Triple Therapy and Clinical Control in B+ COPD Patients: A Pragmatic, Prospective, Randomized Trial.

INTRODUCTION: Treatment with LABA/LAMA is recommended in GOLD B patients. We hypothesized that triple therapy (LABA/LAMA/ICS) will be superior to LABA/LAMA in achieving and maintaining clinical control (CC), a composite outcome that considers both impact and disease stability in a subgroup of GOLD B patients (here termed GOLD B+ patients) characterized by: (1) remaining symptomatic (CAT≥10) despite regular LABA/LAMA therapy; (2) having suffered one moderate exacerbation in the previous year; and (3) having blood eosinophil counts (BEC) ≥150cells/µL. METHODS: The ANTES B+ study is a prospective, multicenter, open label, randomized, pragmatic, controlled trial designed to test this hypothesis. It will randomize 1028 B+ patients to continue with their usual LABA/LAMA combination prescribed by their attending physician or to begin fluticasone furoate (FF) 92µg/umeclidinium (UMEC) 55µg/vilanterol (VI) 22µg in a single inhaler q.d. for 12 months. The primary efficacy outcome will be the level of CC achieved. Secondary outcomes include the clinical important deterioration index (CID), annual rate of exacerbations, and FEV1. Exploratory objectives include the interaction of BEC and smoking status, all-cause mortality and proportion of patients on LABA/LAMA arm that switch therapy arms. Safety analysis include adverse events and incidence of pneumonia. RESULTS: The first patient was recruited on February 29, 2024; results are expected in the first quarter of 2026. CONCLUSIONS: The ANTES B+ study is the first to: (1) explore the efficacy and safety of triple therapy in a population of B+ COPD patients and (2) use a composite index (CC) as the primary result of a COPD trial.

One-year follow-up of changes in refraction and aberrations induced by corneal incision.

PURPOSE: To evaluate the surgically induced changes in refraction (sphere and astigmatism) and higher order aberrations by corneal incision for one year. SETTING: University Hospital "Virgen de la Arrixaca", Murcia, Spain. DESIGN: Retrospective interventional case series. METHODS: Corneal power, astigmatism and higher order aberrations (HOA) were calculated from corneal topography measured in 27 eyes prior to surgery and at 2 weeks, 1, 2, 3 and 6 months and 1 year following cataract surgery with 3.2-mm corneal incision. At every stage, optical changes were calculated as the difference between pre- and post-surgery data (in each follow-up) using the formulas of obliquely crossed cylinders for the refraction and Zernikes coefficients for HOA. RESULTS: At 2 weeks after surgery the mean corneal values of induced sphere, cylinder and the root mean square (RMS) of HOA were +0.54±0.27 D, -0.77±0.32 D and 0.15 microns respectively. These parameters decreased significantly (p-values between 0 and 0.01) at 3 months to +0.33±0.27 D sphere, -0.50±0.24 D cylinder and 0.10±0.05 microns HOA and were stable at the next follow-ups. Induced spherical equivalent was around zero at all visits. The changes in HOA were mainly due to trefoil aberration. CONCLUSIONS: Linear corneal incisions do not change the spherical power but can induce significant values of astigmatism and trefoil aberration in the cornea. However, these changes revert fully or partially to preoperative values by the third month after surgery and remain stable with time.

Three-Dimensional Cataract Crystalline Lens Imaging With Swept-Source Optical Coherence Tomography.

Purpose: To image, describe, and characterize different features visible in the crystalline lens of older adults with and without cataract when imaged three-dimensionally with a swept-source optical coherence tomography (SS-OCT) system. Methods: We used a new SS-OCT laboratory prototype designed to enhance the visualization of the crystalline lens and imaged the entire anterior segment of both eyes in two groups of participants: patients scheduled to undergo cataract surgery, n = 17, age range 36 to 91 years old, and volunteers without visual complains, n = 14, age range 20 to 81 years old. Pre-cataract surgery patients were also clinically graded according to the Lens Opacification Classification System III. The three-dimensional location and shape of the visible opacities were compared with the clinical grading. Results: Hypo- and hyperreflective features were visible in the lens of all pre-cataract surgery patients and in some of the older adults in the volunteer group. When the clinical examination revealed cortical or subcapsular cataracts, hyperreflective features were visible either in the cortex parallel to the surfaces of the lens or in the posterior pole. Other type of opacities that appeared as hyporeflective localized features were identified in the cortex of the lens. The OCT signal in the nucleus of the crystalline lens correlated with the nuclear cataract clinical grade. Conclusions: A dedicated OCT is a useful tool to study in vivo the subtle opacities in the cataractous crystalline lens, revealing its position and size three-dimensionally. The use of these images allows obtaining more detailed information on the age-related changes leading to cataract.

Optical Measurement of Straylight in Eyes With Cataract.

PURPOSE: To measure straylight in a cohort of patients with cataract using a novel optical instrument and to correlate optical straylight values with clinical grade of cataracts and psychophysical straylight values. METHODS: Measurements were performed on 53 eyes of 44 patients with cataract admitted to the ophthalmology service of the university hospital in Murcia, Spain, and 9 young volunteers with no known ophthalmic pathology. Lens opacities were classified according to the Lens Opacities Classification System Ill (LOCS III) under slit-lamp examination. Intraocular straylight was additionally assessed psychophysically using the C-Quant straylight meter (Oculus Optikgeräte GmbH, Wetzlar, Germany). RESULTS: Optical measurements of the logarithm of the straylight parameter ranged from 1.01 to 2.01 (mean: 1.43 ± 0.244) in patients with cataract and 0.80 to 1.08 (mean: 0.92 ± 0.104) in healthy young volunteers. Straylight differed by a statistically significant amount among different LOCS III groups (P < .05). Moreover, the optically measured straylight parameter was positively correlated to the psychophysically estimated value (r = 0.803, P < .05). CONCLUSIONS: A new compact optical instrument suitable for clinical measurements of straylight in the human eye has been developed. Optically measured straylight values were highly correlated to those that were obtained psychophysically. Optical measurement of straylight can be used for the objective classification of cataract opacities based on their optical impact. [J Refract Surg. 2016;32(12):846-850.].

Comparison of the optical image quality in the periphery of phakic and pseudophakic eyes.

PURPOSE: The natural lens may provide some compensatory optical effect in the periphery. When it is substituted by an IOL during cataract surgery, the quality of the peripheral optics will be modified. We compared the peripheral image quality in the eyes of patients with one eye implanted with a monofocal IOL and the fellow eye still with the natural precataract lens. METHODS: We used a scanning peripheral Hartmann-Shack wavefront sensor to measure the central 80° of visual angle along the horizontal meridian. Twelve patients with ages ranging between 65 to 81 years were evaluated. The results of the phakic and pseudophakic eyes were compared using the spherical equivalent, astigmatism, higher order aberrations, and the Strehl ratio. The statistical differences at each angle between the two eyes were evaluated. RESULTS: In the eyes implanted with IOLs, the peripheral mean spherical equivalent was slightly more myopic than in the phakic eyes, although the differences were only significant for some angles. Astigmatism increased much faster in the periphery for the pseudophakic eyes as compared with the phakic eyes. The mean values were significantly different from 9° and 17° outwards at the temporal and nasal retina, respectively. As an example, at 30°, eyes implanted with IOLs presented 1.5 diopters (D) of additional astigmatism. The higher order aberrations were not significantly different between the two groups. CONCLUSIONS: Eyes implanted with monofocal IOLs present more astigmatism in the periphery than the healthy older eyes. This suggests that the crystalline lens provides a beneficial effect to partially compensate off-axis astigmatism. The degradation of the peripheral retinal image may reduce the pseudophakic patient's performance in common visual tasks.

Aberration generation by contact lenses with aspheric and asymmetric surfaces.

PURPOSE: We explored the potential of aberration correction in the human eye by using a new generation of soft contact lenses with aspheric and asymmetric surfaces. METHODS: Soft contact lens samples were designed with one asymmetrical surface (front) and one spherical (back) to produce predetermined amounts of desired pure defocus, astigmatism, trefoil, coma, and spherical aberration. Contact lens wavefront aberrations were measured ex vivo using a Fizeau-Tolanski interferometer and compared with the in vivo wavefronts obtained by subtracting the aberrations of the eye with and without the contact lenses. These second set of measurements were obtained using a Shack-Hartmann sensor. RESULTS: We found that an aberration-free contact lens sample induced in the eye a small amount of residual aberration. We obtained a good match between the ex vivo and in vivo wavefront measurements for most of the samples of the contact lenses. CONCLUSIONS: The aberrations generated by soft contact lenses on the eye were predictable. Rotations and translations of the contact lenses with respect to correct position on the eye were, however, the main limitation for precise correction of the ocular aberrations.

Fortalecimiento de la funcion rectora de las autoridades sanitarias en las reformas del sector de la salud / Strengthening the steering role of health authorities within the context of health sector reform

El fortalecimiento de la capacidad rectora de las autoridades sanitarias, ahora y en futuras decadas, es asunto de relieve en el contexto de la reforma sectorial. Implica, entre otras cosas, replantear el lugar que ocupa la salud en el contexto de las principales tendencias sociales y economicas observables en el mundo en los albores del nuevo siglo, constituidas fundamentalmente por la redefinicion del modelo de desarrollo, la creciente participacion en el quehacer sanitario de entidades ajenas al Estado, la transicion hacia una democracia participativa en diversos paises, la modificacion del concepto de lo "publico" y lo "privado" y la globalizacion de la economia. En este nuevo panorama, se impone la necesidad de que el sector sanitario asuma una funcion distinta: coordinar la movilizacion de los recursos nacionales, a escala multisectorial, con miras a mejorar la equidad y el bienestar social y focalizar los escasos recursos que exiten en los grupos sociales mas desprotegidos. La liberalizacion de la produccion y de la distribucion de los bienes y servicios de salud, asi como la dinamica de mercado que se observa cada vez mas en el ambito de estos servicios y la creciente autonomia de los sistemas de aseguramiento, constituyen nuevos retos para el ejercicio de la autoridad en materia de salud. Adicionalmente, la formacion de bloques economicos regionales y el enorme peso ejervido por las grandes companias multinacionales, con su control del mercado de medicamentos, instrumentos y tecnologias medicas, obligan al sector de la salud a buscar maneras de armonizar la legislacion en el ambito sanitario con la negociaciones de caracter internacional. Y todas estas exigencias superan, al parecer de no pocos expertos, la capacidad de los ministerios de salud de los paises latinoamericanos para responder con la debida eficacia, en vista de las limitaciones impuestas en la actualidad por la organizacion, poder politico, marco juridico e infraestructura tecnica del sector de la salud en los paises. Como resultado, estos ultimos se ven llamados a dar prioridad al fortalecimiento de la capacidad rectora de sus autoridades sanitarias para hacer frente a los retos del presente y el futuro

Strengthening the ability of health authorities to provide leadership and guidance, now and in the future, is an important issue within the context of health sector reform. It means, among other things, redefining the role of health in light of leading social and economic trends seen in the world at the beginning of the 21st century, increasing participation in health by nongovernmental entities, moving toward participatory democracy in many countries, and modifying concepts of what is considered "public" and "private." Within this scenario, it is necessary to redirect the role of the health sector toward coordinating the mobilization of national resources, on a multisectoral scale, in order to improve equity and social well-being and to channel the limited available resources to the most disadvantaged groups in society. The liberalization of the production and distribution of health-related goods and services, including insurance, challenges the exercise of authority in the area of health. Furthermore, the formation of regional economic blocks and the enormous weight wielded by multinational companies in the areas of pharmaceuticals and other medical supplies and technologies are forcing the health sector to seek ways of harmonizing health legislation and international negotiations. According to many experts, all of these demands surpass the ability of Latin American ministries of health to effectively respond, given most countries' current organizational, legal, and political conditions and technical infrastructure. The countries of the Americas must make it a priority to strengthen their health officials' ability to provide leadership and guidance in order to meet present and future challenges.

Teoria y tecnicas de desarrollo organizaciónal / Organizational development: Theory and techniques

Los volumes contienen los siguientes módulos y unidades:. Vol. 1 Contenido y presentacion: Modulo I. Teoria de la organización de las instituciones de salud, Modulo II. Modelo para el analisis de la organización: Unidad I. Areas criticas y variables de analisis del ambiente de la organización. Vol. 2: Modulo II. Modelo para el analisis de la organización: Unidad II. Areas criticas e indicadores de los problemas de la estructura de la organización, Unidad III. Areas criticas e indicadores de problemas del funcionamiento de la organización, Unidad IV. Métodologia e instrumentos para el analisis de estructura y funcionamiento. Vol. 3: Modulo II. Modelo para el analisis de la organización: Unidad V. Areas criticas de analisis del clima organizaciónal, Unidad VI. Métodologia e instrumentos para el analisis del clima organizaciónal. Vol. 4: Modulo III. Reorganización: Unidad I. Introducción. Condiciones y fases para desarrollar procesos de reorganización, Unidad II. Diseno organizaciónal, Unidad III. Métodologia para la elaboración de manuales de organización. Vol. 5: Modulo IV. Desarrollo organizaciónal: Técnicas de intervención. Vol. 6: Apendice 1. Sintesis de las teorias organizaciónales, Apendice 2. Bibliografia