[Is the introduction of clinical management programs for patients with chronic obstructive pulmonary disease useful? Comparison of the effectiveness of two interventions on the clinical progress and care received]. / ¿Es útil la implantación de programas de gestión clínica de los pacientes con enfermedad pulmonar obstructiva crónica? Comparación de la efectividad de dos intervenciones sobre la evolución clínica y la atención recibida.

OBJECTIVE: To evaluate the effectiveness of two management programs on patients with chronic obstructive pulmonary disease (COPD). DESIGN: A study with a quasi-experimental design was used to evaluate the effectiveness of two interventions (I1, I2) for the care of patients with COPD after a mean follow-up of 31.2months. SETTING: Primary Care Centres in two Barcelona Health Areas and their referral hospitals. PARTICIPANTS: Patients with COPD selected by simple random sampling using any disease code corresponding to COPD. INTERVENTIONS: I1: Integrated management program that was optimised and coordinated the resources. Training was given, as well as quality control of spirometry. I2: Isolated interventions like a call-centre. Care circuits and computerised clinical notes were shared. MAIN MEASUREMENTS: Variables were recorded as regards lung function, severity, use of inhalers, lifestyles, quality of life, and exacerbations. RESULTS: Of the 393 patients evaluated at the beginning, 120 and 104 (I1 and I2, respectively) received the final evaluation. With I1, there was a reduction in patients who smoked (P=.034). Lung function and quality of life did not change significantly in either group, but shortness of breath was slightly worse. There was an increase in the correct use of inhalers, although it only reached 48% and 61% with interventions I1 and I2, respectively. The percentage of patients with exacerbations decreased with I1 compared to that of I2 (P<.001), and there were less hospital admissions due to exacerbations with I2 compared to I1 (P<.003]). CONCLUSIONS: Both interventions achieved significant improvements, and no overall worsening of a chronic and progressive disease as is COPD.

Improving clinical outcomes through centralization of rectal cancer surgery and clinical audit: a mixed-methods assessment.

BACKGROUND: The aim of centralizing rectal cancer surgery in Catalonia (Spain) was to improve the quality of patient care. We evaluated the impact of this policy by assessing patterns of care, comparing the clinical audits carried out and analysing the implications of the healthcare reform from an organizational perspective. METHODS: A mixed methods approach based on a convergent parallel design was used. Quality of rectal cancer care was assessed by means of a clinical audit for all patients receiving radical surgery for rectal cancer in two time periods (2005-2007 and 2011-2012). The qualitative study consisted of 18 semi-structured interviews in September-December 2014, with healthcare professionals, managers and experts. RESULTS: From 2005-2007 to 2011-2012, hospitals performing rectal cancer surgery decreased from 51 to 32. The proportion of patients undergoing surgery in high volume centres increased from 37.5% to 52.8%. Improved report of total mesorectal excision (36.2 vs. 85.7), less emergency surgery (5.6% vs. 3.6%) and more lymph node examinations (median: 14.1 vs. 16) were observed (P < 0.001). However, centralizing highly complex cancers using different critical masses and healthcare frameworks prompted the need for rearticulating partnerships at a hospital, rather than disease, level. CONCLUSION: The centralization of rectal cancer surgery has been associated with better quality of care and conformity with clinical guidelines. However, a more integrated model of care delivery is needed to strengthen the centralization strategy.

Estimation of lung cancer diagnosis and treatment costs based on a patient-level analysis in Catalonia (Spain).

BACKGROUND: Assessing of the costs of treating disease is necessary to demonstrate cost-effectiveness and to estimate the budget impact of new interventions and therapeutic innovations. However, there are few comprehensive studies on resource use and costs associated with lung cancer patients in clinical practice in Spain or internationally. The aim of this paper was to assess the hospital cost associated with lung cancer diagnosis and treatment by histology, type of cost and stage at diagnosis in the Spanish National Health Service. METHODS: A retrospective, descriptive analysis on resource use and a direct medical cost analysis were performed. Resource utilisation data were collected by means of patient files from nine teaching hospitals. From a hospital budget impact perspective, the aggregate and mean costs per patient were calculated over the first three years following diagnosis or up to death. Both aggregate and mean costs per patient were analysed by histology, stage at diagnosis and cost type. RESULTS: A total of 232 cases of lung cancer were analysed, of which 74.1% corresponded to non-small cell lung cancer (NSCLC) and 11.2% to small cell lung cancer (SCLC); 14.7% had no cytohistologic confirmation. The mean cost per patient in NSCLC ranged from 13,218 Euros in Stage III to 16,120 Euros in Stage II. The main cost components were chemotherapy (29.5%) and surgery (22.8%). Advanced disease stages were associated with a decrease in the relative weight of surgical and inpatient care costs but an increase in chemotherapy costs. In SCLC patients, the mean cost per patient was 15,418 Euros for limited disease and 12,482 Euros for extensive disease. The main cost components were chemotherapy (36.1%) and other inpatient costs (28.7%). In both groups, the Kruskall-Wallis test did not show statistically significant differences in mean cost per patient between stages. CONCLUSIONS: This study provides the costs of lung cancer treatment based on patient file reviews, with chemotherapy and surgery accounting for the major components of costs. This cost analysis is a baseline study that will provide a useful source of information for future studies on cost-effectiveness and on the budget impact of different therapeutic innovations in Spain.

Risk factors of early spontaneous preterm birth despite carrying a cervical pessary in singleton pregnancies with a short cervix: Development of a risk prediction model.

Introduction: We aimed to identify the incidence and risk factors of spontaneous preterm birth in pessary carriers with singleton pregnancies and a short cervix in the mid-trimester of pregnancy. Material and Methods: Patient data were obtained from the PECEP Trial. We analyzed singleton pregnancies in pessary carriers with a short cervix (≤25 mm) between 18 and 22 gestational weeks. Demographics and obstetric history were compared to identify risk factors for spontaneous preterm birth < 34 gestational weeks. Each demographic and obstetric variable was compared between spontaneous preterm birth < 34 and ≥ 34 weeks of gestation.Regression analysis was used to identify risk factors. A risk score model was generated using the odds ratio for significant factors. The risk score model and spontaneous preterm birth risk were assessed using the receiver operating characteristic curve. Perinatal outcomes were compared by risk score. Results: Among 190 pregnant individuals, 12 (6.3%) had spontaneous preterm birth < 34 gestational weeks. In the bivariate analysis, statistically significant differences between those with and without spontaneous preterm birth were only observed for mean cervical length at diagnosis and mean cervical length after pessary placement. By multiple logistic regression analysis, maternal age (OR 0.818; 95% CI 0.69-0.97; P 0.020), cervical length at diagnosis (OR 0.560; 95% CI 0.43-0.73; P < 0.001) and smoking status (OR 7.276; 95% CI 1.02-51.80; P 0.048) remained significantly associated with spontaneous preterm birth.The ROC curve from the multiple logistic regression analysis, including cervical length, maternal age and smoking status, had an area under the curve (AUC) of 0.952 (P < 0.001). The ROC curve for the risk score model incorporating all three variables had an AUC of 0.864 (95% CI 0.77-0.96; P < 0.001). A high-risk score was predictive of spontaneous preterm birth with a sensitivity of 75%, specificity of 84%, positive predictive value of 24%, and negative predictive value of 98%.Women with a high-risk score had a significantly reduced latency to delivery and poorer neonatal outcomes than those with a low-risk score. Conclusions: Patients at a high risk for spontaneous preterm birth despite pessary therapy may be identified using cervical length at diagnosis added to maternal age and smoking status.

Corrigendum to "Risk factors of early spontaneous preterm birth despite carrying a cervical pessary in singleton pregnancies with a short cervix: Development of a risk prediction model" [Eur J Obstet Gynecol Reprod Biol X 22 (2024) 100305].

[This corrects the article DOI: 10.1016/j.eurox.2024.100305.].

The Impact of the COVID-19 Pandemic on Adherence to Endocrine Therapy for Breast Cancer in Catalonia (Spain).

Purpose. To assess the impact of the COVID-19 pandemic on adherence to oral endocrine therapy in patients diagnosed with breast cancer in the public healthcare system in Catalonia (Spain). Methods. Retrospective cohort study in patients starting endocrine therapy from 2017 to 2021. Adherence was measured during the first year of treatment, and the impact of the pandemic was calculated according to the calendar year and whether the first year of treatment included the peak period of the pandemic in our setting (March-September 2020). Analyses were performed using a chi-square test and multivariable logistic regression, with results stratified by year, age group, and drug type. Results. Mean overall adherence during the first year of treatment was 89.6% from 2017 to 2021. In contrast, the patients who started treatment in 2019 and 2020 and whose treatment included the peak pandemic period presented an adherence of 87.0% and 86.5%, respectively. Young age and tamoxifen or combination therapy were predictors of low adherence. An increase in neoadjuvant therapy was also observed in 2020. Conclusions. The COVID-19 pandemic had only a modest impact on adherence to endocrine therapy (≈3%), despite the enormous disruptions for patients, the healthcare system in general, and cancer care in particular that were occurring in that period.

Posttraumatic stress disorder comorbidity and clinical implications in patients with severe mental illness.

Traumatic experiences and posttraumatic stress disorder (PTSD) are more frequent in patients with serious mental illness than in the general population. This study included 102 patients with schizophrenia, bipolar disorder, and schizoaffective disorder, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Epidemiological and clinical data were collected using the Brief Psychiatric Rating Scale and Traumatic Life Events and Distressing Event questionnaires. We found a high number of traumatic experiences, and 15.1% of the patients met all criteria for PTSD. We found no differences based on diagnosis or sex, although there was a nonsignificant trend toward greater PTSD comorbidity in women. Among patients with serious mental illness and PTSD, 64.3% had made some attempt at suicide at some point in life, compared with 37.4% of patients without PTSD.

Prevalence and clinical impact of childhood trauma in patients with severe mental disorders.

A high prevalence of childhood abuse has been reported in patients with severe mental illness. We conducted a cross-sectional study of 102 patients with schizophrenia, bipolar disorder, or schizoaffective disorder. Social, demographic, and clinical data were obtained. Patients were evaluated using Brief Psychotic Relative Scale, and Traumatic Life Events and Distressing Event questionnaires. Almost half (47.5%) of these patients had suffered some kind of child abuse, and our results confirmed a relationship between a history of childhood abuse and more severe psychosis. Diagnosis of schizophrenia was determined 4.1 years earlier in victims of childhood abuse. Hospital admissions were twice as high in victims of psychological abuse. Patients with a history of sexual abuse were more than twice as likely to attempt suicide (68% vs. 28.9%).

Class relations and all-cause mortality: a test of Wright's social class scheme using the Barcelona 2000 Health Interview Survey.

The aim of this study is to test the effects of neo-Marxian social class and potential mediators such as labor market position, work organization, material deprivation, and health behaviors on all-cause mortality. The authors use longitudinal data from the Barcelona 2000 Health Interview Survey (N=7526), with follow-up interviews through the municipal census in 2008 (95.97% response rate). Using data on relations of property, organizational power, and education, the study groups social classes according to Wright's scheme: capitalists, petit bourgeoisie, managers, supervisors, and skilled, semi-skilled, and unskilled workers. Findings indicate that social class, measured as relations of control over productive assets, is an important predictor of mortality among working-class men but not women. Workers (hazard ratio = 1.60; 95% confidence interval, 1.10-2.35) but also managers and small employers had a higher risk of death compared with capitalists. The extensive use of conventional gradient measures of social stratification has neglected sociological measures of social class conceptualized as relations of control over productive assets. This concept is capable of explaining how social inequalities are generated. To confirm the protective effect of the capitalist class position and the "contradictory class location hypothesis," additional efforts are needed to properly measure class among low-level supervisors, capitalists, managers, and small employers.

[Prevalence of use of hormone replacement therapy in women participating in a breast cancer screening program]. / Prevalencia de tratamiento hormonal sustitutivo en mujeres que participan en un programa de cribado de cáncer de mama.

BACKGROUND AND OBJECTIVE: The purpose of the study was to determine the prevalence and type of hormone replacement therapy (HRT) in participants in a breast cancer screening program (BCSP) in Barcelona. PATIENTS AND METHOD: Prevalence of use of HRT was obtained through a survey. Information about type of HRT, gynecological history and socioeconomic and educational level was collected. Prevalence was calculated with its corresponding 95% confidence interval. RESULTS: From May 2001 to June 2005 there were 21835 participants in the BCSP with a mean age of 57,6 years. Most of the participants were postmenopausal (86,7%). Confirmed prevalence of use of HRT was 5,2%(CI95% 5,3-6,0) with a greater use among women aged 55 to 59 years. The most frequent types of HRT were tibolone (39,5%) followed by combined estrogens plus progestin (30,4%). Higher education was associated with a higher use of HRT. Neither the use or the type of HRT influenced the results of the screening program. CONCLUSIONS: Prevalence of use of HRT was 5,2% in this study. The most frequently used agents were tibolone and combined estrogens plus progestin.

Impact of non-adherence to radiotherapy on 1-year survival in cancer patients in Catalonia, Spain.

BACKGROUND: This study aims to assess the effects of non-adherence to external beam radiation therapy in cancer patients receiving treatment with a curative. METHODS: This retrospective cohort study collected health records data for all cancer patients treated with external beam radiotherapy with curative intent in 2016 in Catalonia, Spain. Adherence was defined as having received at least 90% of the total dose prescribed. A logistic regression model was used to assess factors related to non-adherence, and its association with one-year survival was evaluated using Cox regression. RESULTS: The final sample included 8721 patients (mean age 63.6 years): breast cancer was the most common tumour site (38.1%), followed by prostate and colon/rectum. Treatment interruptions prolonged the total duration of therapy in 70.7% of the patients, and 1.0% were non-adherent. Non-adherence was associated with advanced age, female gender, and some localization of primary tumour (head and neck, urinary bladder, and haematological cancers). The risk of death in non-adherent patients was higher than in adherent patients (hazard ratio [HR] 1.63, 95% confidence interval 0.97-2.74), after adjusting for the potential confounding effect of age, gender, tumour site and comorbidity. CONCLUSION: Non-adherence to radiotherapy, as measured by the received dose, is very low in our setting, and it may have an impact on one-year survival.

Capitalists, managers, professionals and mortality: findings from the Barcelona social class and all cause mortality longitudinal study.

AIMS: To examine the effects of Neo-Marxian social class (i.e. measured as relations of control over productive assets) and potential mediators such as labour-market position, work organization, material deprivation and health behaviours upon mortality in Barcelona, Spain. METHODS: Longitudinal data from the Barcelona 2000 Health Interview Survey (n = 7526) with follow-up interviews through the municipal census in 2008 (95.97% response rate) were used. Using data on relations of property, organizational power, and education, social classes were grouped according to Wright's scheme: capitalists, petit bourgeoisie, managers, supervisors, and skilled, semi-skilled and unskilled workers. RESULTS: Social class, measured as relations of control over productive assets, is an important predictor of mortality among working-class positions for men but not for women. Workers (hazard ratio 1.60, 95% confidence interval 1.10-2.35), managers and small employers had a higher risk of death than capitalists. CONCLUSIONS: The extensive use of conventional gradient measures of social stratification has neglected sociological measurements of social class conceptualized as relations of control over productive assets. This concept is capable of explaining how social inequalities are generated. To confirm the protective effect of the capitalist class position and the ''contradictory class location hypothesis'', additional efforts are needed to properly measure class among low-level supervisors, capitalists, managers, and small employers.

Understanding variations in the use of hypofractionated radiotherapy and its specific indications for breast cancer: A mixed-methods study.

BACKGROUND AND PURPOSE: Radiation oncology guidelines favour hypofractionated whole-breast radiotherapy (HWBRT) over more conventional schemes in the conservative treatment of breast cancer, but its adoption still varies in clinical practice. This study assessed the patterns of HWBRT adoption in Catalonia (Spain). MATERIAL AND METHODS: We used a mixed-methods approach based on an explanatory sequential design, first collecting and analysing quantitative data on HWBRT use (>2.5Gy per fraction) in 11 public radiotherapy centres (2005-2015) and then performing 25 semi-structured interviews with all department heads and reference radiation oncologist/s. RESULTS: Of the 34,859 patients fulfiling the study criteria over the study period, just 12% were hypofractionated, reaching a percentage of 29% in 2015 (p<0.001). Our analysis showed a narrowing age gap between patients receiving conventional fractionation and hypofractionation in centres leading adoption. However, there were important differences in clinicians' interpretation of evidence (e.g. regarding the perceived risk of long-term toxicity) and selection of patients for specific indications, both within and between departments. CONCLUSIONS: Differences observed in the rate of adoption of HWBRT could not be tackled only using a rational, evidence-based approach. Factors related to the management of radiotherapy departments play a major role in the diffusion of therapeutic strategies.

Spirometric standards and patient characteristics: an exploratory study of factors affecting fulfillment in routine clinical practice.

BACKGROUND: Spirometry is an apparently simple test, yet the recommended criteria for acceptability and reproducibility can be difficult to fulfill. This study aimed (1) to prospectively assess the number of tests that meet the American Thoracic Society/European Respiratory Society (ATS/ERS) 2005 acceptability and repeatability criteria in the routine practice of an experienced technician at a referral hospital's lung function laboratory, (2) to identify the most common errors, and (3) to explore patient characteristics possibly associated with failure to meet standards. METHODS: We prospectively evaluated 257 consecutive spirometries supervised by the same technician, who gave priority to achieving a minimum of 3 correct maneuvers within a maximum of 8 attempts. We recorded FVC, FEV1, expiratory time (TE), back-extrapolated volume (VE), end-of-test volume (VEOT), number of maneuvers with and without errors, and errors (VE > 0.15 L or 5% of FVC, TE < 6 s, and VEOT ≥ 0.025 L for ≥ 1 s). RESULTS: Two-hundred and fifteen spirometries (83.7%, 95% CI 78.6-87.7%) met the ATS/ERS 2005 criteria. Acceptability criteria were met in 73.9% (95% CI 71.2-76.3%) of the maneuvers and repeatability criteria in 90.7% (95% CI 86.5-93.6%). A mean ± SD of 3.3 ± 1.4 per subject was acceptable, and a mean ± SD of 4.5 ± 1.9 was obtained. TE and VEOT errors were the most common. CONCLUSIONS: Nearly 15% of the subjects failed to fulfill all the ATS/ERS 2005 criteria for spirometry performed even though they were coached by a qualified and regularly trained technician in a hospital lung function laboratory. The fact that the ATS/ERS 2005 criteria cannot be met by all patients in optimal technical conditions should be further considered and explored.

p53 and p21 Expression levels predict organ preservation and survival in invasive bladder carcinoma treated with a combined-modality approach.

BACKGROUND: The purpose of the current study was to evaluate the expression levels of p53, p21 and pRB as predictors of for long-term organ preservation and survival in patients with bladder carcinoma who were treated with bladder-sparing intent using a combined-modality approach. METHODS: Tumor samples from 82 consecutive patients with localized invasive bladder carcinoma treated on 3 different bladder-sparing studies were examined for p53, p21, and pRB expression by immunohistochemical methods. Treatment consisted of transurethral resection, platinum-based neoadjuvant chemotherapy, and, according to response, either radiotherapy or radical cystectomy. The median follow-up duration was 55 months. RESULTS: Positive immunoreactivity for p53, p21, and pRB was observed in 47%, 52%, and 67% of patients, respectively. Positive p53 immunoreactivity and positive p21 immunoreactivity were independent predictors of decreased survival with bladder preservation (P = 0.02 and P = 0.02, respectively) and disease-free survival (DFS; P = 0.005 and P = 0.009, respectively) in a multivariate analysis adjusting for clinical stage, ureteral obstruction, and age. Regarding overall survival (OS), p53 overexpression was associated with poor outcome (P = 0.03), whereas the association of poor outcome with p21 expression did not reach statistical significance (P = 0.07). No association between pRB immunoreactivity and outcome was found. When the combined expression of p53 and p21 was assessed, the positive expression of both markers was a strong and unfavorable prognostic factor for survival with bladder preservation (P = 0.006), DFS (P = 0.003), and OS (P = 0.02). CONCLUSIONS: Expression levels of p53 and p21, especially when simultaneously assessed, exhibit independent predictive value for long-term bladder preservation and survival in patients with bladder carcinoma treated with combined-modality therapy. These determinations could be useful in the selection of candidates for bladder-preserving treatment.

Prevalence of Kaposi's sarcoma-associated herpesvirus infection in sex workers and women from the general population in Spain.

Transmission routes of Kaposi's sarcoma-associated herpesvirus (KSHV) in the general population are poorly understood. Whereas sexual transmission appears to be common in homosexual men, the evidence for heterosexual transmission is less convincing. In our study, prevalence of KSHV infection was examined among women in the Spanish general population and among sex workers. Subjects consisted of 100 prostitutes and 100 women randomly sampled from the general population and age-matched to the prostitutes. Women had a personal interview and gynecologic examinations in which a blood sample, cervical cells and oral cells were obtained. Peripheral blood mononuclear cells (PBMC), oral and cervical samples were tested for KSHV DNA by quantitative real-time PCR. Sera were tested for antibodies against human immunodeficiency virus (HIV) by ELISA and against KSHV by latent IFA and K8.1 ELISA. Women who were positive in either serologic assay or PCR were considered infected by KSHV. Human papillomavirus (HPV) DNA in cervical scrapes were evaluated using the Hybrid Capture System. The study population had an average age of 30 years and were HIV-negative. Women from the general population were largely of Spanish nationality, and 61% reported lifetime monogamy. The majority of the prostitutes (76%) were immigrants, primarily from South America. Sex workers were twice as likely to be infected with KSHV than women in the general population (16% vs. 8%, prevalence odds ratio [OR] = 2.2). KSHV was more prevalent among HPV DNA-positive women (OR = 2.5) and among women with an early age at first sexual intercourse (OR = 2.7, p < 0.05). KSHV DNA was detected by PCR in 3% of the oral cavity samples, in 2% of the cervical samples of the prostitutes and in 1% of the cervical samples of women in the general population. All PBMC samples were negative. These results suggest that in low-risk countries for KSHV, oral shedding and heterosexual contacts are potential pathways for KSHV transmission.