Variability in the performance of preventive services and in the degree of control of identified health problems: A primary care study protocol

Background: Preventive activities carried out in primary care have important variability that makes necessary to know which factors have an impact in order to establish future strategies for improvement. The present study has three objectives: 1) To describe the variability in the implementation of 7 preventive services (screening for smoking status, alcohol abuse, hypertension, hypercholesterolemia, obesity, influenza and tetanus immunization) and to determine their related factors; 2) To describe the degree of control of 5 identified health problems (smoking, alcohol abuse, hypertension, hypercholesterolemia and obesity); 3) To calculate intraclass correlation coefficients. Design: Multi-centered cross-sectional study of a randomised sample of primary health care teams from 3 regions of Spain designed to analyse variability and related factors of 7 selected preventive services in years 2006 and 2007. At the end of 2008, we will perform a cross-sectional study of a cohort of patients attended in 2006 or 2007 to asses the degree of control of 5 identified health problems. All subjects older than16 years assigned to a randomised sample of 22 computerized primary health care teams and attended during the study period are included in each region providing a sample with more than 850.000 subjects. The main outcome measures will be implementation of 7 preventive services and control of 5 identified health problems. Furthermore, there will be 3 levels of data collection: 1) Patient level (age, gender, morbidity, preventive services, attendance); 2) Health-care professional level (professional characteristics, years working at the team, workload); 3) Team level (characteristics, electronic clinical record system). Data will be transferred from electronic clinical records to a central database with prior encryption and dissociation of subject, professional and team identity. Global and regional analysis will be performed including standard analysis for primary health care teams and health-care professional level. Linear and logistic regression multilevel analysis adjusted for individual and cluster variables will also be performed. Variability in the number of preventive services implemented will be calculated with Poisson multilevel models. Team and health-care professional will be considered random effects. Intraclass correlation coefficients, standard error and variance components for the different outcome measures will be calculated

Diagnosis and clinical behavior in patients with Lynch-like syndrome

Introduction and aims: Lynch-like syndrome is diagnosed when there is an expression deficit in DNA mismatch repair proteins but a normal genetic study. The behavior and management of that pathology are currently a subject of debate. We present herein the characteristics of patients with Lynch-like syndrome, together with a surveillance proposal. Materials and methods: Immunohistochemistry was carried out on families suspected of presenting with Lynch syndrome. Germline analysis was done if there was loss of mismatch repair protein expression and no BRAF mutation. Results: Of the 148 patients that underwent immunohistochemistry testing, 23 presented with loss of mismatch repair protein expression. Seven of those patients were identified as having Lynch-like syndrome: 3 had colon cancer, 2 had endometrial tumor, and 2 were healthy, with an affected relative. Mean patient age was 56.9 years and only one patient presented with another tumor associated with Lynch syndrome. Conclusions: Until there is a better understanding of the etiology of that heterogeneous entity, intermediate surveillance is an adequate strategy. Resumen: Introducción y objetivos: La sospecha de síndrome de Lynch sin mutación conocida (SSL) se diagnostica cuando existe déficit de expresión de las proteínas reparadoras de ADN pero con estudio genético normal. El comportamiento y el manejo son controvertidos. Presentamos las características de pacientes con SSL y proponemos una vigilancia. Material y métodos: Se realiza análisis inmunohistoquímico (IMH) en familias con sospecha de síndrome de Lynch. Si existe pérdida de expresión, sin mutación BRAF, se procede al análisis germinal. Resultados: De ciento cuarenta y ocho pacientes en los que se realizó IMH, 23 presentaron pérdida de expresión. Siete fueron identificados como SSL: 3 con cáncer de colon, 2 con tumor endometrial y otros 2 sanos con familiar afectado. La edad media fue de 56.9 años y solo uno presentó otro tumor asociado al síndrome de Lynch. Conclusiones: Hasta que conozcamos mejor la etiología de esta entidad heterogénea, una vigilancia intermedia sería una estrategia adecuada. Keywords: Suspected Lynch syndrome, Immunohistochemistry, Genetic analysis, Risk for cancer, Surveillance, Palabras clave: Sospecha de síndrome de Lynch, Inmunohistoquímica, Análisis genético, Riesgo de cáncer, Vigilanci

Diagnóstico y comportamiento clínico de pacientes con sospecha de síndrome de Lynch sin mutación conocida

Resumen: Introducción y objetivos: La sospecha de síndrome de Lynch sin mutación conocida (SSL) se diagnostica cuando existe déficit de expresión de las proteínas reparadoras de ADN pero con estudio genético normal. El comportamiento y el manejo son controvertidos. Presentamos las características de pacientes con SSL y proponemos una vigilancia. Material y métodos: Se realiza análisis inmunohistoquímico (IMH) en familias con sospecha de síndrome de Lynch. Si existe pérdida de expresión, sin mutación BRAF, se procede al análisis germinal. Resultados: De ciento cuarenta y ocho pacientes en los que se realizó IMH, 23 presentaron pérdida de expresión. Siete fueron identificados como SSL: 3 con cáncer de colon, 2 con tumor endometrial y otros 2 sanos con familiar afectado. La edad media fue de 56.9 años y solo uno presentó otro tumor asociado al síndrome de Lynch. Conclusiones: Hasta que conozcamos mejor la etiología de esta entidad heterogénea, una vigilancia intermedia sería una estrategia adecuada. Abstract: Introduction and aims: Lynch-like syndrome is diagnosed when there is an expression deficit in DNA mismatch repair proteins but a normal genetic study. The behavior and management of that pathology are currently a subject of debate. We present herein the characteristics of patients with Lynch-like syndrome, together with a surveillance proposal. Materials and methods: Immunohistochemistry was carried out on families suspected of presenting with Lynch syndrome. Germline analysis was done if there was loss of mismatch repair protein expression and no BRAF mutation. Results: Of the 148 patients that underwent immunohistochemistry testing, 23 presented with loss of mismatch repair protein expression. Seven of those patients were identified as having Lynch-like syndrome: 3 had colon cancer, 2 had endometrial tumor, and 2 were healthy, with an affected relative. Mean patient age was 56.9 years and only one patient presented with another tumor associated with Lynch syndrome. Conclusions: Until there is a better understanding of the etiology of that heterogeneous entity, intermediate surveillance is an adequate strategy. Palabras clave: Sospecha de síndrome de Lynch, Inmunohistoquímica, Análisis genético, Riesgo de cáncer, Vigilancia, Keywords: Suspected Lynch syndrome, Immunohistochemistry, Genetic analysis, Risk for cancer, Surveillanc