Postoperative endometrial carcinoma treated with external beam irradiation plus vaginal-cuff brachytherapy. Is there a dose relationship with G2 vaginal complications?

AIM: To analyse the possible relationship between the EQD2(α/ß=3Gy) at 2 cm3 of the vagina and late toxicity in vaginal-cuff-brachytherapy (VBT) after external-beam-irradiation (EBRT) for postoperative endometrial carcinoma (EC). MATERIALS AND METHODS: From 2014 to 2016, 62 postoperative EC patients were treated with EBRT + VBT. The median EBRT dose was 45 Gy (44 Gy-50.4 Gy). VBT involved a single 7 Gy dose. Toxicity was prospectively evaluated using the RTOG score for the rectum and bladder and the objective LENT-SOMA criteria for the vagina. EQD2(α/ß = 3Gy) at 2 cm3 of the most exposed part of the vagina was calculated by the sum of the EBRT + VBT dose. Statistics: Boxplot, Student's t and Chi-square tests and ROC curves. RESULTS: Mean follow-up: 39.2 months (15-68). Late toxicity: bladder:0 patient; rectum:2 patients-G1; Vagina: 26 patients-17G1, 9G2; median EQD2(α/ß=3Gy) at 2 cm3 in G0-G1 patients was 70.4 Gy(SD2.36), being 72.5 Gy(SD2.94) for G2p. The boxplot suggested a cut-point identifying the absence of G2: 100 % of G2p received >68 Gy, ROC curves showed an area under the curve of 0.72 (sensitivity of 1 and specificity of 0.15). CONCLUSIONS: Doses >68 Gy EQD2(α/ß=3Gy) at 2 cm3 to the most exposed area of the vagina were associated with late G2 vaginal toxicity in postoperative EC patients treated with EBRT + VBT suggesting a very good dose limit to eliminate the risk of G2 late toxicity. The specificity obtained indicates the need for prospective analyses.

Microscopic observation drug-susceptibility assay vs. Xpert® MTB/RIF for the diagnosis of tuberculosis in a rural African setting: a cost-utility analysis.

OBJECTIVE: To compare the cost-utility of microscopic observation drug-susceptibility assay (MODS) and Xpert® MTB/RIF implementation for tuberculosis (TB) diagnosis in rural northern Mozambique. METHODS: Stochastic transmission compartmental TB model from the healthcare provider perspective with parameter input from direct measurements, systematic literature reviews and expert opinion. MODS and Xpert® MTB/RIF were evaluated as replacement test of smear microscopy (SM) or as an add-on test after a negative SM. Costs were calculated in 2013 USD, effects in disability-adjusted life years (DALY). Willingness to pay threshold (WPT) was established at once the per capita Gross National Income of Mozambique. RESULTS: MODS as an add-on test to negative SM produced an incremental cost-effectiveness ratio (ICER) of 5647.89USD/DALY averted. MODS as a substitute for SM yielded an ICER of 5374.58USD/DALY averted. Xpert® MTB/RIF as an add-on test to negative SM yielded ICER of 345.71USD/DALY averted. Xpert® MTB/RIF as a substitute for SM obtained an ICER of 122.13USD/DALY averted. TB prevalence and risk of infection were the main factors impacting MODS and Xpert® MTB/RIF ICER in the one-way sensitivity analysis. In the probabilistic sensitivity analysis, Xpert® MTB/RIF was most likely to have an ICER below the WPT, whereas MODS was not. CONCLUSION: Our cost-utility analysis favours the implementation of Xpert® MTB/RIF as a replacement of SM for all TB suspects in this rural high TB/HIV prevalence African setting.

A Bayesian approach to model the conditional correlation between several diagnostic tests and various replicated subjects measurements.

Two key aims of diagnostic research are to accurately and precisely estimate disease prevalence and test sensitivity and specificity. Latent class models have been proposed that consider the correlation between subject measures determined by different tests in order to diagnose diseases for which gold standard tests are not available. In some clinical studies, several measures of the same subject are made with the same test under the same conditions (replicated measurements), and thus, replicated measurements for each subject are not independent. In the present study, we propose an extension of the Bayesian latent class Gaussian random effects model to fit the data with binary outcomes for tests with replicated subject measures. We describe an application using data collected on hookworm infection carried out in the municipality of Presidente Figueiredo, Amazonas State, Brazil. In addition, the performance of the proposed model was compared with that of current models (the subject random effects model and the conditional (in)dependent model) through a simulation study. As expected, the proposed model presented better accuracy and precision in the estimations of prevalence, sensitivity and specificity. Copyright © 2017 John Wiley & Sons, Ltd.

Evaluation of the paediatric dose of chloroquine in the treatment of Plasmodium vivax malaria.

BACKGROUND: Chloroquine (CQ) continues to be the first-line medication used worldwide in the treatment of Plasmodium vivax malaria. The dose recommended by the World Health Organization is 25 mg/kg independently of the age of the subject. Nonetheless, the pharmacokinetics and pharmacodynamics of drugs in children are different from those in adults and may influence the drug concentrations in blood and become risk factors for therapeutic failure and/o resistance to CQ. METHODS: This study is a secondary analysis of the data from a clinical trial in which children over 5 years of age were administered 25 mg/kg of CQ, and CQ concentrations in blood were measured at day 7 of follow-up. Models of regression and comparison were used to evaluate and compare the CQ dose taken per kg/body weight, the CQ dose calculated based on body surface area, CQ levels in blood on day 7 and the age of the population. RESULTS: The younger the study population the greater the difference between the dose per kg/body weight (real dose) and that calculated according to the BSA (theoretical dose). The difference between the two doses was -181.206 mg in the 5-9 years of age group (CI 95 % -195.39; -167.02 mg) and -71.39 mg (CI 95 % -118.61; -23.99 mg) in the 10-14-year-old group. The CQ concentrations in blood on day 7 differed in patients over and under 15 years (p = 0.008). A negative correlation was found between the real and theoretical dose (difference in dose) and the age in years (R2 = 0.529, p = 0.001). A negative correlation was also found between the difference in dose (mg) and CQ concentrations on day 7 (ng/ml) (r = -0.337, p = 0.001). Children under 15 years were found to have a higher rate of therapeutic failure than those over 15 (28 vs 4.2 %, respectively) (Kaplan-Meier p = 0.005). CONCLUSIONS: A CQ dose of 25 mg/kg for the treatment of P. vivax malaria may be too low in children as demonstrated by the reduction in CQ concentrations in blood at day 7 of follow-up. This under-dosage is probably associated with the higher rate of therapeutic failure found in children under 15 years (28 vs 4.3 %). These results suggest the need to review the paediatric doses of CQ currently used.

Resistance of infection by Plasmodium vivax to chloroquine in Bolivia.

BACKGROUND: Chloroquine (CQ) over three days plus primaquine (PQ) for seven days is the treatment of choice of infections by Plasmodium vivax in Bolivia, where 95% of the cases of malaria are attributed to this species. The aim of this study was to evaluate the therapeutic efficacy of CQ in this setting. METHODS: Patients in the Amazon region of northern Bolivia, were included in the study from May to November 2011 and the therapeutic efficacy of CQ was evaluated over a 28-day follow-up period. Patients with P. vivax mono-infection received 25 mg/Kg body weight of CQ over three days. The concentrations of CQ + desethylchloroquine (DCQ) in blood were determined at days 7 and 28 of follow up; at follow-up and on the day of treatment failure was administered PQ. RESULTS: One hundred patients fulfilled the inclusion criteria, two were lost to follow up and another two were later excluded for protocol violation. Of the 96 patients who completed the follow up 10 showed TF; one presented continued parasitaemia until day 7 of follow up, three on day 21 and six on day 28 of follow up. The geometric mean of CQ + DCQ on day 7 was 321.7 ng/ml (range 197-535 ng/ml). In six patients with TF the CQ + DCQ concentrations in blood on the day of TF were >100 ng/ml. The rate of resistance was 6.5%. CONCLUSION: The present study demonstrates the presence of resistance to CQ in the treatment of malaria by P. vivax in the Amazon region of Bolivia. New clinical trials are needed to establish alternative treatments against these parasites in this region of South America.

Women doctors and their careers in a large university hospital in Spain at the beginning of the 21st century.

BACKGROUND: The feminization of medicine has risen dramatically over the past decades. The aim of this article was to compare the advance of women with that of men and determine the differences between hierarchical status and professional recognition achieved by women in medicine. METHODS: A retrospective study was carried out in the Hospital Clinic Barcelona, Spain, of the period from 1996 to 2008. Data relating to temporary and permanent positions, hierarchy and career promotion achieved, specialty, age and the sex of the participants were analysed with the ANOVA test and logistic regression using the generalized estimated equation. RESULTS: After completion of specialist training, fewer women than men doctors obtained permanent positions. The ratios between the proportions of women and men remained 1.2 for permanent non-hierarchal medical positions and below 0.2 for higher hierarchal levels. Fewer women than men with hierarchy and fewer women than men achieved the rank of consultant. Promotion to consultant and senior consultant was lower than that to senior specialist, being higher in specialties with gender parity and in masculinised specialties. On comparing the two genders using a statistical model, the probability of continuous promotion decreased with the year of the application and the age of the applicant, except in women. CONCLUSIONS: Despite the number of women training as specialists having increased to 50%, women remained in temporary positions twofold longer than men. Compared to women, men showed significant representation in hierarchal medical positions, and women showed a lower adjusted probability of internal professional promotion throughout the study period.

Microscopic observation drug susceptibility assay for the diagnosis of TB and MDR-TB in HIV-infected patients: a systematic review and meta-analysis.

The objective of the present study was to assess the diagnostic accuracy of the microscopic observation drug susceptibility (MODS) assay for tuberculosis (TB) diagnosis in HIV-infected patients. MEDLINE, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials, African Index Medicus, ResearchGate, SciELO, and the abstracts of the main conferences on infectious diseases and tropical medicine were searched, and other sources investigated. Only studies including HIV-infected patients evaluating MODS for the diagnosis of TB and using culture-based diagnostic tests as a gold standard were analysed. Summary sensitivity and specificity were calculated with a bivariate model. 3259 citations were found, 29 were selected for full-text review and 10 studies including 3075 samples were finally analysed. Overall diagnostic accuracy of MODS for the diagnosis of TB was a sensitivity of 88.3% (95% CI 86.18-90.2%) and specificity 98.2% (95% CI 97.75-98.55%). For multidrug-resistant (MDR)-TB, sensitivity was 89% (95% CI 66.07-97%) and specificity was 100% (95 CI 94.81-100%). For smear-negative pulmonary TB, a sensitivity of 88.2% (95% CI 86.1-89.9%) and specificity of 98.2% (95% CI 96.8-98.9%) were found. Costs varied between USD 0.72 and 7.31 per sample. Mean time to positivity was 8.24 days. MODS was found to have a good accuracy for the diagnosis of TB and MDR-TB in HIV-infected patients with low cost and fast results.

Pathologic prognostic factors in stage I-III uterine carcinosarcoma treated with postoperative radiotherapy.

PURPOSE: To analyse the impact of prognostic factors on specific overall survival (SOS) after postoperative radiotherapy (P-RT) in carcinosarcomas. METHODS: We retrospectively analysed 81 patients who received P-RT from 1977 to 2010 after the diagnosis of carcinosarcomas. 2009 FIGO stage: 25-IA, 20-IB, 6-II, 9-IIIA, 11-IIIC. Age, stage, vascular and lymphatic space invasion (VLSI), myometrial invasion, grade, mitotic index, sarcomatous/epithelial components, tumour size and necrosis were considered for the analysis. STATISTICS: we used the Kaplan-Meier method for survival analysis and the Cox model for risk factor evaluation. RESULTS: The mean follow-up of the series was 78.86 months (range 7-381). The median age was 72 years (range 51-89). 30 out 81 (37 %) patients relapsed and died (22.2 % pelvic and abdominal, 13.5 % exclusive distant metastasis). On univariate and multivariate analysis only stage had a significant impact on SOS. At 5 years, stage I-II had a SOS of 66 % in comparison with stage III with 30 %. CONCLUSIONS: Two groups of patients showing different outcome were found after P-RT in uterine carcinosarcomas: stage I-II patients had a life expectancy 2.5-fold longer compared to stage III patients. New therapeutic strategies are warranted in carcinosarcomas considering the high incidence of distant metastasis.

Stages I-III Inoperable Endometrial Carcinoma: A Retrospective Analysis by the Gynaecological Cancer GEC-ESTRO Working Group of Patients Treated with External Beam Irradiation and 3D-Image Guided Brachytherapy.

BACKGROUND/PURPOSE: Analyse the outcomes of stages I-III inoperable endometrial cancer (IEC) patients treated with external-beam-irradiation (EBRT) and 3D-image-guided-brachytherapy (IGBT). MATERIAL AND METHODS: Medical records of IEC patients receiving EBRT + IGBT in eight European and one Canadian centres (2004-2019) were examined, including: pelvic ± para-aortic EBRT and lymph node boost; anaesthetic procedure, applicators, BT-planning imaging, clinical target volume (CTV), brachytherapy schedule, and EQD2 to the CTV(α/ß=4.5Gy) and D2 cm3(α/ß=3Gy) for organs at risk. Complications are evaluated using CTCAEv4 scores. The 2- and 5-year survival probability according to stages was estimated (cancer-specific survival (CSS), disease-free survival (DFS), local relapse-free survival (LRFS), loco-regional relapse-free survival (LRRFS), and distant metastasis-free survival (DMFS)). STATISTICS: descriptive analysis and the Kaplan-Meier method. RESULTS: 103 patients (stages: I-44, II-14, III-44) were included. Median follow-up: 28 months (7-170). All patients received pelvic ± para-aortic EBRT. Median D90-EQD2(α/ß=4.5) to the CTV:73.3 Gy (44.6-132.7), 69.9 Gy (44.7-87.9 and 75.2 Gy (55.1-97) in stages I, II, and III, respectively. Thirty patients presented relapse (stages: 10-I, 3-II, 17-III): 24 uterine (stages: 7-I, 3-II, 14-III), 15 nodal (stages: 4-I, 1-II, 10-III), and 23 distant (stages: 6-I, 2-II, 15-III). Five year CSS was 71.2% (stages: 82%-I-II and 56%-III) and DFS, LRFS, LRRFS, and DMFS were 55.5%, 59%, 72%, and 67.2%, respectively. Late G3-G4 complications (crude): 1.3% small bowel, 2.5% rectum, and 5% bladder. CONCLUSION: In stages I-III of the IEC, EBRT + IGBT offer good 2- and 5-year CSS of 88.7% and 71.2%, respectively, with the best outcomes in stages I-II. Prospective studies are needed to determine how better outcomes can be achieved.

Spatio-temporal analysis of mortality among children under the age of five in Manhiça (Mozambique) during the period 1997-2005.

BACKGROUND: Reducing childhood mortality is the fourth goal of the Millennium Development Goals agreed at the United Nations Millennium Summit in September 2000. However, childhood mortality in developing countries remains high. Providing an accurate picture of space and time-trend variations in child mortality in a region might generate further ideas for health planning actions to achieve such a reduction. The purpose of this study was to examine the spatio-temporal variation for child mortality rates in Manhiça, a district within the Maputo province of southern rural Mozambique during the period 1997-2005 using a proper generalized linear mixed model. RESULTS: The results showed that childhood mortality in all the area was modified from year to year describing a convex time-trend but the spatial pattern described by the neighbourhood-specific underlying mortality rates did not change during the entire period from 1997 to 2005, where neighbourhoods with highest risks are situated in the peripheral side of the district. The spatial distribution, though more blurred here, was similar to the spatial distribution of child malaria incidence in the same area. The peak in mortality rates observed in 2001 could have been caused by the precipitation system that started in early February 2000, following which heavy rains flooded parts of Mozambique's southern provinces. However, the mortality rates at the end of the period returned to initial values. CONCLUSIONS: The results of this study suggest that the health intervention programmes established in Manhiça to alleviate the effects of flooding on child mortality should cover a period of around five years and that special attention might be focused on eradicating malaria transmission. These outcomes also suggest the utility of suitably modelling space-time trend variations in a region when a point effect of an environmental factor affects all the study area.

Cancer mortality inequalities in urban areas: a Bayesian small area analysis in Spanish cities.

BACKGROUND: Intra-urban inequalities in mortality have been infrequently analysed in European contexts. The aim of the present study was to analyse patterns of cancer mortality and their relationship with socioeconomic deprivation in small areas in 11 Spanish cities. METHODS: It is a cross-sectional ecological design using mortality data (years 1996-2003). Units of analysis were the census tracts. A deprivation index was calculated for each census tract. In order to control the variability in estimating the risk of dying we used Bayesian models. We present the RR of the census tract with the highest deprivation vs. the census tract with the lowest deprivation. RESULTS: In the case of men, socioeconomic inequalities are observed in total cancer mortality in all cities, except in Castellon, Cordoba and Vigo, while Barcelona (RR = 1.53 95%CI 1.42-1.67), Madrid (RR = 1.57 95%CI 1.49-1.65) and Seville (RR = 1.53 95%CI 1.36-1.74) present the greatest inequalities. In general Barcelona and Madrid, present inequalities for most types of cancer. Among women for total cancer mortality, inequalities have only been found in Barcelona and Zaragoza. The excess number of cancer deaths due to socioeconomic deprivation was 16,413 for men and 1,142 for women. CONCLUSION: This study has analysed inequalities in cancer mortality in small areas of cities in Spain, not only relating this mortality with socioeconomic deprivation, but also calculating the excess mortality which may be attributed to such deprivation. This knowledge is particularly useful to determine which geographical areas in each city need intersectorial policies in order to promote a healthy environment.

Core indicators evaluation of effectiveness of HIV-AIDS preventive-control programmes carried out by nongovernmental organizations. A mixed method study.

BACKGROUND: The number of nongovernmental organizations working on AIDS has grown. There is great diversity in the type of activities and population groups that have been targeted. The purposes of this study are: to describe and analyze the objectives and HIV-AIDS preventive activities that are carried out by the AIDS-NGOs that work with AIDS in Catalonia and that receive subsidies from the Department of Health; and to develop a comprehensive proposal for measurable and agreed upon core quality evaluation indicators to monitor and assess those objectives and activities that can have an impact on the fight against inequalities and stigmatization, and incorporate the perspectives of the service providers and users. METHODS: A mixed method study has been carried out with professionals from the 36 NGOs that work with HIV/AIDS in Catalonia, as well as their users. This study achieved the completeness model using the following phases:1. A systematic review of AIDS-NGOs annual reports and preparation of a catalogue of activities grouped by objectives, level of prevention and AIDS-NGOs target population; 2. A transversal study through an ad-hoc questionnaire administered to the AIDS-NGOs representatives; 3. A qualitative study with a phenomenological approach through focus groups, individual interviews and observations; 4. Consensus meetings between AIDS-NGOs professionals and the research team using Haddon matrices in order to establish a proposal of evaluation indicators. RESULTS: The information was classified according to level of prevention and level of intervention. A total of 248 objectives and 258 prevention activities were identified. 1564 evaluation indicators, addressed to 7 target population groups, were produced. Thirty core activities were selected. The evaluation indicators proposed for these activities were: 76 indicators for 15 primary prevention activities, 43 for 5 secondary prevention activities and 68 for 10 tertiary prevention activities. CONCLUSIONS: The results could help to homogeneously assess the preventive-control activities carried out of AIDS-NGOs. The proposed indicators could help the professionals to improve the evaluation of the preventive-control AIDS-NGOs activities. Furthermore, the Haddon matrix enables us to identify deficiencies of activities at intervention levels and strategies to bear in mind in order to enhance the future AIDS prevention programs.

The total deviation index estimated by tolerance intervals to evaluate the concordance of measurement devices.

BACKGROUND: In an agreement assay, it is of interest to evaluate the degree of agreement between the different methods (devices, instruments or observers) used to measure the same characteristic. We propose in this study a technical simplification for inference about the total deviation index (TDI) estimate to assess agreement between two devices of normally-distributed measurements and describe its utility to evaluate inter- and intra-rater agreement if more than one reading per subject is available for each device. METHODS: We propose to estimate the TDI by constructing a probability interval of the difference in paired measurements between devices, and thereafter, we derive a tolerance interval (TI) procedure as a natural way to make inferences about probability limit estimates. We also describe how the proposed method can be used to compute bounds of the coverage probability. RESULTS: The approach is illustrated in a real case example where the agreement between two instruments, a handle mercury sphygmomanometer device and an OMRON 711 automatic device, is assessed in a sample of 384 subjects where measures of systolic blood pressure were taken twice by each device. A simulation study procedure is implemented to evaluate and compare the accuracy of the approach to two already established methods, showing that the TI approximation produces accurate empirical confidence levels which are reasonably close to the nominal confidence level. CONCLUSIONS: The method proposed is straightforward since the TDI estimate is derived directly from a probability interval of a normally-distributed variable in its original scale, without further transformations. Thereafter, a natural way of making inferences about this estimate is to derive the appropriate TI. Constructions of TI based on normal populations are implemented in most standard statistical packages, thus making it simpler for any practitioner to implement our proposal to assess agreement.

Community-based approaches for malaria case management in remote communities in the Brazilian Amazon.

INTRODUCTION: Malaria case management is a pivotal intervention in malaria elimination. However, many remote areas in Brazil still lack access to basic health services. This study describes a community-based approach (CBA) for malaria case management in the large remote area of the Jaú National Park (JNP), Amazonas, Brazil. METHODS: In 2001, a general health CBA was initiated with a motor group (MG); a participative community health diagnosis (PCHD) was subsequently implemented between 2001 and 2005. In 2006, a CBA for malaria case management started with an expanded MG including all sectors with a stake in malaria control, from the local residents to the federal government. In 2008, community microscopists were selected and trained to diagnose hemoparasites. A full malaria strategy was implemented in 2009 with subsequent quality control follow-up. RESULTS: Two educational materials were co-created with local communities. The MG identified malaria as a major health problem and the malaria MG planned the control activities. Ten communities selected a resident to become malaria microscopists, and ten solar-operated health centers were built. The number of slide readings increased from 923 in 2006 to 1,900 in 2009, while malaria infections decreased from 354 cases in 2005 to 20 cases in 2015. The excess time (≥ 48 hours) between first symptoms and diagnosis/treatment decreased from 68.9% of cases in 2005 to 14.3% in 2010. CONCLUSIONS: While many factors were likely involved in the reduction of malaria transmission in the JNP, the CBA played an important role in the sustained success of the initiative.

Economic impact of decreasing the fraction number in vaginal cuff brachytherapy: A direct cost analysis.

PURPOSE: The purpose of this study was to analyze the direct economic impact of two vaginal cuff brachytherapy (VBT) schedules in postoperative endometrial carcinoma (PEC) with similar vaginal control and toxicity results. MATERIALS AND METHODS: From 2006 to 2015, 397 PEC patients (p) were treated with VBT: mean 40p/year, 67.5% received external beam radiotherapy (EBRT)+VBT and 32.5% exclusive VBT. Schedule 1: 3 fractions (Fr) after EBRT and 6Fr (4-6 Gy/Fr) in exclusive VBT. Schedule 2: 7Gy × 1Fr + EBRT and 6Gy × 3Fr in exclusive VBT. Differential cost analysis of the two schedules was retrospectively performed. The direct costs in each schedule were (1) Personnel: radiotherapy technicians, nurses, radiation oncologists, medical physicists, administrative personnel, orderlies; time dedicated by each professional during CT planning acquisitions and delineation of vagina/organs at risk, dosimetric study and evaluation, autoradiography, procedure reporting time during/after treatment, removal of bladder/rectal tubes and applicators, material cleaning and transportation for sterilization; (2) Health care material (gels, gauzes, gloves, etc); (3) Equipment (time equipment used). The differential between the two schedules was estimated. Indirect costs and evaluation of quality of life-adjusted costs were not considered. RESULTS: The overall reduction in the number of Fr per year in Schedule 2 was 93. Cost savings included treatment time per year: 4,185 min (70 h); personnel: 221€ ($246)/p in EBRT + VBT and 331€ ($368)/p in exclusive VBT; and health care material and equipment: 40€ ($44.5)/p in EBRT + VBT and 90€ ($100.2)/p in exclusive VBT. The overall savings per patient was 261€ ($295) in combined treatment and 421€ ($475.7) in exclusive VBT. The total savings per year with Schedule 2 in 40p was 12,503€ ($13,915.8). CONCLUSIONS: A 41% reduction in the fractions number in VBT for PEC allowed economic savings of 261€ ($290.5)/p in combined treatment and 421€ ($475.7)/p in exclusive VBT. Other benefits include patient comfort and fewer treatment visits.

EQD2 Analyses of Vaginal Complications in Exclusive Brachytherapy for Postoperative Endometrial Carcinoma.

Background: To evaluate whether EQD2(α/ß = 3Gy) at 2 cm3 of the most exposed area of the vagina is related to late vaginal toxicity in postoperative endometrial cancer (PEC) patients (p) treated with exclusive brachytherapy (BT). Methods: From 2014 to 2017, 43p were included in this study. BT was administered: 3-fractions of 6Gy in 37p and 2-fractions of 7.5Gy in 6p. The dose was prescribed at a depth of 5 mm from the applicator surface with dose-point optimization based on distance. The active treatment length was 2.5 cm. CTV-D90 and the dose to the most exposed 2 cm3 of the vagina was calculated for each patient. Late toxicity of the bladder and rectum was assessed using Radiation Therapy Oncology Group (RTOG) criteria, and vaginal toxicity by objective Late Effects Normal Tissue Task Force (LENT)-Subjective, Objective, Management, Analytic (SOMA) (LENT-SOMA) criteria. Statistics: frequency tables, mean, median, range, standard deviation, and box plot. Results: The median follow-up was 51 months (12-68). 20 p (46.5%) and 2 p (4.7%) developed G1 and G2 vaginal complications, respectively. Only 1/2 p-G2 receiving EQD2(α/ß = 3Gy) at 2 cm3 >68Gy presented vaginal shortening and 18/20 p-G1 received doses < 68Gy. Conclusions: PECp receiving exclusive brachytherapy with doses < 68Gy EQD2(α/ß = 3Gy) at 2 cm2 of the vagina presented only G0-G1 vaginal toxicity, except for one with bleeding telangiectasias. Larger prospective studies are necessary to confirm the present results.

Geographical variability of the incidence of Type 1 diabetes in subjects younger than 30 years in Catalonia, Spain.

BACKGROUND AND OBJECTIVE: We decided to assess the geographical variability of the incidence of Type 1 diabetes in Catalonia (Spain) in subjects younger than 30 years at onset during the period 1989-1998. The effect of sex, age at onset, periods of years, and population density was also analyzed. MATERIAL AND METHODS: Data were obtained from the prospective Catalan Registry of Diabetes Mellitus. Generalized linear mixed models were used to determine the effects of the risk factors and to find out the geographical distribution. The best model was selected by the AKAIKE information criterion. RESULTS: The crude incidence of type 1 diabetes in subjects younger than 30 years was 11.8/100,000/year (95% CI 11.4-12.3). The incidence was similar between males and females in the 0-14 age group. However, there was a male preponderance in young adults. The incidence did not vary annually and was not associated with population density. The incidence did not present a spatial pattern around Catalonia. There was an unstructured geographical variability. CONCLUSIONS: Some regions of Catalonia displayed values of type I diabetes higher or lower than the expected incidence. Counties with extreme values of incidence were specific for each demographic group and in no case did these counties make up clusters, suggesting that there are explanatory factors with patterns of geographic distribution. The incidence of diabetes in young male adults in some counties was similar to that of European countries with a high incidence.

Course of a major postpartum depressive episode: A prospective 2 years naturalistic follow-up study.

BACKGROUND: Survival methodology has not already been used in studies about postpartum depression (PPD) course. The aims of the present study were to estimate the duration of a Major Postpartum Depressive Episode (MPDE) during 2 years, as well as to explore factors associated with the course. METHOD: This was a prospective, naturalistic, longitudinal study with a cohort of 165 women with a MPDE (DSM-IV criteria). Potential predictors of prognosis were recorded at baseline. Follow-up was conducted using the Longitudinal Interval Follow-up Evaluation (LIFE). RESULTS: Of the total sample, 110 (66.7%) completed the 2 years follow-up. The mean time to full remission was 49.4 weeks (95% CI: 44.0-59.8). The probability of recovering was 30.2% (95% CI: 22.1%-37.4%) at 6 months of follow-up, 66.3% (95% CI: 57.4%-73.4%) at 12 months of follow-up, and 90.3% (95% CI: 79.8%-95.4%) at 24 months of follow-up. Mothers with financial difficulties, onset of depressive episode previous to birth, and those with prior treated depressive episodes took longer in achieving full remission. LIMITATIONS: Results are only generalizable to mothers with PPD treated in a psychiatric outpatient setting. Psychopharmacological treatment was uncontrolled and personality was not assessed. CONCLUSIONS: Our findings suggest that PPD could become a chronic disorder, particularly in mothers with an onset of the episode previous to birth, with a history of depression or with financial problems. Knowledge of these factors may help to improve the guidelines of depression management and treatment during the perinatal period.

A Model Based on the Combination of IFN-γ, IP-10, Ferritin and 25-Hydroxyvitamin D for Discriminating Latent From Active Tuberculosis in Children.

In recent years, pediatric research on tuberculosis (TB) has focused on addressing new biomarkers with the potential to be used as immunological non-sputum-based methods for the diagnosis of TB in children. The aim of this study was to characterize a set of cytokines and a series of individual factors (ferritin, 25-hydroxyvitamin D [25(OH)D], parasite infections, and nutritional status) to assess different patterns for discriminating between active TB and latent TB infection (LTBI) in children. The levels of 13 cytokines in QuantiFERON-TB Gold In-Tube (QFT-GIT) supernatants were analyzed in 166 children: 74 with active TB, 37 with LTBI, and 55 uninfected controls. All cytokines were quantified using Luminex or ELISA. Ferritin and 25(OH)D were also evaluated using CLIA, and Toxocara canis Ig-G antibodies were detected with a commercial ELISA kit. The combination of IP-10, IFN-γ, ferritin, and 25(OH)D achieved the best diagnostic performance to discriminate between active TB and LTBI cases in children in relation to the area under receiver operating characteristic (ROC) curve 0.955 (confidence interval 95%: 0.91-1.00), achieving optimal sensitivity and specificity for the development of a new test (93.2 and 90.0%, respectively). Children with TB showed higher ferritin levels and an inverse correlation between 25(OH)D and IFN-γ levels. The model proposed includes a combination of biomarkers for discriminating between active TB and LTBI in children to improve the accuracy of TB diagnosis in children. This combination of biomarkers might have potential for identifying the onset of primary TB in children.

Detection of significant disease risks using a spatial conditional autoregressive model.

SUMMARY: The conditional autoregressive (CAR) model is widely used to describe the geographical distribution of a specific disease risk in lattice mapping. Successful developments based on frequentist and Bayesian procedures have been extensively applied to obtain two-stage disease risk predictions at the subregional level. Bayesian procedures are preferred for making inferences, as the posterior standard errors (SE) of the two-stage prediction account for the variability in the variance component estimates; however, some recent work based on frequentist procedures and the use of bootstrap adjustments for the SE has been undertaken. In this article we investigate the suitability of an analytical adjustment for disease risk inference that provides accurate interval predictions by using the penalized quasilikelihood (PQL) technique to obtain model parameter estimates. The method is a first-order approximation of the naive SE based on a Taylor expansion and is interpreted as a conditional measure of variability providing conditional calibrated prediction intervals, given the data. We conduct a simulation study to demonstrate how the method can be used to estimate the specific subregion risk by interval. We evaluate the proposed methodology by analyzing the commonly used example data set of lip cancer incidence in the 56 counties of Scotland for the period 1975-1980. This evaluation reveals a close similarity between the solutions provided by the method proposed here and those of its fully Bayesian counterpart.