Regionalización en la atención de cáncer de cabeza y cuello: Concepto y consideraciones / Regionalization of care in head and neck cancer: Concept and considerations

Resumen El cáncer de cabeza y cuello es una enfermedad infrecuente, con un manejo tanto médico como quirúrgico complejo. La regionalización o centralización de la atención, definida como la concentración de pacientes con enfermedades complejas, en instituciones que presenten equipos multidisciplinarios con mayor experiencia y altamente funcionales, puede ser una alternativa viable para lograr mejores resultados oncológicos. Actual-mente existe evidencia que avala esta estrategia, dando cuenta de mejores resultados oncológicos en centros con un mayor volumen; que tengan una mayor adherencia a guías clínicas basadas en la evidencia y a indicadores de calidad; y que presenten un equipo multidisciplinario a cargo de la toma de decisiones en estos pacientes. La población de Ontario, Canadá, se enmarca como uno de los ejemplos de esta estrategia, consiguiendo mejorar sus resultados manteniendo un alto nivel de calidad en su manejo. El objetivo del presente artículo de revisión es sistematizar el conocimiento actual en relación con la centralización de la atención en oncología de cabeza y cuello y sus consecuencias en la práctica de la otorrinolaringología-cirugía de cabeza y cuello.

Abstract Head and neck cancer is an infrequent disease, with complex medical and surgical management. The regionalization of care, defined as the concentration of patients with complex diseases, in institutions that present highly experienced and highly functional multidiscipli-nary teams, may be an efficient alternative to achieve better oncological outcomes. Currently, there is evidence that supports this strategy, accounting for better oncological outcomes in institutions with higher volume; that have greater compliance to evidence-based guidelines and quality indicators; and that present a multidisciplinary team in charge of the decision-making process in these patients. The population of Ontario, Canada, is framed as one of the examples of this strategy, managing to improve its results while maintaining a high level of quality in its management. The aim of this review paper is to systematize the current knowledge regarding head and neck regionalization of cancer care and its impact in the practice of otolaryngology-head and neck surgery.

Impacto de la pandemia COVID-19 en las consultas de urgencias otorrinolaringológicas en el Hospital Guillermo Grant Benavente de Concepción / Impact of the COVID-19 pandemic on emergency ENT consultations at Guillermo Grant Benavente Hospital, Concepcion

Resumen Introducción: La pandemia COVID-19 ha afectado significativamente el uso de los sistemas de salud en todo el mundo y se han reducido las consultas de urgencia por patologías no relacionadas con el virus SARS-CoV-2. Objetivo: Analizar el impacto de la pandemia COVID-19 en las consultas de urgencia otorrinolaringológicas atendidas en el servicio de urgencia de un centro de alta complejidad. Material y Método: Se realizó un estudio retrospectivo en que se analizaron las consultas de urgencia otorrinolaringológicas atendidas entre el 3 de marzo y 31 de diciembre de 2020. Se comparó con los datos obtenidos el año 2019 para determinar los cambios epidemiológicos de la pandemia en curso. Resultados: Se evidenció una notoria disminución en las atenciones de urgencia otorrinolaringológicas desde el inicio de la pandemia COVID-19 (-23,3%). El mayor descenso se observó en el periodo de cuarentena o restricción total de movilidad (-59%). No hubo diferencias significativas entre los antecedentes sociodemográficos, tipo de patología otorrinolaringológica, número de cirugías de urgencias y admisiones hospitalarias en comparación con el periodo anterior. Conclusión: La pandemia COVID-19 ha generado una disminución de las consultas de urgencia otorrinolaringológicas agudizándose en el periodo de restricción total de movilidad impuesta por el gobierno. Si bien no se evidenciaron cambios en el patrón de atenciones predominante con respecto al periodo prepandemia, se estima un aumento de las patologías descompensadas o complicadas a mediano-largo plazo. Se requieren estudios prospectivos para determinar el verdadero impacto de la pandemia en curso.

Abstract Introduction: The COVID-19 pandemic has significantly affected the use of health systems around the world, and emergency consultations for diseases not related to the SARS-CoV-2 virus, have been reduced. Aim: To analyze the impact of the COVID-19 pandemic on emergency otolaryngology consultations attended in the emergency department of a highly complex center. Material and Method: A retrospective study was carried out in which the emergency otolaryngology consultations attended between March 3 and December 31, 2020. These data were analyzed and compared with the data obtained in 2019, to determine the epidemiological changes of the ongoing pandemic. Results: There was a noticeable decrease in ENT emergency care since the beginning of the COVID-19 pandemic (-23.3%). The greatest decrease is recorded in the period of quarantine or total mobility restriction (-59%). There were no significant differences between sociodemographic history, type of ENT pathology, number of emergency surgeries and hospital admissions compared to the previous period. Conclusion: The COVID-19 pandemic has generated a decrease in ENT emergency consultations, exacerbating the period of total mobility restriction imposed by the government. Although no changes were evidenced in the predominant care pattern with respect to the pre-pandemic period, an increase in decompensated or complicated pathologies is estimated in the medium-long term. Prospective studies are required to determine the true impact of the ongoing pandemic.

Predictive factors for prolonged hospital stay after retropubic radical prostatectomy in a high-volume teaching center

ABSTRACT Objective: To evaluate the length hospital stay and predictors of prolonged hospitalization after RRP performed in a high-surgical volume teaching institution, and analyze the rate of unplanned visits to the office, emergency care, hospital readmissions and perioperative complications rates. Materials and Methods: Retrospective analysis of prospectively collected data in a standardized database for patients with localized prostate cancer undergoing RRP in our institution between January/2010 - January/2012. A logistic regression model including preoperative variables was initially built in order to determine the factors that predict prolonged hospital stay before the surgical procedure; subsequently, a second model including both pre and intraoperative variables was analyzed. Results: 1011 patients underwent RRP at our institution were evaluated. The median hospital stay was 2 days, and 217 (21.5%) patients had prolonged hospitalization. Predictors of prolonged hospital stay among the preoperative variables were ICC (OR. 1.40 p=0.003), age (OR 1.050 p<0.001), ASA score of 3 (OR. 3.260 p<0.001), prostate volume on USG-TR (OR, 1.005 p=0.038) and African-American race (OR 2.235 p=0.004); among intra and postoperative factors, operative time (OR 1.007 p=0.022) and the presence of any complications (OR 2.013 p=0.009) or major complications (OR 2.357 p=0.01) were also correlated independently with prolonged hospital stay. The complication rate was 14.5%. Conclusions: The independent predictors of prolonged hospitalization among preoperative variables were CCI, age, ASA score of 3, prostate volume on USG-TR and African-American race; amongst intra and postoperative factors, operative time, presence of any complications and major complications were correlated independently with prolonged hospital stay.

The Association of Hospital Volume of Percutaneous Coronary Intervention with Cardiac Mortality / 보건행정학회지

BACKGROUND: This study investigates the potential volume and outcome association of coronary heart disease (CHD) patients who have undergone percutaneous coronary intervention (PCI) using a large and representative sample. METHODS: We used a National Health Insurance Service-Cohort Sample Database from 2002 to 2013 released by the Korean National Health Insurance Service. A total of 8,908 subjects were analyzed. The primary analysis was based on Cox proportional hazards models to examine our hypothesis. RESULTS: After adjusting for confounders, the hazard ratio of thirty-day and 1-year mortality in hospitals with a low volume of CHD patients with PCI was 2.8 and 2.2 times higher (p=0.00) compared to hospitals with a high volume of CHD patients with PCI, respectively. Thirty-day and 1-year mortality of CHD patients with PCI in low-volume hospitals admitted through the emergency room were 3.101 (p=0.00) and 2.8 times higher (p=0.01) than those in high-volume hospitals, respectively. Only 30-day mortality in low-volume hospitals of angina pectoris and myocardial infarction patients with PCI was 5.3 and 2.4 times those in high-volume hospitals with PCI, respectively. CONCLUSION: Mortality was significantly lower when PCI was performed in a high-volume hospital than in a low-volume hospital. Among patients admitted through the emergency room and diagnosed with angina pectoris, total PCI volume (low vs. high) was associated with significantly greater cardiac mortality risk of CHD patients. Thus, There is a need for better strategic approaches from both clinical and health policy standpoints for treatment of CHD patients.

Effects of Physician Volume on Readmission and Mortality in Elderly Patients with Heart Failure: Nationwide Cohort Study

PURPOSE: Readmission and mortality rates of patients with heart failure are good indicators of care quality. To determine whether hospital resources are associated with care quality for cardiac patients, we analyzed the effect of number of physicians and the combined effects of number of physicians and beds on 30-day readmission and 1-year mortality. MATERIALS AND METHODS: We used national cohort sample data of the National Health Insurance Service (NHIS) claims in 2002–2013. Subjects comprised 2345 inpatients (age: >65 years) admitted to acute-care hospitals for heart failure. A multivariate Cox regression was used. RESULTS: Of the 2345 patients hospitalized with heart failure, 812 inpatients (34.6%) were readmitted within 30 days and 190 (8.1%) had died within a year. Heart-failure patients treated at hospitals with low physician volumes had higher readmission and mortality rates than high physician volumes [30-day readmission: hazard ratio (HR)=1.291, 95% confidence interval (CI)=1.020–1.633; 1-year mortality: HR=2.168, 95% CI=1.415–3.321]. Patients admitted to hospitals with low or middle bed and physician volume had higher 30-day readmission and 1-year mortality rates than those admitted to hospitals with high volume (30-day readmission: HR=2.812, 95% CI=1.561–5.066 for middle-volume beds & low-volume physicians, 1-year mortality: HR=8.638, 95% CI=2.072–36.02 for middle-volume beds & low-volume physicians). CONCLUSION: Physician volume is related to lower readmission and mortality for heart failure. Of interest, 30-day readmission and 1-year mortality were significantly associated with the combined effects of physician and institution bed volume.

What Matters in the Performance of a Medial Institution?

No abstract available.

Rapid Response Systems Reduce In-Hospital Cardiopulmonary Arrest: A Pilot Study and Motivation for a Nationwide Survey / 대한중환자의학회지

BACKGROUND: Early recognition of the signs and symptoms of clinical deterioration could diminish the incidence of cardiopulmonary arrest. The present study investigates outcomes with respect to cardiopulmonary arrest rates in institutions with and without rapid response systems (RRSs) and the current level of cardiopulmonary arrest rate in tertiary hospitals. METHODS: This was a retrospective study based on data from 14 tertiary hospitals. Cardiopulmonary resuscitation (CPR) rate reports were obtained from each hospital to include the number of cardiopulmonary arrest events in adult patients in the general ward, the annual adult admission statistics, and the structure of the RRS if present. RESULTS: Hospitals with RRSs showed a statistically significant reduction of the CPR rate between 2013 and 2015 (odds ratio [OR], 0.731; 95% confidence interval [CI], 0.577 to 0.927; P = 0.009). Nevertheless, CPR rates of 2013 and 2015 did not change in hospitals without RRS (OR, 0.988; 95% CI, 0.868 to 1.124; P = 0.854). National university-affiliated hospitals showed less cardiopulmonary arrest rate than private university-affiliated in 2015 (1.92 vs. 2.40; OR, 0.800; 95% CI, 0.702 to 0.912; P = 0.001). High-volume hospitals showed lower cardiopulmonary arrest rates compared with medium-volume hospitals in 2013 (1.76 vs. 2.63; OR, 0.667; 95% CI, 0.577 to 0.772; P < 0.001) and in 2015 (1.55 vs. 3.20; OR, 0.485; 95% CI, 0.428 to 0.550; P < 0.001). CONCLUSIONS: RRSs may be a feasible option to reduce the CPR rate. The discrepancy in cardiopulmonary arrest rates suggests further research should include a nationwide survey to tease out factors involved in in-hospital cardiopulmonary arrest and differences in outcomes based on hospital characteristics.

Rapid Response Systems Reduce In-Hospital Cardiopulmonary Arrest: A Pilot Study and Motivation for a Nationwide Survey / 대한구급학회지

BACKGROUND: Early recognition of the signs and symptoms of clinical deterioration could diminish the incidence of cardiopulmonary arrest. The present study investigates outcomes with respect to cardiopulmonary arrest rates in institutions with and without rapid response systems (RRSs) and the current level of cardiopulmonary arrest rate in tertiary hospitals. METHODS: This was a retrospective study based on data from 14 tertiary hospitals. Cardiopulmonary resuscitation (CPR) rate reports were obtained from each hospital to include the number of cardiopulmonary arrest events in adult patients in the general ward, the annual adult admission statistics, and the structure of the RRS if present. RESULTS: Hospitals with RRSs showed a statistically significant reduction of the CPR rate between 2013 and 2015 (odds ratio [OR], 0.731; 95% confidence interval [CI], 0.577 to 0.927; P = 0.009). Nevertheless, CPR rates of 2013 and 2015 did not change in hospitals without RRS (OR, 0.988; 95% CI, 0.868 to 1.124; P = 0.854). National university-affiliated hospitals showed less cardiopulmonary arrest rate than private university-affiliated in 2015 (1.92 vs. 2.40; OR, 0.800; 95% CI, 0.702 to 0.912; P = 0.001). High-volume hospitals showed lower cardiopulmonary arrest rates compared with medium-volume hospitals in 2013 (1.76 vs. 2.63; OR, 0.667; 95% CI, 0.577 to 0.772; P < 0.001) and in 2015 (1.55 vs. 3.20; OR, 0.485; 95% CI, 0.428 to 0.550; P < 0.001). CONCLUSIONS: RRSs may be a feasible option to reduce the CPR rate. The discrepancy in cardiopulmonary arrest rates suggests further research should include a nationwide survey to tease out factors involved in in-hospital cardiopulmonary arrest and differences in outcomes based on hospital characteristics.

Esophageal carcinoma: is squamous cell carcinoma different disease compared to adenocarcinoma? A transversal study in a quaternary high volume hospital in Brazil

ABSTRACT Background Esophageal cancer is one of the leading causes of mortality among the neoplasms that affect the gastrointestinal tract. There are several factors that contribute for development of an epidemiological esophageal cancer profile in a population. Objective This study aims to describe both clinically and epidemiologically the population of patients with diagnosis of esophageal cancer treated in a quaternary attention institute for cancer from January, 2009 to December, 2011, in Sao Paulo, Brazil. Methods The charts of all patients diagnosed with esophageal cancer from January, 2009, to December, 2011, in a Sao Paulo (Brazil) quaternary oncology institute were retrospectively reviewed. Results Squamous cell cancer made up to 80% of the cases of esophageal cancer. Average age at diagnosis was 60.66 years old for esophageal adenocarcinoma and 62 for squamous cell cancer, average time from the beginning of symptoms to the diagnosis was 3.52 months for esophageal adenocarcinoma and 4.2 months for squamous cell cancer. Average time for initiating treatment when esophageal cancer is diagnosed was 4 months for esophageal adenocarcinoma and 4.42 months for squamous cell cancer. There was a clear association between squamous cell cancer and head and neck cancers, as well as certain habits, such as smoking and alcoholism, while adenocarcinoma cancer showed more association with gastric cancer and gastroesophageal reflux disease. Tumoral bleeding and pneumonia were the main causes of death. No difference in survival rate was noted between the two groups. Conclusion Adenocarcinoma and squamous cell carcinoma are different diseases, but both are diagnosed in advanced stages in Brazil, compromising the patients' possibilities of cure.

RESUMO Contexto Câncer esofágico é uma das principais causas de morte por câncer dentre as neoplasias do trato gastrointestinal. Há diversos fatores que contribuem para o desenvolvimento de um perfil epidemiológico de câncer de esôfago em uma população. Objetivo Este estudo visa descrever tanto clínica quanto epidemiologicamente a população de pacientes com diagnóstico de câncer esofágico tratados em um instituto quaternário de atendimento ao câncer desde janeiro de 2009 a dezembro de 2011, em São Paulo, Brasil. Métodos Os prontuários de todos os pacientes diagnosticados com câncer de esôfago de janeiro de 2009 a dezembro de 2011 em um Instituto quaternário de tratamento oncológico foram revisados retrospectivamente. Resultados Carcinoma epidermóide foi responsável por 80% dos diagnósticos de câncer esofágico. Idade média ao diagnóstico foi de 60 anos para adenocarcinoma (EA) e 62 para carcinoma epidermóide e o tempo médio entre início dos sintomas até o diagnóstico foi de 3,52 meses para adenocarcinoma e 4,2 para carcinoma epidermóide. O tempo médio para iniciar tratamento foi de 4 meses para adenocarcinoma e 4,42 meses para carcinoma epidermóide. Houve uma clara associação entre carcinoma epidermóide e neoplasias de cabeça e pescoço, bem como com alguns hábitos, tais como tabagismo e etilismo. Adenocarcinoma, por sua vez, mostrou-se associado a câncer gástrico e doença do refluxo gastroesofágico. Sangramento tumoral e pneumonia foram as principais causas de morte para ambos os tipos de câncer. Não foi observada diferença na sobrevida entre os dois grupos. Conclusão Adenocarcinoma e carcinoma epidermóide são doenças diferentes, mas ambas ainda são diagnosticadas em estados avançados no Brasil, comprometendo a possibilidade de cura dos pacientes.

Current Status and Challenges of Cancer Clinical Trials in Korea / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Cancer clinical trials in Korea have rapidly progressed in terms of quantity and quality during the last decade. This study evaluates the current status of cancer clinical trials in Korea and their associated problems. MATERIALS AND METHODS: We analyzed the clinical trials approved by the Korea Food and Drug Administration (KFDA) between 2007 and 2013. A nationwide on-line survey containing 22 questions was also performed with several cooperative study groups and individual researchers in 56 academic hospitals. RESULTS: The number of cancer clinical trials approved by the KFDA increased almost twofold from 2007 to 2013. The number of sponsor-initiated clinical trials (SITs) increased by 50% and investigator-initiated clinical trials (IITs) increased by almost 640%. Three hundred and forty-four clinical trials were approved by the KFDA between 2012 and 2013. At the time of the on-line survey (August 2013), 646 SITs and 519 IITs were ongoing in all hospitals. Six high volume hospitals were each conducting more than 50 clinical trials, including both SITs and IITs. Fifty-six investigators (31%) complained of the difficulties in raising funds to conduct clinical trials. CONCLUSION: The number of cancer clinical trials in Korea rapidly increased from 2007 to 2013, as has the number of multicenter clinical trials and IITs run by cooperative study groups. Limited funding for IIT is a serious problem, and more financial support is needed both from government agencies and public donations from non-profit organizations.

Perfil epidemiológico dos pacientes atendidos pelo serviço de cirurgia plástica do hospital João XXIII em Belo Horizonte/MG no período de março à agosto de 2013 / Epidemiological profile of patients treated by the plastic surgery service of the João XXIII hospital in Belo Horizonte/MG from March to August 2013

Introdução: O Serviço de Cirurgia Plástica Programada do Hospital João XXIII exerce o suporte às demais especialidades através de inter-consultas e, realiza atendimento aos pacientes com entrada no Hospital pela cirurgia plástica. O escopo deste estudo foi analisar o perfil epidemiológico dos pacientes atendidos durante o período de Março à Agosto de 2013. Métodos: Trata-se de um estudo observacional prospectivo com coleta de dados realizada através de anamnese e exame físico. Resultados: Dentre os pacientes avaliados 75,23% eram do sexo masculino e 21,34% do sexo feminino. A faixa etária predominante foi a economicamente ativa com 62,86% dos pacientes entre 16 e 45 anos. Foi observado que os acidentes de trânsito figuraram como os principais determinantes de atendimentos (44,85%). As escaras constituíram os diagnósticos mais frequentes e dentre as outras lesões avaliadas, observou-se que se concentraram nos membros. A Clínica Médica e a Ortopedia solicitaram o maior número de inter-consultas. Evidenciou-se que o tratamento através de abordagem cirúrgica (52,9%) e o acompanhamento com cuidados locais (47,1%) apresentaram frequências aproximadas. Conclusão: Na busca por propor medidas para prevenir e tratar as lesões próprias de abrangência da cirurgia plástica reparadora destacaram-se dois pontos: os acidentes de trânsito e as escaras de decúbito. Ambos com fatores determinantes bem elucidados, porém mantendo alta prevalência. Torna-se evidente a necessidade de atuação nas esferas públicas para uma melhor educação no trânsito e redução da ocorrência de acidentes. No âmbito hospitalar é primordial que se adotem medidas eficazes que impeçam o surgimento das temíveis escaras de decúbito.

Introduction: The Plastic Surgery Service of the João XXIII Hospital provides support to other specialties through interdepartmental consultation and follows patients admitted to the hospital for plastic surgery. This study analyzed the epidemiological profile of patients treated from March to August 2013. Methods: This was a prospective observational study with data collection performed by medical history and physical examination. Results: Of the patients evaluated, 75.23% were male and 21.34% female. The predominant age group was economically active, with 62.86% of the patients between 16 and 45 years. Traffic accidents were the main reason for care (44.85%). Pressure ulcers were the most frequent diagnoses, and other lesions evaluated were predominantly of the extremities. Internal Medicine and Orthopedics requested most consultations. Surgical treatment (52.9%) and follow-up with local care (47.1%) showed similar frequencies. Conclusion: In order to propose measures for prevention and treatment of injuries within the scope of reconstructive plastic surgery, two issues were highlighted: traffic accidents and pressure ulcers. Both have well-defined causes, but remain at high prevalence. The need for public action that promotes better traffic education and reduction of accidents is clear. In the hospital environment, it is essential to take effective measures to prevent the emergence of dreaded pressure ulcers.

Relationship between Percutaneous Transluminal Coronary Angioplasty Volume and Associated Immediate Outcome / 예방의학회지

OBJECTIVES: To explore the relationship between Percutaneous Transluminal Coronary Angioplasty (PTCA) volume and the associated immediate outcome. METHODS: A total of 1,379 PTCAs were performed in 25 hospitals in Korea between October 1 and December 31 in 1997. Data from 1,317 PTCAs (95.5%) were collected through medical record abstraction. Inter-observer reliability of the data was examined using the Kappa statistic on a subsample of 110 PTCA procedures from five hospitals. Intra-observer reliability of the data was also examined. PTCA success and immediate adverse outcomes were selected as the outcome variables. A successful PTCA was defined as a case that shows less than 50% diameter stenosis and more than 20% reduction of diameter stenosis. Immediate adverse outcomes included deaths during the same hospitalization, emergency coronary artery bypass graft (CABG) within 24 hours after PTCA, and acute myocardial infarction within 24 hours after PTCA. The numbers of PTCAs performed in 1997 per hospital were used as the volume variables. RESULTS: Without adjusting for patient risk factors that may affect outcomes, procedures at high volume hospitals (200 cases per year) had a greater success rate (P=0.001) than low volume hospitals. There was a marginally significant difference (P=0.070) in major adverse outcome rates between high and low volume hospitals. After adjusting for risk factors, there were significant differences in procedural failure and major adverse outcome rates between high and low volume hospitals. CONCLUSIONS: After adjusting for patient clinical risk factors, the hospital volume of PTCA was associated with immediate outcomes. It is recommended that a PTCA volume per year be established in order to improve the immediate outcome of this procedure in Korea.