Who Should Bear the Cost of Convenience? A Cost-effectiveness Analysis Comparing External Beam and Brachytherapy Radiotherapy Techniques for Early Stage Breast Cancer.

AIMS: Standard treatment for early breast cancer includes whole breast irradiation (WBI) after breast-conserving surgery. Recently, accelerated partial breast irradiation (APBI) has been proposed for well-selected patients. A cost and cost-effectiveness analysis was carried out comparing WBI with two APBI techniques. MATERIALS AND METHODS: An activity-based costing method was used to determine the treatment cost from a societal perspective of WBI, high dose rate brachytherapy (HDR) and permanent breast seed implants (PBSI). A Markov model comparing the three techniques was developed with downstream costs, utilities and probabilities adapted from the literature. Sensitivity analyses were carried out for a wide range of variables, including treatment costs, patient costs, utilities and probability of developing recurrences. RESULTS: Overall, HDR was the most expensive ($14 400), followed by PBSI ($8700), with WBI proving the least expensive ($6200). The least costly method to the health care system was WBI, whereas PBSI and HDR were less costly for the patient. Under cost-effectiveness analyses, downstream costs added about $10 000 to the total societal cost of the treatment. As the outcomes are very similar between techniques, WBI dominated under cost-effectiveness analyses. CONCLUSIONS: WBI was found to be the most cost-effective radiotherapy technique for early breast cancer. However, both APBI techniques were less costly to the patient. Although innovation may increase costs for the health care system it can provide cost savings for the patient in addition to convenience.

[Implementation of a quality management system according to the UNE-UN-ISO 9001:2008 standard in a nuclear medicine department]. / Implantación de un sistema de gestión de calidad según norma UNE-UN-ISO 9001:2008 en un servicio de medicina nuclear.

OBJECTIVE: To describe the process of implementing a quality management system according to UNE-EN-ISO 9001:2008 standard in a Nuclear Medicine Department. MATERIAL AND METHOD: In February 2008, the committee on internal quality of the Department was established, naming a responsible physician. The general operating plan was drawn up, following the requirements established by the ISO 9001:2008 standard. It defined the scope of the standard, defining, preparing and transcribing the various activities of our Department. Four training sessions were carried out. RESULTS: A total of nine general and two specific procedures were documented in which all the activities performed in our Department were included. Personnel records of each worker were created, including their profiles and training plan. A record of the equipment and service providers was created, as well as issues with the latter. Satisfaction surveys were obtained from external (patients) and internal customers (faculty applicants). Targets for improvement and activity markers were established. Two audits were performed to complete the process, one internal and one external. The Department was accredited in April 2010. CONCLUSION: The quality accreditation process is a tool that requires reflection on how we do things and how they can be improved. It makes it possible to measure what we do, to analyze and introduce improvement measures, and therefore, to achieve a higher level of quality in the service we provide our customers. The involvement of the Department workers with a commitment to team performance was essential.

Diagnóstico molecular por reacción en cadena de la polimerasa del síndrome X frágil: aplicación de un protocolo diagnóstico en 50 familias del norte de España / Molecular diagnosis of fragile x syndrome by polymerase chain reaction: application of a diagnostic protocol in 50families from northern spain

Objetivos: Poner a punto una metodología rápida y eficaz para el diagnóstico molecular del síndrome X frágil (SXF), mediante técnicas de reacción en cadena de la polimerasa (PCR) del triplete CGG, y establecer así un protocolo que nos sirva para: a)descartar el síndrome en pacientes con retraso mental no clasificado; b)averiguar el genotipo exacto de los individuos afectados; c)estudiar todos los individuos en riesgo de las familias con síndrome X frágil y encontrar los portadores asintomáticos, y d)proporcionar así el adecuado asesoramiento genético y reproductor a las familias en las que se transmita el síndrome. Pacientes y métodos: Se estudiaron 438 muestras de individuos de 50 familias con síndrome X frágil. Se utilizaron tres protocolos de PCR, uno para detección con bromuro de etidio y luz ultravioleta; el segundo para detección con digoxigenina y el sustrato quimioluminiscente (CSPD), tras blotting e hibridación con la oligosonda (CGG) 5; el tercero para amplificar y detectar de forma parecida el microsatélite DXS548. Resultados: Se encontraron 121 individuos con la mutación completa (60 varones y 61 mujeres); 86 premutados (7 varones y 79 mujeres); 16 mosaicos y 215 normales. La PCR amplificó hasta 120-150 repeticiones, y fue necesario el estudio directo con sonda en el caso de ausencia de banda o banda única en mujeres. La PCR resultó más precisa que el Southern-blot de ADN genómico en los portadores premutados. Finalmente, se halló en una familia recombinación entre el locus FRAXA y el microsatélite DXS548. Conclusiones: Estos protocolos de PCR no radiactiva permiten el diagnóstico rápido y seguro del síndrome X frágil, y están especialmente indicados en posibles portadoras y para establecer el diagnóstico prenatal (AU)

[Molecular diagnosis of fragile X syndrome with polymerase chain reaction: application of a diagnostic protocol in 50 families from northern Spain]. / Diagnóstico molecular por reacción en cadena de la polimerasa del síndrome X frágil: aplicación de un protocolo diagnóstico en 50 familias del norte de España.

OBJECTIVES: The aim of this study was to develop a rapid, non-radioactive and effective method for the molecular diagnosis of fragile X syndrome (FXS) by the polymerase chain reaction (PCR) of the CGG repeat and to establish a protocol to be used in: a)ruling out FXS in patients with non-specific mental retardation; b)determining the exact genotype of affected individuals; c)studying all at-risk individuals from families with FXS and identifying asymptomatic carriers, and d)offering accurate genetic and reproductive counselling to families with FXS. MATERIALS AND METHODS: Samples from 438 individuals from 50 families with FXS were studied using three different PCR tests: the first to detect ethidium bromide through ultraviolet light, the second to detect digoxigenin and CSPD after blotting and hybridisation with the (CGG)5 oligoprobe, and the third to amplify and detect the DXS548 microsatellite. RESULTS: Of the 438 individuals studied, 121 had full mutations (60 males and 61 females), 86 had pre-mutations (7 males and 79 females), 16 showed mosaic patterns and 215 had no mutations. PCR techniques amplified up to 120-150 repeats, and direct study with probes was required when no bands or only one band was detected in females. PCR was more accurate than genomic DNA Southern blot analysis in pre-mutated carriers. In one family, recombination between the FRAXA locus and the DXS548 microsatellite was found. CONCLUSIONS: These non-radioactive PCR protocols permit rapid and accurate diagnosis of FXS. They and are especially useful in prenatal diagnosis and in the identification of carriers.

Phenotypic and functional characteristics of hematopoietic cell lineages in CD69-deficient mice.

AIM/CD69 is the earliest leukocyte activation antigen and is expressed mainly by activated T, B, and natural killer (NK) cells. It is also constitutively expressed by platelets, by bone marrow myeloid precursors, and by small subsets of resident lymphocytes in the secondary lymphoid tissues. The engagement of CD69 by specific antibodies induces intracellular signals, including Ca(++) flux, cytokine synthesis, and cell proliferation. To investigate the physiological relevance of CD69, we generated mice deficient in CD69 (CD69-/-) by gene targeting in embryonic stem cells. CD69 (-/-) mice showed largely normal hematopoietic cell development and normal T-cell subpopulations in thymus and periphery. Furthermore, studies of negative- and positive-thymocyte selection using a T-cell receptor transgenic model demonstrated that these processes were not altered in CD69 (-/-) mice. In addition, natural killer and cytotoxic T lymphocyte cells from CD69-deficient mice displayed cytotoxic activity similar to that of wild-type mice. Interestingly, B-cell development was affected in the absence of CD69. The B220(hi)IgM(neg) bone marrow pre-B cell compartment was augmented in CD69 (-/-) mice. In addition, the absence of CD69 led to a slight increase in immunoglobulin (Ig) G2a and IgM responses to immunization with T-dependent and T-independent antigens. Nevertheless, CD69-deficient lymphocytes had a normal proliferative response to different T-cell and B-cell stimuli. Together, these observations indicate that CD69 plays a role in B-cell development and suggest that the putative stimulatory activity of this molecule on bone marrow-derived cells may be replaced in vivo by other signal transducing receptors.

[The follow-up of pregnancy in the province of Salamanca]. / Control de gestación en la provincia de Salamanca.

AIM: To discover the level of health care accorded to pregnant women, the type of professional who attends them, and to what extent guidelines proposed for monitoring pregnancies are carried through. DESIGN: A transversal, retrospective, observational study: without a control and with a random sample. SITE. The data were obtained in a Public Hospital and came from women who had been monitored at all levels of health care, whether public or private. PATIENTS: The study was of all the women who gave birth in the General Hospital over a period of three months. MEASUREMENTS AND MAIN FINDINGS: An interview was administered to 500 pregnant women. It was found that the number of pregnancies attended to at the Primary Care level is small (9% in Health Centre consultations and 6% by the General Practitioner). The entry of pregnant women into the Health System is late: 48% from the fourth mont. In a high percentage of cases, no explorations of the neck of the womb are made; nor are certain analytic tests (e.g. renal and liver function tests and urinary cultures) and various complementary checks made. CONCLUSIONS: 1) Health Education programmes must be initiated at the Primary Care level, in order to draw in at an early stage the pregnant woman. 2) There is a need to use guidelines for pregnancy and develop programmes of ongoing training for Primary Care professionals, in order to improve the quality of health care during pregnancy.