Disability, support and long-term social care of an elderly Spanish population, 2008-2009: an epidemiologic analysis

BACKGROUND

Though poorly known, relationships between disability, need of help (dependency) and use of social services are crucial aspects of public health. The objective of this study was to describe the links between disability, officially assessed dependency, and social service use by an industrial population, and identify areas of inequity.

METHODS

We took advantage of a door-to-door survey conducted in the Cinco Villas district, Spain, in 2008-2009, which provided data on disability, morbidity, and service use among 1216 residents aged ≥50 years, and officially assessed dependency under the 2006 Dependency Act (OAD). Using logistic regression, we combined data collected at homes/residences on 625 disability screened-positive participants, and administrative information on degree of OAD and benefits at date of visit.

RESULTS

Based on 163 disabled persons, the prevalence of residential/community-care users was 13.4% overall, with 6.0% being market-provided, 2.5% supported by the 2006 Act, and 4.9% supported by other public funds. Of 111 OAD applicants, 30 had been assigned an OAD degree; in 29 cases this was the highest OAD degree, with 12 receiving direct support for residential care and 17 receiving home care. Compared to unassessed dependency, the highest OAD degree was linked to residential care (OR and 95% CI) 12.13 (3.86-38.16), declared non-professional care 10.99 (1.28-94.53), and publicly-funded, non-professional care 26.30 (3.36-205.88). In contrast, 43 persons, 58% of the severely/extremely disabled, community-dwelling sample population, 81% of whom were homebound, including 10 persons with OAD but no implemented service plan, made no use of any service, and of these, 40% lacked a non-professional carer.

CONCLUSIONS

Formal service use in the Cinco Villas district attained ratios observed for established welfare systems but the publicly-funded proportion was lower. The 2006 Act had a modest, albeit significant, impact on support for non-professional carers and residential care, coexisting with a high prevalence of non-use of social services by severely disabled persons.

Experience in management of 51 non-functioning pituitary adenomas: indications for post-operative radiotherapy

OBJECT

The indications for additional radiotherapy (RT) after surgery for non-functioning pituitary adenoma are controversial. The goal of this retrospective study was to evaluate the outcome of surgically treated patients, with or without post- operative irradiation.

METHODS

Review of cases treated for non-functioning pituitary adenoma. Fifty-one patients were identified, with a mean post-operative follow-up of 6.4+/-3.5 yr. Twenty-nine patients showed residual tumor after surgery and 22 did not. Serial endocrine, visual and radiological evaluations were made after treatment to assess the efficacy and toxicity of surgery and RT. Twenty-seven patients with residual tumor after surgery received RT (22 of them during the post-operative period and 5 after an interval of several yr: 3 because of increased tumor size and 2 with stable residual lesion); tumors in 14 of these patients decreased in size, 11 appeared to be stable on imaging and one patient showed some increase in tumor size (one patient was not followed-up). The residual tumors of the 2 non-irradiated patients remained stable after 5 and 7 yr, respectively. Twenty-two patients without residual disease after surgery (11 with post-operative irradiation, 1 with RT 5 yr after transsphenoidal surgery because of tumor recurrence, and 10 without RT) have shown no evidence of tumor regrowth on serial images.

CONCLUSIONS

Radiotherapy can be avoided in patients with complete macroscopic resection and absence of residual tumor in post-operative images; they must be carefully followed using imaging techniques and, in the case of recurrence, they should be re-operated and/or irradiated.

Phase II study of radiochemotherapy with UFT and low-dose oral leucovorin in patients with unresectable rectal cancer

PURPOSE

To determine the activity and evaluate the toxicity of uracil and tegafur in a 4:1 molar concentration (UFT) plus low-dose leucovorin administered concomitantly with pelvic irradiation in patients with unresectable or recurrent rectal cancer.

METHODS AND MATERIALS

Thirty-five patients (22 with primary unresectable tumors and 13 with locally recurrent tumors) were enrolled in the trial. Thirty-five patients were evaluable for toxicity and 32 of these were evaluable for clinical response. Patients received 300 mg/m2/day UFT and 30 mg/day leucovorin on days 8-35 concomitantly with pelvic radiotherapy, to a total dose of 45 Gy.

RESULTS

Eight of the 35 (23%) patients developed Grade 3 diarrhea and were treated with radiotherapy alone after this event. Of the 22 patients with unresectable primary tumors, 17 underwent surgery, and resection was feasible in 15 cases (88%). Of the 32 patients evaluable for clinical response, 4 (13%) had a complete clinical response (CR) and 22 (69%) a partial response (PR). A complete pathologic response was observed in 3 cases (18%) and, a PR in 11 cases (65%).

CONCLUSION

The response rates achieved with this schedule seem comparable to those obtained with 5-FU and radiotherapy. These results warrant further evaluation of this combination in patients with unresectable or locally advanced tumors.

The long-term outcome of pituitary irradiation after unsuccessful transsphenoidal surgery in Cushing's disease

BACKGROUND

Irradiation of the pituitary is widely considered the most appropriate treatment for patients with Cushing's disease in whom transsphenoidal microsurgery has been unsuccessful. However, there is little information about the long-term efficacy of this treatment.

METHODS

We used external pituitary radiation to treat 30 adult patients with persistent or recurrent Cushing's disease after unsuccessful transsphenoidal surgery. The mean (+/-SD) dose of radiation was 50+/-1 Gy. Pituitary and adrenal function was assessed every six months after radiation therapy. Remission was defined as the regression of symptoms and signs of Cushing's syndrome, normal urinary cortisol excretion, and a low plasma cortisol concentration in the morning after the administration of 1 mg of dexamethasone at midnight.

RESULTS

Twenty-five patients (83 percent) had remissions during a median follow-up of 42 months (range, 18 to 114). The remissions began 6 to 60 months after radiation therapy, but in most cases (22 patients) remission occurred during the first 2 years. None of the 25 patients had a relapse of Cushing's disease after remission was achieved. There was no relation between the response to radiotherapy and sex, age, urinary cortisol excretion before radiotherapy, the interval between surgery and radiotherapy, whether a pituitary adenoma was found by pathological examination, or tumor size. Seventeen patients had a deficiency of growth hormone after radiation therapy, 10 had a deficiency of gonadotropins, 4 had a deficiency of thyrotropin, and 1 had a deficiency of corticotropin.

CONCLUSIONS

Pituitary irradiation is an effective and well-tolerated treatment for patients with Cushing's disease in whom transsphenoidal surgery is unsuccessful.

Influence of boost technique (external beam radiotherapy or brachytherapy) on the outcome of patients with carcinoma of the base of the tongue

We reviewed 90 patients with squamous cell carcinoma of the base of the tongue. Fifty-three patients were treated with external beam radiotherapy alone (3 T1, 11 T2, 21 T3, and 18 T4 tumors) and thirty-seven patients were treated with external beam radiotherapy plus brachytherapy boost (4 T1, 15 T2, 11 T3, and 7 T4 tumors). For patients with T1, T2 and T3 primaries, the actuarial 3-year local relapse-free survival was 42% following external beam radiotherapy alone and 67% following external beam radiotherapy plus brachytherapy (p < 0.05). The actuarial 3-year cause specific survival for these T-stages was 37% for patients treated with external beam radiotherapy alone and 53% for patients treated with external beam radiotherapy plus brachytherapy (p = 0.1). In the Cox multivariate analyses restricted patients with T1, T2 and T3 staged tumors, treatment modality was the only predictor for local control but no influence on specific survival was found. The trend towards significant differences in specific survival found in the univariate comparison of both treatment modalities was probably due to the significantly higher number of N-positive patients treated with external beam radiotherapy alone. When all stages were included in the Cox analysis, low hemoglobin level, invasion of deep muscle, number of palpable nodes, and history of weight loss significantly influenced the outcome. Soft tissue necrosis occurred more frequently in patients treated with external beam radiotherapy plus brachytherapy (33% vs. 10%, p = 0.52).

Salvage brachytherapy and salvage surgery for recurrent oropharyngeal carcinoma following radiotherapy

We reviewed 21 patients who underwent salvage treatment after a biopsy of proven locally recurrent carcinoma of the oropharynx. Two of these patients underwent a second salvage treatment after failure of the first. Treatment was performed with Ir192 interstitial implant in 17 cases (13 rT1 and 4 rT2); by surgery in five cases (3 rT1, 1 rT2, 1 rTx), including two patients who had relapsed after salvage treatment with Ir192 implant; and by hyperfractionated external beam irradiation plus concomitant Tegafur chemotherapy in one case (rT3). The primary tumour was controlled in four of the 17 cases (23 per cent) treated with Ir192 implant. Of these four patients, two remained disease-free 42 and 59 months after treatment, one died of nodal metastases eight months after treatment and another of distant metastases 19 months after treatment. Four of the five cases (80 per cent) treated with surgery, including two patients who relapsed after salvage brachytherapy, remained free from local, regional and distant relapse 21, 25, 31 and 56 months after treatment.

Episcleral iridium-192 wire therapy for choroidal melanomas

PURPOSE

To evaluate the effectivity of high-dose episcleral iridium-192 wires in the treatment of choroidal melanoma.

METHODS AND MATERIALS

In 1983, the Departments of Radiation Oncology and Ophthalmology at the Clínica Puerta de Hierro, Madrid, Spain, initiated a clinical study using removable episcleral iridium-192 wires in the treatment of choroidal melanoma. Sixty-six evaluable patients were treated from January 1983 through July 1992. Two patients had a small sized tumor (3%), 28 had a medium sized tumor (42%), and 36 patients had a large tumor (54%). The mean follow-up was 40 months (6-118 months). The dose to the apex of the tumor ranged from 66 to 97 Gy (mean 76.6 Gy), and the doses at 2 mm depth ranged from 77 to 433 Gy (mean 200 Gy).

RESULTS

Tumor regression or stabilization was observed in 53 of the 66 patients (90%). Visual acuity improved following treatment in 5 out of 54 patients (9%), remaining unchanged in 30 out of 54 (56%), and decreased in 19 out of 54 (35%) patients. The remaining seven patients had undergone enucleation. Late complications have been documented in 20 out of 66 patients (30%), including 6 patients in whom enucleation was required because of radiation-related complications. The probability of survival and survival free of local progression was 93% at 5 years and 79% at 10 years. The probability of retaining the treated eye is 82% after the fifth year posttreatment.

CONCLUSIONS

Treatment of choroidal melanomas with episcleral iridium-192 wires is as effective as treatment with other radioactive applications. We feel that our results using iridium-192 wires are comparable to the other methods. However, we think that our technique is simple to implement, relatively inexpensive, and well tolerated.

Medulloblastoma in adulthood: prognostic factors influencing survival and recurrence

Thirty adult patients presenting with medulloblastoma between 1974 and 1991 were studied and treated at Puerta de Hierro Clinic. After diagnosis, all patients were treated by surgery followed by radiotherapy and eight of them received adjuvant chemotherapy. We have studied the influence of some factors such as age, sex, location of tumour in the cerebellum, amount of surgical resection and histological variants on survival and recurrence of the disease. Only the histological type has a statistically significant influence on survival and recurrence: we have found that patients presenting classic medulloblastoma have a long survival and a long relapse-free interval.

Prognostic factors for local control, regional control and survival in oropharyngeal squamous cell carcinoma

We have performed univariate and multivariate analysis to identify the clinical and treatment-related prognostic factors in a series of 254 patients with newly diagnosed, histologically proven, oropharyngeal squamous cell carcinoma treated with radical radiation therapy. The probabilities of local control, regional control, disease-free survival (DFS) and adjusted survival (AS) were calculated using the Kaplan-Meier method and differences between curves were evaluated by the Mantel-Cox test. The obtained significant variables in the univariate analysis were analysed using the Cox proportional hazards model. In the Cox multivariate analysis, four variables significantly influenced local control probability in the following order: tumour diameter, N stage, alcohol intake and weight loss. N stage significantly influenced the probability of regional control. Five variables influenced both DFS and AS: N stage, tumour diameter, weight loss, alcohol intake and tumour origin within the posterior oropharyngeal wall.

[Community participation in health at the Instituto Mexicano del Seguro Social in Jalisco]

This paper describes the achievements and problems of a community participation model in health care, developed by the Mexican Social Security Institute since 1985. The health team involved between 10 and 20 percent of the personnel due to the slow adoption this program requires in new of the cultural change it implies. The community's answer has been satisfactory, as it can be seen by the ware of 100 neighbours and school committees, and around the 2,000 housewives and school students who are been working as promoters. This figures stand monthly. The self-care groups on chronic diseases constitute another form of participation. The community activities are progressively focused on causes of health and disease, embracing our 70 per cent of health promotion and disease prevention actions. The work realized by the community over cause one third of that realized by the preventive medicine personnel. This health community participation model represents a valuable and viable alternative.

[Psychiatric diseases in the elderly in an urban Aragonese population (Spain) and their relation to health determinants]

As a part of the SAMAR 89 Project on mental health, we present the results of a psychiatric epidemiological research (in two stages) in a representative sample of the elderly urban population of Zaragoza (Spain). We study the relation between psychological disorders and sociodemographic factors, and network and social support. In the first stage we use a adaptation of the Enquête Santé Quebec and the General Health Questionnaire of 28 items of Goldberg. The Clinical Interview Schedule and the monumental state of Folstein were used for the psychiatric diagnoses in the second stage (diagnoses criteria of the DSM-III). The psychological disorders were more frequent on the women, the more aged and the ones of low socioeconomic level. Also was detected a correspondence between bad mental health and problems in the network and social support.

Intracranial metastases to the pineal region. Report of three cases

The pineal region is one of the rarest sites in the brain for metastatic involvement of systemic malignant tumors. A review of the literature shows that approximately 70 such cases have been reported previously, and most of them were diagnosed by autopsy. In this brief report we describe three cases of isolated intracranial metastasis to the pineal region that were diagnosed in patients alive. Although occurring rarely, metastatic lesions should be considered in the differential diagnosis of pineal region tumors.

Immunohistochemical study of natural killer cells in tumor-infiltrating lymphocytes of primary intracranial germinomas

A monoclonal antibody against the surface marker IOT-10 of natural killer (NK) cells was used to investigate the presence and distribution of these cells in a series of nine primary intracranial germinomas. In all of these tumors, IOT-10-positive NK cells were found in small numbers, mainly distributed among the tumor cells. The data obtained in the present study suggest that the presence of NK cells in primary intracranial germinomas can be influenced by factors other than the mere quantity of tumor-infiltrating lymphocytes.

Conjunctival intraepithelial and invasive squamous cell carcinomas treated with strontium-90

Twenty-seven patients with malignant epithelial tumors of the conjunctiva were treated between 1967 and 1987. Histological diagnosis was intraepithelial epithelioma in 15 cases (56%) and squamous cell carcinoma in 12 (44%). All patients were treated with a strontium-90 source on cup-shaped applicators of different sizes according to the extension of the tumor. Surface dose ranged from 60 Gy in a single treatment to 140 Gy in 7 fractions, depending on the thickness of the lesion. Fifteen patients were previously untreated, 7 were irradiated after some type of surgical treatment and 5 were treated for recurrence after multiple surgical excisions. Follow-up period ranged from 2 to 15 years. No patient died of his tumor. There were four local recurrences, three of them in patients with intraepithelial carcinoma. Two of the recurrences were salvaged with a new beta-ray treatment and the other two with enucleation. Since 1981, standard policy was to irradiate the entire conjunctiva in patients with diagnosis of intraepithelial epithelioma. Five patients developed cataracts. Considering the high primary control rate and minimal morbidity, strontium irradiation should be considered as a first-choice treatment for conjunctival tumors.

Immunohistochemical study of IOT-10 natural killer cells in brain metastases

The presence of NK-cells in a series of 40 metastatic brain tumours has been studied by means of the monoclonal antibody IOT-10. There appeared IOT-10 NK-cells in all tumours studied, but in most cases these cells represented less than 10% of the tumour infiltrating lymphocytes (TIL). In the present series, the obtained data suggest that the number of NK-cells in brain metastases can be influenced by other factors than the mere quantity of TIL.