Predicción de la mortalidad a muy corto plazo de los pacientes con insuficiencia cardiaca crónica agudizada: escala EAHFE-3D / Predicting short-term mortality in patients with acute exacerbation of chronic heart failure: The EAHFE-3D scale

INTRODUCCIÓN Y OBJETIVOS: Disponer de escalas pronósticas en la insuficiencia cardiaca crónica agudizada para detectar la mortalidad precoz es fundamental. El objetivo de este estudio es crear una escala pronóstica (escala EAHFE-3D) que estratifique el riesgo de muerte a muy corto plazo. PACIENTES Y MÉTODO: Se utilizó el registro EAHFE, multipropósito y multicéntrico, con seguimiento prospectivo que incluye 6.597 pacientes con insuficiencia cardiaca crónica agudizada atendidos en 34 servicios de urgencias españoles entre 2007 y 2014. Se recogieron variables demográficas, antecedentes personales, datos del episodio agudo, destino final y mortalidad a los 3 días. La cohorte de derivación incluye pacientes seleccionados entre 2009 y 2011 en el registro EAHFE (n = 3.640). La variable a estudio fue la mortalidad a los 3 días. Se creó una escala pronóstica (escala EAHFE-3D) con los resultados del estudio multivariante en función del peso de la OR. La escala fue validada utilizando una cohorte de pacientes incluidos en 2014 (n = 2.957). RESULTADOS: Se analizaron 3.640 pacientes (102 muertos a los 3 días, 2,8%) en la cohorte de derivación. La escala final contiene las siguientes variables (máximo 165 puntos): edad≥ 75 años (30 puntos), NYHA basal III-IV (15 puntos), presión arterial sistólica < 110 mmHg (20 puntos), saturación de O2 < 90% (30 puntos), hiponatremia (20 puntos), tratamiento inotropo o vasopresor (30 puntos) y necesidad de ventilación mecánica no invasiva (20 puntos), con un área bajo la curva ROC de 0,80 (IC 95% 0,76-0,84; p < 0,001). La cohorte de validación incluye 2.957 pacientes (66 muertos a los 3 días, 2,2%) y la escala obtiene un área bajo la curva ROC de 0,76 (IC 95% 0,70-0,82; p < 0,001). Los grupos fueron: muy bajo riesgo (0-20 puntos), bajo riesgo (21-40 puntos), riesgo intermedio (41-60 puntos), alto riesgo (61-80 puntos) y muy alto riesgo (> 80 puntos), con una mortalidad (cohorte de derivación/validación) de 0/0,5, 0,8/1,0%, 2,9/2,8, 5,5/5,8 y 12,7/22,4%, respectivamente. CONCLUSIONES: La escala EAHFE-3D puede ser de ayuda para estratificar el pronóstico a muy corto plazo de los pacientes con insuficiencia cardiaca crónica agudizada en 5 grupos de riesgo

INTRODUCTION AND OBJECTIVES: Prognostic scales are needed in acute exacerbation of chronic heart failure to detect early mortality. The objective of this study is to create a prognostic scale (scale EAHFE-3D) to stratify the risk of death the very short term. PATIENTES AND METHOD: We used the EAHFE database, a multipurpose, multicenter registry with prospective follow-up currently including 6,597 patients with acute heart failure attended at 34 Spanish Emergency Departments from 2007 to 2014. The following variables were collected: demographic, personal history, data of acute episode and 3-day mortality. The derivation cohort included patients recruited during 2009 and 2011 EAHFE registry spots (n=3,640). The classifying variable was all-cause 3-day mortality. A prognostic scale (3D-EAHFE scale) with the results of the multivariate analysis based on the weight of the OR was created. The 3D-EAHFE scale was validated using the cohort of patients included in 2014 spot (n=2,957). RESULTS: A total of 3,640 patients were used in the derivation cohort and 102 (2.8%) died at 3 days. The final scale contained the following variables (maximum 165 points): age≥75 years (30 points), baseline NYHA III-IV (15 points), systolic blood pressure < 110mmHg (20 points), room-air oxygen saturation<90% (30 points), hyponatremia (20 points), inotropic or vasopressor treatment (30 points) and need for noninvasive mechanical ventilation (20 points); with a ROC curve of 0.80 (95% CI 0.76-0.84; P < .001). The validation cohort included 2,957 patients (66 died at 3 days, 2.2%), and the scale obtained a ROC curve of 0.76 (95% CI 0.70-0.82; P < .001). The risk groups consisted of very low risk (0-20 points), low risk (21-40 points), intermediate risk (41-60 points), high risk (61-80 points) and very high risk (>80 points), with a mortality (derivation/validation cohorts) of 0/0.5, 0.8/1.0, 2.9/2.8, 5.5/5.8 and 12.7/22.4%, respectively. CONCLUSIONS: EAHFE-3D scale may help to predict the very short term prognosis of patients with acute heart failure in 5 risk groups

Predicting short-term mortality in patients with acute exacerbation of chronic heart failure: The EAHFE-3D scale. / Predicción de la mortalidad a muy corto plazo de los pacientes con insuficiencia cardiaca crónica agudizada: escala EAHFE-3D.

INTRODUCTION AND OBJECTIVES: Prognostic scales are needed in acute exacerbation of chronic heart failure to detect early mortality. The objective of this study is to create a prognostic scale (scale EAHFE-3D) to stratify the risk of death the very short term. PATIENTS AND METHOD: We used the EAHFE database, a multipurpose, multicenter registry with prospective follow-up currently including 6,597 patients with acute heart failure attended at 34 Spanish Emergency Departments from 2007 to 2014. The following variables were collected: demographic, personal history, data of acute episode and 3-day mortality. The derivation cohort included patients recruited during 2009 and 2011 EAHFE registry spots (n=3,640). The classifying variable was all-cause 3-day mortality. A prognostic scale (3D-EAHFE scale) with the results of the multivariate analysis based on the weight of the OR was created. The 3D-EAHFE scale was validated using the cohort of patients included in 2014 spot (n=2,957). RESULTS: A total of 3,640 patients were used in the derivation cohort and 102 (2.8%) died at 3 days. The final scale contained the following variables (maximum 165 points): age≥75 years (30 points), baseline NYHA III-IV (15 points), systolic blood pressure<110mmHg (20 points), room-air oxygen saturation<90% (30 points), hyponatremia (20 points), inotropic or vasopressor treatment (30 points) and need for noninvasive mechanical ventilation (20 points); with a ROC curve of 0.80 (95% CI 0.76-0.84; P<.001). The validation cohort included 2,957 patients (66 died at 3 days, 2.2%), and the scale obtained a ROC curve of 0.76 (95% CI 0.70-0.82; P<.001). The risk groups consisted of very low risk (0-20 points), low risk (21-40 points), intermediate risk (41-60 points), high risk (61-80 points) and very high risk (>80 points), with a mortality (derivation/validation cohorts) of 0/0.5, 0.8/1.0, 2.9/2.8, 5.5/5.8 and 12.7/22.4%, respectively. CONCLUSIONS: EAHFE-3D scale may help to predict the very short term prognosis of patients with acute heart failure in 5 risk groups.

[Minor physical abnormalities and clinical features in patients with schizophrenia spectrum disorders]. / Anomalias fisicas menores y caracteristicas clinicas en pacientes con trastornos del espectro de la esquizofrenia.

INTRODUCTION: Minor physical anomalies are nonspecific morphologic variants generated during gestation. They are markers of events (inherited and/or acquired) related with the 'neuroprogression' of the schizophrenia spectrum disorders and may be differentially involved with their symptom profiles. The aim of the study was to explore the relationship of minor physical anomalies with positive syndrome, negative syndrome and general psychopathology in patients with schizophrenia or other functional psychoses. PATIENTS AND METHODS: Cross-sectional study of patients with schizophrenia or other functional psychoses consecutively hospitalized with an acute psychotic episode. Minor physical anomalies were evaluated with the Waldrop scale and clinical characteristics of psychosis were measured with the Positive and Negative Syndrome Scale (PANSS). RESULTS: 41 patients with functional psychoses were evaluated: 32 (78%) with schizophrenia, 9 (21.9%) with psychotic disorder not otherwise specified. There was no relationship between the Waldrop scale score and score on the PANSS, its negative scale and its general psychopathology scale. The positive scale of the PANSS and the Waldrop scale were correlated in the whole sample (Spearman rho = 0.356; p = 0.022). In the group of patients with schizophrenia, the correlation was even greater (Spearman rho = 0.420; p = 0.017). CONCLUSIONS: The path from apparently premorbid stages to specific clinical pictures in patients with schizophrenia spectrum disorders is determined by the neurodevelopment, a dynamic process influenced by genetic inheritance and environmental injuries.

Clinical profiles in fibromyalgia patients of the community mental health center: a predictive index of psychopathological severity.

INTRODUCTION: In recent years we have seen an increasing demand for mental health care in patients with fibromyalgia and psychiatric symptoms, although it is not clear if the symptoms are primary or secondary to the presence of the syndrome. This fact has led mental health providers to think that there would be some psychological factors influencing the vulnerability of suffering this painful syndrome, because its etiology is quite non-specific. Bradley et al. (1978) identified different psychopathological profiles within chronic pain syndromes with the MMPI, which were subsequently adapted by Yunus et al. (1991) for fibromyalgia. This present work studied the clinical profile in patients with fibromyalgia. SAMPLE: 75 patients with fibromyalgia from the community mental health center and 55 healthy subjects. Tools: STAI-E/R, BDI, MMPI-2, MMPI-2 personality disorders, MMPI-2 PSY-5. STATISTICAL ANALYSIS: descriptive statistics and mean comparison (Student's t test). Confirmatory cluster analysis. Discriminative analysis of subgroups. RESULTS: Two different patterns were obtained: group A (32 %) with a typical chronic pain profile (CP) and group B (68 %) with a psychological maladjustment profile (PM). With the discriminative analysis, we obtained the coefficients of the discriminative canonical functions that maximize the differences between both groups. CONCLUSIONS: We confirmed Bradley's classification, obtaining two different psychopathological patterns in the fibromyalgia syndrome sample we studied. We obtained an index of psychopathological profile in fibromyalgia, which would form a new scale, from MMPI-2 for discriminating psychopathological severity in fibromyalgia.

Perfiles clínicos en pacientes con fibromialgia que acuden a un centro de salud mental: obtención de un índice predictivo de gravedad psicopatológica / Clinical profiles in fibromyalgia patients of the community mental health center: a predictive index of psychopathological severity

Introducción. En los últimos años se ha visto incrementada la demanda asistencial en salud mental de pacientes que presentan fibromialgia y sintomatología psiquiátrica, y no queda claro en la mayoría de los casos si esta patología es primaria o secundaria a la aparición del síndrome. Esto ha hecho plantearse a los profesionales de la salud mental la influencia de distintos factores psicológicos de vulnerabilidad a padecer este síndrome doloroso dada la inespecificidad a nivel etiológico. Bradley et al. (1978) identificaron a través del MMPI distintos perfiles psicopatológicos dentro de síndromes con dolor crónico que posteriormente fueron adaptados por Yunus et al. (1991) para la fibromialgia. En el presente trabajo se estudian los perfiles clínicos en pacientes con fibromialgia. Método. Muestra: 75 pacientes derivados al centro de salud mental que presentan fibromialgia; 55 sujetos control sanos. Instrumentos: STAI-E/R; BDI, MMPI-2, MMPI-2 trastornos de la personalidad, MMPI-2 PSY-5. Análisis estadísticos: estadísticos descriptivos y comparación de medias (t de Student). Análisis de clúster confirmatorio. Análisis discriminante de los subgrupos. Resultados. Se obtienen dos patrones diferenciales: grupo A (32 %) con un perfil típico del dolor crónico (DC) y grupo B (68 %) con un perfil de desajuste psicológico (DP). Mediante el análisis discriminante obtuvimos los coeficientes de las funciones canónicas discriminantes que maximizan las diferencias entre los dos grupos. Conclusiones. Se confirma la clasificación de Bradley obteniendo dos patrones psicopatológicos diferenciales en la muestra de síndrome de fibromialgia estudiada. Se obtiene un índice de perfil psicopatológico en fibromialgia que configura una nueva escala a partir del MMPI-2, que discrimina gravedad psicopatológica en la fibromialgia

Introduction. In recent years we have seen an increasing demand for mental health care in patients with fibromyalgia and psychiatric symptoms, although it is not clear if the symptoms are primary or secondary to the presence of the syndrome. This fact has led mental health providers to think that there would be some psychological factors influencing the vulnerability of suffering this painful syndrome, because its etiology is quite non-specific. Bradley et al. (1978) identified different psychopathological profiles within chronic pain syndromes with the MMPI, which were subsequently adapted by Yunus et al. (1991) for fibromyalgia. This present work studied the clinical profile in patients with fibromyalgia. Method. Sample: 75 patients with fibromyalgia from the community mental health center and 55 healthy subjects. Tools: STAI-E/R, BDI, MMPI-2, MMPI-2 personality disorders, MMPI-2 PSY-5. Statistical analysis: descriptive statistics and mean comparison (Student's t test). Confirmatory cluster analysis. Discriminative analysis of subgroups. Results. Two different patterns were obtained: group A (32 %) with a typical chronic pain profile (CP) and group B (68 %) with a psychological maladjustment profile (PM). With the discriminative analysis, we obtained the coefficients of the discriminative canonical functions that maximize the differences between both groups. Conclusions. We confirmed Bradley's classification, obtaining two different psychopathological patterns in the fibromyalgia syndrome sample we studied. We obtained an index of psychopathological profile in fibromyalgia, which would form a new scale, from MMPI-2 for discriminating psychopathological severity in fibromyalgia

Estudio de los trastornos depresivos en atención primaria de salud / Study of depressive disorders in primary health care

OBJETIVOS: Determinar la prevalencia y analizar la expresión de la depresión en atención primaria. PACIENTES Y MÉTODO: El estudio se realizó en dos fases. En la primera se llevó a cabo el cribado de 906 pacientes consecutivos con la Zung’s Self-Rating Depression Scale para seleccionar una submuestra con 306 pacientes, que fueron evaluados en detalle en la segunda fase en la que se incluía en una entrevista psiquiátrica y otros cuestionarios. RESULTADOS: La prevalencia de depresión mayor fue del 14,3% (intervalo de confianza [IC] del 95%, 11,2-17,4) y la de distimia del 4,8% (IC del 95%, 2,8-6,8). El sexo femenino, el trastorno de angustia, el trastorno de ansiedad generalizada, la úlcera gastroduodenal/gastritis, la frecuencia de visitas al médico y la presentación con síntomas psicológicos se asociaron de manera independiente con la depresión mayor. El trastorno de ansiedad generalizada, los síntomas psicológicos y el número de enfermedades orgánicas crónicas se asociaron de manera independiente con la distimia. En cuanto a la somatización, el 45,4% de las depresiones se presentaron de forma psicológica, el 35,6% como somatizadas y el 19% como enfermedad orgánica con depresión concomitante. Los somatizadores tenían menor educación y su depresión era menos grave y ocasionaba menor disfunción. La detección, el tratamiento antidepresivo y la atención especializada psiquiátrica fueron menores en los somatizadores. La infradetección de la depresión en pacientes deprimidos se asoció con una menor educación, menor gravedad y menor disfunción asociada con la depresión, y con la manifestación exclusiva de síntomas somáticos. Sólo un tercio de los pacientes deprimidos tomaba antidepresivos. CONCLUSIONES: En atención primaria, la depresión es frecuente. A menudo se manifiesta en forma somatizada, lo que interfiere en su detección y tratamiento. La mayoría de los deprimidos, en cualquier estrato de gravedad, no recibe el tratamiento apropiado

OBJECTIVES: To determine the prevalence and analyze the manifestations of depression in primary care. PATIENTS AND METHOD: A study was performed in two phases. In the first phase 906 consecutive patients were screened using Zung’s Self-Rating Depression Scale to select a subsample of 306 patients who underwent detailed evaluation in the second phase, which included a psychiatric interview and completion of other questionnaires. RESULTS: The prevalence of major depression was 14.3% (95% CI, 11.2-17.4) and that of dysthymia was 4.8% (95% CI, 2.8-6.8). Factors independently associated with major depression were female sex, panic disorder, generalized anxiety disorder, gastroduodenal ulcer/gastritis, the frequency of medical consultations, and presentation with psychological symptoms. Factors independently associated with dysthymia were generalized anxiety disorder, psychological symptoms, and the number of chronic organic diseases. A total of 45.4% of depressions presented as psychological depression, 35.6% as physical symptoms and 19% as organic disease with concomitant depression. Those with physical symptoms were better educated and their depression was less severe and caused less dysfunction. Detection, antidepressant treatment and specialized psychiatric care were less frequent in somatizers. Under-detection of depression in depressed patients was associated with a lower level of education, lesser severity and lower dysfunction related to depression and with exclusive manifestation of somatic symptoms. Only one-third of depressed patients was taking antidepressant therapy. CONCLUSIONS: Depression is frequent in primary care. It often manifests as somatic symptoms, which hampers its detection and treatment. Most depressed patients, whatever the severity of the depression, do not receive appropriate treatment

[Dementia and cognitive impairment pattern: its association with epsilon4 allele of apolipoprotein E gene]. / Demencia y patrón de deterioro cognitivo: asociación con el alelo epsilon4 del gen de la apolipoproteína E.

INTRODUCTION: The APOE epsilon4 allele is a well-established risk factor for Alzheimer's disease. This disease is characterized by a typical progressive cognitive impairment pattern, different from that of other primary dementias such as dementia with Lewy bodies or frontotemporal and vascular dementias, for which there are no conclusive results on the influence of the APOE genotype. OBJECTIVE: Our aim is to study how the APOE genotype associates with different dementia types, and the association of this genotype with mild cognitive impairment and age related cognitive decline, which might be stages in a continuum between normality and dementia. PATIENTS AND METHODS: From a group of 1,022 people we selected 733 patients with different dementia diagnosis and 205 controls. APOE genotype for each participant in the study was determined. RESULTS: As it was already known, the epsilon4 allele is associated to senile Alzheimer's disease (OR= 5.6; 95% CI= 3.6-8.9; p< 0.001) and presenile Alzheimer's disease (OR= 5.4; 95% CI= 2.1-13.8; p< 0.001). It is also associated to mild cognitive impairment (OR= 3.7; 95% CI= 2.3-6.0; p< 0.001) and to age related cognitive decline (OR= 3.0; 95% CI= 1.2-7.3; p< 0.01). Female Alzheimer patients with at least one epsilon4 allele present significantly an earlier age at onset (epsilon4+= 73.4 +/- 5.4; epsilon4- = 76.9 +/- 5.5; p< 0.001). CONCLUSION: The APOE genotype is associated to Alzheimer's disease and to its cognitive impairment pattern. This association has a growing value according to the degree of clinical impairment. The APOE genotype could be used in differential diagnostic of cognitive impairment.

Demencia y patrón de deterioro cognitivo: asociación con el alelo e4 del gen de la apolipoproteína E / Dementia and cognitive impairment pattern: its association with e4 allele of apolipoprotein E gene

Introducción. El alelo e4 de la APOE es un factor de riesgo bien establecido para la enfermedad de Alzheimer (EA). Esta enfermedad se caracteriza por un patrón de deterioro cognitivo (DC)progresivo bastante típico, diferente del de otras demencias, como la demencia con cuerpos de Lewy, la demencia frontotemporal o la demencia vascular, en las que no se han obtenido resultados concluyentes sobre la influencia de este gen. Objetivo. Estudiar la asociación del genotipo APOE con diferentes tipos de demencia, y la asociación de este genotipo con el deterioro cognitivo ligero (DCL) y eldeterioro cognitivo asociado a la edad (DECAE), posibles estadios de un continuo entre la normalidad y la demencia. Pacientes y métodos. Se reclutaron 1.022 personas, de las que se seleccionaron 733 pacientes con distintos subtipos de demencia y 205 controles, a los que se determinó el genotipo del APOE. Resultados. Como ya se conocía, el alelo e4 se asocia a la EA de edad de inicio senil (OR = 5,6; IC 95 por ciento = 3,6-8,9; p < 0,001) y presenil (OR = 5,4; IC 95 por ciento = 2,1-13,8; p < 0,001). También se asocia al DCL (OR = 3,7; IC 95 por ciento = 2,3-6,0; p < 0,001) y al DECAE (OR = 3,0; IC 95 por ciento = 1,2-7,3; p < 0,01). La edadde inicio de la EA es significativamente inferior en las pacientes que poseen al menos un alelo e4 (e4+ = 73,4 ñ 5,4; e4- = 76,9 ñ 5,5; p <0,001). Conclusiones. El genotipo APOE se asocia a la EA y alpatrón de deterioro que la caracteriza. Esta asociación tiene un valor creciente según el grado de deterioro objetivable. El genotipo APOE podría servir en el diagnóstico diferencial del DC (AU)

Introduction. The APOE e4 allele is a well-established risk factor for Alzheimer’s disease. This disease is characterized by a typical progressive cognitive impairment pattern, different from that of other primary dementias such as dementia with Lewy bodies or frontotemporal and vascular dementias, for which there are no conclusive results on the influence of the APOE genotype. Objective. Our aim is to study how the APOE genotype associates with different dementia types, and the asso ciation of this genotype with mild cognitive impairment and age-related cognitive decline, which might be stages in a continuum between normality and dementia. Patients and methods. From a group of 1.022 people we selected 733 patients with different dementia diagnosys and 205 controls. APOE genotype for each participant in the study was determined. Results. As it was already known, the e4 allele is associated to senile Alzheimer’s disease (OR = 5,6; 95% CI = 3,6-8,9; p < 0,001) and presenile Alzheimer’s disease (OR = 5,4; 95% CI = 2,1-13,8; p < 0,001). It is also associated to mild cognitive impairment (OR = 3,7; 95% CI = 2,3-6,0; p < 0,001) and to age-related cognitive decline (OR = 3,0; 95% CI = 1,2-7,3; p < 0,01). Female Alzheimer patients with at least one e4 allele present significantly an earlier age at onset (e4 + = 73,4 ± 5,4; e4 - = 76,9 ± 5,5; p < 0,001). Conclusion. The APOE genotype is associated to Alzheimer’s disease and to its cognitive impairment pattern. This association has a growing value according to the degree of clinical impairment. The APOE genotype could be used in differential diagnostic of cognitive impairment (AU)

[Thyrotoxic psychosis: a case report]. / Psicosis tirotóxica: a propósito de un caso.

The first step in the assessment of a patient who presents psychiatric symptoms is to discard somatic illness. We present a case of a patient whose symptoms began with confusion, behavior alterations and agitation, which were followed by psychomotor inhibition with visual hallucinations, with underlying thyrotoxicosis. In the discussion, we analyze the aspects to consider in order to detect similar cases and their treatment, since, although it is a rare form of presentation of hyperthyroidism, it should be taken into account due to the seriousness of the picture.

Psicosis tirotóxica: a propósito de un caso / Tbyrotoxic psychosis: a case report

El primer paso en la valoración de un paciente con síntomas psiquiátricos es descartar la patología somática. Presentamos el caso de una paciente cuya clínica se inició con síntomas confusionales, desestructuración conductual y agitación, seguida de inhibición psícomotriz y alucinaciones visuales, con una tirotoxicosis subyacente. En la discusión se analizan los aspectos a tener en cuenta para la detección de casos similares y su tratamiento, ya que, aunque sea una forma poco común de presentación del hipertiroidismo, debe tenerse en cuenta por la gravedad del cuadro (AU)

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[Prevalence, expression and impact of depressive disorders in primary care]. / Prevalencia, expresión e impacto de los trastornos depresivos en atención primaria.

OBJECTIVE: To determine the prevalence and forms of clinical expression of depressive disorders in primary care patients. To analyse the under-detection of depression by primary care doctors. DESIGN: Descriptive and transversal study, with two-stage sampling. Setting. Primary care consultations in the Camp de Tarragona area. PARTICIPANTS: 1000 consecutive patients visiting their doctor for any reason will make up the first-stage sample. Of these 350 go on to the second stage (all the positive results in the screening for depression test plus a random one-seventh of the negative results). MAIN MEASUREMENTS: The first stage will consist of the screening of the sample for depressive disorders with Zung's Self-Rating Depression Scale. In the sub-sample that will go on to the second stage, the Structured Clinical Interview for DSM-IV Disorders will be used to establish diagnoses of depressive disorders and other co-morbid psychiatric disorders. There will also be a range of specific questionnaires to find reasons for consultation and the form of presentation of an eventual depressive disorder, medical co-morbidity, medication taken, use of health services, the functional and vital repercussions of depression. A questionnaire for the patient's G.P. will assess and detect depression. DISCUSSION: The study will enable us to check the validity for our patients of pre-suppositions on depression in primary care obtained from studies in other countries with different health structures and social and cultural conditioners, and to find diverse information extrapolated from specialist studies.

Prevalencia, expresión e impacto de los trastornos depresivos en atención primaria / Prevalence, expression and impact of depressive disorders in primary care

Objetivo. Determinar la prevalencia y formas de expresión clínica de los trastornos depresivos en los pacientes de atención primaria. Analizar la infradetección de la depresión por los médicos de atención primaria. Diseño. Estudio descriptivo, transversal, muestreo en dos fases. Emplazamiento. Consultas de atención primaria representativas del ámbito geográfico del Camp de Tarragona. Participantes. Mil pacientes consecutivos que visitan a su médico por cualquier motivo constituyen la muestra de la primera fase, de los que 350 pasan a la segunda fase (todos los resultados positivos en el test de cribado de la depresión más 1/7 aleatorio de los negativos).Mediciones principales. La primera fase consistirá en el cribado de la muestra para trastornos depresivos con la Self-Rating Depression Scale de Zung. En la submuestra que pasará a la segunda fase se aplicará la entrevista psiquiátrica Structured Clinical Interview for DSM-IV Disorders para establecer los diagnósticos de trastornos depresivos y otros trastornos psiquiátricos comórbidos, así como una batería de cuestionarios específicos para averiguar motivos de consulta y forma de presentación de un eventual trastorno depresivo, comorbilidad médica, medicación consumida, utilización de servicios sanitarios, repercusión funcional y vital de la depresión y una encuesta de valoración y detección de la depresión por el médico de cabecera del paciente Discusión. El estudio permitirá comprobar la validez para nuestros pacientes de asunciones previas sobre la depresión en atención primaria obtenidas de estudios en otros países con estructuras sanitarias y condicionantes sociales y culturales diferentes, así como diversos conocimientos extrapolados de estudios del ámbito especializado (AU)

Serological confirmation of Chagas' disease by a recombinant and peptide antigen line immunoassay: INNO-LIA chagas.

Although screening for Trypanosoma cruzi antibodies is mandatory in most South American countries, current tests are insensitive and have poor specificity. A recently optimized line immunoassay (the INNO-LIA Chagas assay) for the serological confirmation of Chagas' disease was evaluated at a large blood bank in São Paulo, Brazil. Sera from blood donors who reacted in at least one of three serological screening assays (n = 1,604) and who returned for a follow-up were retested, and the donors were interviewed to assess their epidemiological risk. The results obtained by the confirmatory assay evaluated in this study were compared to those obtained by the three different screening assays. Upon consideration of the consensus results obtained by the three different screening assays as a "gold standard," the INNO-LIA Chagas assay showed a sensitivity of 99.4% (95% confidence interval [CI], 98.3 to 99.9) and a specificity of 98.1% (95% CI, 96.6 to 99.0) for positive (n = 503) and negative (n = 577) sera. The INNO-LIA Chagas assay confirmed the results for significantly larger numbers of positive samples of at-risk individuals independent of the number of positive screening tests (P = 0.017, Mantel-Haenszel test). In conclusion, the INNO-LIA Chagas assay reliably confirmed the presence of antibodies to T. cruzi and can be implemented as a confirmatory assay for Chagas' disease serology.

Chronic hepatitis C virus infections in brazilian patients: association with genotypes, clinical parameters and response to long term alpha interferon therapy

The present study assessed the clinical significance of hepatitis C virus (HCV) genotypes and their influence on response to long term recombinant-interferon-alpha (r-IFN-alpha) therapy in Brazilian patients. One hundred and thirty samples from patients previously genotyped for the HCV and with histologically confirmed chronic hepatitis C (CH-C) were evaluated for clinical and epidemiological parameters (sex, age, time of HCV infection and transmission routes). No difference in disease activity, sex, age or mode and time of transmission were seen among patients infected with HCV types 1, 2 or 3. One hundred and thirteen of them were treated with 3 million units of r-IFN-alpha, 3 times a week for 12 months. Initial response (IR) was significantly better in patients with genotype 2 (100%) and 3 (46%) infections than in patients with genotype 1 (29%) (p < 0. 005). Among subtypes, difference in IR was observed between 1b and 2 (p < 0.005), and between 1b and 3a (p < 0.05). Sustained response (SR) was observed in 12% for (sub)type 1a, 13% for 1b, 19% for 3a, and 40% for type 2; significant differences were found between 1b and 2 (p < 0.001), and between 1b and 3a (p < 0.05). Moreover, presence of cirrhosis was significantly associated with non response and response with relapse (p < 0.05). In conclusion, non-1 HCV genotype and lack of histological diagnosis of cirrhosis were the only baseline features associated with sustained response to treatment. These data indicate that HCV genotyping may have prognostic relevance in the responsiveness to r-IFN-alpha therapy in Brazilian patients with chronic HCV infection, as seen in other reports worldwide.

Human T-cell lymphotropic virus type 1 infection and ocular manifestations in São Paulo, Brazil.

OBJECTIVES: Although human T-cell lymphotropic virus type 1 (HTLV-1)-associated uveitis has been well recognized in Japan, related studies in Brazil are scarce. We performed a serologic survey for HTLV-1 infection among patients with uveitis and investigated the ocular findings in HTLV-1-asymptomatic carriers. METHODS: One hundred ninety serum samples from patients with uveitis of determined (n = 137) and undetermined origins (n = 53) being examined at the Uveitis Service, University of São Paulo, São Paulo, Brazil, underwent testing using HTLV enzyme-linked immunosorbent assay and discriminatory Western blots. One hundred five asymptomatic blood donors and/or their relatives who were seropositive for HTLV-1 (carrier group) and 105 age- and sex-paired blood donors who were seronegative for HTLV-1 (control group) underwent ocular evaluation. For the statistical analysis, chi2 test was used. RESULTS: Only 1 patient with uveitis was seropositive for HTLV- 1, and she belonged to the group with uveitis of undetermined origin. Results of tear films were evaluated in 52 carriers. The prevalence of a decreased tear break-up time was significantly higher in the carrier compared with the control group (P = .02). Two carriers had keratoconjunctivitis sicca. Three of the 105 carriers exhibited mild uveitis (cells in the vitreous, retinal and choroidal infiltrates, retinal vasculitis, and bilateral pars planitis). Retinal pigmentary changes were found in both groups (no statistical difference). CONCLUSIONS: Early tear abnormalities may be present in asymptomatic carriers, and mild uveitis may be found among them. The relatively low seroprevalence of HTLV-1 in the Brazilian population made it difficult to establish the real importance of HTLV-1-associated uveitis among our patients with uveitis.