Los grupos de morbilidad ajustados: un debate pendiente / Adjusted morbidity groups: A pending debate

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Estimates of patient costs related with population morbidity: can indirect costs affect the results?

A number of health economics studies require patient cost estimates as basic information input. However, the accuracy of cost estimates remains generally unspecified. We propose to investigate how the allocation of indirect costs or overheads can affect the estimation of patient costs and lead to improvements in the analysis of patient cost estimates. Instead of focussing on the costing method, this paper will highlight observed changes in variation explained by a methodology choice. We compare four overhead allocation methods for a specific Spanish population adjusted using the Clinical Risk Groups model. Our main conclusion is that the amount of global variation explained by the risk adjustment model depends mainly on direct costs, regardless of the cost allocation methodology used. Furthermore, the variation explained can be slightly increased, depending on the cost allocation methodology, and is independent of the level of aggregation in the classification system.

Prognostic significance of surgical margins in transoral CO2 laser microsurgery for T1-T4 pharyngo-laryngeal cancers.

Histological affected or close margin is an adverse factor in conventional surgery of larynx-hypopharynx cancer. Our objective was to analyze the relevance of the margins in transoral laser microsurgery (TLM). A retrospective study of 357 consecutive patients with cancer of the larynx and hypopharynx (T1-T4) treated with TLM. Three possible margins were considered: tumor free, affected, and uncertain. An affected margin showed marked tumor infiltration. An uncertain margin was defined when the sample was insufficient, when it showed carbonization impeding accurate evaluation, or when tumor cells were less than 2 mm. Margins were free in 254 (71.1%) patients, affected in 64 (17.9%) and uncertain in 39 (10.9%). One hundred and three patients (28.9%) presented tumor relapse. The margins were associated with tumor relapse (P < 0.001), but were not significantly related to the tumor site (P = 0.307), the pT classification (P = 0.183), or the difficulty of surgical exposure (P = 0.427). Distant metastases were found in 4.7% of the patients with free margins, in 7.7% of those with uncertain margins, and in 14.1% with affected margins. These differences were statistically significant (P = 0.028). Tumor involvement of the surgical margin was associated with higher rates of local relapse, distant metastasis and the necessity of salvage surgery, together with a lower specific actuarial survival rate.

Preliminary functional results of tympanoplasty with titanium prostheses.

OBJECTIVE: To assess the use of titanium prostheses in tympanoplasty for reconstruction of the sound pressure and to evaluate the audiometric results obtained. STUDY DESIGN AND SETTING: and patients Retrospective chart review in a tertiary referral center. Between September 1998 and October 2000, 23 titanium middle ear implants (23 TORP) were used for reconstruction of the ossicular chain after tympanomastoidectomy. Preliminary functional results were obtained in 23 cases. RESULTS: Average follow-up time was 18 months (range, 12-40) and no adverse reactions or extrusions occurred. Seven of 16 canal wall down tympanoplasties (43.7%), and 3 of 7 canal wall up tympanoplasties performed (42.9%) had a postoperative air-bone gap of between 0 and 10 dB. CONCLUSIONS: Preliminary results show that titanium prosthesis provide a promising hearing result after total ossicular reconstruction, although long-term results are not yet available. The low weight of these prostheses may be the reason for the decrease in the air-bone gap.

Hacia la definición de un conjunto mínimo básico de datos de atención primaria / Towards the definition of a set of basic minimun data in primary care

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Metástasis de origen sistémico en Otorrinolaringología / Metastases of systemic origin in Otorhinolaryngology

Introducción. En las vías aéreo-digestivas superiores el cáncer siempre es primitivo; éste cáncer es muy frecuente, pero existen cánceres secundarios de extrema rareza. Desarrollo. Se estudian los casos propios, algunos ya publicados: cánceres de riñón de cáncer de mama en hueso temporal y se revisa la bibliografía sobre estas raras metástasis. Conclusiones. Ante todo cáncer otorrinolaringológico hay que realizar una historia detallada del paciente sobre todo investigando anteriores neoplasias. Muy especialmente estudiar y revisar antecedentes de tumores renales de mama y de próstata en cuanto a tumor primitivo y en cuanto a órganos receptor de las metástasis, los senos paranasales y el hueso temporal. El problema difícil es cuando el tumor primitivo existe y no ha sido diagnosticado. Por ello, en todo cáncer de hueso temporal o de senos paranasales debemos antes de emprender ningún tratamiento, practicar un examen de riñón, próstata y mama y de todos los demás órganos supra o infradiafragmáticos en los que podamos sospechar una tumoración. El pronóstico de estas metástasis es muy malo, prácticamente siempre mortal, por lo que muchas veces en vez de tratamientos más agresivos serán sólo paliativos (AU)

[Bipolar disorder. Follow-up of lithium therapy in a clinic]. / Trastorno bipolar. Seguimiento en una clínica de litio.

Lithium carbonate is the drug of choice in the prophylactic treatment of bipolar disorder. The purpose of this article is to describe the effective functioning of lithium in a clinical way in our hospital under the control of university graduates in nursing. During the first ten months of its use, 40 patients have been included which led to 122 appointments, absenteeism being 8.62%. 20% (8/40) of the lithium intoxications at the start of the follow-up were inferior to 0.5% mmol/l while at the end, only 5.3% (2/38) fell below 0.5% mmol/l. The average of the lithium intoxications at the end of the study period was significantly higher than in the moment of entrance to the program (p = 0.009). During the study period, three relapses were registered.

[Metastasis of systemic origin in otorhinolaryngology]. / Metástasis de origen sistémico en otorrinolaringología.

INTRODUCTION: In the upper respiratory-digestive tract cancer is always primary. Such cancer is very common, but other extremely rare secondary cancers may be found. DEVELOPMENT: We studied our own patients and some published in the literature: cancer of the kidney with metastases in the paranasal sinuses and cancer of the breast metastasizing to the temporal bone. We review the bibliography on these rare metastases. CONCLUSIONS: In all cases of otorhinolaryngological cancer a detailed history should be taken, with special reference to previous neoplasms. It is particularly important to study and review any history of renal, breast or prostate tumors with regard to the primary tumor and the receptor organs of metastases, the paranasal sinuses and temporal bones. The most difficult problem occurs when the primary tumor is present but undiagnosed. Therefore, in all cases of cancer of the paranasal sinuses and temporal bones, before treatment is started the kidney, prostate, breast and other organs above and below the diaphragm where tumor may be present should be examined. The prognosis of these metastases, which are almost always fatal, is very poor so that often treatment is only palliative rather than aggressive.

[Evaluation of the possible ototoxicity of josamycin by high frequency audiometry]. / Evaluacíon de la posible ototoxicidad de la josamicina mediante audiometría de alta frecuencia.

Josamycin is an antibiotic macrolide similar to erythromycin, with some differences in its biologic behaviour. There have been no reports of ototoxic effects caused by this drug, but its similitudes with erythromycin have prompted us to undertake a study about its possible cochleo-toxicity. Most trials of this kind have been carried out using conventional audiometry (up to 8,000 Hz), thus not being able to detect threshold shifts above this frequency. Ototoxic lesions usually begin in the upper frequency limit. Twenty-eight patients without previous auditory impairment were studied with conventional (up to 8,000 Hz) and high-frequency audiometry (up to 20,000 Hz) before and after oral treatment with josamycin during eight days. No significant differences were found in auditory thresholds registered before and after treatment in any of the patients. These results suggest that josamycin is devoid of any cochleo-toxic effect in all the frequencies that a normal subject can hear.