Quantitative assessment of macular and circumpapillary retinal vessel density across all stages of Leber hereditary optic neuropathy using swept source optical coherence tomography angiography.

PURPOSE: To investigate the macular and circumpapillary retinal microvasculature across all stages of Leber hereditary optic neuropathy (LHON) using swept source optical coherence tomography angiography (OCTA). METHODS: This prospective, multicentre, cross-sectional, observational study analysed a total of 119 eyes of 60 patients with molecularly confirmed LHON across all stages and 120 eyes of 60 control subjects. Optical coherence tomography angiography maps centred on the fovea and optic disc were obtained to measure vessel densities (VDs) in the macular superficial (SCP) and deep (DCP) capillary plexuses, and the radial peripapillary capillary plexus (RPCP) respectively. RESULTS: In asymptomatic eyes, only the SCP showed significant changes on average (B coefficient = -0.72, 95% CI = -1.34 to -0.10, p = 0.022) or in sectors representing the papillomacular bundle (PMB) (B coefficient = -1.17, 95% CI = -2.23 to -0.11, p = 0.031). However, in chronic eyes, the greatest magnitude of change was found in the temporal sector of the RPCP (B coefficient = -12.36, 95% CI = -14.49 to -10.23, p < 0.001). The RPCP showed the strongest correlations with visual acuity (VA, logarithm of the minimum angle of resolution; R = -0.677, p < 0.001) and structural parameters (R = 0.747, p < 0.001). CONCLUSIONS: Retinal VD changes in the circumpapillary region of the PMB appear later than in the macula but end up being more profound and correlate better with VA and structural parameters. Further studies are needed to assess the clinical utility of retinal VDs as potential LHON biomarkers.

La formación médica en el ámbito de las capacidades, según las necesidades del entorno / Medical training concerning capacities, based on the setting-related needs

Introducción: El análisis crítico y la modificación de la formación médica en Colombia es un asunto de gran relevancia en el sistema educativo universitario. Los procesos educativos y formativos de los médicos no pueden estar a espaldas de las realidades actuales, de los contextos contemporáneos y de las diferentes necesidades que han determinado las nuevas condiciones de orden legal, político, económico y cultural. Objetivo: Identificar las necesidades en la formación médica en el ámbito de las capacidades, de acuerdo con las necesidades del entorno, en el programa de Medicina de la Facultad de Ciencias de la Salud de la Universidad de Manizales. Métodos: Estudio exploratorio, diagnóstico y descriptivo, con enfoque empírico analítico, a partir de preguntas validadas por expertos y utilizadas en grupos focales. Los datos y la información obtenidos se analizaron estructuralmente a través de Atlas Ti, para obtener categorías emergentes. Estas fueron descritas a través de redes semánticas, las cuales, de manera complementaria, se confrontaron con categorías empíricas. Resultados: Los resultados precisaron que la profesión médica como ocupación atiende fundamentalmente a la definición convencional de competencias, que expresa que estas son un saber hacer en contexto. Se encontraron capacidades como: proactividad, toma de decisiones, empatía, perfil investigado y habilidades comunicativas, como perfiles de mayor importancia. Conclusiones: El estudio mostró la importancia de orientar la formación médica integral con un currículo flexible, donde se puedan dar procesos educativos problematizantes. Asimismo, se evidenció la relevancia de la práctica(AU)

Introduction: Critical analysis and modification of medical training in Colombia is a matter of great relevance in the university educational system. Educational and training processes for physicians cannot be ignored by current realities, in contemporary contexts and considering the different needs that have determined the new legal, political, economic and cultural conditions. Objective: To identify the needs in medical training in the field of skills, according to the needs of the environment, in the Medicine major's program of the School of Health Sciences of the University of Manizales. Methods: An exploratory, diagnostic and descriptive study, with an analytical empirical approach, based on questions validated by experts and used in focus groups. The data and information obtained were structurally analyzed through ATLAS.ti, to obtain emerging categories. These were described through semantic networks, which, in a complementary way, were confronted with empirical categories. Results: The results specified that the medical profession as an occupation fundamentally attends to the conventional definition of competences, which expresses that these are know-how in context. Capabilities such as: proactivity, decision making, empathy, researched profile and communication skills were found as the most important profiles. Conclusions: The study showed the importance of guiding comprehensive medical training with a flexible program of studies, in which problematic educational processes can occur. Likewise, the relevance of the practice was evidenced(AU)

Economic burden of age-related macular degeneration in routine clinical practice: the RAMDEBURS study.

PURPOSE: To describe and evaluate the main direct health costs, in routine clinical practice, of age-related macular degeneration (AMD) patients, from hospital perspective, in Spain. METHODS: Retrospective, multicenter, and observational study conducted on five third-level Spanish hospitals, between December 2018 and December 2019. The study included patients who were diagnosed of AMD before December 2018. Direct healthcare costs were obtained from a Spanish database. Study variables included demographic and clinical variables, and resources, such as treatment, diagnostic tests, medical examination, and surgery. Among the 1414 screened AMD patients, 1164 patients were included. In the overall study patients, the total cost was €5,386,511.0, with a mean cost per patient of €4627.6 ± 2383.9. The largest cost items were diagnostic examinations (€2.832.902,0) and vascular endothelial growth factor inhibitors (anti-VEGF) treatment (€2.038.257,2). Bevacizumab was administered to 325 (27.9%) patients, ranibizumab to 328 (28.2%), and aflibercept to 626 (53.8%); 115 (10.7%) patients received two anti-VEGF treatments, while 90 (7.7%) did not receive any. Over the course of the study, a total of 6,057 anti-VEGF injections were administered, with a mean (95% confidence interval) of 4.8 (4.4-5.2) injections per patient. Regarding safety, 29 patients experience injection-related adverse events, among them 12 patients had cataract and 11 ones elevated intraocular pressure (IOP). The incidence of endophthalmitis was 0.5% (6/1164). CONCLUSIONS: AMD was associated with considerable healthcare costs for regional healthcare systems. Diagnostic examinations, particularly OCT examinations, and anti-VEGF treatment represented the largest cost items.

Budget impact analysis of dexamethasone intravitreal implant for the treatment of diabetic macular oedema.

OBJECTIVE: To assess the economic impact following the inclusion of an intravitreal implant of dexamethasone for the treatment of diabetic macular oedema in a healthcare area in Spain. METHOD: A 3-year budget impact model was designed to estimate healthcare  direct costs for adult patients with diabetic macular oedema from the National  Health System perspective. The approved therapies in use  (aflibercept/ranibizumab/dexamethasone) were considered. The target  population was estimated from published diabetic macular oedema prevalence  (6.41%) and incidence (0.82%) for a population of 25,000 adults.  Dexamethasone was assumed to be used annually in 20%, 30% and 40% of  patients, respectively. Annual total costs included: drug acquisition (based on  frequency of injections per every year, considering exfactory prices with  mandatory deduction and split of vials), intravitreal administration, patient  monitoring, management of cardiovascular and ocular adverse events  (cataracts, increased intraocular pressure, endophthalmitis, vitreous  haemorrhage and retinal detachment). Detailed resource consumption reflecting  clinical practice was provided from local experts in retina and vitreous. Unitary  costs (€, 2016) were obtained from national databases and literature. Sensitivity  analyses were performed to assess model robustness. RESULTS: The inclusion of intravitreal dexamethasone implant would lead to  annual cost savings of €35,030 (-4.2%), €10,743 (-1.8%) and €5,051 (-0.9%), years 1-3 respectively. Total costs were reduced mainly by the fewer annual  injections required by dexamethasone. The average annual incremental costs  were -€350, -€96 and -€41 per patient. CONCLUSIONS: The inclusion of an intravitreal dexamethasone implant for the  treatment of diabetic macular oedema would lead to cost-savings for the  considered health area, mainly by reducing the administration costs.

Objetivo: Determinar el impacto económico tras la inclusión del implante intravítreo de dexametasona para el tratamiento del edema macular diabético en un área sanitaria en España.Método: Se diseñó un modelo de impacto presupuestario a tres años para  estimar los costes directos en pacientes adultos con edema macular diabético,  desde la perspectiva del Sistema Nacional de Salud, considerando terapias  intravítreas actualmente utilizadas (aflibercept/ranibizumab/dexametasona). La  población diana se obtuvo a partir de la prevalencia (6,41%) e incidencia  (0,82%) del edema macular diabético publicadas para una población de 25.000  pacientes adultos. Se asumió un 20%, 30% y 40% anual de pacientes tratados  con dexametasona, respectivamente. El coste total incluyó: coste farmacológico  (precio de venta del laboratorio con deducción obligatoria y fraccionamiento de  viales, según frecuencia de inyecciones necesarias cada año de tratamiento),  administración intravítrea, seguimiento de pacientes y manejo de eventos  oculares (cataratas, hipertensión ocular, endoftalmitis, hemorragia intravítrea y  desprendimiento de retina) y cardiovasculares. El consumo de recursos según la  práctica habitual fue estimado por expertos en retina y vítreo. Los costes  unitarios (€, 2016) se obtuvieron de la literatura y de bases de datos nacionales.  Los análisis de sensibilidad evaluaron la robustez del modelo. Resultados: La inclusión del implante intravítreo de dexametasona supondría reducciones de 35.030 € (­4,2%), 10.743 € (­1,8%) y 5.051 € (­ 0,9%) cada año, respectivamente, disminuyendo principalmente por el menor  número anual de inyecciones requeridas con dexametasona. La reducción anual  promedio supondría 350 €, 96 € y 41 € por paciente.Conclusiones: La inclusión del implante intravítreo de dexametasona para el  tratamiento del edema macular diabético supone ahorros para el área sanitaria  considerada, fundamentalmente por la reducción de costes de administración.

Prognostic Factors and Decision Tree for Long-Term Survival in Metastatic Uveal Melanoma.

PURPOSE: The purpose of this study was to demonstrate the existence of a bimodal survival pattern in metastatic uveal melanoma. Secondary aims were to identify the characteristics and prognostic factors associated with long-term survival and to develop a clinical decision tree. MATERIALS AND METHODS: The medical records of 99 metastatic uveal melanoma patients were retrospectively reviewed. Patients were classified as either short (≤ 12 months) or long-term survivors (> 12 months) based on a graphical interpretation of the survival curve after diagnosis of the first metastatic lesion. Ophthalmic and oncological characteristicswere assessed in both groups. RESULTS: Of the 99 patients, 62 (62.6%) were classified as short-term survivors, and 37 (37.4%) as long-term survivors. The multivariate analysis identified the following predictors of long-term survival: age ≤ 65 years (p=0.012) and unaltered serum lactate dehydrogenase levels (p=0.018); additionally, the size (smaller vs. larger) of the largest liver metastasis showed a trend towards significance (p=0.063). Based on the variables significantly associated with long-term survival, we developed a decision tree to facilitate clinical decision-making. CONCLUSION: The findings of this study demonstrate the existence of a bimodal survival pattern in patients with metastatic uveal melanoma. The presence of certain clinical characteristics at diagnosis of distant disease is associated with long-term survival. A decision tree was developed to facilitate clinical decision-making and to counsel patients about the expected course of disease.

Estrategias de apropiación y desviación de recursos en el Sistema Municipal de Planeación de Santiago de Cali / Estratégias de apropriação e desvio de recursos no Sistema Municipal de Planejamento de Santiago de Cali / Resource appropriation and deviation strategies in Santiago de Cali's Municipal Planning System

Resumen A partir de algunos elementos que caracterizan un mecanismo de captura de élite mencionado en la literatura, este artículo compara cinco estrategias de apropiación de recursos realizadas por ciertos actores del Sistema Municipal de Planeación (SMP) participativa, de la tercera ciudad más poblada de Colombia, entre 1998 y 2008. Desde un enfoque de evaluación centrada en el uso, se abordaron los actores del SMP y sus alianzas que, aprovechando asimetrías informacionales, restringieron la participación y sesgaron el uso de los recursos. La investigación identificó, como causal básica de la captura, la desarticulación del SMP en tres subsistemas: la comunidad, las instancias de participación local y el Departamento de Planeación. El artículo describe igualmente la serie de ajustes institucionales desarrollados entre 2012 y 2015 (monitoreo, e-voting) buscando minimizar las posibilidades de captura.

Resumo A partir de alguns elementos que caracterizam o mecanismo de captura de elite mencionado na literatura, este artigo compara cinco estratégias de apropriação de recursos feitas por certos atores do Sistema Municipal de Planejamento (SMP) participativo, numa cidade colombiana entre 1998 e 2008. A partir de uma abordagem de avaliação com foco no uso foram abordados os atores do SPM, e as parcerias, aproveitando assimetrias de informação, restringiram a participação e enviesaram o uso de recursos territoriais. A pesquisa identificou, como a causa básica da captura, o desmantelamento do SMP em três subsistemas: a comunidade, as instâncias de participação local e o Departamento Municipal de Planejamento. O artigo também descreve os ajustes institucionais desenvolvidos entre 2012 e 2015 (monitoração, voto eletrônico), buscando reduzir as possibilidades de captura.

Abstract From some elements that characterize an elite capture mechanism mentioned in literature, this article compares five resource appropriation strategies carried out by certain players from the participative Municipal Planning System (MPS) from Colombia's third largest municipality between 1998 and 2008. By using mixed methods and a utilization-focused evaluation design, the MPS players and their partnerships were approached by which their availing of informational asymmetries restricted participation and biased the use of resources. The research identified as the basic cause of the capture the disarticulation of the MPS into three subsystems: the community, instances of local participation, and the Planning Department. The article also describes the series of institutional adjustments carried out between 2012 and 2015 (monitoring, e-voting) seeking to minimize capture possibilities.

Optical coherence tomography assessment of apparent foveal swelling in patients with foveal sparing secondary to geographic atrophy.

OBJECTIVE: To determine whether foveal swelling exists in patients with foveal sparing and geographic atrophy (GA) secondary to dry age-related macular degeneration (AMD) and to establish the contribution of different foveal layers to this condition by use of spectral-domain optical coherence tomography (SD-OCT). DESIGN: Prospective comparative case series. PARTICIPANTS: We assessed patients from a longitudinal study with foveal sparing and GA secondary to AMD. Of an initial sample of 108 patients, 13 eyes of 10 patients complied with the inclusion criteria to study eyes in which apparent swelling would not be questionable. We used a control group of 13 healthy patients to compare the outcome measurements. METHODS: We acquired high-resolution SD-OCT horizontal and oblique B-scans centered at the umbo. Two retinal specialists (J.M., F.T.) independently classified the SD-OCT images. MAIN OUTCOME MEASURES: Difference in foveal center thickness, apparent outer nuclear layer (ONL) thickness, ONL thickness without Henle's fiber layer (HFL), sub-ONL thickness, and retinal thickness at 1000 µm and 3500 µm from the foveal center. RESULTS: The thickness at the foveal center was similar between patients with apparent foveal swelling (cases) and controls without AMD (226 vs. 227 µm; P = 0.56), but the apparent ONL was thicker in cases than in controls (125 vs. 114 µm; P = 0.02). However, when HFL was excluded from the measurements, there was little difference in the results (74 vs. 73 µm; P = 0.82). CONCLUSIONS: We found neither foveal nor ONL swelling in this study. We observed HFL thickening in foveal sparing secondary to GA, which might be related to swelling of the axons of the photoreceptors, or Müller's cells. We also observed thinning of the retina below the external limiting membrane. The clinical significance of these findings should be addressed by longitudinal studies and may have specific therapeutic implications.

Trends in the consumption of attention deficit hyperactivity disorder medications in Castilla y León (Spain): changes in the consumption pattern following the introduction of extended release methylphenidate.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is the most diagnosed behavioural disorder in children and adolescents; prevalence has been estimated around 5%. Studies have shown an increase in the use of ADHD medications during the last years. The aim of the present study was to learn the pattern and the evolution of ADHD medication consumption in Castilla y León (Spain). METHOD: Consumption data for the period 1992-2009 were obtained from databases containing information upon consumption and cost of medications dispensed by pharmacies at the expense of the Spanish National Health System. The data were expressed in defined daily doses (DDDs) per 1000 inhabitants per day (DDD/1000 inhabitants/day). A model to forecast consumption was built. RESULTS: Attention deficit hyperactivity disorder medication consumption increased in Castilla y León from 0.1 DDD/1000 inhabitants/day in 1992 to 1.5 DDD/1000 inhabitants/day in 2009; expected consumption will reach 2.5 DDD/1000 inhabitants/day by 2013. The drugs accounting for this increase were mainly made up of methylphenidate preparations (1.4 DDD/1000 inhabitants/day in 2009). From 1992 to 1999, there was a slight reduction in methylphenidate use; following amphetamine withdrawal, the consumption of stimulants began to increase, and figures showed a sharp rise after marketing of extended-release formulations in 2003. CONCLUSIONS: There has been an enormous increase in ADHD medication consumption in Castilla y León in the last few years; increase rocketed when extended-release methylphenidate was marketed. A rapid increase in the consumption is a warning on possible overdiagnosis and inappropriate prescription.

Trends in the consumption of antidepressants in Castilla y León (Spain). Association between suicide rates and antidepressant drug consumption.

OBJECTIVE: To learn the evolution of antidepressant and lithium use in Castilla y León (Central Spain) and its relationship with suicide rates. METHODS: A search in the ECOM (Especialidades Consumo de Medicamentos) database of the Spanish Ministry of Health for antidepressants and lithium was carried out for the period 1992-2005. Defined daily doses (DDD) per 1000 inhabitants per day were obtained as consumption data. Population and suicide rates data come from the Spanish National Statistics Institute. RESULTS: Antidepressant consumption increased 7-fold, from 6.9 DDD per 1000 inhabitants per day in 1992 to 47.3 in 2005; the corresponding increase in cost was more than 10-fold. Selective serotonin reuptake inhibitors (SSRIs) comprised 77% of the total consumption. Venlafaxine consumption multiplied by 2.2. The consumption of monoamine oxidase inhibitors (MAOIs) decreased after venlafaxine and mirtazapine were marketed. Lithium consumption increased by 76% during the period studied, but it plateaued in 2000. CONCLUSIONS: The consumption of antidepressants in Castilla y León has increased remarkably and the pattern has changed; there is an increase in the consumption of the new and more expensive antidepressants such as venlafaxine and escitalopram. No association was observed between suicide rates and antidepressant consumption.