Spatial and temporal variations in Spain in the standardised ratio of in-hospital mortality due to colorectal cancer, 2008-2014.

BACKGROUND: Colorectal cancer (CRC) is the second cause of tumour mortality in Spain and Europe. To date, no studies have been conducted in Spain to evaluate the spatial and temporal distribution of the excess risk of death during hospitalisation for CRC. METHODS: A cohort was constructed of all episodes of hospitalisation in Spain due to CRC (codes 153 and 154 of the International Classification of Diseases, 9th edition, Clinical Modification) during the period 2008-2014, based on the minimum basic data set published by the Ministry of Health. Mortality ratios were calculated per region for each of the years analyzed (spatial or cross-sectional analysis) and during the overall study period, for each region independently (temporal or longitudinal analysis). In the first of these analyses, particular note was taken of the regions and years in which the limits of two and three standard deviations were exceeded. RESULTS: Two hundred and fifty eight thousand, nine hundred and twenty seven episodes of CRC were analysed. The patients were predominantly male (60.6%), with an average hospital stay of 13.16 days. Half underwent surgery during admission and on average presented more than six diagnoses at discharge. The spatial analysis revealed mortality ratios that deviated by at least three standard deviations in the following regions: Islas Canarias, Asturias, Valencia, Extremadura, País Vasco and Andalucía. The longitudinal analysis showed that most regions presented one or more years when CRC mortality was at least 15% higher than expected during the period; outstanding in this respect were Asturias, Navarra and La Rioja, where this excess risk was detected in at least 2 years. CONCLUSIONS: Geographic and temporal patterns of the distribution of the excess risk of mortality from CRC in Spain are described using SMRs. We conclude that during the study period, the geographic pattern of mortality in Spain did not coincide with the excess risk of mortality calculated using the SMR method described by Jarman and Foster. This method of risk estimation can be a useful tool for the study of mortality risk and its spatial variations.

Cajal's first steps in scientific research.

More than 125 years ago, Santiago Ramón y Cajal was able to draft and prove the neuron doctrine, and later, to develop prophetic theories about neural function and plasticity, many of which have been proven by current neuroscience. It was chance that made Cajal, during his doctorate studies, have his first contact with histology and force him to study the then current theories about pathogenesis of inflammation. Thus, he gained knowledge of the vascular hypothesis, by Julius Cohnheim, a German pathologist who, opposing the opinion of his teacher and father of cellular pathology, Rudolf Virchow, made leukocytes the protagonists of inflammation, given their ability to develop ameboid movements directed by chemical signals. Cohnheim's chemotactic theory deeply influenced Cajal's conception of biology. So, the basic postulates of chemotaxis can be identified at different moments in Cajal's research, from the description of the "growth cone" in embryonic neuroblasts, the origin of the neurotrophic theory, to the proposal of the pathophysiological mechanisms of neuronal plasticity. From Cajal's point of view, the neurons move during their development and also adapt to different external circumstances. Chemical endogenous substances can stimulate this movement in a similar way to leukocytes during the process of inflammation.

Factores asociados a las estancias anormalmente prolongadas en las hospitalizaciones por insuficiencia cardiaca en España / Associated factors with unusually long stays in heart failure hospitalizations in Spain

Fundamento. La insuficiencia cardiaca es un proceso de altaprevalencia que origina repetidos ingresos hospitalarios consobrecarga asistencial e incremento del gasto sanitario. Losobjetivos de este trabajo son describir y caracterizar los casoscon estancias prolongadas por este síndrome, detectandoposibles factores asociados a la misma.Método. Estudio de cohorte histórica de todos los episodiosde personas mayores de 45 años, ingresados por insuficienciacardiaca en el Sistema Sanitario Público Español en el período1997-2007. Fuente: 808.229 episodios clasificados como GruposRelacionados de Diagnóstico 127 y 544, según el Conjunto MínimoBásico de Datos del Instituto de Información Sanitaria. Seevaluaron variables sociodemográficas (edad, género, comunidadautónoma), clínicas (comorbilidades, complicaciones, tipode ingreso y alta) y de gestión (estancia, tipo de hospital, reingresos).Se definió estancia anormalmente prolongada aquellaque superó el percentil 90 (14 y 16 días, respectivamente),construyéndose un modelo de regresión logística para valorarsus posibles factores asociados.Resultados. Presentaron estancias anormalmente prolongadasel 11,4%, mostrando inferior edad media y mayor número dediagnósticos y procedimientos, reingresos y mortalidad que elgrupo sin estancias prolongadas. Padecer anemia, insuficienciarenal, TEP o ictus así como el reingreso y el ingreso programadose asociaron a mayor probabilidad de estancia anormalmenteprolongada.Conclusión. Es posible definir un perfil de comorbilidady sociodemográfico que valore la probabilidad de tener uningreso prolongado, si bien dadas las características de lasbases de datos administrativas la capacidad discriminativadel modelo es discreta(AU)

Background. Heart failure is a process of high prevalencethat causes repeated hospital admissions with increasedhealth care costs. The aim of this article is to describe andcharacterize the cases with long stays due to this syndrome,identifying associated factors wherever possible.Method. An historical cohort of all the episodes of peopleover 45 years with a diagnosis of heart failure admitted inthe Spanish Public Health System in the period 1997-2007.Source: 808,229 episodes classified as Diagnosis RelatedGroups 127 and 544 according to the Minimum Basic Dataprovided by the Institute for Health Information. We assessedsociodemographic variables (age, gender, region),clinical variables (comorbidities, complications, type of admissionand discharge) and management variables (lengthof stay, type of hospital readmissions). An abnormally prolongedstay (APS) was defined as one exceeding the 90thpercentile (14 and 16 days, respectively); we built a logisticregression model to assess their possible associated factors.Results. Eleven point four percent (11.4%) presented abnormallyprolonged stays, showing lower mean age and increasednumber of diagnoses and procedures, readmissions andmortality than the non-abnormally prolonged stay group.Anemia, kidney failure, pulmonary embolism or stroke aswell as readmission and scheduled admission were associatedwith increased likelihood of APS.Conclusion. It is possible to define a comorbidities andsociodemographic profile to assess the likelihood of a prolongedhospital stay, but given the nature of administrativedatabase the model’s discriminative ability is quite discreet(AU)

¿Es más eficiente el implante de marcapasos permanentes en hospitales de nivel I? / Is the permanent pacemaker implant more efficient in level 1 hospital?

Objetivo Determinar si el implante de marcapasos permanentes (MPP) y cambio de generador resultan más eficientes en hospitales pequeños.DiseñoAnálisis de costeefectividad. Estudio retrospectivo, transversal y observacional de cinco GDR.AmbitoLos datos son procedentes del conjunto mínimo básico de datos (CMBD) nacional del año 2007, facilitado por el Ministerio de Sanidad.PacientesSon el total de los pacientes que requirieron asistencia en algún hospital nacional por 5 GRD: 115, complicación bradiarrítmica durante la fase aguda de un síndrome coronario, insuficiencia cardíaca o shock; 116, trastorno de conducción sintomático aislado; 117, revisión pero sin cambio de batería; 118, aplicación de una nueva, y 549, implantación o revisión pero con complicaciones graves.Variables de interés principalesSe analizaron variables demográficas, clínicas (número de diagnósticos secundarios (NDS), de procedimientos (NP), mortalidad) y de gestión (estancia total y preoperatoria (Epo), forma de acceso y alta, tamaño de hospital), definiendo ineficiente una estancia superior 2 días a la media.Resultados23.154 episodios (5,3% en hospitales<200 camas). El estudio bivariado comparativo entre hospitales pequeños y el resto, no discriminado por GDR, mostró estancia media 7,87±11,01 días vs 8,78±12,95 (p=0,005, IC 95% [0,17; 1,65]) y Epo 3,62±6,14 vs 4,22±6,68 días [p=0,015]), sin mayor comorbilidad, medida como proxy por NDS (5,23±2,88 vs 5,42±3,28 [p=0,055]); y NP como proxy de esfuerzo diagnóstico-terapéutico (3,79±2,50 vs 3,55±2,69 [p=0,002]). 24,1% fueron ineficientes, encontrándose asociación con Epo, NDS, NP y acceso urgente.ConclusionesLa implantación de marcapasos y cambio de generador en hospitales pequeños es más eficiente, con consistencia interna por subgrupos (AU)

Abstract Objective: To determine if permanent pacemaker implants (PPM) interventions and change ofgenerator are more efficient in small hospitals.Design: A cost-effective analysis and retrospective, cross-sectional and observational study ofdiagnostic related groups (DRG).Setting: The data was obtained from the national Minimum Basic Data Set (MBDS) for the year2007 provided by the Health Ministry.Patients: This includes the total number of patients who required treatment in all nationalhospitals for 5 DRG: 115 - bradyarrhythmic complication during the acute coronary syndrome,heart failure or shock; 116 -symptomatic isolated conduction defects; 117 -revisions, but withoutchanging the battery, 118- application of a new one, 549 - implementation or revision butwith serious complications.Principal variables of interest: demographic, clinical (number of secondary diagnoses (NSD)and procedures (NP), mortality) and management (total and preoperative length of stay (LOS),access, discharge, hospital size), defining inefficient stays as those exceeding 2 days on theaverage.Results: 23,154 episodes, 5.3% small hospitals. The comparative bivariate study between smallhospitals and the rest, not discriminated by DRG, showed a mean LOS of 7.87±8.78 days vs11.01±12.95 (p=0.005, 95% CI for mean difference [0.17, 1.65]) and also lower than preoperatively(3.62±6.14 vs. 4.22±6.68 days (p=0.015)) without greater comorbidity, as measured byproxy through the NSD (5.23±2.88 vs 5.42±3.28 (p=0.055)) and NP as proxy of diagnostic andtherapeutic effort (3.79±2.50 vs 3.55±2.69 (p=0.002)). A total of 24.1% were inefficient, therebeing an association with preoperative stay, NDS, NP and emergency access.Conclusion: Pacemaker implantation and generator change in small hospitals is more efficient,with internal consistency by subgroups (AU)

[Is the permanent pacemaker implant more efficient in level 1 hospital?]. / ¿Es más eficiente el implante de marcapasos permanentes en hospitales de nivel I?

OBJECTIVE: To determine if permanent pacemaker implants (PPM) interventions and change of generator are more efficient in small hospitals. DESIGN: A cost-effective analysis and retrospective, cross-sectional and observational study of diagnostic related groups (DRG). SETTING: The data was obtained from the national Minimum Basic Data Set (MBDS) for the year 2007 provided by the Health Ministry. PATIENTS: This includes the total number of patients who required treatment in all national hospitals for 5 DRG: 115 - bradyarrhythmic complication during the acute coronary syndrome, heart failure or shock; 116 -symptomatic isolated conduction defects; 117 -revisions, but without changing the battery, 118- application of a new one, 549 - implementation or revision but with serious complications. PRINCIPAL VARIABLES OF INTEREST: demographic, clinical (number of secondary diagnoses (NSD) and procedures (NP), mortality) and management (total and preoperative length of stay (LOS), access, discharge, hospital size), defining inefficient stays as those exceeding 2 days on the average. RESULTS: 23,154 episodes, 5.3% small hospitals. The comparative bivariate study between small hospitals and the rest, not discriminated by DRG, showed a mean LOS of 7.87±8.78 days vs 11.01±12.95 (p=0.005, 95% CI for mean difference [0.17, 1.65]) and also lower than preoperatively (3.62±6.14 vs. 4.22±6.68 days (p=0.015)) without greater comorbidity, as measured by proxy through the NSD (5.23±2.88 vs 5.42±3.28 (p=0.055)) and NP as proxy of diagnostic and therapeutic effort (3.79±2.50 vs 3.55±2.69 (p=0.002)). A total of 24.1% were inefficient, there being an association with preoperative stay, NDS, NP and emergency access. CONCLUSION: Pacemaker implantation and generator change in small hospitals is more efficient, with internal consistency by subgroups.

[Economics and equity in urgency and emergency care]. / Economía y equidad en urgencias y emergencias.

The financial sustainability of public health systems (PHS) is currently threatened by population growth, increased prevalence of chronic conditions and disabilities, inequality in access and use of resources, zero cost delivery and global economic crisis. The emergency department (ED) is one for which demand is highest--without relation to the health model--because disease becomes established in disadvantaged socio-demographic areas and inequalities, hyperconsumption and decision making more closely linked to the user are maintained. The medical device of ED is a multiple one and its diverse product lines make it difficult to measure. This review discusses the need to deploy measurement tools in ED, where there are high direct costs--primarily structural--and other variables related to the activity, where the marginal cost is higher than the average and there is no economy of scale in such interventions. The possible mechanisms of private copayment in financing the supply of EDs are also studied, showing their advantages and disadvantages, with the conclusion that they are not recommendable--due to their scarce fund raising and deterrent capacity, which is why fundamental strategic changes in the management of these resources are needed.

[Prevalence of processes and pathologies in emergency hospital care]. / Prevalencia de procesos y patologías en la atención urgente hospitalaria.

OBJECTIVES: To study the behavioural differences between scheduled and emergency admissions in the processes most prevalent in Spanish hospitals and their relationship with the age of patients, comparing 2002 and 2007. METHODS: Observational and descriptive design for those years. Diagnostic related groups (DRGs) were classified into high prevalence (the 25 most frequent) and the rest; four subgroups were prepared according to this (high or low) and admission (elective or not). Mean length of stay was analyzed, together with relative weight, number of diagnoses and procedures and mortality by age, using the Student and/or ANOVA tests for quantitative variables and Pearson's chi(2) qualitative comparison of means and proportions for tabular data, assuming statistical significance at p <0.05. RESULTS: The high prevalence and emergency admission subgroup has higher age, ratio of males, mean length of stay, mortality, number of diagnoses and procedures (all p <0.0001), in both 2002 and 2007. The complexity and resource consumption measured by such variables peaks in the 65-69 and 70-74 cohorts respectively, with emergency admission. CONCLUSIONS: There are clear differences between the processes according to their prevalence and accessibility; priority must be given to knowledge and information on the most frequent and urgent admissions to improve the effectiveness, efficiency and quality.

Economía y equidad en urgencias y emergencias / Economics and equity in urgency and emergency care

públicos (SSP) está amenazada por el crecimientopoblacional, la mayor prevalencia de procesos crónicosy discapacidades, la inequidad residual en el acceso yutilización de los recursos, el coste nulo en la prestacióny la crisis económica mundial.Los servicios de Urgencias y Emergencias (SUE)son uno de los más demandados –sin relación con elmodelo de salud– porque la enfermedad asienta enáreas sociodemográficas menos favorecidas, se mantieneninequidad, hiperconsumo y capacidad de decisiónmás ligada al usuario. El producto sanitario de los SUEes múltiple y con líneas de producción diversas quedificultan su medición. En esta revisión se analiza lanecesidad de implantar herramientas de medida en losSUE, donde existen altos costes directos –fundamentalmenteestructurales– y otros variables relacionadoscon la actividad, donde el coste marginal es superior almedio y sin economía de escala en estas intervenciones.Se estudian, asimismo, los posibles mecanismos decoparticipación privada en la financiación de la ofertade los SUE, se muestran sus ventajas e inconvenientesy se concluye que no son recomendables –por su escasacapacidad recaudadora y disuasoria– por lo queson necesarios cambios estratégicos fundamentales enla gestión de estos recursos(AU)

The financial sustainability of public health systems(PHS) is currently threatened by populationgrowth, increased prevalence of chronic conditions anddisabilities, inequality in access and use of resources,zero cost delivery and global economic crisis.The emergency department (ED) is one for whichdemand is highest – without relation to the health model– because disease becomes established in disadvantagedsocio-demographic areas and inequalities, hyperconsumptionand decision making more closely linkedto the user are maintained. The medical device of EDis a multiple one and its diverse product lines make itdifficult to measure.This review discusses the need to deploy measurementtools in ED, where there are high direct costs– primarily structural – and other variables related tothe activity, where the marginal cost is higher than theaverage and there is no economy of scale in such interventions.The possible mechanisms of private copaymentin financing the supply of EDs are also studied,showing their advantages and disadvantages, with theconclusion that they are not recommendable – due totheir scarce fund raising and deterrent capacity, whichis why fundamental strategic changes in the managementof these resources are needed(AU)

Prevalencia de procesos y patologías en la atención urgente hospitalaria / Prevalence of processes and pathologies in emergency hospital care

Objetivos. Estudiar las diferencias de comportamientoentre ingresos urgentes y programados en los procesosmás prevalentes y el resto en la casuística hospitalariaespañola y su relación con la edad de los pacientes,comparando los años 2002 y 2007.Métodos. Diseño observacional y descriptivo duranteesos años. Se clasifican los grupos relacionados de diagnóstico(GRD) en alta prevalencia (25 más frecuentes)y resto, se confeccionan cuatro subgrupos según ésta(alta o baja) e ingreso (electivo o no). Se analiza estanciamedia, peso relativo, número de diagnósticos y procedimientosy mortalidad en función de la edad, por mediodel test de Student y/o ANOVA, según proceda, para variablescuantitativas y el de χ2 de Pearson para cualitativas,comparando ambas según análisis de datos ya tabulados.Se asume significación estadística para p<0,05.Resultados. El subgrupo de alta prevalencia e ingresourgente presenta mayor edad, proporción de varones,estancia media, mortalidad, número de diagnósticosy procedimientos (todo con p<0,0001), tanto en 2002como en 2007. La gravedad, complejidad y consumode recursos –medidos con esas variables– alcanza sumáximo en las cohortes de 65-69 y 70-74 años, respectivamente,con ingreso urgente.Conclusiones. Existen claras diferencias entre los procesos,según su prevalencia y acceso, y debe priorizarseel conocimiento y la información de los más frecuentesy urgentes para mejorar la efectividad, la eficienciay la calidad(AU)

Objectives. To study the behavioural differences betweenscheduled and emergency admissions in the processesmost prevalent in Spanish hospitals and theirrelationship with the age of patients, comparing 2002and 2007.Methods. Observational and descriptive design forthose years. Diagnostic related groups (DRGs) wereclassified into high prevalence (the 25 most frequent)and the rest; four subgroups were prepared accordingto this (high or low) and admission (elective or not).Mean length of stay was analyzed, together with relativeweight, number of diagnoses and procedures andmortality by age, using the Student and/or ANOVA testsfor quantitative variables and Pearson’s χ2 qualitativecomparison of means and proportions for tabular data,assuming statistical significance at p <0.05.Results. The high prevalence and emergency admissionsubgroup has higher age, ratio of males, mean lengthof stay, mortality, number of diagnoses and procedures(all p <0.0001), in both 2002 and 2007. The complexityand resource consumption measured by such variablespeaks in the 65-69 and 70-74 cohorts respectively, withemergency admission.Conclusions. There are clear differences between theprocesses according to their prevalence and accessibility;priority must be given to knowledge and informationon the most frequent and urgent admissions toimprove the effectiveness, efficiency and quality(AU)

Diferencias de gestión entre los ingresos urgentes y los programados en función de los grupos relacionados de diagnóstico y la edad de los pacientes / Management differences between urgent and elective admissions as related to the Diagnosis-Related Groups and the patients’ age

Objetivos: Analizar las diferencias de comportamiento entre los ingresos urgentes (IU) y los programados (IP) de los procesos más habituales en la casuística hospitalaria española y su relación con la edad de los pacientes. Métodos: Diseño observacional, descriptivo, transversal, en hospitales públicos de agudos de toda España durante el año 2002. Los grupos relacionados de diagnóstico (GRD) se agruparon en alta prevalencia (los 25 más frecuentes, GRD-AP) y el resto (GRD-resto). Se comparan la estancia media hospitalaria, el peso de los GRD, el número de diagnósticos secundarios, el de procedimientos y la mortalidad en función del tipo de ingreso (IU o IP), el subconjunto de GRD (GRD-AP o resto) y la edad. Resultados: Los GRD-AP concentran el 33,5% de la casuística. Con respecto a los IP, los IU se caracterizan por una edad superior (p<0,001), tener una mayor proporción de varones, tener unos GRD con mayor peso y generar una estancia media hospitalaria (p<0,001), un número de diagnósticos secundarios (p<0,001) y un número de procedimientos (p<0,001) superiores. La gravedad, complejidad, consumo y gasto en los IU del subconjunto GRD-resto alcanza el máximo entre los 65-69 años para disminuir posteriormente con la edad, mientras que estos parámetros aumentan uniformemente con ella en los GRD-AP. Conclusiones: Estos datos muestran la potencial relevancia del papel gestor de los profesionales de las áreas de urgencias, y la necesidad de programas alternativos a la hospitalización convencional en los procesos más frecuentes que motivan IU, cuya concentración debería facilitar la gestión clínica y económica (AU)

Aims: To analyse the management behaviour differences between urgent and elective admissions (respectively, UA and EA) in the most frequent conditions in the Spanish hospital practise and their relation to the patients’ age. Methods: Observational, descriptive, cross-sectional study carried out in public acute-patient hospitals throughout Spain in the year 2002. the Diagnosis-Related Groups were further subgrouped as “high-prevalence” (HP-DRG, the 25 most frequent ones) and “remaining” (remaining-DRG). The parameters compared were mean duration of hospital admission, DRG weight, number of secondary diagnoses, number of procedures and mortality, as related to the type of admission (UA, EA), the DRG subgroup (HP-DRG or remaining- DRG) and the patients’ age. Results: HP-DRG cases encompass 33.5% of the case population. As compared to EA’s, UA’s are characterised by older age (p<0.001), a higher proportion of males, higher-weighted DRG’s, and generating a longer mean duration of admission, a greater number of secondary diagnoses and a greater number of procedures (p<0.001 in all three cases). The severity, complexity, resource consumption and expense of UA’s in the “remaining-DRG” subgroup reach their maximum in the 65-69-year age group and then decrease, while all three parameters increase uniformly with age among the HP-DRG. Conclusions: These data highlight the potential relevance of the management role of health care professional in the emergency areas and the need for alternatives to conventional hospital admission for the more frequent conditions causing UA’s, the grouping whereof should facilitate their clinical and economic management (AU)

Mujer joven con múltiples lesiones ocupantes de espacio en el sistema nervioso central / Young woman with multiple space-occupying lesions in the central nervous system

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Search of a topological pattern to evaluate toxicity of heterogeneous compounds.

Molecular connectivity has been applied to the search of mathematical models able to predict the carcinogenic and teratogenic activity of a wide group of structurally heterogeneous compounds. Through the linear discriminant analysis and the diagrams of distribution of pharmacological activity, the classification criteria that minimizes the percentage of error are established. The easiness and speed of the calculation of the descriptors used in this work make the models developed useful in data bases containing a huge number of compounds.

Enema opaco

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Varón de 62 años con lesiones cutáneas de larga evolución: un diagnóstico a primera vista / 62-year old male patient with long-term evolving cutaneous lesions: diagnosis at first glance

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