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OBJECTIVE: The measurement of quality of life has become important in evaluating new treatments of cardiac disease. This review focuses on definition and general concepts underlying quality of life in patients with cardiac disease, the ways in which it is measured, and the uses and limitations of quality-of-life measurement. METHODS: A Medline search, from 1988 to 1998, was undertaken using the search terms "cardiovascular disease and quality of life" and "cardiovascular disease and health status." Results of clinical trials of cardiovascular therapies using quality-of-life instruments were not reviewed. RESULTS: Quality of life is defined as "...the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient." Domains of quality of life include physical, mental, social, and occupational function; health perceptions; and symptoms of disease. CONCLUSION: Psychosomatic medicine contributions to understanding patients' reactions to physical illness and injury may offer enhanced insight into assessment of health perceptions. Generic health profiles and cardiac-disease-specific quality-of-life measures would also be useful in psychosomatic investigations of personality, hostility, depression, and social isolation in patients with cardiac disease.
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Enfermedades Cardiovasculares/psicología , Medicina Psicosomática , Calidad de Vida , Anciano , Geriatría , Estado de Salud , Humanos , Persona de Mediana Edad , PsicometríaRESUMEN
OBJECTIVE: To determine the influence of maternal smoking on fetal erythropoietin concentrations in health term pregnancies and test the correlation between cotinine, a biomarker of maternal smoking, and erythropoietin levels in fetuses. METHODS: We invited women with healthy term pregnancies to participate in the study, excluding those with conditions previously known to be associated with elevated fetal erythropoietin levels. We recorded demographic data, smoking status, and labor outcome prospectively for each patient. Umbilical venous samples were collected, and serum was stored at -70C to be analyzed later for erythropoietin and cotinine. Umbilical arterial samples were tested for pH and base excess determination. We compared fetal erythropoietin and cotinine between smokers and nonsmokers and examined correlations between erythropoietin and cotinine. Kruskal-Wallis test, t test, median test, and Spearman rank correlation test were used when appropriate. Statistical significance was P <.05. RESULTS: We recruited 35 nonsmokers and 26 smokers and analyzed their samples. The two groups were comparable in demographics and birth outcomes, except for birth weights, which were lower in smokers. Fetal erythropoietin concentrations increased significantly with increasing maternal cigarette consumption, ranging from none to more than 15 cigarettes per day (P =.03). There was positive correlation between fetal erythropoietin and cotinine concentrations (r =.41; P =.04), suggesting a dose-response relationship. CONCLUSION: Fetuses of smokers had increased erythropoietin concentrations that correlate positively with fetal cotinine levels; which suggests an increased risk of subacute hypoxia related to degree of maternal cigarette consumption.
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Eritropoyetina/sangre , Sangre Fetal/química , Conducta Materna , Fumar , Adulto , Cotinina/sangre , Femenino , Humanos , EmbarazoRESUMEN
To ensure quality of care, palliative care programs need to document the effectiveness of their relief of physical and psychological distress. The Edmonton Symptom Assessment Scale (ESAS) is a validated, reliable instrument developed to measure 9 different symptoms in palliative care patients. To see if symptom management could be compared across institutions, we first reviewed the charts of 188 successive admissions to the palliative care unit at St. Boniface General Hospital, Winnipeg, Manitoba. Our study showed that the ESAS is a useful audit tool for assessing patterns of palliative symptom control that allows for institutional comparisons. Procedures that ensure completeness of data collection remain to be developed.
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Ansiedad/diagnóstico , Depresión/diagnóstico , Disnea/diagnóstico , Cuidados Paliativos al Final de la Vida/normas , Auditoría Médica/organización & administración , Náusea/diagnóstico , Evaluación de Resultado en la Atención de Salud/organización & administración , Dolor/diagnóstico , Índice de Severidad de la Enfermedad , Análisis de Varianza , Ansiedad/prevención & control , Depresión/prevención & control , Disnea/prevención & control , Humanos , Manitoba , Náusea/prevención & control , Dolor/prevención & control , Garantía de la Calidad de Atención de Salud/organización & administración , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
PURPOSE: To examine the safety, efficacy, costs, and impact on quality of life of venous access ports implanted at the outset of a course of intravenous cancer chemotherapy. PATIENTS AND METHODS: Adults beginning a course of intravenous chemotherapy at two university-affiliated hospitals were randomly allocated to have venous access using a surgically implanted venous access port (Port-a-Cath; Pharmacia, Canada Inc, Montreal, Québec, Canada) or using standard peripheral venous access. All accesses were documented by number, route, purpose, and procedure duration. Outcome measurements included port complications, access strategy failure, access-related anxiety and pain, quality of life (Functional Living Index-Cancer [FLI-C]), and costs. RESULTS: Port complication rates were low (0.23/1,000 days). Failure occurred in two (3.4%) of 59 port subjects and 16 (26.7%) of 60 controls (P =. 0004) at a median period of 26 days after randomization (95% confidence interval, 8 to 92). Peripheral accesses in port subjects took less time, had less access-related anxiety and pain, and were less costly to perform than in controls. Allocation had no effect on FLI-C scores. Peripheral access failure correlated with allocation to the control group (P =.007), higher pain scores with intravenous (IV) starts (P =.003), and anxiety with IV starts (P =.01). Venous accessing overall in port patients was four times more costly than that in controls ($2,178/patient v $530/patient, respectively). CONCLUSION: Ports were safe and effective but had no detectable impact on functional quality of life, despite less access-related anxiety, pain, and discomfort. Because only approximately one quarter of control patients ultimately required central venous access, economic considerations suggest that port-use policies should be based upon defined criteria of need.
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Antineoplásicos/administración & dosificación , Catéteres de Permanencia , Neoplasias/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Catéteres de Permanencia/efectos adversos , Catéteres de Permanencia/economía , Distribución de Chi-Cuadrado , Costos y Análisis de Costo , Estudios Cruzados , Falla de Equipo , Seguridad de Equipos , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Calidad de VidaRESUMEN
BACKGROUND: Complex biomedical and psychosocial considerations figure prominently in the debate about euthanasia and assisted suicide. No study to date, however, has examined the extent to which a dying patient's will to live fluctuates as death approaches. METHODS: This study examined patients with cancer in palliative care. Will to live was measured twice daily throughout the hospital stay on a self-report 100 mm visual analogue scale. This scale was incorporated into the Edmonton symptom assessment system, a series of visual analogue scales measuring pain, nausea, shortness of breath, appetite, drowsiness, depression, sense of well-being, anxiety, and activity. Maximum and median fluctuations in will-to-live ratings, separated by 12 h, 24 h, 7 days, and 30 days, were calculated for each patient. FINDINGS: Of 585 patients admitted to palliative care during the study period (November, 1993, to May, 1995), 168 (29%; aged 31-89 years) met criteria of cognitive and physical fitness and agreed to take part. The pattern of median changes in will-to-live score suggested that will to live was stable (median changes <10 mm on 100 mm scale for all time intervals). By contrast, the average maximum changes in will-to-live score were substantial (12 h 33.1 mm, 24 h 35.8 mm, 7 days 48.8 mm, 30 days 68.0 mm). In a series of stepwise regression models carried out at 12 h, 24 h, and 1-4 weeks after admission, the four main predictor variables of will to live were depression, anxiety, shortness of breath, and sense of well-being, with the prominence of these variables changing over time. INTERPRETATION: Among dying patients, will to live shows substantial fluctuation, with the explanation for these changes shifting as death approaches.
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Actitud Frente a la Muerte , Enfermo Terminal/psicología , Anciano , Eutanasia , Eutanasia Activa Voluntaria , Femenino , Humanos , Masculino , Escala del Estado Mental , Neoplasias/psicología , Cuidados Paliativos , Suicidio AsistidoRESUMEN
PURPOSE: The University of Manitoba Adult Acute Leukemia Study Group sought to examine the safety, efficacy, and impact on quality of life of a non-cytarabine-containing remission-induction regimen followed by intermediate-dose cytarabine (IDARA-C) postremission therapy for the management of untreated acute myeloid leukemia (AML) in patients age 60 to 80 years. PATIENTS AND METHODS: Eligible patients received mitoxantrone 10 mg/m2 and etoposide 100 mg/m2 on days 1 to 5. Complete remitters received a single course of cytarabine 0.5 mg/m2 every 12 hours on days 1 to 6. Cytogenetic and immunophenotyping studies were performed at diagnosis and were examined for prognostic importance. The Functional Living Index-Cancer (FLI-C) was used in the longitudinal assessment of quality of life. RESULTS: A total of 37 (55%) of 67 eligible patients achieved remission, 34 (92%) of whom did so with a single course. The induction mortality rate was 12%. The median disease-free and overall survival times were 8.4 and 9.2 months, respectively. CD34 stem-cell phenotype, poor performance status, and high cytogenetic complexity score were independent covariates of failure to achieve remission. Very complex karotype combined with CD34 stem-cell phenotype to predict induction death in 67% of cases (P = .0003). Cytotoxic therapy-related gut epithelial damage was maximal during weeks 2 and 3 of therapy. Complete remitters and partial responders exhibited significantly improved global FLI-C scores following completion of therapy. CONCLUSION: Mitoxantrone plus etoposide was an effective and well-tolerated first-line induction regimen for AML in the elderly that should be studied further in comparison to the standard cytarabine/anthracycline-based therapy.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Leucemia Mieloide/tratamiento farmacológico , Enfermedad Aguda , Anciano , Antimetabolitos Antineoplásicos/administración & dosificación , Antineoplásicos Fitogénicos/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Citarabina/administración & dosificación , Supervivencia sin Enfermedad , Esquema de Medicación , Etopósido/administración & dosificación , Femenino , Humanos , Mucosa Intestinal/efectos de los fármacos , Masculino , Persona de Mediana Edad , Mitoxantrona/administración & dosificación , Calidad de Vida , Inducción de Remisión , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: Euthanasia and physician-assisted suicide have become prominent medical and social issues. This study investigated the prevalence of the desire for death in terminally ill patients, the stability of this desire over time, and its association with psychiatric disorders. METHOD: Two hundred terminally ill inpatients were given semistructured interviews that assessed their desire for death and evaluated them for major and minor depressive episodes according to the Research Diagnostic Criteria. Each patient also completed a short form of the Beck Depression Inventory and provided ratings of pain and social support. When possible, patients who expressed a desire for death received a follow-up interview after a 2-week interval. RESULTS: Although occasional wishes that death would come soon were common (reported by 44.5% of the patients), only 17 (8.5%) of these individuals acknowledged a serious and pervasive desire to die. The desire for death was correlated with ratings of pain and low family support but most significantly with measures of depression. The prevalence of diagnosed depressive syndromes was 58.8% among patients with a desire to die and 7.7% among patients without such a desire. Follow-up interviews were conducted with six patients; in four cases, the desire to die had decreased during the 2-week interval. CONCLUSIONS: The desire for death in terminally ill patients is closely associated with clinical depression--a potentially treatable condition--and can also decrease over time. Informed debate about euthanasia should recognize the importance of psychiatric considerations, as well as the inherent transience of many patients' expressed desire to die.
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Eutanasia Activa Voluntaria , Eutanasia/psicología , Neoplasias/psicología , Adulto , Factores de Edad , Anciano , Trastorno Depresivo/epidemiología , Trastorno Depresivo/psicología , Eutanasia/estadística & datos numéricos , Familia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/epidemiología , Dolor/psicología , Escalas de Valoración Psiquiátrica , Derecho a Morir , Apoyo Social , Estrés PsicológicoRESUMEN
BACKGROUND: To the authors' knowledge, the natural history of myelosuppression and infectious complications associated with the use of standard cytarabine (ARA-C) plus daunorubicin ("7 + 3") remission-induction therapy for adult acute myeloid leukemia (AML) and high dose ARA-C (HDARA-C) consolidation has not been described completely. METHODS: A retrospective study of untreated adult AML patients receiving standard 7 + 3 induction followed by "5 + 2" and HDARA-C consolidation was undertaken to describe the relationship of the myelosuppression profiles, blood product use, and infectious morbidity, and to correlate this finding with the outcome of antileukemic therapy. Multivariate techniques were used to evaluate variables of prognostic importance. RESULTS: Fifty-nine percent of the patients achieved remission after a median of 35 days; almost half (48%) of these patients required more than one 7 + 3 induction course. For one, two, and three induction courses, the mean number of days the patients experienced severe neutropenia (< 0.5 x 10(9)/l) were 22.5 +/- 10.9, 39.3 +/- 14.3, and 47.4 +/- 9.7 days (P < 0.001), respectively, and the infection rates were 1.45, 2.45, and 3 infections per course (P < 0.0001), respectively. The pattern of blood product use was similar. HDARA-C consolidation was the most significant factor related to prolonged disease free survival, however the myelosuppression profiles and infection rates were surprisingly similar to those for the single 7 + 3 induction courses. CONCLUSIONS: The 7 + 3 induction regimen used in this center provided only limited antileukemic activity, while requiring multiple induction courses in a high proportion of patients. The use of multiple induction courses had consequences of prolonged myelosuppression, increased blood product use, and incremental risks of infectious complications. HDARA-C consolidation for those who experienced complete remission appeared to improve disease free survival with myelosuppression comparable with that of patients who received primary induction therapy. The infection risk was acceptable, with only a marginal increase in bacteremic and fungal infections.