Variabilidad y coste de oportunidad de las alternativas quirúrgicas en cáncer de mama

Objective

To analyze medical practice variation in breast cancer surgery (either inpatient-based or day-case surgery), by comparing conservative surgery (CS) plus radiotherapy vs. non-conservative surgery (NCS). We also analyzed the opportunity costs associated with CS and NCS.

Methods

We performed an observational study of age- and sex-standardized rates of CS and NCS, performed in 199 Spanish healthcare areas in 2008-2009. Costs were calculated by using two techniques: indirectly, by using All-Patients Diagnosis Related Groups (AP-DRG) based on hospital admissions, and directly by using full costing from the Spanish Network of Hospital Costs (SNHC) data.

Results

Standardized surgery rates for CS and NCS were 6.84 and 4.35 per 10,000 women, with variation across areas ranging from 2.95 to 3.11 per 10,000 inhabitants. In 2009, 9% of CS was performed as day-case surgery, although a third of the health care areas did not perform this type of surgery. Taking the SNHC as a reference, the cost of CS was estimated at 7,078 € and that of NCS was 6,161 €. Using AP-DRG, costs amounted to 9,036 € and 8,526 €, respectively. However, CS had lower opportunity costs than NCS when day-case surgery was performed frequently–more than 46% of cases (following SNHC estimates) or 23% of cases (following AP-DRG estimates).

Conclusions

Day-case CS for breast cancer was found to be the best option in terms of opportunity-costs beyond a specific threshold, when both CS and NCS are elective.     

Micropapillary Carcinoma of the Breast with Necrosis-like Cell Death: A Case Report

A primary invasive micropapillary carcinoma of the breast in a 46-year-old woman is reported. Histologically, it was composed predominantly of papillary tumor cell clusters without fibrovascular cores, surrounded by a clear space. Tumor cells were positive for cytokeratin (CK) 7, estrogen receptor (ER), and progesterone receptor (PR), but negative for p53, CK 20, CD34, c-Erb-B2, CK5, epidermal growth factor receptor (EGFR), vimentin, and c-kit. MUC1 expression was found at the reversed apical membrane of neoplastic cell clusters. Accordingly, electron microscopy showed the lack of basement membrane and presence of microvilli at the basal surface of the tumor cells. Moreover, ultrastructural examination revealed single tumor cell death characterized by patchy condensations of chromatin throughout the nucleus. These nuclear alterations were associated with the occurrence of empty cytoplasmic vacuoles, conferring a necrosis-like phenotype to this cell death. Alternative programmed cell deaths are reviewed and their morphologic distinction is discussed.     

Metabolic effects of ethanol on primary cell cultures of rat skeletal muscle.

Individuals who have consumed alcohol chronically accumulate glycogen in their skeletal muscles. Changes in the energy balance caused by alcohol consumption might lead to alcoholic myopathy. Experimental models used in the past, such as with skeletal muscle biopsy samples of alcohol-dependent individuals or in animal models, do not distinguish between direct effects and indirect effects (i.e., alterations to the nervous or endocrine system) of alcohol. In the current study, we evaluated the direct effect of ethanol on skeletal muscle glycogen concentrations and related glycolytic pathways. We measured the changes in metabolite concentrations and enzyme activities of carbohydrate metabolism in primary cell cultures of rat skeletal muscle exposed to ethanol for two periods. The concentrations of glycolytic metabolites and the activities of several enzymes that regulate glucose and glycogen metabolism were measured. After a short exposure to ethanol (6 h), glucose metabolism slowed. After 48 h of exposure, glycogen accumulation was observed.     

Nitric oxide system alteration at spinal cord as a result of perinatal asphyxia is involved in behavioral disabilities: Hypothermia as preventive treatment

Perinatal asphyxia (PA) is able to induce sequelae such as spinal spasticity. Previously, we demonstrated hypothermia as a neuroprotective treatment against cell degeneration triggered by increased nitric oxide (NO) release. Because spinal motoneurons are implicated in spasticity, our aim was to analyze the involvement of NO system at cervical and lumbar motoneurons after PA as well as the application of hypothermia as treatment. PA was performed by immersion of both uterine horns containing full‐term fetuses in a water bath at 37°C for 19 or 20 min (PA19 or PA20) or at 15°C for 20 min (hypothermia during PA‐HYP). Some randomly chosen PA20 rats were immediately exposed for 5 min over grain ice (hypothermia after PA‐HPA). Full‐term vaginally delivered rats were used as control (CTL). We analyzed NO synthase (NOS) activity, expression and localization by nicotinamide adenine dinucleotide phosphate diaphorase (NADPH‐d) reactivity, inducible and neuronal NOS (iNOS and nNOS) by immunohistochemistry, and protein nitrotyrosilation state. We observed an increased NOS activity at cervical spinal cord of 60‐day‐old PA20 rats, with increased NADPH‐d, iNOS, and nitrotyrosine expression in cervical motoneurons and increased NADPH‐d in neurons of layer X. Lumbar neurons were not altered. Hypothermia was able to maintain CTL values. Also, we observed decreased forelimb motor potency in the PA20 group, which could be attributed to changes at cervical motoneurons. This study shows that PA can induce spasticity produced by alterations in the NO system of the cervical spinal cord. Moreover, this situation can be prevented by perinatal hypothermia. © 2008 Wiley‐Liss, Inc.     

Physical activity,activity change,and their correlates in a population-based sample of colorectal cancer survivors

Background: Physical activity can provide benefits to cancer survivors, including reduced symptoms and treatment side effects, improved overall quality of life, and decreased risk of other chronic diseases.Purpose: The aim of the study was to describe physical activity before and after diagnosis of colorectal cancer and to examine the associations with sociodemographic and disease-related variables.Methods: Telephone interviews were conducted with 1,996 colorectal cancer survivors recruited through a cancer registry.Results: In comparison to prediagnosis activity levels, there were 21% fewer participants meeting the physical activity and health guideline (150 min of moderate-intensity physical activity per week) postdiagnosis. Meeting the guideline postdiagnosis was associated with being male, living outside of the state capital city, having a higher education, having a healthy body mass index, not smoking, having had surgery only, and no reported fatigue. Attributes associated with a decrease in physical activity following diagnosis were being female, living within the state capital city, having a lower level of education, having a stoma, having adjuvant therapy, and experiencing fatigue.Conclusions: There is considerable scope for targeted interventions to increase the physical activity of colorectal cancer survivors, particularly for those groups that we have identified as being less active and/or have reduced their activity. This project was funded by The Cancer Council Queensland. We acknowledge Mrs Monica West for her contribution to the data collection.     

Suicide attempts in bulimia nervosa: Personality and psychopathological correlates

BackgroundLittle evidence exists about suicidal acts in eating disorders and its relation with personality. We explored the prevalence of lifetime suicide attempts (SA) in women with bulimia nervosa (BN), and compared eating disorder symptoms, general psychopathology, impulsivity and personality between individuals who had and had not attempted suicide. We also determined the variables that better correlate with of SA.MethodFive hundred sixty-six BN outpatients (417 BN purging, 47 BN non-purging and 102 subthreshold BN) participated in the study.ResultsLifetime prevalence of suicide attempts was 26.9%. BN subtype was not associated with lifetime SA (p = 0.36). Suicide attempters exhibited higher rates on eating symptomatology, general psychopathology, impulsive behaviors, more frequent history of childhood obesity and parental alcohol abuse (p < 0.004). Suicide attempters exhibited higher scores on harm avoidance and lower on self-directedness, reward dependence and cooperativeness (p < 0.002). The most strongly correlated variables with SA were: lower education, minimum BMI, previous eating disorder treatment, low self-directedness, and familial history of alcohol abuse (p < 0.006).ConclusionOur results support the notion that internalizing personality traits combined with impulsivity may increase the probability of suicidal behaviors in these patients. Future research may increase our understanding of the role of suicidality to work towards rational prevention of suicidal attempts.