Estudio de la calidad de la prescripción hospitalaria de antibioterapia en la población pediátrica y propuesta de mejora con la colaboración de un farmacéutico en el equipo asistencial

El uso incorrecto de los medicamentos ocurre en todos los países, es nocivo para los pacientes y constituye un desperdicio de recursos. Se estima que aproximadamente el 50% de los antibióticos son administrados innecesariamente. Existe una relación entre el uso indiscriminado de agentes antimicrobianos y el aumento de los microorganismos resistentes a dichos agentes. Consecuencia de ello es la aparición cada vez más frecuente de infecciones nosocomiales, cuyas responsables la mayoría de las veces, son bacterias multirresistentes. Se asocian con incidencias más elevadas de morbimortalidad, ya que limitan la opción de tratamiento por la falta de eficacia de los antibióticos, alargando el período convaleciente del paciente y encareciendo los costes del ingreso. Todo esto y el alto costo de los nuevos antibacterianos hacen que por primera vez desde la introducción de los antibióticos, exista la posibilidad de no contar con ninguna quimioterapia efectiva para los pacientes con infecciones. Este hecho es especialmente preocupante en los pacientes pediátricos, ya que por su edad se verán obligados a combatir infecciones futuras, y precisan de la mayor sensibilidad posible a los agentes antimicrobianos y de la mayor cantidad de antibióticos activos frente a ellos. Además, en los primeros años de vida se produce la mayor exposición innecesaria a antibióticos de toda la población, por ser la mayoría de las infecciones a esta edad de etiología viral y autolimitadas. Precisamente por tratarse de niños, es muy importante no olvidar que dentro del mismo Área de Pediatría existe una amplia gama de pacientes, muy diferentes unos de otros, que deben ser tratados de forma individualizada para asegurar una terapia farmacológica efectiva. La población infantil presenta diferencias farmacocinéticas y farmacodinámicas en cuanto a la respuesta a un fármaco, lo cual hace de la farmacología pediátrica una especialidad en sí misma. A día de hoy, los estudios sobre pacientes pediátricos son más bien escasos. Este trabajo podría resultar de gran utilidad para ampliar y enriquecer estos conocimientos...

Comparison between clinical results of two diffractive multifocal lenses with the same platform but different additions

PURPOSE: To evaluate visual results with two multifocal diffractive lenses designed with the same platform but with different additions. SETTING: Grupo Innova Ocular clinics. METHODS: A total of 50 eyes from 50 patients were included. Group 1 (n = 25) was implanted with the TECNIS® 1 ZLB +3.25 and group 2 (n = 25) with the TECNIS® 1 ZKB +2.75. Patients were assessed at 24 hours, 1 week and 1 month postoperatively. At surgical discharge, corrected (CDVA) and uncorrected distance visual acuity (UCDVA), near visual acuity (VA) at 25, 40 and 80 cm, visual quality and the defocus curve were measured. RESULTS: Changes in sphere and spherical equivalent were statistically significant (p<0.01) in both groups at 1 week and 1 month compared to preoperative values. In group 1, UCDVA logMAR at 1 month was 0.06 ± 0.02. In group 2, UCDVA at 1 month was 0.03 ± 0.03. In near vision, the TECNIS® 1 ZLB group obtained a VA logMAR of 0.35 ± 0.02 at 25 cm, 0.13 ± 0.02 at 40 cm and 0.27 ± 0.02 at 80 cm, while in the TECNIS® 1 ZKB group, the values were 0.38  ± 0.03, 0.14 ± 0.03 and 0.23 ± 0.06, respectively. No statistically significant differences were found either when results for visual quality were compared. CONCLUSION: Both the TECNIS® 1 ZLB and TECNIS® 1 ZKB are excellent options for obtaining good distance and near vision, in addition to providing good intermediate vision, especially at distances such as those required for working with computers.

Adaptación del BRIEF ("Behavior Rating Inventory of Executive Function") a población española y su utilidad para el diagnóstico del trastorno por déficit de atención-hiperactividad subtipos inatento y combinado

La valoración de las funciones ejecutivas tiene una especial dificultad cuando se intenta llevar a cabo mediante un enfoque tradicional de pruebas neuropsicológicas. Este aspecto es especialmente relevante en la evaluación de funciones ejecutivas en población pediátrica, lo que propició el desarrollo de cuestionarios de conducta como el Behavior Rating Inventory of Executive Function (BRIEF), con el fin de convertirse en una medida ecológica de las alteraciones de funciones ejecutivas. Resulta necesario realizar una adaptación completa de una prueba psicométrica para que ésta pueda ser utilizada en una población diferente para la cual fue diseñada. El BRIEF ha sido utilizado para la valoración de las alteraciones ejecutivas en numerosas patologías, pero destacan los estudios realizados en niños con Trastorno por Déficit de Atención - Hiperactividad (TDAH). El TDAH presenta alteraciones neuropsicológicas que implican especialmente a las funciones ejecutivas, lo que justifica el uso de la prueba en esta patología. Incluso, algunas de las teorías más importantes sobre TDAH apuntan a las alteraciones en inhibición como el síntoma nuclear del trastorno. La existencia de dos subtipos principales en el TDAH (subtipo predominantemente inatento y combinado) podría implicar un patrón diferente de alteraciones ejecutiva en cada tipo. OBJETIVOS: Se presentan dos objetivos principales: 1) Adaptación del BRIEF a población española, y 2) Estudio del perfil diferencial del BRIEF entre los subtipos inatento y combinado del TDAH...

Disk halo size measured in individuals with monofocal versus diffractive multifocal intraocular lenses

PURPOSE: To compare disk halo size in response to a glare source in eyes with an aspheric apodized diffractive multifocal intraocular lens (IOL) or aspheric monofocal IOL. SETTING: Rementeria Ophthalmological Clinic, Madrid, Spain. DESIGN: Prospective randomized masked study. METHOD: Halo radius was measured using a vision monitor (MonCv3) with low-luminance optotypes in eyes that had cataract surgery and bilateral implantion of an Acrysof Restor SN6AD1 multifocal IOL or Acrysof IQ monofocal IOL 6 to 9 months previously. The visual angle subtended by the disk halo radius was calculated in minutes of arc (arcmin). Patient complaints of halo disturbances were recorded. Monocular uncorrected distance visual acutity (UDVA) and corrected distance visual acuity (CDVA) were measured using high-contrast (96%) and low-contrast (10%) logMAR letter charts. RESULTS: The study comprised 39 eyes of 39 subjects (aged 70 to 80 years); 21 eyes had a multifocal IOL and 18 eyes a monofocal IOL. The mean halo radius was 35 arcmin larger in the multifocal IOL group than the monofocal group (P<.05). Greater halo effects were reported in the multifocal IOL group (P<.05). The mean monocular high-contrast UDVA and low-contrast UDVA did not vary significantly between groups, whereas the mean monocular high-contrast CDVA and low-contrast CDVA were significantly worse at 0.12 logMAR and 0.13 logMAR in the multifocal than in the monofocal IOL group, respectively (P <.01). A significant positive correlation was detected by multiple linear regression between the halo radius and low-contrast UDVA in the multifocal IOL group (r = 0.72, P<.001). CONCLUSIONS: The diffractive multifocal IOL gave rise to a larger disk halo size, which was correlated with a worse low-contrast UDVA.

Stability of a Novel Intraocular Lens Design: Comparison of Two Trifocal Lenses

PURPOSE: To compare visual outcomes, rotational stability, and centration in a randomized controlled trial in patients undergoing cataract surgery who were bilaterally implanted with two different trifocal intraocular lenses (IOLs) with a similar optical zone but different haptic shape. METHODS: Twenty-one patients (42 eyes) with cataract and less than 1.50 D of corneal astigmatism underwent implantation of one FineVision/MicoF IOL in one eye and one POD FineVision IOL in the contralateral eye (PhysIOL, Liège, Belgium) at IOA Madrid Innova Ocular, Madrid, Spain. IOL allocation was random. Outcome measures, all evaluated 3 months postoperatively, included monocular and binocular uncorrected distance (UDVA), corrected distance (CDVA), distance-corrected intermediate (DCIVA), and near (DCNVA) visual acuity (at 80, 40, and 25 cm) under photopic conditions, refraction, IOL centration, haptic rotation, dysphotopsia, objective quality of vision and aberration quantification, patient satisfaction, and spectacle independence. RESULTS: Three months postoperatively, mean monocular UDVA, CDVA, DCIVA, and DCNVA (40 cm) under photopic conditions were 0.04 ± 0.07, 0.01 ± 0.04, 0.15 ± 0.11, and 0.16 ± 0.08 logMAR for the eyes implanted with the POD FineVision IOL and 0.03 ± 0.05, 0.01 ± 0.02, 0.17 ± 0.12, and 0.14 ± 0.08 logMAR for those receiving the FineVision/MicroF IOL. Moreover, the POD FineVision IOL showed similar centration (P > .05) and better rotational stability (P < .05) than the FineVision/MicroF IOL. Regarding halos, there was a minimal but statistically significant difference, obtaining better results with FineVision/MicroF. Full spectacle independence was reported by all patients. CONCLUSIONS: This study revealed similar visual outcomes for both trifocal IOLs under test (POD FineVision and FineVision/MicroF). However, the POD FineVision IOL showed better rotational stability, as afforded by its design.

Pupillary behavior in relation to wavelength and age

Pupil light reflex can be used as a non-invasive ocular predictor of cephalic autonomic nervous system integrity. Spectral sensitivity of the pupil's response to light has, for some time, been an interesting issue. It has generally, however, only been investigated with the use of white light and studies with monochromatic wavelengths are scarce. This study investigates the effects of wavelength and age within three parameters of the pupil light reflex (amplitude of response, latency, and velocity of constriction) in a large sample of younger and older adults (N = 97), in mesopic conditions. Subjects were exposed to a single light stimulus at four different wavelengths: white (5600° K), blue (450 nm), green (510 nm), and red (600 nm). Data was analyzed appropriately, and, when applicable, using the General Linear Model (GLM), Randomized Complete Block Design (RCBD), Student's t-test and/or ANCOVA. Across all subjects, pupillary response to light had the greatest amplitude and shortest latency in white and green light conditions. In regards to age, older subjects (46-78 years) showed an increased latency in white light and decreased velocity of constriction in green light compared to younger subjects (18-45 years old). This study provides data patterns on parameters of wavelength-dependent pupil reflexes to light in adults and it contributes to the large body of pupillometric research. It is hoped that this study will add to the overall evaluation of cephalic autonomic nervous system integrity.

Anafilaxia en urgencias: incidencia, diagnóstico y manejo clínico

La anafilaxia fue descrita en 1902, sin embargo, sigue sin existir una definición de anafilaxia universalmente aceptada. La más utilizada, en la actualidad, es la publicada en el documento de consenso del simposio sobre la definición y el manejo de la anafilaxia del año 2005, que la describe como “una reacción alérgica de inicio rápido que puede producir la muerte”. Actualmente, la anafilaxia se clasifica en inmunológica (IgE dependiente o independiente) y no inmunológica (por ejemplo, la originada por algunos contrastes iodados). Sus síntomas están causados por una liberación masiva de mediadores, principalmente de mastocitos y basófilos, que pueden tener como diana cualquier órgano. Los datos epidemiológicos acerca de la anafilaxia son escasos. La prevalencia se estima entre el 0,05% y el 2%, aunque su incidencia parece estar aumentando. En los últimos años, se han publicado varios estudios que han intentado establecer la incidencia de anafilaxia en los servicios de urgencias de diversos hospitales. Los datos publicados en estos estudios oscilan entre el 0,07% y el 0,4%. Esta variabilidad puede deberse a características de la población y zona geográfica, y también a limitaciones metodológicas, condicionadas principalmente por la falta de consenso en cuanto a su definición, las dificultades para la codificación de la anafilaxia mediante códigos CIE y el funcionamiento de los servicios de urgencias. Además, la mayor parte de estos estudios se centran en pacientes adultos, y en menos ocasiones analizan las características de los pacientes en edad pediátrica...

Cambios en el polo anterior tras la ortoqueratología nocturna

La Ortoqueratología nocturna (OKN) es una técnica que utiliza lentes de contacto especialmente diseñadas y adaptadas al ojo con el fin de modificar el contorno corneal induciendo un aplanamiento en la región central de la córnea, cambiando así el estado refractivo del mismo. El efecto buscado es similar al de la cirugía refractiva salvo que con este sistema, el efecto inducido es reversible. La aparición de lentes capaces de inducir de forma efectiva los cambios deseados en la córnea, en tan sólo siete días de manera rápida, eficaz y reversible, ha propiciado que esta técnica haya comenzado a utilizarse con resultados muy satisfactorios permitiendo que el paciente pueda estar libre de gafas o lentes de contacto durante el día. Esta terapia ha despertado un gran interés en la comunidad científica, convirtiéndose en una alternativa real a la Cirugía Refractiva. Además, se ha reportado en diversos estudios que el uso de lentes de OKN en niños, reduce el crecimiento axial entre un 30% y un 50%, en comparación con los niños que usan gafas o lentes de contacto 1-6 . El auge de la OKN y la creciente utilización de esta técnica en niños para el control de la miopía implica la necesidad de una mayor comprensión del mecanismo por el cual las LC de geometría inversa inducen la corrección del error refractivo en el ojo...

Signs and Symptoms of Dry Eye in Keratoconus Patients: A Pilot Study

Purpose: To compare signs and symptoms of dry eye in keratoconus (KC) patients versus healthy subjects. Methods: A total of 15 KC patients (KC group, n = 15 eyes) and 16 healthy subjects (control group, 16 eyes) were enrolled in this study. The Schirmer I test with no anesthetic, tear break-up time (TBUT), corneal staining characteristics, and ocular surface disease index (OSDI) scores were evaluated for both groups. Impression cytology, combined with/scanning laser confocal microscopy (LCM), was performed to evaluate goblet cell density, mucin cloud height (MCH), and goblet cell layer thickness (CLT). Finally, tear concentrations of di-adenosine tetraphosphate (Ap4A) were assessed. Results were statistically analyzed using Shapiro–Wilk and non-parametric Wilcoxon rank sum tests. Statistical significance was set at p < 0.05. Results: KC patients had lower tear volumes and greater corneal staining than did healthy subjects (p < 0.05). OSDI scores were 44.96 ± 8.65 and 17.78 ± 6.50 for the KC and control groups, respectively (p < 0.05). We found no statistically significant differences in TBUT between groups. Impression cytology revealed lower goblet cell densities in KC group patients versus control group subjects (84.88 ± 32.98 and 128.88 ± 50.60 cells/mm,2 respectively, p < 0.05). There was a statistically significant reduction in MCH and CLT in KC group patients compared with control group subjects. Ap4A tear concentrations were higher in KC group patients than in control group subjects (2.56 ± 1.10 and 0.15 ± 0.12 µM, respectively, p < 0.05). Conclusions: The parameters evaluated in this study indicate that KC patients suffer greater symptoms of dry eye and greater tear instability, primarily due to the decreased mucin production in their tears, than do healthy patients with no KC.

Effect of overnight orthokeratology on conjunctival goblet cells

Objective: To evaluate the differences between goblet cell density (GCD) and symptomatology after one month of orthokeratology lens wear. Methods: A pilot, short-term study was conducted. Twenty-two subjects (29.7. ±. 7.0 years old) participated voluntarily in the study. Subjects were divided into two groups: habitual silicone hydrogel contact lens wearers (SiHCLW) and new contact lens wearers (NCLW). Schirmer test, tear break up time (TBUT), Ocular Surface Disease Index (OSDI) questionnaire and conjunctival impression cytology. GCD, mucin cloud height (MCH) and cell layer thickness (CLT) were measured. All measurements were performed before orthokeratology fitting and one month after fitting to assess the evolution of the changes throughout this time. Results: No differences in tear volume and TBUT between groups were found (p>0.05). However, the OSDI score was statistically better after one month of orthokeratology lens wear than the baseline for the SiHCLW group (p=0.03). Regarding the goblet cell analysis, no differences were found in CLT and MCH from the baseline visit to the one month visit for the SiHCLW compared with NCLW groups (p>0.05). At baseline, the GCD in the SiHCLW group were statistically lower than NCLW group (p<0.001). There was a significant increase in GCD after orthokeratology fitting from 121±140cell/mm2 to 254±130cell/mm2 (p<0.001) in the SiHCLW group. Conclusion: Orthokeratology improves the dry eye subject symptoms and GCD after one month of wearing in SiHCLW. These results suggest that orthokeratology could be considered a good alternative for silicone hydrogel contact lens discomfort and dryness. © 2016 British Contact Lens Association.

Contrast sensitivity evaluation with filter contact lenses in patients with retinitis pigmentosa: a pilot study

Purpose: the aim of this pilot study was to test whether retinitis pigmentosa patients would benefit from filter contact lenses as an effective optical aid against glare and photophobia. Methods: fifteen subjects with retinitis pigmentosa were enrolled in this study. All of them were evaluated with filter soft contact lenses (MaxSight), filter glasses (CPF 527) and without filters (control). All patients were assessed for the three aid conditions by means of best corrected visual acuity (BCVA), contrast sensitivity (without glare and with central and peripheral glare)(CSV-1000) and a specific subjective questionnaire about quality of vision. Results: BCVA was slightly better with filters than without filter but the differences were not statistically significant. Contrast sensitivity without glare improved significantly with the contact lenses (p<0.05). The central glare had significant differences for the frequencies of 3 cpd and 18 cpd between the contact lens filter and the control group (p=0.021 and p=0.044, respectively). For the peripheral glare contrast sensitivity improved with contact lens versus control group for highest frequencies, 12 and 18 cpd (p<0.001 and p=0.045, respectively). According to the questionnaire the contact lens filter gave them more visual comfort than the glasses filter under the scenarios of indoors glare, outdoors activities and indoors comfort. Conclusion: the filter contact lenses seem to be a good option to improve the quality of vision of patients with retinitis pigmentosa.

Nuevo instrumento para medir la sensibilidad al contraste sin y con deslumbramiento

Objetivo/Método: Valorar la sensibilidad al contraste fotópica, sin y con deslumbramiento con un nuevo instrumento. Se estudiaron 78 ojos derechos de 49 adultos jóvenes y de 29 adultos entre 35 y 55 años. La sensibilidad al contraste se midió con el Contrast Glaretester CGT-1000 mediante una estrategia automatizada de reconocimiento para seis frecuencias espaciales. Resultados/Conclusiones: Los valores de sensibilidad al contraste fueron semejantes a los obtenidos con otros tests clínicos. El aumento de la edad disminuyó significativamente la sensibilidad al contraste sin y con deslumbramiento. Sin embargo, el deslumbramiento no modificó la sensibilidad al contraste fotópica.

Impaired Mesopic Visual Acuity in Eyes with Early Age-Related Macular Degeneration

Purpose.: To determine photopic and mesopic distance high-contrast visual acuity (HC-VA) and low-contrast visual acuity (LC-VA) in eyes with early age-related macular degeneration (AMD). Methods.: Measurements were made in 22 subjects with early AMD and 28 healthy control subjects. Inclusion criteria included a photopic HC-VA of 20/25 or better. Distance VA was measured using HC (96%) and LC (10%) Bailey-Lovie logMAR letter charts under photopic (85 cd/m2) and mesopic (0.1–0.2 cd/m2) luminance conditions. Results.: Mean mesopic distance HC-VA and LC-VA were significantly worse (0.1 logMAR and 0.28 logMAR, respectively) in the early AMD group than in the control group. Under mesopic conditions, the mean difference between LC-VA and HC-VA was significantly greater in the early AMD (0.45 logMAR) than the control group (0.27 logMAR). Mean differences between mesopic versus photopic HC-VA and mesopic versus photopic LC-VA were significantly greater in the early AMD than the control group (0.13 and 0.32 logMAR of difference between the means, respectively). Sensitivity and specificity were significantly greater for mesopic LC-VA than for mesopic HC-VA (Receiver Operating Characteristics, area under the curve [AUC], 0.94 ± 0.030 and 0.76 ± 0.067, respectively). AUC values for photopic HC-VA and LC-VA were below 0.70. Conclusions.: Visual acuity testing under low luminance conditions emerged as an optimal quantitative measure of retinal function in early AMD.

Automatic Counting of Microglial Cells in Healthy and Glaucomatous Mouse Retinas

Proliferation of microglial cells has been considered a sign of glial activation and a hallmark of ongoing neurodegenerative diseases. Microglia activation is analyzed in animal models of different eye diseases. Numerous retinal samples are required for each of these studies to obtain relevant data of statistical significance. Because manual quantification of microglial cells is time consuming, the aim of this study was develop an algorithm for automatic identification of retinal microglia. Two groups of adult male Swiss mice were used: age-matched controls (naïve, n = 6) and mice subjected to unilateral laser-induced ocular hypertension (lasered; n = 9). In the latter group, both hypertensive eyes and contralateral untreated retinas were analyzed. Retinal whole mounts were immunostained with anti Iba-1 for detecting microglial cell populations. A new algorithm was developed in MATLAB for microglial quantification; it enabled the quantification of microglial cells in the inner and outer plexiform layers and evaluates the area of the retina occupied by Iba-1+ microglia in the nerve fiber-ganglion cell layer. The automatic method was applied to a set of 6,000 images. To validate the algorithm, mouse retinas were evaluated both manually and computationally; the program correctly assessed the number of cells (Pearson correlation R = 0.94 and R = 0.98 for the inner and outer plexiform layers respectively). Statistically significant differences in glial cell number were found between naïve, lasered eyes and contralateral eyes (P<0.05, naïve versus contralateral eyes; P<0.001, naïve versus lasered eyes and contralateral versus lasered eyes). The algorithm developed is a reliable and fast tool that can evaluate the number of microglial cells in naïve mouse retinas and in retinas exhibiting proliferation. The implementation of this new automatic method can enable faster quantification of microglial cells in retinal pathologies.