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Objective: our objective was to evaluate the cost-effectiveness of the use of peripherally inserted central venous catheters (PICCs) by a vascular access team (VAT) versus central venous catheters (CVCs) for in-hospital total parenteral nutrition (TPN). Methods: the study used a cost-effectiveness analysis based on observational data retrospectively obtained from electronic medical records from 2018 to 2019 in a teaching hospital. We included all interventional procedures requiring PICCs or CVCs with the indication of TPN. We recorded the costs of insertion, maintenance, removal, and complications. The main outcome measure was the incidence rate of catheter-associated bacteremia per 1000 catheter days. Cost-effectiveness analysis was performed from the hospital perspective within the context of the publicly funded Spanish health system. Confidence intervals for costs and effectiveness differences were calculated using bootstrap methods. Results: we analyzed 233 CVCs and 292 PICCs from patients receiving TPN. Average duration was longer for PICC (13 versus 9.4 days, P < 0.001). The main reason for complications in both groups was suspected infection (9.77% CVC versus 5.18% PICC). Complication rates due to bacteremia were 2.44% for CVC and 1.15% for PICC. The difference in the incidence of bacteremia per 1000 catheter days was 1.29 (95% confidence interval, -0.89 to 3.90). Overall, costs were lower for PICCs than for CVCs: the difference in mean overall costs was -€559.9 (95% confidence interval, -€919.9 to -€225.4). Uncertainty analysis showed 86.37% of results with lower costs and higher effectiveness for PICC versus CVC.Conclusions: placement of PICC by VAT compared with CVC for TPN reduces costs and may decrease the rate of bacteremia.

Purpose To identify adherence to follow-up recommendations in long-term breast cancer survivors (LTBCS) of the SURBCAN cohort and to identify its determinants, using real-world data. Methods We conducted a retrospective study using electronic health records from 2012 to 2016 of women diagnosed with incident breast cancer in Spain between 2000 and 2006 and surviving at least 5 years. Adherence to basic follow-up recommendations, adherence according to risk of recurrence, and overall adherence were calculated based on attendance at medical appointments and imaging surveillance, by year of survivorship. Logistic regression models were fitted to depict the association between adherence and its determinants. Results A total of 2079 LTBCS were followed up for a median of 4.97 years. Of them, 23.6% had survived ≥ 10 years at baseline. We estimated that 79.5% of LTBCS were overall adherent to at least one visit and one imaging test. Adherence to recommendations decreased over time and no differences were found according to recurrence risk. Determinants of better overall adherence were diagnosis in middle age (50–69 years old), living in a more-deprived area, having fewer years of survival, receiving primary treatment, and being alive at the end of follow-up. Conclusion We identified women apparently not complying with surveillance visits and tests. Special attention should be paid to the youngest and eldest women at diagnosis and to those with longer survival.

Introduction: breast cancer (BC) is the most common cancer in women and its relationship with dietary factors particularly dairy products, has been investigated trough several studies but up to now there are still not enough results to confirm the association between breast cancer and dairy products. Objective: the purpose of this systematic review was to expand the number of systematic reviews that to date exist on the relationship between dairy products consumption and risk of breast cancer. A comprehensive search of the PubMed, Scopus and Embase was performed from September 2005 to September 2018 in which one case control and cohorts’ studies were included. Results: eighteen studies were finally selected for the review (10 case-control and 8 cohorts’ studies). These studies reported several statistically significant associations (OR, HR, RR) between dairy product consumption and the risk of breast cancer. Seven case-control and four cohorts’ studies showed that dairy product consumption was inversely associated with the risk of breast cancer, on the other hand, a positive association was found in two case-control and non- significant association was found between dairy product consumption and the risk of breast cancer in the remaining studies (one case-control and four cohorts’ studies) Conclusion: although an inverse association was observed in most studies, it’s difficult to draw conclusions when the methodology methods to collect the dairy product intake and the servings or portions measurements were different in each study. On the other hand, not all studies used the same confounding variable to estimate risk. Introducción: el cáncer de mama (BC) es de los cánceres más comunes en mujeres, y su relación con los factores dietéticos y, en particular, con los productos lácteos, ha sido investigada a través de varios estudios, pero hasta ahora no hay resultados suficientes que confirmen la asociación entre cáncer de mama y productos lácteos. Objetivo: el objetivo de esta revisión fue ampliar y actualizar el número de revisiones sistemáticas que hasta día de hoy existen sobre la relación entre el consumo de productos lácteos y el cáncer de mama. Metodología: se realizó una búsqueda exhaustiva en las bases de datos PubMed, Scopus y Embase entre septiembre de 2005 y septiembre de 2018 en la que se incluyeron estudios de casos y controles y estudios de cohortes. Resultados: se seleccionaron 18 estudios (10 estudios de casos-controles y 8 estudios de cohorte). Siete casos-controles y cuatro estudios de cohorte mostraron que el consumo de productos lácteos tenía una asociación inversa con el riesgo de cáncer de mama y, por otro lado, en dos estudios de casos-controles se observó una asociación positiva. No se encontró una asociación significativa entre el consumo de productos lácteos y el cáncer de mama en los restantes estudios (1 caso-control y 4 cohortes). Conclusión: aunque se observó una asociación inversa en la mayoría de los estudios, es difícil sacar conclusiones cuando los métodos metodológicos para recolectar la ingesta de lácteos y las porciones o las mediciones de las porciones fueron diferentes en cada estudio. Por otro lado, no todos los estudios tienen en cuenta las mismas variables de confusión.

BACKGROUND: In Spain, women invited to breast screening are not usually informed about potential harms of screening. The objective of the InforMa study is to assess the effect of receiving information about the benefits and harms of breast screening on informed choice and other decision-making outcomes, in women approaching the age of invitation to mammography screening. METHODS: Two-stage randomised controlled trial. In the first stage, 40 elementary territorial units of the public healthcare system were selected and randomised to intervention or control. In the second stage, women aged 49-50 years were randomly selected. The target sample size was 400 women. Women in the intervention arm received a decision aid (DA) with detailed information on the benefits and harms of screening. Women in the control arm received a standard leaflet that did not mention harms and recommended accepting the invitation to participate in the Breast Cancer Screening Program (BCSP). The primary outcome was informed choice, defined as adequate knowledge and intentions consistent with attitudes. Secondary outcomes included decisional conflict, worry about breast cancer, time perspective, opinions about the DA or the leaflet, and participation in the BCSP. RESULTS: In the intervention group, 23.2% of 203 women made an informed choice compared to only 0.5% of 197 women in the control group (p < 0.001). Attitudes and intentions were similar in both study groups with a high frequency of women intending to be screened, 82.8% vs 82.2% (p = 0.893). Decisional conflict was significantly lower in the intervention group. No differences were observed in confidence in the decision, anxiety, and participation in BCSP. CONCLUSIONS: Women in Spain lack knowledge on the benefits and harms of breast screening. Providing quantitative information on benefits and harms has produced a considerable increase in knowledge and informed choice, with a high acceptance of the informative materials. TRIAL REGISTRATION: Trial identifier NCT03046004 at ClinicalTrials.gov registry. Registered on February 4 2017. Trial name: InforMa study. This study was supported by the research grant “Women participation in decisions and strategies on early detection of breast cancer” (PI14/00113) from the Instituto de Salud Carlos III and cofunded by Fondo Europeo de Desarrollo Regional (FEDER) “Una manera de hacer Europa.” Anna Pons received a grant for PhD students from the Lleida Biomedical Research Institute (IRBLleida). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The aim of this study is to determine the survival of patients with breast cancer treated with adjuvant chemotherapy (ACh) after the diagnosis by screening, taking comorbidity into account. This multicenter cohort study examined a population of patients taking part in four national screening programs for the early detection of breast cancer (localized or locally advanced), during the period 2000‐2008. Of the 1248 cancers detected, 266 were prevalent (21.3%), 633 were incident (50.7%), and 349 were interval (27.9%). No significant differences were detected between the three groups in terms of the distribution of comorbidity according to the CCI. After a median follow‐up of 102 months, 22.1% of the patients with interval cancer had died. The corresponding figures for the incident and prevalent cancers were 10.4% and 7.9%, respectively (P, Adjuvant chemotherapy seems to benefit patients with interval breast cancer, who have a poorer prognosis than those with prevalent or incident cancer. However, the role of adjuvant chemotherapy is unclear with respect to prevalent and incident cancers when comorbidity is taken into account.

Background: We aimed to evaluate survival and disease-free survival in different subtypes of interval cancers by breast density, taking into account clinical and biological characteristics. Methods: We included 374 invasive breast tumors (195 screen-detected cancers; 179 interval cancers, classified into true interval, false-negatives, occult tumors and minimal-sign cancers) diagnosed in women ages 50–69 years undergoing biennial screening from 2000–2009, followed up to 2014. Breast density was categorized into non-dense ( Results: Interval cancers were detected in younger women, at more advanced stages, in denser breasts and showed a higher proportion of triple-negative cancers, especially among true interval cancers. Women with interval cancer and non-dense breasts had an aHR for death of 3.40 (95% CI, 0.92–12.62). Women with true interval cancers detected in non-dense breasts had the highest adjusted risk of death (aHR, 6.55; 95% CI, 1.37–31.39). Conclusions: Women with true interval cancer in non-dense breasts had a higher risk of death than women with screen-detected cancers. Impact: These results support the advisability of routinely collecting information on breast density, both for further tailoring of screening strategies and as a prognostic factor for diagnosed breast cancers. Cancer Epidemiol Biomarkers Prev; 27(8); 908–16. ©2018 AACR.

Background The decision to participate or not in breast cancer screening is complex due to the trade-off between the expected benefit of breast cancer mortality reduction and the major harm of overdiagnosis. It seems ethically necessary to inform women so that they can actively participate in decision-making and make an informed choice based on their values and preferences. The objective of this study is to assess the effects of receiving information about the benefits and harms of screening on decision-making, in women approaching the age of invitation to mammography screening. Methods A two-stage, randomized controlled trial (RCT). In the first stage, 40 Basic Health Areas (BHAs) will be selected and randomized to intervention or control. In the second stage, women within each BHA will be randomly selected (n = 400). Four breast cancer screening programs (BCSPs) of the Spanish public health system, three in Catalonia and one in the Canary Islands will participate in the study. Women in the intervention arm will receive a leaflet with detailed information on the benefits and harms of screening using mammography. Women in the control arm will receive a standard leaflet that does not mention harms and recommends accepting the invitation to participate in the biennial examinations of the BCSP. The primary outcome is informed choice, a dichotomous variable that combines knowledge, attitudes, and intentions. Secondary outcomes include decisional conflict; confidence in the decision made; anxiety about screening participation; worry about breast cancer; anticipated regret; time perspective; perceived importance of benefits/harms of screening; perceived risk of breast cancer; and leaflet acceptability. Primary and secondary outcomes are assessed 2–3 weeks after the intervention. Discussion This is the first RCT that assesses the effect of informing about the benefits and harms of breast cancer screening in Spain in women facing the decision to be screened using mammography. It aims to assess the impact of information on several decisional outcomes and to contribute to paving the road towards shared decision-making in breast cancer screening in our country. Trial registration ClinicalTrials.gov registry, ID: NCT03046004. Retrospectively registered on 4 February 2017. Trial name: InforMa study. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2161-7) contains supplementary material, which is available to authorized users.

Introducció. La bacterièmia és una de les manifestacions més greus de les infeccions, s'ha associat a un increment de la morbiditat, de la mortalitat i del consum de recursos. Aquest problema és superior quan la bacterièmia és d'origen hospitalari. L'excés de cost associat a les bacterièmies s'utilitza com a mesura de l'impacte d'aquestes infeccions. Hi ha molta variabilitat en l’estimació dels costos incrementals associats a les bacterièmies hospitalàries, s’ha descrit un excés de cost entre 5.875$ i 86.500$ Quan una bacterièmia és causada per un microorganisme resistent als antibiòtics, s’incrementa la gravetat, el risc pel pacient i els costos. Els Centers for Disease Control and Prevention (CDC) estimen que la resistència antimicrobiana té un excés de costos de 20 bilions de dòlars, als Estats Units. A causa de la complexitat per valorar les activitats que es realitzen als malalts, els treballs que analitzen els costos de les bacterièmies sovint es basen en estimacions secundàries i no en costos reals. D’altra banda, la possibilitat de desenvolupar una bacterièmia nosocomial està lligada al temps d'exposició; alhora, aquesta infecció incrementa els dies d'estada, essent l'estada hospitalària una variable confusora. Això pot provocar en les anàlisis d'impacte econòmic un biaix conegut com survivor-treatment selection bias. Pocs estudis han avaluat el cost incremental tenint en compte tots aquest factors. Objectius. L’objectiu principal és avaluar el cost incremental associat a l’adquisició de bacterièmies nosocomials. Es concreta en: 1er. Avaluar l’ajust amb propensity score matching (PSM) en la disminució dels biaixos associats al càlcul del cost incremental. I 2on calcular el cost incremental de les bacterièmies nosocomials, diferenciant segons la sensibilitat als antimicrobians 2.a. dels microorganismes causants i 2.b. desglossant el focus que origina la bacterièmia. Mètodes Es van analitzar els episodis d’hospitalització de l’Hospital del Mar, de Barcelona dels anys 2005 a 2007 en el primer objectiu i fins al 2012, en el segon. Es comparen els costos dels malalts que presenten algun episodi de bacterièmia amb la resta d’altes d’hospitalització atesos en el mateix període i agrupats en els mateixos APR-DRG. En el segon objectiu es van seleccionen les bacterièmies causades pels microorganismes més freqüents i que molt sovint desenvolupen multiresistència en bacterièmies, Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae i Pseudomonas aeruginosa. Es va calcular un propensity score (PS) de cada malalt i posteriorment aquest PS s’utilitzà en els models economètrics per ajustar el cost incremental dels malalts que han desenvolupat una bacterièmia i les diferències en funció que el microorganisme fos sensible o multiresistent i també del focus origen. Resultats Objectiu 1, en l’ajust amb PSM el cost incremental mitjà per al total de pacients va ser de 11.916 €, el cost inferior correspon als Gram negatiu amb 6.933€ i el superior als fongs, 32.886€. Objectiu 2.a. El cost incremental més elevat va correspondre a les bacterièmies causades per Pseudomonas aeruginosa multiresistent, mitjana de 44.709€. Les bacterièmies nosocomials per E coli multiresistent presenten un cost incremental mitjà de 8.872€ i si és multisensible de 10.481€. Objectiu 2.b. Les bacterièmies causades per una infecció urinària, per microorganisme multisensible, van presentar un cost incremental mitjà de 6.786€ i de 13.299€ quan era multiresistent. El cost mitjà incremental més elevat va correspondre a les bacterièmies primàries, tant si el microorganisme era sensible (26.082€) com si era multiresistent (29.186€), seguit del focus respiratori quan la infecció va ser produïda per un microorganisme multiresistent (25.292€). Conclusions. Amb l’eliminació dels biaixos mitjançant un bon sistema d’ajust es confirma que la bacterièmia ocasiona un increment considerable en el cost de l’assistència. Aquest increment varia en funció del tipus de microorganisme, la sensibilitat als antimicrobians i el focus que la origina., Introduction. Bacteremia is a severe infection with high levels of mortality rates, morbidity and resources consumption. The burden is even greater for hospital bacteremia (HB). The incremental cost associated with bacteremia is used as a measure of the impact of these infections. Studies of the incremental costs of hospital infections showed different and variable results: excess cost of infections has been estimated between $ 5,875 and $ 86,500. Bacteremia caused by multidrug-resistant microorganisms have worse prognosis than those caused by antimicrobial-susceptible microorganisms. Centers for Disease Control and Prevention (CDC) estimated that antimicrobial resistance causes excess costs of $ 20 billion per year in United States. Due to the complexity of identifying the multitude of activities performed in a hospital, currently few hospitals have developed detailed per patient cost accounting. Consequently, most of studies that analyze cost of bacteremia are based on secondary estimates rather than real costs. Moreover, the possibility of developing a hospital bacteremia is linked to the exposure time; in addition, this infection increases the length of stay. For this reason, hospital stay can be considered a confounding variable and it can cause a bias in the analysis of economic impact known as survivor-treatment selection bias. Few studies have assessed the incremental cost taking into account all these factors. Aim. The main objective was to evaluate the incremental cost associated with hospital acquired bacteremia. It focuses on: 1.- Assess an adjustment model with Propensity score matching (PSM) for the reduction of biases associated with the calculation of the incremental cost, 2.- to calculate the incremental cost of hospital bacteremia classified by antibiotic sensitivity, 2.a.- caused by the most common organisms, 2.b.- according the causative focus. Methods. Patients admitted to the Hospital del Mar in Barcelona from 2005 to 2007 were analyzed for the first objective, and those from 2005 to 2012 for the second. The costs of patients who experienced an episode of HB were compared with patients grouped into the same APR-DRG but without HB. For the second objective, cases of hospital bacteremia caused by Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae or Pseudomonas aeruginosa were selected and analyzed because of their high prevalence and their multidrug resistance. For each admission, the probability of developing bacteremia (propensity score) was estimated. Subsequently, propensity score was included in an econometric model to adjust the incremental cost of patients who developed bacteremia, as well as to differentiate it for the infections that caused the bacteremia and whether it was classified by the antibiotic sensitivity of the causative organism. Results. Objective 1: adjusting with PSM the mean incremental cost was €11,916. Gram positive microorganism had the lowest mean incremental cost, €6,933 and the highest was fungi, €32,886. Objective 2a: Multidrug-resistant P. aeruginosa bacteremia had the highest mean incremental cost, €44,709. Antimicrobial-susceptible E. coli, €10,481, and multidrug-susceptible, €10.481, were the nosocomial bacteremia with the lowest mean incremental cost. Objective 2b: The mean incremental cost was €6,786 for antimicrobial-susceptible UTI and €13,299 for multidrug-resistant UTI bacteremia. The highest incremental costs were found for primary or unknown sources of bacteremia: €26,082 for antimicrobial-susceptible bacteremia, €29,186 for multidrug-resistant bacteremia and €25,292 when the source of bacteremia was a respiratory infection with a multidrug-resistant microorganism. Conclusions. Controlling for possible biases in a structured adjustment model confirms that bacteremia causes a substantial increase of the cost of care. This increase varies according to the type of microorganism sensitivity to antibiotics and to the causes of the focus.

L’aigua és un dels components bàsics per a la vida i una font d’exposició a contaminants ubiqua, ja que tota la població en consumeix. L’estudi epidemiològic INMA avaluarà si l’exposició a nitrats durant l’embaràs i a la duresa de l’aigua durant la infància es relaciona amb el baix pes al néixer i l’èczema atòpica, respectivament. Objectiu: Fer una avaluació dels nivells de nitrats i duresa de l’aigua en aigua de consum de la població de l’estudi INMA. Metodologia: l’estudi descriptiu realitzat a quatre de les set cohorts INMA, a Astúries, Guipúscoa, Sabadell i València. S’ha recopilat dades dels nivells de nitrats i duresa a l’aigua de consum dels municipis durant el període d’interès (2003 al 2008 i 2004 al 2012), a través d’ajuntaments i companyies d’aigua. S’ha calculat la mitjana, la desviació estàndard, el màxim i el mínim dels nivells de nitrat i de duresa en total i segons l’àrea geogràfica, l’any i l’estació. A Sabadell s’han fet tres mostrejos d’aigua per analitzar la duresa a diferents punts de la ciutat. Resultats: el nivell promig de nitrats (mg/L NO3-) és de 4,2 a Astúries, 4,0 a Guipúscoa, 9,2 a Sabadell i 15,2 a València. El nivell promig de duresa (mg/L CaCO3) és de 89,1 a Astúries, 132,7 al Guipúscoa, 178,3 a València i 230,9 a Sabadell. En l’anàlisi que es va realitzar a Sabadell, es detecta una duresa lleugerament inferior a la reportada sense variabilitat geogràfica. No s’observa una pauta clara de variabilitat estacional ni de variabilitat temporal tant per nitrats com per duresa. Conclusions: S’ha detectat variabilitat en els nivells de nitrats i duresa de l’aigua a les zones d’estudi. Els nivells de nitrats són moderats i els més alts es troben a zones agrícoles de València. La duresa de l’aigua és força alta degut al domini calcari dels subsòls de les zones d’estudi. El agua es uno de los componentes básicos para la vida y una fuente ubicua de exposición a contaminantes, ya que toda la población la consume. El estudio epidemiológico INMA evaluará si la exposición a nitratos durante el embarazo y la dureza del agua durante la infancia se relaciona con el bajo peso al nacer y el eczema atópico, respectivamente. Objetivo: Realizar una evaluación de los niveles de nitratos y niveles de dureza en el agua de consumo de la población del estudio INMA. Metodología: este estudio descriptico se ha realizado en cuatro de las siete cohortes INMA (Asturias, Guipúzcoa, Sabadell y Valencia). Se han recopilado datos de niveles de nitratos y dureza en el agua de consumo de los municipios durante el periodo de interés (2003 a2008 y 2004 a2012), a través de ayuntamientos y compañías de agua. Se han calculado el promedio, la desviación estándar, el máximo y el mínimo de los niveles de nitratos y de dureza en total y dependiendo de la área geográfica, el año y la estación. En Sabadell se han realizado tres muestreos de agua para analizar la dureza en diferentes puntos de la ciudad. Resultados: los niveles promedio de nitratos (mg/L NO3-) fueron: 4,2 a Asturias; 4,0 en Guipúzcoa; 9,2 en Sabadell y 15,2 en Valencia. Los niveles promedio de dureza del agua (mg/L CaCO3) fueron: 89,1 en Asturias; 132,7 en Guipúzcoa; 178,3 en Valencia y 230,9 en Sabadell. En el análisisrealizado en Sabadell, se detectaron niveles de dureza ligeramente inferiores a los reportados, sin variabilidad geográfica. No se observó una pauta clara de variabilidad estacional ni temporal, tanto para nitratos como para dureza. Conclusiones: Se ha observado variabilidad geográfica en los niveles de nitrato y de dureza del agua en las zonas de estudio. Los niveles observados de nitratos son moderados y los más altos se encontraron en zonas agrícolas de Valencia. La dureza del agua es bastante alta debido al dominio calcáreo del subsuelo de las zonas de estudio. Water is a basic component of life and is an ubiquitous environmental exposure for the population. The epidemiologic study INMA will evaluate if the exposure to nitrate in drinking water during the pregnancy and water hardness in childhood is linked to low birth weight and atopic eczema, respectively. Objective: To evaluate the levels of nitrates and water hardness in water consumed by the study population of INMA. Methods: a descriptive study was conducted in four of the seven INMAs cohorts: Asturias, Gipuzkoa, Sabadell and Valencia. Nitrate levels and water hardness information in drinking water have been collected from local governments and water companies for the period of interest (2003 to 2008 and 2004 to 2012),. We have calculated the average, the standard deviation, the maximum, the minimum levels of nitrate and total hardness in drinking water by geographical area, year and seasons. In Sabadell, water samples were collected in three different periods during 2014 to determine the levels of hardness in different areas of the city. Results: the average level of nitrate (mg/L NO3-) was 4,2 in Asturias, 4,0 inGipuzkoa, 9,2 in Sabadell and 15,2 in Valencia. The average level of water hardness (mg/L CaCO3) was 89,1 in Asturias, 132,7 inGipuzkoa and 230,9 in Valencia. The analysis conducted in Sabadell detected lower levels of hardness than previous reports, without geographical variability. Finally, we did not observe an evident seasonal and temporary variability. Conclusions: We detected a geographical variability in nitrate levels and water hardness. Nitrate levels are moderate overall areas, and the highest levels were located in agricultural areas of Valencia. The hardness of the water is fairly high probably due to the predominance of calcareous subsoil across the study areas.

Introducció. La detecció precoç del càncer de mama s’ha visualitzat com la millor estratègia per millorar el pronòstic de la malaltia i disminuir-ne la mortalitat a llarg termini. Tanmateix, els resultats sobre l’efectivitat del cribratge en el context poblacional són controvertits. Aquesta tesi està centrada en tres qüestions que formen part del debat. Objectius. La tesi té com a principal objectiu aprofundir en l’avaluació del cribratge poblacional del càncer de mama, concretament i) estudiant l’impacte de la introducció dels programes poblacionals de cribratge en la detecció del càncer de mama en el conjunt de la població diana; ii) avaluant l’associació entre la via diagnòstica (detecció en el cribratge o en l’interval entre mamografies) amb les característiques i el pronòstic dels tumors; i iii) estudiant l’impacte del tipus de prova d’imatge sobre els indicadors de qualitat del programa. Mètodes. Pel primer objectiu (Article 1), s’estudiaren les taxes d’incidència del càncer de mama en la població diana de dues regions daneses (Copenhagen i Fyn) entre 1991-2008. Es recolliren els diagnòstics de càncer de mama realitzats en el cribratge, entre intervals i en dones no participants. Es calcularen les taxes segons la via diagnòstica i es compararen els principals indicadors de cribratge i les característiques dels tumors diagnosticats en les dues regions. Pel segon objectiu (Articles 2 i 3), s’estudiaren els càncers d’interval en la cohort de dones cribrades al programa de l’Hospital del Mar (Barcelona), entre 1995-2008. Mitjançant un disseny cas-control es compararen les característiques biològiques dels càncers de cribratge, els càncers d’interval i els seus principals subtipus radiològics (veritables càncers d’interval i falsos negatius). S’estudiaren les associacions entre les característiques clíniques, el fenotip tumoral i la densitat mamària entre els grups d’estudi. S’avaluà la supervivència global i la supervivència lliure de malaltia en funció de la via diagnòstica, mitjançant corbes de Kaplan-Meier i models de riscos proporcionals de Cox. Pel tercer objectiu (Article 4), s’avaluà l’impacte de la transició de la mamografia analògica a la digital en una cohort de 103.613 dones cribrades entre 1996-2007 en quatre programes poblacionals espanyols. Es compararen els patrons radiològics i els valors predictius positius (VPP=càncers diagnosticats, entre el total de dones reconvocades) obtinguts en el període analògic i digital, i les característiques dels tumors diagnosticats amb ambdues tècniques. Resultats. i) La introducció del cribratge poblacional a Dinamarca suposà un pic de prevalença de diagnòstics de càncer de mama entre les dones participants als programes (5.79 per 1000 persones-any a Copenhaguen i 4.47 a Fyn), i entre les no participants (4.23 i 5.93, respectivament). ii) Els veritables càncers d’interval s’associaren amb el fenotip triple negatiu [OR=8.85 (IC95%:2.03–38.62)] i l’elevada densitat mamària [OR=3.08 (IC95%:1.03–9.24)]. Aquestes dones també presentaren un major risc de recaigudes [HR=1.89; (IC95%: 0.67–5.31)] i de mortalitat [HR= 5.55 (IC95%: 1.61-19.15)]. iii) El VPP de la mamografia digital fou superior al de la mamografia analògica (7.0% vs. 5.5%, respectivament; p, Introduction. Early detection of breast cancer has been recognized as the best strategy to improve the prognosis of breast cancer and decrease mortality in the long term. However, there is some disagreement on the effectiveness of screening. This thesis examines three issues that form part of the debate. Objectives. This thesis aims to provide greater knowledge of the evaluation of population-based breast cancer screening programmes, specifically by i) assessing the impact of the introduction of screening programmes on detection rates in the entire target population, ii) studying the association of the mode of diagnosis (detected at screening or in the interval between screenings) with tumour features and cancer prognosis, and iii) evaluating the impact of the imaging modality on performance indicators. Methods. For the first objective (Article 1), we assessed the breast cancer incidence rates of the target populations of two Danish regions (Copenhagen and Fyn), from 1991 to 2008. We identified breast cancers diagnosed at screening, during the screening interval, or among unscreened women. We computed rates by mode of diagnosis and compared tumour-related characteristics and performance indicators between the two regions. For the second objective (Articles 2 and 3), we focused on the study of interval cancers in the cohort of women screened between 1995 and 2008 at Hospital del Mar, Barcelona. We designed a case-control study to compare the biological characteristics of screen-detected cancers, interval cancers, and their main subtypes (true interval cancers and false negatives). Bivariate and multivariate analyses were performed to compare patient and molecular characteristics among study groups. We carried out a follow-up study in the same cohort of women to evaluate overall survival and disease-free survival by mode of detection, using the Kaplan–Meier method and Cox proportional hazard models. For the third objective (Article 4), we evaluated the impact of the transition from screen-film mammography to digital mammography among a cohort of 103,613 women screened in Spain between 1996 and 2007. Tumour characteristics (invasiveness, tumour size, lymph node involvement) and radiological patterns were compared among study groups. We also compared the positive predictive values (PPV= cancers diagnosed among the total number of women recalled) obtained during the screen-film and digital periods. Results. i) The introduction of population-based screening in Denmark resulted in a prevalence peak of breast cancer diagnoses among screening participants (5.79 per 1000 persons-year in Copenhagen and 4.47 in Fyn), and among unscreened women (4.23 and 5.93, respectively). ii) True interval cancers showed a strong association with the triple-negative phenotype (lack of hormone receptor and HER2 expression) [OR=8.85 (95%CI: 2.03–38.62] and high breast density [OR=3.08 (95%CI:1.03–9.24)]. True interval cancers had the highest hazard ratio for relapse prediction [HR=1.89; (95%CI: 0.67–5.31)] and a HR of death of 5.55 (95%CI:1.61–19.15). iii) PPV was higher for digital mammography than for screen-film mammography (7.0% vs. 5.5%, respectively; p

Antecedentes: La versión española del CHIP-CE es la adaptación para uso en España del Child Health and Illness Profile, instrumento de medida de salud autopercibida infantil (6-12 años de edad) genérico e ilustrado creado por la profesora Barbara Starfield (EEUU). Los resultados obtenidos en la prueba piloto con la versión española del CHIP-CE/Child Report Form (CHIP-CE/CRF) permiten confirmar la capacidad de comprensión y la factibilidad de su uso a partir de los 6 años de edad. La versión española del CHIP-CE/CRF consta de 44 ítems distribuidos en 5 dimensiones (Satisfacción, Bienestar, Resistencia, Riesgos y Funciones). Tiene versión para padres, el CHIP-CE/Parent Report Form (CHIP-CE/PRF), de 75 ítems (cinco dimensiones y doce subdimensiones). También tiene versión para padres reducida compuesta por los mismos 44 ítems que la infantil. Todas estas versiones tienen una estructura paralela a su vez con la versión española para adolescentes permitiendo enlazar la medición de la salud autopercibida de la etapa infantil con la adolescencia (6-18 años). El reducido número de instrumentos pediátricos genéricos autoadministrados en niños 6-11/12 años de edad pone de manifiesto la necesidad de analizar la aceptabilidad, fiabilidad y validez de la versión española del CHIP-CE en nuestro contexto, comparar los resultados con el instrumento original norteamericano y analizar el acuerdo entre padres e hijos/as en la salud percibida de los niños/as de 6-12 años de edad. Método: Estudio transversal descriptivo de base poblacional. Para obtener una muestra de población general de niños/as de 6-12 años de edad escolarizados en educación primaria en la ciudad de Barcelona se llevó a cabo un diseño probabilístico basado en una muestra por conglomerados estratificada de forma proporcional siguiendo un proceso multietápico. Se seleccionó una submuestra de conveniencia de niños/as de 6-12 años de edad para llevar a cabo mediciones múltiples. Se administró la versión española del CHIP-CE, la infantil y la de padres. Se administró la versión española del Child Behaviour CheckList (CBCL) de Achenbach para padres, instrumento estandarizado para evaluar los problemas conductuales pediátricos. Resultados: La tasa de respuesta global de la versión española del CHIP-CE/CRF fue del 75% (n= 919) y de la versión española del CHIP-CE/PRF del 67% (n=871). Los resultados de la versión infantil fueron: consistencia interna >0,70 en 3 de las 5 dimensiones, coeficientes de correlación intraclase (CCI) para la estabilidad test-retest entre 0,69 a 0,80, análisis factorial confirmatorio que replicó el modelo original, los niños/as más pequeños puntuaron más elevado en Satisfacción que los niños/as mayores y las niñas puntuaron más bajo en Bienestar pero más elevado en Riesgos que los niños. La versión para padres no mostró efecto suelo, encontrándose efecto techo en 4 subdimensiones. Los resultados de fiabilidad fueron aceptables a nivel de dimensión (consistencia interna: 0,68-0,86; test-retest: 0,69-0,85). Las niñas pequeñas obtuvieron puntuaciones mejores en Satisfacción y Funciones que las niñas mayores siendo la puntuación en la dimensión Bienestar más baja (peor) en niños/as con un probable problema de salud mental (tamaño de efecto: 1,45). El grado de acuerdo entre padres-hijos/as fue bajo (CCI 0,22-0,37). Conclusiones: La versión española del CHIP-CE es un instrumento pediátrico de salud autopercibida de tipo genérico con coeficientes de validez conocidos y desarrollado según el modelo psicométrico clásico al replicarse el modelo conceptual y de métrica del instrumento original. Los resultados de bajo grado de acuerdo entre padres e hijos/as indican que el uso en paralelo de ambas versiones aporta una perspectiva multiinformante de una misma realidad. Financiación: Fondo de Investigación Sanitaria del Ministerio de Sanidad y Política Social español (contrato número 01/0420) y Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública., Background: The Spanish CHIP-CE is an adapted version of the CHIP-CE for use in Spain. The CHIP-CE is an instrument designed to collect self-reported and parent-reported information on the health of children aged 6 to 12. It is a multidimensional, generic, and illustrated measure created in the United States of America (US) by Professor Barbara Starfield. The results obtained in the pilot study with the Spanish CHIP-CE/Child Report Form (CHIP-CE/CRF) showed that it was feasible for use in children as young as 6. The Spanish version of the CHIP-CE/CRF includes 44 items organized into 5 domains (Satisfaction, Comfort, Resilience, Risk Avoidance, and Achievement). It also includes a parent version, the Spanish CHIP-CE/Parent Report Form (CHIP-CE/PRF), which comprises 75 items included in 5 domains and 12 subdomains. A short format of the Spanish CHIP-CE/PRF containing 44 items in parallel with the child version is also available. These versions have a parallel structure to the Spanish version for adolescents (CHIP-Adolescent Edition, CHIP-AE). There are only seven self-administered measures for the 6-11/12 year’s age range, one of which is the CHIP-CE. However, of these seven measures, only four have been adapted for use in Spain. This highlights the need to assess the acceptability, reliability, and validity of the Spanish version of the CHIP-CE for use in Spain to measure the perceived health of children 6-12 years old, to compare the results with the original US version, and to analyze parent-child agreement. Methods: Design: a Cross-sectional study. Sample selection: children 6-12 years of age and their parents selected to form a representative sample of primary school children from the city of Barcelona during the academic year 2002 to 2003 were invited to participate in this study. A probabilistic sampling selection was conducted following a 2-stage process, in which the primary sample units were schools. A convenience subsample of children was selected to perform multiple measurements. Measures: Spanish versions of CHIP-CE/CRF and CHIP-CE/PRF were administered to child and parents, respectively. The Spanish parent of the Achenbach Child Behavioral Checklist (CBCL) was administered to assess emotional and behavioral pediatric problems. Results: The Spanish version of the CHIP-CE/CRF: the overall response rate was 75% (n = 919). Internal consistency was >0.70 for 3 out of 5 domains, and the ICCs for test-retest stability ranged from 0.69 to 0.80. Confirmatory factor analysis replicated the original model. Younger children scored higher in satisfaction than older children. Girls scored lower in Comfort but higher in Risk Avoidance than boys. The Spanish version of the CHIP-CE/PRF: the overall response rate was 67% (n = 871). There was no floor effect. A ceiling effect was found in 4 subdomains. Reliability was acceptable at the domain level (internal consistency: 0.68-0.86; test-retest: 0.69-0.85). Younger girls had better scores on Satisfaction and Achievement than older girls. Comfort domain score was lower (worse) in children with a probable mental health problem, with high ES (1.45). The level of parent-child agreement was low (0.22-0.37). Conclusions: The Spanish version of the CHIP-CE has acceptable psychometric properties which meet the recommended standards of reliability and validity in a manner similar to that of the original US version. The low level of agreement observed between parents and children suggest that it may be necessary to use both versions in parallel. The study allows assessment from a multi-informant perspective. Financing: Fondo de Investigación Sanitaria of the Spanish Ministry of Health (contract Nº. 01/0420) and the Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública.

Durante las primeras décadas del s. XX se contempló un importante aumento de las enfermedades coronarias, este hecho estimuló la investigación sobre las causas de dichas enfermedades. En 1978, y para investigar este fenómeno se inició el estudio REGICOR en el Hospital Josep Trueta de Girona. En el s. XX también se contempló un creciente problema de contaminación de las atmósferas urbanas, esto hizo que diferentes científicos estudiaran las relaciones entre las enfermedades coronarias y la contaminación atmosférica en áreas urbanas (Godish, 1997; Krupa & Legge, 2000; Brook et al., 2004 y Krewski et al., 2004). El proyecto realizado está situado en el contexto del primer estudio realizado en España que investiga los efectos sobre la salud de la contaminación atmosférica (REGICOR 2000-AIR). En el proyecto se pretende investigar la influencia de diferentes factores (distancia de los tubos a la calle, altura de los tubos, anchura de la calle, tráfico y densidad de tráfico) sobre la contaminación atmosférica de las ciudades de Girona y Salt, con el fin de poder caracterizar lo mejor posible la exposición a contaminación atmosférica. Para este fin se utilizará el NO2 como marcador de contaminación atmosférica y se seleccionaran varios puntos de muestreo en las dos ciudades dónde se pondrán captadores de NO2 para la medición de dicha contaminación. Después, y mediante un análisis estadístico, se podrá determinar la influencia de los factores en la variación de concentración de NO2 en el área seleccionada. Durant les primeres dècades del s. XX es va observar un important augment de les malalties coronàries, fet va estimular la investigació sobre les causes d’aquestes malalties. Al 1978, y per investigar aquest fenomen es va iniciar l’estudi REGICOR a l’Hospital Josep Trueta de Girona. Durant el s. XX també es va observar un creixent problema de contaminació d’atmosferes urbanes, això va impulsar a diversos científics a estudiar les relacions entre les malalties cardiovasculars i la contaminació atmosfèrica en àrees urbanes (Godish 1997; Krupa & Legge, 2000; Brook et al., 2004 i Krewski et al., 2004). El projecte que s’ha realitzat se situa en el context del primer estudi realitzat a Espanya que investiga els efectes sobre la salut de la contaminació atmosfèrica (REGICOR 2000-AIR). Al projecte es pretén investigar la influència de diferents factors (distància dels tubs al carrer, amplada del carrer, trànsit y densitat de trànsit) sobre la contaminació atmosfèrica de les ciutats de Girona i Salt, amb la finalitat de poder caracteritzar el millor posible l’exposició a la contaminació atmosfèrica. Per aconseguir-ho s’utilitzarà el NO2 com a marcador de contaminació atmosfèrica i es seleccionaran diversos punts de mesura a les dos ciutats on s’instal·laran captadors de NO2 per poder realitzar la mesura. Després, y mitjançant un anàlisi estadístic, es podrà determinar la influència dels factors en la distribució de la concentració de NO2 a la zona d’estudi. During the first decades of 20th century has contemplated an important increase of the coronary diseases, that stimulated this research for the reasons mentioned above. In 1978, in order to investigate this phenomenon, Josep Trueta Hospital of Girona began a study called REGICOR. In the 20th century also has contemplated an increasing problem of pollution of the urban atmospheres, this did that different scientists were studying the relations between the coronary diseases and the atmospheric pollution in urban areas (Godish, 1997; Krupa and Legge, 2000; Brook et at., 2004 and Krewski et at., 2004). The project is placed in the context of the first study realized in Spain that investigates the effects on the health of the atmospheric pollution (REGICOR 2000-AIR). In the project one tries to investigate the influence of different factors (distance of the pipes to the street, width of the street, traffic and density of traffic) on the atmospheric pollution of the cities of Girona and Salt, in order the possible better(best) thing is able to characterize the exhibition to atmospheric pollution. For this purpose the NO2 will be in use as scoreboard of atmospheric pollution and several points of the sample were selected in both cities where they will put on captators of NO2 for the measurement of the above mentioned pollution. Later, and by means of a statistical analysis, it will be possible to determine the influence of the factors in the variation of concentration of NO2 in the selected area.

El presente proyecto es un estudio epidemiológico transversal, con el propósito de describir la exposición a la contaminación petrolera y el estado de salud de una Comuna indígena de etnia shuar en la provincia de Sucumbíos, Región Amazónica Ecuatoriana.