Dissemination of health technologies: Trends in the use of diagnostic test in breast cancer screening.

OBJECTIVE: To analyse trends in the use of diagnostic test in breast cancer screening programs in Spain. MATERIALS AND METHODS: Retrospective study of 542,695 women who had undergone at least one screening mammogram in any of the screening centres of three administrative regions in Spain, between 1996 and 2011. Process measures were: overall recall rate, overall invasive test rate, and rates of each type of invasive test (fine-needle aspiration biopsy, core-needle biopsy and surgical biopsy). As results measures were included detection of benign lesions rate, ductal in situ cancer rate and invasive cancer rate. Adjusted by age rates were estimated year by year for each measure and, also, the annual percent of change and its corresponding joint points. RESULTS: Core-needle biopsy rates decreased between 1996 and 1999 and changed trends in 1999-2011 with an increase of 4.9% per year. Overall recall rate declined by 4.6% from 1999 to 2004, invasive test rate declined between 1996 and 2004 by 24.3%. Fine-needle aspiration biopsy rate changes were: a 22.4% declined per year (1996-1998), and 13.5% declined per year (1998-2005). Benign lesions rate decreased from 1996 to 2011, 21.4% per year (1996-2001) and 6.0% (2001-2011). Ductal carcinoma in situ and invasive cancer had no-statistically significant changes. CONCLUSION: The introduction of core-needle biopsy was slow and not concurrent with the reduction in the use of other diagnostic tests, but also represented a reduction in the rate of overall diagnostic tests and in the detection rate of benigns lesions without affecting the cancer detection rates.

[Risk of falls and consumption of medicines in an elderly population]. / Riesgo de caídas asociado al consumo de medicamentos en la población anciana.

OBJECTIVES: To describe the risk factors and the effect of medication use on the risk of falls in a population of 65 years or older. MATERIAL AND METHODS: Descriptive study of falls in the elderly population. The risk factors and consequences of the fall were recorded. Hypnotic and sedative risk drugs, opioids, and the simultaneous consumption of six or more drugs were considered. Diuretics were also included. The cumulative incidence for each group and the corresponding relative risks of falls were analysed from the cases registered between June and November 2016. RESULTS: During the study period, 60 falls were reported, of which 66% were by women and 34% by men. The cumulative incidence of falls was 3 per thousand women (95% CI: 2.22-4.08), and 2 per thousand men (95% CI: 1.44-3.41). The majority (71%) had consumed risk medication. Six or more medications were taken by 40% of the men and 62.5% of the women, and 97.6% was risk medication. The relative risk of falls in people using hypnotics, sedatives and opioids compared to non-users was 8.7 in men and 7.1 in women. In people who took diuretics, the relative risk was 4.6 for both genders. In women on multiple medications the relative risk was 3.7 compared to 1.7 in men. CONCLUSIONS: Polypharmacy and the use of hypnotic and sedative drugs and opioids and diuretics are an important public health problem, due to being risk factors for falls in this population, with a greater impact for women.

[Impact of chronic illness on hospital nursing workloads]. / Impacto de la cronicidad en las cargas de trabajo de la enfermería hospitalaria.

OBJECTIVES: To evaluate the short-term impact of chronic illness in hospital units and to establish a method that allows nursing workloads to be adapted according to the care needs of patients. METHODS: A descriptive study of the evolution of workloads of nursing staff associated with the care needs of patients between 1 July 2014 and 30 June 2016, in a county hospital. The care needs of the patients were assessed daily using an adaptation of the Montesinos scheme. The estimated times of nursing care and auxiliary nursing required by the patients, based on their level of dependence for time distribution, were based on the standards and recommendations of the Ministry of Health, Social Services and Equality. RESULTS: During the study period, there was a change in the patient care needs, with no increase in activity, which resulted in an increase in the nursing staffing needs of 1,396 theoretical hours per year. This increase implies an increase in the workforce of 5 nurses in the second period. CONCLUSIONS: In the study period, the needs for direct nursing care increased by 7%, this increase is not related to the increase in activity, but to the level of dependency of the patients with chronic diseases. This increase occurred in both medical and surgical units.

Ser o no ser revisor de Revista de Calidad Asistencial / To be or not to be a reviewer of revista de Calidad Asistencial

No disponible

False-positive results in mammographic screening for breast cancer in Europe: a literature review and survey of service screening programmes.

OBJECTIVE: To estimate the cumulative risk of a false-positive screening result in European mammographic screening programmes, and examine the rates and procedures of further assessment. METHODS: A literature review was conducted to identify studies of the cumulative risk of a false-positive result in European screening programmes (390,000 women). We then examined aggregate data, cross-sectional information about further assessment procedures among women with positive results in 20 mammographic screening programmes from 17 countries (1.7 million initial screens, 5.9 million subsequent screens), collected by the European Network for Information on Cancer project (EUNICE). RESULTS: The estimated cumulative risk of a false-positive screening result in women aged 50-69 undergoing 10 biennial screening tests varied from 8% to 21% in the three studies examined (pooled estimate 19.7%). The cumulative risk of an invasive procedure with benign outcome ranged from 1.8% to 6.3% (pooled estimate 2.9%). The risk of undergoing surgical intervention with benign outcome was 0.9% (one study only). From the EUNICE project, the proportions of all screening examinations in the programmes resulting in needle biopsy were 2.2% and 1.1% for initial and subsequent screens, respectively, though the rates differed between countries; the corresponding rates of surgical interventions among women without breast cancer were 0.19% and 0.07%. CONCLUSION: The specific investigative procedures following a recall should be considered when examining the cumulative risk of a false-positive screening result. Most women with a positive screening test undergo a non-invasive assessment procedure. Only a small proportion of recalled women undergo needle biopsy, and even fewer undergo surgical intervention.

Mammographic screening programmes in Europe: organization, coverage and participation.

OBJECTIVES: To summarize participation and coverage rates in population mammographic screening programmes for breast cancer in Europe. METHODS: We used the European Network for Information on Cancer (EUNICE), a web-based data warehouse (EUNICE Breast Cancer Screening Monitoring, EBCSM) for breast cancer screening, to obtain information on programme characteristics, coverage and participation from its initial application in 10 national and 16 regional programmes in 18 European countries. RESULTS: The total population targeted by the screening programme services covered in the report comprised 26.9 million women predominantly aged 50-69. Most of the collected data relates to 2005, 2006 and/or 2007. The average participation rate across all programmes was 53.4% (range 19.4-88.9% of personally invited); or 66.4% excluding Poland, a large programme that initiated personal invitations in 2007. Thirteen of the 26 programmes achieved the European Union benchmark of acceptable participation (>70%), nine achieved the desirable level (>75%). Despite considerable invitation coverage across all programmes (79.3%, range 50.9-115.2%) only 48.2% (range 28.4-92.1%) of the target population were actually screened. The overall invitation and examination coverage excluding Poland was 70.9% and 50.3%, respectively. CONCLUSIONS: The results demonstrate the feasibility of European-wide screening monitoring using the EBCSM data warehouse, although further efforts to refine the system and to harmonize standards and data collection practices will be required, to fully integrate all European countries. The more than three-fold difference in the examination coverage should be taken into account in the evaluation of service screening programmes.

Effect of false-positives and women's characteristics on long-term adherence to breast cancer screening.

False-positive results may influence adherence to mammography screening. The effectiveness of breast cancer screening is closely related to adequate adherence among the target population. The objective of this study was to evaluate how false-positives and women's characteristics affect the likelihood of reattendance at routine breast cancer screening in a sequence of routine screening invitations. We performed a retrospective cohort study of 1,371,218 women aged 45-69 years, eligible for the next routine screening, who underwent 4,545,346 screening mammograms from 1990 to 2006. We estimated the likelihood of attendance at seven sequential screening mammograms. Multilevel discrete time hazard models were used to estimate the effect of false-positive results on reattendance, and the odds ratios (OR) of non-attendance for the women's personal characteristics studied. The overall reattendance rate at the second screening was 81.7% while at the seventh screening was 95.6%. At the second screening invitation reattendance among women with and without a false-positive mammogram was 79.3 vs. 85.3%, respectively. At the fourth and seventh screenings, these percentages were 86.3 vs. 89.9% and 94.6 vs. 96.0%, respectively. The study variables associated with a higher risk of failing to participate in subsequent screenings were oldest age (OR = 8.48; 95% CI: 8.31-8.65), not attending their first screening invitation (OR = 1.12; 95% CI: 1.11-1.14), and previous invasive procedures (OR = 1.09; 95% CI: 1.07-1.10). The risk of non-attendance was lower in women with a familial history of breast cancer (OR = 0.97; 95% CI: 0.96-0.99), and those using hormone replacement therapy (OR = 0.96; 95% CI: 0.94-0.97). In conclusion, reattendance was lower in women with false-positive mammograms than in those with negative results, although this difference decreased with the number of completed screening participations, suggesting that abnormal results in earlier screenings more strongly influence behavior. These findings may be useful in providing women with accurate information and in improving the effectiveness of screening programs.

[Cost-effectiveness of photodynamic therapy in age-related macular degeneration]. / Coste-efectividad de la terapia fotodinámica en la degeneración macular asociada a la edad.

OBJECTIVE: The aim of this study was to estimate the public health service cost of visual acuity improvement or maintenance with photodynamic therapy in patients with age-related macular degeneration (ARMD). This illness is the most frequent cause of blindness in elderly patients in western countries. METHODS: A cost-effectiveness analysis was carried out to compare photodynamic therapy versus no treatment. The analysis point of view was that of the health service. The improvement or maintenance of visual acuity and contrast sensitivity were considered efficacy results. Direct costs were estimated by means of cost accountancy. Quality adjusted costs per visual acuity life year gained (QACVAG) were calculated through utility values from other studies. RESULTS: The cost per year of maintenance of visual acuity in a two-year period was 36,530 euro for women and 34,804 euro for men. If this cost was estimated for life expectancy in Asturias, it would be reduced to 4,298 euro for women and 5,354 euro for men. If costs of the QACVAG, in a two-year period, were considered, photodynamic therapy would cost 66,931 euro for women and 70,249 euro for men. CONCLUSION: This cost-effectiveness analysis allows decisions to be made about public financing. Some research in our country suggests that public health financing should be provided for interventions whose cost-effectiveness is less than 30,000 euro of CVAQA. The treatment evaluated here far exceeds this value. It is recommended that the use of more restrictive patient selection, incorporating diagnostic criteria and patient autonomy indicators, could improve the results of this intervention.

Regulation of apoptosis by peptides of fibronectin in human monocytes.

Synthetic peptides with sequences present in extracellular matrix protein fibronectin have been described to stimulate human monocytes. We describe now that one of these peptides, FN6, induces apoptotic effects on monocytes and we investigate the molecular mechanisms involved in the regulation of this response. Incubation of monocytes with FN6 induces the activation of the small GTPase Rac. In turn, Rac mediates the increase of both JNK and p38 activities in a sustained fashion, as well as the phosphorylation levels of their respective substrates c-Jun and ATF-2. FN6 also stimulates caspases -9 and -3 and the delayed proteolysis of its substrates PARP and D4-GDI. In addition, initiator caspases-1 and -5 were activated by FN6 treatment of monocytes but, in contrast to that observed for caspases-9 and -3, this effect was not dependent on JNK or p38 activities. These kinases also mediated the increase of Bax levels, but only in some conditions Bcl-2 depletion caused by the peptide. Moreover, whereas initially only caspase-1 is involved in caspase-3 activation, later on caspase-9 seems also to participate. Therefore, we demonstrate that FN6 stimulation allows multiple, JNK and p38-dependent and -independent interacting signals to regulate the apoptotic response in human monocytes.

Pemphigus vulgaris autoantibodies induce apoptosis in HaCaT keratinocytes.

Pemphigus vulgaris (PV) is an autoimmune disease characterized by binding of IgG autoantibodies to epidermal keratinocyte desmosomes. IgG autoantibodies obtained from a patient with mucocutaneous PV reacted with plakoglobin (Plkg) in addition to desmoglein-3 (Dsg3) and Dsg1. Immunofluorescence analysis confirmed that IgG autoantibodies, unlike antibodies from a healthy volunteer, caused disruption of cell-cell contacts in HaCaT keratinocytes. Moreover, apoptosis was enhanced in cells treated with autoantibodies compared to those treated with normal antibodies. The apoptotic process induced by IgG autoantibodies was characterized by caspase-3 activation, Bcl-2 depletion and Bax expression. The present report demonstrates that PV IgG autoantibodies promote apoptosis in HaCaT keratinocytes.

La variabilidad de la práctica médica. A propósito de la utilización de TAC y RNM en el territorio Insalud / Variations in medical practice. A propos of use of computerized axial tomography and nuclear magnetic resonance in the Spanish National Health System

Objetivo: Determinar la variabilidad de la utilización de tomografía axial computarizada (TAC) y resonancia nuclear magnética (RNM) entre hospitales y provincias en 1996 en el ámbito INSALUD, y evaluar la contribución de la disponibilidad de recursos, tanto humanos como materiales, a la variabilidad observada. Métodos: Los recursos, la utilización y la población asignada se obtuvieron del Sistema de Información de Atención Especializada (SIAE) del INSALUD. Las unidades de análisis fueron los hospitales y las provincias del territorio gestionado por el INSALUD. Las variables independientes analizadas fueron el número de equipos de TAC y RNM, el número de médicos de diversas especialidades, la lista de espera para estas tecnologías, y el nivel económico de la provincia. Para el análisis estadístico se utilizó la razón de variación entre las tasas de utilización y la regresión múltiple. Resultados: La relación de la mayor a la menor tasa de utilización de TAC y RNM es de 15 y 27 entre hospitales, y de 3 y 4 entre provincias, respectivamente. El número de neurocirujanos, el número de equipos TAC, la lista de espera para TAC y la tasa de utilización de RNM, todo ello por habitante, explican el 61 por ciento de la variabilidad para TAC por hospitales. Por provincias, el número de equipos TAC explica el 31 por ciento de esta variabilidad. Para la utilización de RNM por hospitales, el número de neurocirujanos, de traumatólogos y la tasa de utilización de TAC, todo ello por habitante, explica el 42 por ciento de la variabilidad. Los recursos disponibles no están asociados a la variabilidad en la utilización de RNM, por provincias. Conclusiones: La variabilidad encontrada en el territorio INSALUD para el uso de RNM y TAC por hospitales es alta y está ecológicamente asociada a la disponibilidad de recursos. Convendría confirmar estos hallazgos con estudios observacionales en los que también se evalúe la posible aportación del uso inadecuado a esta variabilidad (AU)

[Variation in medical practice. Apropos of the use of CAT and NMR in INSALUD]. / La variabilidad de la práctica médica. A propósito de la utilización de TAC y RNM en el territorio INSALUD.

OBJECTIVE: In this study the variability on the utilization of nuclear magnetic resonance (NMR) and computerized tomography (CT) scan among hospitals and provinces in the INSALUD (Spanish National Health System) is evaluated as well as the role of the availability of resources in the variability. METHOD: Data on availability of resources, its use and the reference population for each hospital were obtained from the Specialized Care Information System (SIAE) for the years 1996-1997. The units of analysis were the hospitals and the provinces in the INSALUD territory. The independent variables were the ratio of technologies and professional per inhabitant. Also the waiting list and the economical level of the province were used. Data analysis included the extremal quotient and multiple linear regression. RESULTS: The ratio of the highest to lowest rate of CT and NMR use is 15 and 27 among hospitals and 3 and 4 among provinces, respectively. The number of neurosurgeons, number of CT apparatus, waiting list for CT and rate of NMR use, all standardized per population, explains 61% of CT variability among hospitals. Among provinces, the number of CT apparatus explains 31% of all variability. For NMR use among hospitals, the number of neurosurgeons, number of orthopedic surgeons and CT use, all variables standardized per population, explains 42% of variability. The amount of equipment is not associated with NMR rate among provinces. CONCLUSIONS: The variation found in the INSALUD territory for the two procedures is high and ecologically associated to the availability of resources. It would be convenient to perform an observational study to confirm the findings and evaluate the possible contribution of inappropriate use to the variation.

Changes in the behavioral and immunological parameters of the mollusk Biomphalaria tenagophila induced by disruption of the circadian cycle as a consequence of continuous illumination.

In the present investigation we studied some behavioral and immunological parameters of adult gastropod mollusk, Biomphalaria tenagophila, which have been reproducing for several generations under laboratory conditions. One group of gastropods was kept on a 14-h light/10-h dark cycle, corresponding to a regular circadian cycle, and another group was exposed to continuous light for 48 h. Animals were studied along (behavioral groups) or immediately after (immunological groups) 48 h of regular circadian cycle or continuous light conditions. Stopping/floating, dragging and sliding were the behavioral aspects considered (N = 20 for regular cycle; N = 20 for continuous illumination) and number of hemocytes/microl hemolymph was the immunological parameter studied (N = 15 for regular cycle, N = 14 for continuous illumination). Animals under continuous illumination were more active (sliding = 33 episodes, dragging = 48 episodes) and displayed a lower number of hemocytes (78.0 +/- 24. 27/microl) when compared with mollusks kept on a regular circadian cycle (sliding = 18 episodes, dragging = 27 episodes; hemocytes = 157.6 +/- 53.27/microl). The data are discussed in terms of neural circuits and neuroimmunological relations with the possible stressful effect of continuous illumination.

Changes in the behavioral and immunological parameters of the mollusk Biomphalaria tenagophila induced by disruption of the circadian cycle as a consequence of continuous illumination

In the present investigation we studied some behavioral and immunological parameters of adult gastropod mollusk, Biomphalaria tenagophila, which have been reproducing for several generations under laboratory conditions. One group of gastropods was kept on a 14-h light/10-h dark cycle, corresponding to a regular circadian cycle, and another group was exposed to continuous light for 48 h. Animals were studied along (behavioral groups) or immediately after (immunological groups) 48 h of regular circadian cycle or continuous light conditions. Stopping/floating, dragging and sliding were the behavioral aspects considered (N = 20 for regular cycle; N = 20 for continuous illumination) and number of hemocytes/µl hemolymph was the immunological parameter studied (N = 15 for regular cycle, N = 14 for continuous illumination). Animals under continuous illumination were more active (sliding = 33 episodes, dragging = 48 episodes) and displayed a lower number of hemocytes (78.0 + or - 24.27/µl) when compared with mollusks kept on a regular circadian cycle (sliding = 18 episodes, dragging = 27 episodes; hemocytes = 157.6 + or - 53.27/µl). The data are discussed in terms of neural circuits and neuroimmunological relations with the possible stressful effect of continuous illumination.

The rat accessory optic system: effects of cortical lesions on the directional selectivity of units within the medial terminal nucleus.

Single units within the medial terminal nucleus of the accessory optic system were recorded and examined for their responses to a moving pattern, in both intact and decorticated urethane-anesthetized rats. The preferred directions of motion in control rats were mainly upward with a temporal component and downward with a nasal component. The responses to upward motion were almost absent after cortical ablation, with most units now preferring temporal or downward-nasal directions. These data suggest that cortical structures modulate the directional selectivity of accessory optic neurons in the rat.

The pretectal nucleus of the optic tract modulates the direction selectivity of accessory optic neurons in rats.

Direction-selective single units within the medial terminal nucleus of the rat were shown to prefer motion in upward-temporal or downward-nasal directions. Lesions of the optic tract nucleus practically abolished responses to the nasal direction of motion and increased the directional bias toward the temporal direction. Such results suggest a significant role of that pretectal nucleus in the determination of direction selectivity of accessory optic neurons.

The accessory optic system in pigeons: receptive field properties of identified neurons.

Visual receptive fields of neurons in the nucleus of the basal optic root were investigated in pigeons. Their projections could be traced to vestibulo-cerebellum and oculomotor complex by means of antidromic activation. Units in that nucleus showed large peripheral receptive fields and appeared highly sensitive to moving targets, with the majority displaying axis specificity and direction selectivity. The results seem consistent with the proposed role of the accessory optic system in oculomotor reflexes.