastornos de la identidad de género (Andalucía y Cataluña) durante la década 2000-2009. Método. Estudio descriptivo y comparativo de la demanda sanitaria, características de los solicitantes y cirugías realizadas. Resultados. Han solicitado asistencia sanitaria 828 pacientes en Andalucía y 549 en Cataluña. En ambas comunidades es similar el porcentaje de casos que cumplen criterios de transexualismo (88 vs. 89,8%), la frecuencia de casos excluidos del programa de reasignación sexual (16,7 vs. 15,3%), la razón de sexos hombre/mujer (1,6:1 vs. 2,1:1), y la edad media (28 vs. 29 años). Se han realizado 284 cirugías de reasignación sexual en Andalucía y 50 en Cataluña. Conclusiones. La demanda en Andalucía se ha mantenido estable y en Cataluña se ha incrementado en los últimos años. Las características demográficas y clínicas de los pacientes transexuales son similares y acordes con la mayoría de estudios realizados en otros países(AU)

Objective. To evaluate the demand for public health services in two gender identity disorder units (Andalusia and Catalonia) during the period of 2000-2009. Method. A descriptive and comparative study was made of the demand for health services, the demographic and clinical characteristics of the patients, and the sex reassignment surgeries performed. Results. A total of 828 subjects in Andalusia and 549 in Catalonia requested clinical assistance. In both communities, the percentages of cases diagnosed of transsexualism (88 vs 89.7%), the percentages excluded in the sex reassignment program (16.7 vs 15.3%), the male/female ratio (1.6:1 vs 2.1:1), and the mean age (28 vs 29years) were similar. A total of 284 sex-reassignment surgeries were performed in Andalusia and 50 in Catalonia. Conclusions. The demand has been maintained in Andalusia and has increased in Catalonia in recent years. The basic demographic (AU)

[The demand for health care services in the gender identity units of Andalusia and Catalonia during the period of 2000 to 2009]. / Demanda de atención sanitaria en las unidades de identidad de género de Andalucía y Cataluña durante la década 2000 a 2009.

OBJECTIVE: To evaluate the demand for public health services in two gender identity disorder units (Andalusia and Catalonia) during the period of 2000-2009. METHOD: A descriptive and comparative study was made of the demand for health services, the demographic and clinical characteristics of the patients, and the sex reassignment surgeries performed. RESULTS: A total of 828 subjects in Andalusia and 549 in Catalonia requested clinical assistance. In both communities, the percentages of cases diagnosed of transsexualism (88 vs 89.7%), the percentages excluded in the sex reassignment program (16.7 vs 15.3%), the male/female ratio (1.6:1 vs 2.1:1), and the mean age (28 vs 29 years) were similar. A total of 284 sex-reassignment surgeries were performed in Andalusia and 50 in Catalonia. CONCLUSIONS: The demand has been maintained in Andalusia and has increased in Catalonia in recent years. The basic demographic and clinical characteristics of transsexual patients were similar between both units and comparable to those of other countries.

Diferencias de género en las funciones cognitivas e influencia de las hormonas sexuales / Gender differences in cognitive functions and influence of sex hormones

Objetivo. Revisar las evidencias científicas sobre las diferencias cognitivas en función del género y la posible influencia de las hormonas sexuales en el rendimiento cognitivo. Método. Se realizó una búsqueda sistemática de la bibliografía a través del sistema Medline sobre artículos relacionados con el tema. Resultados. Las mujeres presentan un mayor rendimiento con respecto a los hombres en fluencia verbal, velocidad perceptiva, habilidad motora fina, tareas de memoria verbal y aprendizaje verbal. Los hombres superan a las mujeres en tareas visuoespaciales, resolución de problemas matemáticos y memoria visual. No se encuentran diferencias en función del género en atención y memoria de trabajo. Los estudios que evalúan la influencia de factores hormonales se han realizado en diversos grupos: a) pacientes con trastornos hormonales; b) pacientes sometidos a neuroimagen tras la administración hormonal; c) en mujeres sanas en función del ciclo menstrual, y d) en pacientes sometidos a tratamiento hormonales (hipogonadismo hipogonadotrófico, mujeres posmenopáusicas y trastorno de la identidad de género). Estos estudios en su mayoría encuentran una influencia de los niveles hormonales en diversas capacidades cognitivas, aunque los resultados no son del todo concluyentes por las limitaciones y escasez de estos estudios. Conclusiones. Existen diferencias cognitivas en función del género y las hormonas sexuales parecen ejercer una influencia en estas funciones cognitivas

Objective. To review scientific evidence on gender differences in cognitive functions and influence of sex hormones on cognitive performance. Method. Systematical search of related studies identified in Medline. Results. Women outperform men on verbal fluency, perceptual speed tasks, fine motor skills, verbal memory and verbal learning. Men outperform women on visuospatial ability, mathematical problem solving and visual memory. No gender differences on attention and working memory are found. Researchers distinguish four methods to investigate hormonal influence on cognitive performance: a) patient with hormonal disorders; b) neuroimaging in individuals during hormone administration; c) in women during different phases of menstrual cycle, and d) in patients receiving hormonal treatment (idiopathic hypogonadotropic hypogonadism, postmenopausal women and transsexuals). The findings mostly suggest an influence of sex hormones on some cognitive functions, but they are not conclusive because of limitations and scarcity of the studies. Conclusions. There are gender differences on cognitive functions. Sex hormones seem to influence cognitive performance

[Gender differences in cognitive functions and influence of sex hormones]. / Diferencias de género en las funciones cognitivas e influencia de las hormonas sexuales.

OBJECTIVE: To review scientific evidence on gender differences in cognitive functions and influence of sex hormones on cognitive performance. METHOD: Systematical search of related studies identified in Medline. RESULTS: Women outperform men on verbal fluency, perceptual speed tasks, fine motor skills, verbal memory and verbal learning. Men outperform women on visuospatial ability, mathematical problem solving and visual memory. No gender differences on attention and working memory are found. Researchers distinguish four methods to investigate hormonal influence on cognitive performance: a) patient with hormonal disorders; b) neuroimaging in individuals during hormone administration; c) in women during different phases of menstrual cycle, and d) in patients receiving hormonal treatment (idiopathic hypogonadotropic hypogonadism, postmenopausal women and transsexuals). The findings mostly suggest an influence of sex hormones on some cognitive functions, but they are not conclusive because of limitations and scarcity of the studies. CONCLUSIONS: There are gender differences on cognitive functions. Sex hormones seem to influence cognitive performance.

[Estimation of prevalence, incidence and sex ratio of transsexualism in Catalonia according to health care demand]. / Estimación de la prevalencia, incidencia y razón de sexos del transexualismo en Cataluña según la demanda asistencial.

OBJECTIVE: To estimate the epidemiology of transsexualism in the autonomous community of Catalonia according to data gathered at the Hospital Clinic of Barcelona, the single public hospital providing specialized psychiatric and endocrinological care for transsexual patients in this community. PATIENTS AND METHODS: Prevalence was calculated on the basis of the total number of patients diagnosed of transsexualism (ICD-10, F64.0) at the Hospital Clinic and living in Catalonia, and the incidence by counting all new cases of transsexuals for the last 5 years, based on the population census between 15 and 65 years of age. RESULTS: During the period from 1996 through 2004 a total of 201 subjects were referred to this hospital with complaints of gender dysphoria. Transsexualism was diagnosed in 182 patients, 161 of whom were living in Catalonia. This yields a prevalence rate in Catalonia of 1:21,031 males and 1:48,096 females. The sex ratio was 2.6. Annual incidence in the last five years was 0.73/100,000/year. DISCUSSION: The low prevalence compared with recently published data from European Union countries may be due to the relatively few years of data collection and to the low clinical demand because surgical procedures costs are not covered by the public health insurance. In contrast, the high incidence may be due to the increasing demand since 2000, when a more benevolent and tolerant social climate in Spain started.

Estimación de la prevalencia, incidencia y razón de sexos del transexualismo en Cataluña según la demanda asistencial / Estimation of prevalence, incidence and sex ratio of transsexualism in Catalonia according to health care demand

Introducción. Se realiza una estimación de la distribución epidemiológica del transexualismo en Cataluña según la demanda observada en el Hospital Clínic de Barcelona, que es el único hospital público que proporciona atención psiquiátrica y endocrinológica especializada a estos pacientes en esta comunidad autónoma. Pacientes y método. La prevalencia se calculó según el número total de pacientes diagnosticados de transexualismo (CIE-10, F64.0) en el Hospital Clínic residentes en Cataluña y la incidencia según el número de pacientes con nuevo diagnóstico durante los últimos 5 años en relación con los datos de población de edad entre 15 y 65 años. Resultados. Entre los años 1996 y 2004 solicitaron atención por disforia de género un total de 201 pacientes. Se diagnosticó transexualismo en 182 pacientes, de los cuales 161 vivían en Cataluña. La prevalencia estimada de transexualismo en Cataluña fue de 1:21.031 varones y 1:48.096 mujeres. La razón de sexos fue de 2,6 a favor del grupo de transexuales hombre a mujer. La incidencia media anual en los últimos 5 años fue de 0,72/100.000 habitantes/año. Discusión. La baja prevalencia observada, en comparación con los datos publicados por países de la Unión Europea, se puede atribuir al período corto de recogida de datos y a la baja demanda registrada al no estar financiado el tratamiento de reasignación de sexo por el Sistema Nacional de Salud. La elevada incidencia se puede atribuir al incremento de la demanda desde el año 2000, que coincide con un clima social de mayor aceptación y tolerancia

Objective. To estimate the epidemiology of transsexualism in the autonomous community of Catalonia according to data gathered at the Hospital Clinic of Barcelona, the single public hospital providing specialized psychiatric and endocrinological care for transsexual patients in this community. Patients and methods. Prevalence was calculated on the basis of the total number of patients diagnosed of transsexualism (ICD-10, F64.0) at the Hospital Clinic and living in Catalonia, and the incidence by counting all new cases of transsexuals for the last 5 years, based on the population census between 15 and 65 years of age. Results. During the period from 1996 through 2004 a total of 201 subjects were referred to this hospital with complaints of gender dysphoria. Transsexualism was diagnosed in 182 patients, 161 of whom were living in Catalonia. This yields a prevalence rate in Catalonia of 1:21,031 males and 1:48,096 females. The sex ratio was 2.6. Annual incidence in the last five years was 0.73/100,000/year. Discussion. The low prevalence compared with recently published data from European Union countries may be due to the relatively few years of data collection and to the low clinical demand because surgical procedures costs are not covered by the public health insurance. In contrast, the high incidence may be due to the increasing demand since 2000, when a more benevolent and tolerant social climate in Spain started

Evaluación de parámetros de calidad de vida y repercusión funcional en pacientes con Síndrome de Fatiga Crónica / Evaluation of health related quality of life and functional impairment parameters in patients with chronic fatigue syndrome

Fundamento: El Síndrome de Fatiga Crónica (SFC) es una enfermedad claramente invalidante que altera la calidad de vida y tiene una marcada repercusión funcional en los pacientes. Objetivos: En pacientes con SFC, valorar: 1)Parámetros de Calidad de Vida Relacionada con la Salud (CVRS) y Repercusión funcional (RF), 2) Grado de afectación con una escala clínica funcional. 3) Presencia e influencia de comorbilidad asociada y 4) Relación de los parámetros de CVRS y RF con los valores poblacionales de referencia (VPR) y con los de un grupo de pacientes de similar edad afectos de artritis reumatoide (AR). Metodología: Trabajo descriptivo transversal con inclusión consecutiva de 100 pacientes afectos de SFC. 1) Estudio de datos epidemiológicos y de situación laboral. 2) Valoración de grado de afectación del SFC en una escala clínica de afectación progresiva (grados I a IV). 3) Valoración de comorbilidades: Fibromialgia, Síndrome seco, Obesidad, Distimia, Disfunción tiroidal, Colon irritable y Endometriosis 4) Valoración de CVRS con el cuestionario genérico validado Medical Outcomes Study Short-Form (SF-36) y de la RF con el cuestionario específico validado Standford Health Assessment Questionnaire (HAQ). 5) Comparación de resultados con VPR y con pacientes afectos de AR. Resultados y conclusiones: El grado de afectación funcional era moderado (II) en la mitad de casos, y leve (I) o grave (III-IV) en un 25% de casos, respectivamente. Existían alteraciones valorables en los índices de puntuación de todas las dimensiones del cuestionario HAQ. En los pacientes con SFC existía una mayor afectación de parámetros de CVRS (SF-36) en comparación tanto con parámetros poblacionales como con pacientes con AR. Las dimensiones más relacionadas con el empeoramiento funcional fueron la Función física, el Rol físico, la Vitalidad, la Función Social y el Rol emocional. Existía una correlación positiva entre la escala clínica de afectación funcional y la mayoría de dimensiones del SF- 36. El índice de incapacidad funcional medida con el HAQ presentaba una alta correlación con las puntuaciones de la dimensión función física del SF-36 y de la dimensión dolor corporal. Se objetivó una media de 2,4 tipos diferentes de co-morbilidad en cada paciente con SFC, existiendo una correlación inversa con las dimensiones de CVRS. Conclusiones: En pacientes con SFC existe una marcada afectación de los parámetros de CVRS y RF, superior a los parámetros poblacionales e incluso a los de pacientes afectos de AR. La presencia de comorbilidad supone un mayor empeoramiento funcional. El empleo de una escala clínica de afectación progresiva es útil en la valoración funcional de estos pacientes. Para mejorar potencialmente la CVRS en pacientes con SFC deberá incidirse en modificar las dimensiones afectadas, sobre todo la función física, el dolor corporal y el tratamiento de las comorbilidades

Background: Chronic Fatigue Syndrome is a disabling disease that modifies the quality of life and supposes a marked functional impairment of patients. Aim of Study: In patients with CFS, to evaluate: 1) Health-related quality of life (HRQL) and Functional impairment (FI) parameters, 2) Gradation of FI with a clinical scale. 3) Presence and influence of comorbidity related to CFS, and 4) Relationship between HRQL and FI parameters in CFS with standard population values, and with values form a group of patients of similar age affected of Rheumatoid Arthritis (RA). Patients and Methods: Cross-sectional study with consecutive inclusion of 100 patients affected of CFS. Evaluation of: 1) Epidemiological data and work situation at diagnosis. 2) Function impairment evaluation with a clinical scale of progressive involvement (degrees I to IV). 3) Evaluation of comorbilities: Fibromyalgia, Sicca Syndrome, Obesity, Dysthymia, Thyroid dysfunction, Irritable Bowel Syndrome and Endometriosis 4) Evaluation of HRQL with the validated Medical Outcomes Study Short-Form (SF-36) questionnaire and evaluation of FI with the specific Standford Health Assessment Questionnaire (HAQ). 5) Comparison of results in CFS with those of general population and also with patients affected of RA. Results: In CFS, the functional impairment was moderate (II) in half of patients, and slight (I) or severe (III-IV) in a quarter, respectively. All dimensions of HAQ questionnaire were affected. HRQL parameters measured with SF-36 questionnaire were more affected in patients with CFS as compared to standard population values as well as in comparison to patients affected of RA. The dimensions mainly related to FI were physical function, physical role, vitality, social function and emotional role. There was a direct relationship between the clinical functional scale and most of the SF-36 dimensions. The function disability index measured by HAQ highly related with values of physical role and body pain from SF-36 questionnaire. Patients with CFS presented a mean of 2.4 different types of comorbidity, with an inverse relationship with HRQL dimensions. Conclusions: In patients with CFS there is a clear decrease of HRQL and FI parameters, with significantly lower values as compared to standard population and also to patients with RA. The presence of co morbidity supposes a major degree in functional disability. A clinical scale evaluating progressive degree of involvements was useful in the functional evaluation of patients with CFS. To potentially improve the HRQL and FI in patients with CFS we should address to modify those dimensions clearly affected, mainly physical function, body pain as well as treatment of comorbidities

[Relationship between patient's subjective stress perception and the course of inflammatory bowel disease]. / Relación entre los acontecimientos estresantes y el curso de la enfermedad inflamatoria intestinal según la percepción subjetiva del paciente.

INTRODUCTION: Studies examining the relationship between stress secondary to adverse life events (ALE) and inflammatory bowel disease (IBD) have produced controversial data. The aim of this study was to explore the subjective perception of this relationship in IBD patients. PATIENTS AND METHODS: Seventy consecutive patients suffering from IBD (40 Crohn's disease, 30 ulcerative colitis) were assessed using a self-rating questionnaire related to demographic variables, clinical characteristics, subjective perception of the influence of ALE on the course of IBD, psychiatric background, and the HAD scale. The results of this scale were compared with a group of 25 relatives. RESULTS: Forty-two patients (60%) perceived that there was relationship between ALE and the onset of their disease, forty-nine (70%) between ALE and the increasing IBD symptoms severity, and fifty-one patients (72.9%) with disease activity. Sixteen of the patients (22.9%) had been visited by a psychiatrist during relapses of IBD. Twenty-five patients (42.4%) reached a score of 11 or higher on the depression or anxiety subscales of the HAD, indicating a probable psychological disorder. CONCLUSIONS: IBD patients perceive a strong relationship between ALE and the course of IBD. We have found a high prevalence of anxiety and depression symptoms in these patients. If this observation is confirmed with objective measurements, it will be important to consider psychiatric intervention for these patients.

[Preliminary study of smoking cessation at 6 months following medical counseling, pamphlet, and follow-up]. / Estudio preliminar del abandono del tabaco a los 6 meses tras consejo médico, folleto y seguimiento.

OBJECTIVES: Preliminary study to evaluate the results of a programme to help smokers. DESIGN: Study involving direct intervention, with control group, and with random distribution in experiment group and control group. SITE. The study was carried out in the patients' visits of the five doctors at Primary Attention on the afternoon shift, "V Centennary" Health Centre, San Sebastián de los Reyes, Madrid. PATIENTS: 102 smokers aged from 21 to 67 years who attended the appointments for any reason were selected. INTERVENTION: The participants in the experiment group (n = 48) were given a structured talk which lasted ten minutes and were supplied with a "Guide to Giving up Smoking". The control group (n = 50) were advised to give up the habit. We checked consumption by telephoning subjects, after 30 days, 90 and 180. MAIN MEASUREMENTS AND RESULTS: After 30 days 12 individuals (25%) from the experiment group had given up smoking, and 4 (8%) from the control group. After 90 days 12 subjects from the former group did not smoke (25%) compared with 3 (6%) from the latter. After 6 months 10 out of the former group did not smoke (20.8%) and 5 individuals from the latter (10%) (not significant). CONCLUSIONS: Subjects were positively receptive to the medical advice received from their doctors. The level of non-smoking observed after 6 months is clinically significant, although the difference between the two groups is not statistically significant, possibly as a result of the small size of the sample.