Leucemia mieloide aguda en adultos: estudio comparativo sobre tratamiento y pronóstico por grupos etarios / Acute myeloid leukemia in adults: a comparative study of treatment and prognosis by age groups

El tratamiento de la Leucemia mieloide aguda (LMA) está basado en administración de quimioterapia (QT), que se asocia a importante toxicidad en quienes la reciben. La elección del régimen de QT se basa en edad, estado general y comorbilidades del paciente, empeorando el pronóstico en los adultos mayores. Objetivo: Comparar la evolución de pacientes menores de 60 años (adultos jóvenes) y de mayores de 60 años (adultos mayores) con LMA que recibieron QT. Material y métodos: Estudio descriptivo, retrospectivo en pacientes admitidos en el Hospital Edgardo Rebagliati entre enero de 1995 y diciembre de 2008. Los criterios de inclusión fueron: Diagnóstico de LMA debut, mayor de 18 años, haber recibido QT según Protocolo del Servicio de Hematología. Fueron excluidos los pacientes con LMA promielocítica y los que fueron sometidos a trasplante de progenitores hematopoyéticos. Se determinó la tasa de remisión completa (RC), tasa de persistencia de enfermedad (PE) post QT, tasa de mortalidad asociada a QT (TM) Y curvas de sobrevida libre de enfermedad (SLE) y sobrevida total (ST). Resultados: Se estudiaron 208 pacientes, 153 fueron adultos jóvenes y 55 adultos mayores, los grupos tuvieron características similares. Las tasas de RC, TM y ST mostraron diferencias estadísticamente significativas a favor del grupo adultos jóvenes, mientras que las tasas de PE y SLE no mostraron diferencias. Conclusiones: Los pacientes adultos mayores que reciben QT tienen peor pronóstico en comparación con los pacientes adultos jóvenes. La decisión de tratamiento con QT debe individualizarse, comparando riesgo - beneficio de la QT en cada caso...

Treatment of acute myeloid leukemia (AML) is based on the administration of chemotherapy (CT), which is associated with significant toxicity. The selection of CT is based on age, general condition and presence of comorbidities in the patient, with poor prognosis associated with advanced age. Objective: to compare the clinical outcomes of patients with AML treated with CT below 60 years of age with that of patients above 60 years of age. Methods: A descriptive, retrospective study was carried-out from January 1995 to December 2008 at Hospital Edgardo Rebagliaiti. lnclusion criteria were age above 18 years and to have received CT based on standard protocols by the hospital. Patients with promyelocytic AML and those in whom abone marrow transplant had been performed were excluded. Complete remission rate (CRR), persistence rate (PR), mortality rates (MR) and disease free survival (DFS) and overall survival (OS) curves were obtained. Results: 208 patients were included; 153 were young adults and 55 were older adults, both groups were comparable. CRR, MR and OS were better in young adults, while PR and OS did not differ by age. Conclusions: Older adult patients on CT had poor prognosis compared to younger patients. The decision on staring CT should be individualized balancing the risks and benefits...

Cost-effectiveness analysis of varenicline versus existing smoking cessation strategies in Central America and the Caribbean using the BENESCO model.

OBJECTIVES: In Central American countries, the economic burden of tobacco has not been assessed. In Costa Rica, a study demonstrated that tobacco-related diseases represent high costs for the health care system. The aim of this study was to assess the cost-effectiveness of varenicline compared with other existing strategies for smoking cessation within a 10-year time horizon in an adult population cohort from Central American and Caribbean countries using the health care payer's perspective. METHODS: The Benefits of Smoking Cessation on Outcomes simulation model was used for an adult cohort in Costa Rica (n = 2 474 029), Panama (n = 2 249 676), Nicaragua (n = 3 639 948), El Salvador (n = 4 537 803), and the Dominican Republic (n = 6 528 125) (N = 19 429 581). Smoking cessation therapies compared were varenicline (0.5-2 mg/day) versus bupropion (300 mg/day), nicotine replacement therapy (5-15 mg/day), and unaided cessation. Effectiveness measures were: life-years (LYs) gained and quality-adjusted life-years (QALYs) gained. Resource use and cost data were obtained from a country's Ministry of Health and/or Social Security Institutions (2008-2010). The model used a 5% discount rate for costs (expressed in 2010 US$) and health outcomes. Probabilistic sensitivity analyses were conducted and acceptability curves were constructed. RESULTS: Varenicline reduced smoking-related morbidity, mortality, and health care costs in each country included in the study. Accumulatively, mortality in the varenicline arm was reduced by 1190, 1538, and 2902 smoking-related deaths compared with bupropion, nicotine replacement therapy, and unaided cessation, respectively. The net average cost per additional quitter showed that varenicline was cost-saving when compared with competing alternatives. Regarding LYs and QALYs gained in 10 years, varenicline obtained the greatest number of QALYs and LYs in each country, while unaided cessation obtained the fewest. Cost-effectiveness analyses in all 5 countries showed that varenicline was the dominant strategy. Acceptability curves showed that, independent of the willingness to pay, the probability that varenicline is cost-effective was 99% for this region. The results of the probabilistic sensitivity analyses support the robustness of the findings. CONCLUSION: Smoking cessation therapy with varenicline is cost-saving for the Central American and Caribbean countries included. These results could help to reduce the tobacco-related disease burden and align cost-containment policies.

Cost analysis of varenicline versus bupropion, nicotine replacement therapy, and unaided cessation in Nicaragua.

OBJECTIVES: In Nicaragua, 30% of current morbidities are associated with tobacco smoking. Tobacco control policy measures have been initiated in this Central American country; however, the population does not have a complete understanding of the long-term consequences of tobacco use. The aim of this study was to compare the direct medical costs of smoking cessation therapies with varenicline, bupropion, nicotine replacement therapy, and unaided cessation in Nicaragua over 5 time horizons: 2, 5, 10, and 20 years, and lifetime. METHODS: The current annual costs of chronic obstructive pulmonary disease, lung cancer, coronary heart disease, and stroke were estimated based on the current annual incidence for each disease using 1 public hospital database (Hospital Lenin Fonseca, 2010). The Benefits of Smoking Cessation on Outcomes simulation model was used to obtain the projected direct costs for each strategy. An adult cohort (N = 3 639 948) from Nicaragua was used and the assessment was conducted using the health care payer's perspective. Costs were discounted at 5% annually. Probabilistic sensitivity analyses were conducted using a Monte Carlo second-order approach. RESULTS: Varenicline is associated with the highest health care cost-savings compared with the other 3 alternatives at 5, 10, and 20 years, and lifetime. At lifetime, varenicline would result in savings of US$4 545 008, US$5 859 300, and US$11 033 221 when compared with bupropion, nicotine replacement therapy, and unaided cessation, respectively. Varenicline also avoided the highest number of smoking-related deaths in comparison with the alternatives. At year 10, varenicline avoided 96, 124, and 234 more deaths than bupropion, nicotine replacement therapy, and unaided cessation, respectively. The results of probabilistic sensitivity analyses support these findings. CONCLUSION: The use of a smoking cessation therapy with varenicline would generate long-term savings to Nicaragua's health care institutions of > US$11 million in the lifetime time horizon.

Formación de recursos humanos en salud pública en el Ecuador

Presenta un planteamiento crítico de la situación de la formación de recursos humanos en salud pública en el Ecuador a partir de fuentes de información ya existentes y de la experiencia propia del autor dentro de la vivencia docente asistencial hospitalaria y administrativa