[What determines public-private choice in Spanish healthcare?]

INTRODUCTION AND OBJECTIVES

The aim of the study was to analyze, which individual characteristics (sociodemographic, attitudinal and political factors) mediates in the choice in Spain in 2022, of a private versus public health care alternative for family doctor, doctor specialist, hospital admissions and emergencies.

METHODS

Using the health barometers of the Centro de Investigaciones Sociológicas (CIS), we carried out four logistic regressions (then, average marginal effects [AMEs]) whose dependent variables are the preference for a private choice of family doctor versus a public one, the preference for a private choice of doctor specialist versus a public one; the preference for a private choice of hospital admission versus a public one and the preference for a private choice of emergency admission versus a public one. The dependent variables are binary (1=private; 0=public). The sample consisted of more than 4,500 individuals older than 18years old distributed representatively throughout Spain.

RESULTS

The probability of choosing private rather than public is correlated with the age of the individual: those over 50years are less likely to opt for a private alternative (P<.01), as well as by ideology and satisfaction with the way that the national health system (NHS) works. Patients with a conservative ideology are more likely to choose private options (P<.01) and individuals with greater satisfaction with the NHS are less likely to choose private ones (P<.01).

CONCLUSIONS

Satisfaction with the NHS and patient ideology are the most relevant factors for private versus public choice.

Analysis of P(v-a)CO2/C(a-v)O2 Ratio and Other Perfusion Markers in a Population of 98 Pediatric Patients Undergoing Cardiac Surgery

BACKGROUND

The so-called Low Cardiac Output Syndrome (LCOS) is one of the most common complications in pediatric patients with congenital heart disease undergoing corrective surgery. LCOS requires high concentrations of inotropes to support cardiac contractility and improve cardiac output, allowing for better systemic perfusion. To date, serum lactate concentrations and central venous oxygen saturation (ScVO2) are the most commonly used perfusion markers, but they are not completely reliable in identifying a state of global tissue hypoxia. The study aims to evaluate whether the venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio [P(v-a)CO2/C(a-v)O2] can be a good index to predict the development of LCOS in the aforementioned patients, so as to treat it promptly.

METHODS

This study followed a population of 98 children undergoing corrective cardiac surgery from June 2018 to October 2020 at the Department of Cardiac Surgery of University Hospital Integrated Trust and their subsequent admission at the Postoperative Cardiothoracic Surgery Intensive Care Unit. During the study, central arterial and venous blood gas analyses were carried out before and after cardiopulmonary bypass (CPB) (pre-CPB and post-CPB), at admission to the intensive care unit, before and after extubation, and at any time of instability or modification of the patient's clinical and therapeutic conditions.

RESULTS

The data analysis shows that 46.9% of the children developed LCOS (in line with the current literature) but that there is no statistically significant association between the P(v-a)CO2/C(a-v)O2 ratio and LCOS onset. Despite the limits of statistical significance, however, a 31% increase in the ratio emerged from the pre-CPB phase to the post-CPB phase when LCOS is present.

CONCLUSIONS

This study confirms a statistically significant association between the most used markers in adult patients (serum lactate concentration, ScVO2, and oxygen extraction ratio-ERO2) measured in the pre-CPB phase and the incidence of LCOS onset, especially in patients with hemodynamic instability before surgery.

Oxycodone-Naloxone Combination Hinders Opioid Consumption in Osteoarthritic Chronic Low Back Pain: A Retrospective Study with Two Years of Follow-Up

Chronic low back pain (CLBP) due to osteoarthritis represents a therapeutic challenge worldwide. Opioids are extensively used to treat such pain, but the development of tolerance, i.e., less susceptibility to the effects of the opioid, which can result in a need for higher doses to achieve the same analgesic effect, may limit their use. Animal models suggest that ultra-low doses of opioid antagonists combined with opioid agonists can decrease or block the development of opioid tolerance. In this retrospective study, we tested this hypothesis in humans. In 2019, 53 patients suffering from CLBP were treated with either Oxycodone and Naloxone Prolonged Release (27 patients, OXN patients) or Oxycodone Controlled Release (26 patients, OXY patients). The follow-up period lasted 2 years, during which 10 patients discontinued the treatment, 5 out of each group. The remaining 43 patients reached and maintained the targeted pain relief, but at 18 and 24 months, the OXY patients showed a significantly higher oxycodone consumption than OXN patients to reach the same level of pain relief. No cases of respiratory depression or opioid abuse were reported. There were no significant differences in the incidence of adverse effects between the two treatments, except for constipation, more common in OXY patients. From our results, we can affirm that a long-term opioid treatment with oxycodone-naloxone combination, when compared with oxycodone only, may significantly hinder the development of opioid tolerance. We were also able to confirm, in our cohort, the well known positive effect of naloxone in terms of opioid-induced bowel dysfunction incidence reduction.

[Early diagnosis of nasopharyngeal carcinoma]

For making an early diagnosis of nasopharyngeal carcinoma it is fundamental to fulfill three requirements. First a high suspicion index based in the knowledge of symptoms and signs of the malady. Secondly it is necessary the routinely use in the consulting room of a nasopharyngoscope. An in third place is to make, in doubtful cases, an enlarged biopsy under endoscopic control and local anesthesia.

[Carcinoma of the nasopharynx in Cantabria]

OBJECTIVE

To describe the incidence and main clinicopathologic features of nasopharyngeal carcinoma (NPC) in Cantabria, Spain, and compare these data with reports published in Spain.

MATERIAL AND METHODS

The medical records of all patients with the diagnosis of NPC seen in our division in the last 20 years were reviewed.

RESULTS

Eighty-two patients ranging in age from 11 to 84 years were diagnosed as NPC. Sixty-five (79.3%) were males. The initial physical examination of the nasopharynx was normal in 7% of patients. The most frequent presenting complaint was the presence of a neck mass in 47% of cases. Forty percent of patients had cranial nerve involvement and 4.9% had distant metastases at the time of diagnosis. The lateral wall was the most frequent tumor location. The histopathological type was undifferentiated carcinoma in 71% of cases. Most patients had advanced-stage disease at the first visit.

CONCLUSIONS

The incidence of NPC in Cantabria is 0.8 per 100.000 inhabitants per year. The highest incidence rate occurred in persons 50 to 70 years-old. Males predominated with a male: female ratio of 4:1. Undifferentiated carcinoma was the most frequent histological type. Our findings were similar to those reported in other series of patients with NPC in Spain.

[Diagnosis and treatment of cervical esophageal perforation in adults]

OBJECTIVE

To evaluate the management of cervical esophageal perforation in adult patients.

MATERIAL AND METHODS

A retrospective clinical review was made of all cervical esophageal perforations diagnosed in adult patients in the ear, nose and throat department of Marqués de Valdecilla Hospital (Santander, Spain) between January 1989 and December 1996. Age, sex, symptoms, cause of perforation, time to diagnosis, diagnostic studies, treatment, and evolution were obtained from the clinical records.

RESULTS

Eleven patients with perforation of the cervical esophagus, age range 38 to 84 years, were seen in the study period. In 8 cases, perforation was caused by a foreign body and 3 cases were iatrogenic (after rigid esophagoscopy). The most frequent symptoms of presentation were cervical pain and odinophagia. Nine patients were treated with broad-spectrum intravenous antibiotic therapy and no oral feeding. Two patients were treated surgically. There were no complications or need for further surgery in any case.

CONCLUSIONS

Small perforations of the cervical esophagus in adult patients produced by foreign body impaction or rigid esophagoscopy can be managed by observation, restricted oral intake, and intravenous antibiotics. Neck exploration should be reserved for patients with signs and symptoms of cervical or mediastinal infection.

[Foreign bodies in the esophagus]

OBJECTIVE

To study the management (diagnostic and therapeutic) of esophageal foreign bodies.

MATERIAL AND METHODS

A retrospective study was made of all rigid esophagoscopies performed for suspected foreign bodies in the esophagus by the otolaryngology department of Marqués de Valdecilla Hospital (Santander, Spain) from 1992 to 1996.

RESULTS

Rigid esophagoscopy was performed for suspected foreign bodies in 195 patients (121 females, 74 males; age range 2 to 97 years). In 183 cases an impacted foreign body was found. The most frequent location was the upper third of the esophagus (165/85.2%). The most common type of foreign body was fish bones in adults (75/171) and coins in children (7/12). In 145 cases a barium esophagogram was obtained before surgery, which yielded 1 false negative and 8 false positives. In 16 patients flexible endoscopy had failed previously to remove the foreign body. Twelve patients (all adults) had serious complications.

CONCLUSIONS

The barium esophagogram and rigid esophagoscopy are still appropriate techniques for managing esophageal foreign bodies.

Prognostic factors in supraglottic laryngeal carcinoma

We carried out a retrospective study of patients with supraglottic carcinomas who were treated surgically at the Marques de Valdecilla Hospital (Santander, Spain) between 1978 and 1987 and who were followed up for at least 5 years. The Kaplan-Meier survival curves were calculated for 24 clinical, histologic, and morphometric parameters. Multivariate analysis was then performed by means of the Cox regression model. In the univariate analysis, survival was related to presence of capsule rupture of the involved lymph nodes (p = 0.00001), number of metastatic lymph nodes (p = 0.0002), postoperative TNM stage (p = 0.004), grade of cell differentiation (p = 0.001), presence of intratumoral necrosis (p = 0.01), and type of invasion (p = 0.04). The nuclear area did not have an influence on survival. Only the presence or absence of capsule rupture of the metastatic lymph nodes and the grade of cell differentiation were included in the final Cox model and proved to be parameters with independent prognostic significance.

[Nasal sinus adenocarcinoma in patients exposed to wood dust in the Community of Cantabria, Spain]

OBJECTIVE

To study the incidence and clinical and histological features of sawdust-related nasosinusal adenocarcinoma (SRNA) in the Community of Cantabria.

MATERIAL AND METHODS

A retrospective study was made of all patients diagnosed as SRNA in 9 years.

RESULTS

Ten male patients, ranging in age from 56 to 64 years, were diagnosed as SRNA in this period. The most common location was the ethmoid. Histologically, six tumors were papillary and four were mucinous. Five patients received combined treatment (surgery and postoperative radiotherapy), one surgery alone, two radiotherapy, and one chemotherapy. The 5-year survival rate was 28.5%. The most frequent cause of death was local recurrence.

CONCLUSIONS

The incidence of SRNA in the Community of Cantabria is less than 0.2 cases per 100,000 inhabitants/year. SRNA occurs almost exclusively in men and has an occupational origin. Papillary adenocarcinoma is the most frequent histological type. The treatment of choice is surgery associated with postoperative radiotherapy. The long-term prognosis is poor, so preventive measures to reduce exposure to sawdust are fundamental in risk groups.

[Diagnosis and treatment of laryngeal radionecrosis]

Three cases of laryngeal radionecrosis are reported. In two cases partial surgery after radiotherapy probably triggered the radionecrosis. All patients were treated successfully with medical therapy. Laryngeal radionecrosis is an uncommon complication of radiotherapy for carcinoma of the head and neck. The interval between conclusion of radiation therapy and development of radionecrosis ranges from 3 to 12 months. Neither computed tomography nor magnetic resonance imaging differentiate between necrotic tissue and recurrent tumor. Humidification, broad spectrum antibiotics, steroids, and hyperbaric oxygen, with or without surgery, are successful in many cases.

[Use of embolization in the treatment of pulsatile tinnitus secondary to dural arteriovenous fistula]

Three cases of dural arteriovenous fistula (DAVF) in patients who consulted for pulsatile tinnitus are reported. All were treated successfully by embolization. If DAVF is suspected, angiography of the carotid and vertebral arteries should be performed to confirm its presence and to identify sources of blood flow and venous drainage. If treatment is needed, embolization, surgery, or radiotherapy may be indicated either separately or in combination therapy. The numerous branches and site of the fistula make therapeutic embolization the procedure of choice for many cases.

Experimental study on neurorrhaphy of the recurrent laryngeal nerve in dogs

The effectiveness of anastomosis of a divided recurrent laryngeal nerve was evaluated in six adult mongrel dogs. Videolaryngoscopy and evoked compound muscle action potentials in the intrinsic laryngeal muscles were performed at six months and the posterior cricoarytenoid muscles and recurrent laryngeal nerves were processed for histomorphometric studies. Recovery of compound muscle action potentials in all re-innervated muscles and histomorphometric findings confirmed a good grade of axonal regeneration. The most significant histomorphometric changes observed were: a reactive hypertrophy of type I fibres in the posterior cricoarytenoid muscles of the re-innervated side, and a high nerve fibre density in the distal stump to the anastomosis. However, incomplete recovery of motion and fasciculated movements of the re-innervated vocal folds were observed. Reduction of effective motor units in the re-innervated muscles might be a factor that cause incomplete restoration of vocal fold movements.

[Laryngeal reinnervation: transposition of neuromuscular pedicles]

Following Tucker's technique, a muscle-nerve pedicle implantation in the denervated posterior cricoarytenoid muscle was performed in five dogs. Results were evaluated after six months by videolaryngoscopy, evoked muscle action potentials and histomorphometric studies. Partial motion recovery of the reinnervated side was observed endoscopically in three dogs. Histomorphometric evaluation showed evidence of muscle reinnervation in all of the five dogs. However, no muscle action potentials were obtained in the posterior cricoarytenoid muscles after stimulation of the ansa hypoglossi branch. These data suggest that the ansa hypoglossi neuromuscular pedicle does not result in reinnervation, and that reinnervation of the posterior cricoarytenoid muscle may occur via other neuromuscular pathways.

Comparative study of the nerve endings of the outer and inner hair cells in the organ of Corti

The synaptic region and nerve endings have been studied both in the outer and inner hair cells by using optic and electron microscopy, nerve staining and Acetyl Cholinesterase activity. The findings are described, with a discussion of the results.

Some aspects of the nerve endings and synapses in the vocalis muscle

By histochemical and ultrastructural techniques, the nerve endings and terminal plates in the human vocalis muscle have been studied. The distribution, variety and strong acetylcholinesterase activity of the terminal plates, suggest a diversified muscular activity according to the different physiological activities.

Ultrastructural study of taste buds at rest and after stimulation, and comparative study between type III cell and Merkel cells

Changes in the pore region of the cell membrane have been studied in order to learn if this region plays an active part in the preneural phase of taste. We have observed, though not consistently, that the pore size is variable and that their contents are not constantly amorphous or homogeneous. The results are not so significant, however, as to allow of the formulation of any firm conclusions. The similarity between type III cells and Merkel cells (cells of the tactile system) was surprising. The probable role of the type III cell in taste is discussed.