Surveillance for ocular hypertension: An evidence synthesis and economic evaluation

OBJECTIVES: To determine effective and efficient monitoring criteria for ocular hypertension [raised intraocular pressure (IOP)] through (i) identification and validation of glaucoma risk prediction models; and (ii) development of models to determine optimal surveillance pathways.

DESIGN: A discrete event simulation economic modelling evaluation. Data from systematic reviews of risk prediction models and agreement between tonometers, secondary analyses of existing datasets (to validate identified risk models and determine optimal monitoring criteria) and public preferences were used to structure and populate the economic model.

SETTING: Primary and secondary care.

PARTICIPANTS: Adults with ocular hypertension (IOP > 21 mmHg) and the public (surveillance preferences).

INTERVENTIONS: We compared five pathways: two based on National Institute for Health and Clinical Excellence (NICE) guidelines with monitoring interval and treatment depending on initial risk stratification, 'NICE intensive' (4-monthly to annual monitoring) and 'NICE conservative' (6-monthly to biennial monitoring); two pathways, differing in location (hospital and community), with monitoring biennially and treatment initiated for a ≥ 6% 5-year glaucoma risk; and a 'treat all' pathway involving treatment with a prostaglandin analogue if IOP > 21 mmHg and IOP measured annually in the community.

MAIN OUTCOME MEASURES: Glaucoma cases detected; tonometer agreement; public preferences; costs; willingness to pay and quality-adjusted life-years (QALYs).

RESULTS: The best available glaucoma risk prediction model estimated the 5-year risk based on age and ocular predictors (IOP, central corneal thickness, optic nerve damage and index of visual field status). Taking the average of two IOP readings, by tonometry, true change was detected at two years. Sizeable measurement variability was noted between tonometers. There was a general public preference for monitoring; good communication and understanding of the process predicted service value. 'Treat all' was the least costly and 'NICE intensive' the most costly pathway. Biennial monitoring reduced the number of cases of glaucoma conversion compared with a 'treat all' pathway and provided more QALYs, but the incremental cost-effectiveness ratio (ICER) was considerably more than £30,000. The 'NICE intensive' pathway also avoided glaucoma conversion, but NICE-based pathways were either dominated (more costly and less effective) by biennial hospital monitoring or had a ICERs > £30,000. Results were not sensitive to the risk threshold for initiating surveillance but were sensitive to the risk threshold for initiating treatment, NHS costs and treatment adherence.

LIMITATIONS: Optimal monitoring intervals were based on IOP data. There were insufficient data to determine the optimal frequency of measurement of the visual field or optic nerve head for identification of glaucoma. The economic modelling took a 20-year time horizon which may be insufficient to capture long-term benefits. Sensitivity analyses may not fully capture the uncertainty surrounding parameter estimates.

CONCLUSIONS: For confirmed ocular hypertension, findings suggest that there is no clear benefit from intensive monitoring. Consideration of the patient experience is important. A cohort study is recommended to provide data to refine the glaucoma risk prediction model, determine the optimum type and frequency of serial glaucoma tests and estimate costs and patient preferences for monitoring and treatment.

FUNDING: The National Institute for Health Research Health Technology Assessment Programme.

Attitudes of consultant ophthalmologists in the UK to initial management of glaucoma patients presenting with severe visual field loss: a national survey

BACKGROUND: Recent National Institute of Clinical Excellence guidance suggests primary surgery should be offered to patients presenting with glaucoma with severe visual field loss. We undertook a survey of UK consultant ophthalmologists to determine if this represents current practice and explore attitudes towards managing patients with advanced glaucoma at presentation.

DESIGN: Questionnaire evaluation study.

PARTICIPANTS: All consultant ophthalmologists currently practicing in the UK.

METHODS: A single-page questionnaire was posted to all consultants (n = 910) currently practicing in the UK along with a pre-paid return envelope. A second questionnaire was sent to non-responders (n = 459).

MAIN OUTCOME MEASURES: Questionnaire responses.

RESULTS: 626 responses were received representing 68.8% of the population surveyed. 152 (24%) volunteered a specialist interest in glaucoma. Consensus opinion for both glaucoma specialists (64.9%) and non-glaucoma specialists (62.4%) was to start with primary medical therapy, most commonly citing surgical risk as the primary reason (23% and 22%, respectively) for this approach. Most felt the highest intraocular pressure measurement during follow up (measured in clinic) was the most important variable for prevention of further visual loss (60% of glaucoma specialists and 55% of non-glaucoma specialists). Eighty-three per cent of all responders suggested they would change their practice if evidence supporting primary surgery as a safe and more effective approach existed.

CONCLUSIONS: Recent National Institute of Clinical Excellence guidance does not reflect the current management approach of UK ophthalmologists. The primary concern was related to potential complications of surgery although most practitioners would be willing to change their practice if evidence existed supporting primary surgery in patients presenting with advanced glaucoma.

Dose, dose-rate and field size effects on cell survival following exposure to non-uniform radiation fields

For the delivery of intensity-modulated radiation therapy (IMRT), highly modulated fields are used to achieve dose conformity across a target tumour volume. Recent in vitro evidence has demonstrated significant alterations in cell survival occurring out-of-field which cannot be accounted for on the basis of scattered dose. The radiobiological effect of area, dose and dose-rate on out-of-field cell survival responses following exposure to intensity-modulated radiation fields is presented in this study. Cell survival was determined by clonogenic assay in human prostate cancer (DU-145) and primary fibroblast (AG0-1522) cells following exposure to different modulated field configurations delivered using a X-Rad 225 kVp x-ray source. Uniform survival responses were compared to in- and out-of-field responses in which 25-99% of the cell population was shielded. Dose delivered to the out-of-field region was varied from 1.6-37.2% of that delivered to the in-field region using different levels of brass shielding. Dose rate effects were determined for 0.2-4 Gy min⁻¹ for uniform and modulated exposures with no effect seen in- or out-of-field. Survival responses showed little dependence on dose rate and area in- and out-of-field with a trend towards increased survival with decreased in-field area. Out-of-field survival responses were shown to scale in proportion to dose delivered to the in-field region and also local dose delivered out-of-field. Mathematical modelling of these findings has shown survival response to be highly dependent on dose delivered in- and out-of-field but not on area or dose rate. These data provide further insight into the radiobiological parameters impacting on cell survival following exposure to modulated irradiation fields highlighting the need for refinement of existing radiobiological models to incorporate non-targeted effects and modulated dose distributions.

Ellerman Bombs - Evidence for Magnetic Reconnection in the Lower Solar Atmosphere

The presence of photospheric magnetic reconnection has long been thought to give rise to short and impulsive events, such as Ellerman bombs (EBs) and Type II spicules. In this article, we combine high-resolution, high-cadence observations from the Interferometric BIdimensional Spectrometer and Rapid Oscillations in the Solar Atmosphere instruments at the Dunn Solar Telescope, National Solar Observatory, New Mexico, with co-aligned Solar Dynamics Observatory Atmospheric Imaging Assembly and Hinode Solar Optical Telescope (SOT) data to observe small-scale events situated within an active region. These data are then compared with state-of-the-art numerical simulations of the lower atmosphere made using the MURaM code. It is found that brightenings, in both the observations and the simulations, of the wings of the Hα line profile, interpreted as EBs, are often spatially correlated with increases in the intensity of the Fe I λ6302.5 line core. Bipolar regions inferred from Hinode/SOT magnetic field data show evidence of flux cancellation associated, co-spatially, with these EBs, suggesting that magnetic reconnection could be a driver of these high-energy events. Through the analysis of similar events in the simulated lower atmosphere, we are able to infer that line profiles analogous to the observations occur co-spatially with regions of strong opposite-polarity magnetic flux. These observed events and their simulated counterparts are interpreted as evidence of photospheric magnetic reconnection at scales observable using current observational instrumentation.

Measuring Interactions in Networks: Evidence from Soccer Teams

This paper contributes to the literature on centrality measures in economics by defining a team game and identifying the key players in the game. As an illustration of the theory, we create a unique data set from the UEFA Euro 2008 tournament. To capture the interaction between players, we create the passing network of each team. This all allows us to identify the key player and key groups of players for both teams in each game. We then use our measure to explain player ratings by experts and their market values. Our measure is significant in explaining expert ratings. We also find that players having higher intercentrality measures, regardless of their field position have significantly higher market values.

Evaluation of the diagnostic potential of a novel field immunomagnetic separation-immunochromatographic lateral flow assay to detect Mycobacterium bovis cells in European badger (Meles meles) faeces

The European badger (Meles meles) is a natural reservoir for Mycobacterium bovis, the causative agent of Bovine Tuberculosis, and has consequently been implicated in transmission of the disease to cattle. This study describes application of a novel M. bovis-specific immunochromatographic (lateral flow) assay in combination with immunomagnetic separation (IMS-LFD), to test badger faeces samples. In total, 441 faeces samples from badgers of unknown disease status collected from latrines at 110 badger setts throughout Northern Ireland (NI) and 100 faeces samples from badgers of known infection status from Great Britain (GB) were tested. Faeces (approx. 1g) was homogenised in 9 ml phosphate buffered saline, filtered (70 µm), and then 6-8 ml subjected to the IMS-LFD test. Residual clarified faecal homogenates were subjected to automated IMS followed by MGIT™ liquid culture (AIMS-MGIT™ culture) and qPCR (AIMS-qPCR). Evidence for the presence of M. bovis was obtained for 78 (18%), 61 (14%) and 140 (32%) of 441 NI badger faeces samples, and 10 (10%), 41 (41%) and 56 (56%) of 100 GB badger faeces samples, by IMS-LFD, AIMS-MGIT culture and AIMS-qPCR tests, respectively. The IMS-LFD test was less sensitive than AIMS-qPCR for detection of M. bovis and was, therefore, detecting badgers shedding high numbers of M. bovis in their faeces only. However, these ‘super shedders’ may be primarily responsible for the spread of Bovine Tuberculosis so are, therefore, an important target. This non-invasive test could form the basis of a field surveillance tool to indicate infected badger groups which are actively spreading M. bovis.

Do chitons have a compass? Evidence for magnetic sensitivity in Polyplacophora

Several animals and microbes have been shown to be sensitive to magnetic fields, though the exact mechanisms of this ability remain unclear in many animals. Chitons are marine molluscs which have high levels of biomineralised magnetite coating their radulae. This discovery led to persistent anecdotal suggestions that they too may be able to navigationally respond to magnetic fields. Several researchers have attempted to test this, but to date there have been no large-scale controlled empirical trials. In the current study, four chiton species (Katharina tunicata, Mopalia kennerleyi, Mopalia muscosa and Leptochiton rugatus, n=24 in each) were subjected to natural and artificially rotated magnetic fields while their movement through an arena was recorded over four hours. Field orientation did not influence the position of the chitons at the end of trials, possibly as a result of the primacy of other sensory cues (i.e. thigmotaxis). Under non-rotated magnetic field conditions, the orientation of subjects when they first reached the edge of an arena was clustered around 309-345 degrees (north-north-west) in all four species. However, orientations were random under the rotated magnetic field, which may indicate a disruptive effect of field rotation. This pattern suggests that chitons can detect and respond to magnetism.

Assessment of hydrogen sulfide removal from biogas using a field scale anoxic biotrickling filter.

Hydrogen sulphide is one of the most toxic and corrosive compound present in swine-derived biogas streams.In this study, afield scale biotrickling filter for the removal of hydrogen sulfide was investigated.A Biofilter packed with supporting biofilm materials was fed continuously with a proprietary nutrient solution and operatedfor over 73days. The system has been operating with a H2S inlet concentrations ranging from 1,000to 3,000 ppm.Significant removal efficiencies >95% was demonstrated. pH of the stock feeding solution decreased from 6.2 to as low as 3.5within couple days.The resulting drop in pH provided circumstantial evidence to support biological H2 Soxidation to sulphuric acid by sulfide-oxidizers. Sulfur precipitation was also observed to occur. The results suggested that H2S removal from biogas stream can be efficiently achieved using portable, low cost and maintenance free biotrickling filters.

Leverage instability and persistence: Evidence from the United States and Europe

We find that leverage behavior both in level and time-series variation is very similar between the United States and Europe throughout the 1990-2013 period. Leverage regimes are simultaneously unstable and persistent for both regions. We define instability as the extent to which firms largely deviate from their long-term leverage mean, while persistence as the extent to which today’s leverage influences its future levels. We then show that this simultaneous evidence imply a mean-reversion behavior of leverage and discuss some of its implications for future research on this field.

Swiss clinical practice guidelines on field cancerization of the skin.

Actinic keratosis (AK) affects millions of people worldwide, and its prevalence continues to increase. AK lesions are caused by chronic ultraviolet radiation exposure, and the presence of two or more AK lesions along with photodamage should raise the consideration of a diagnosis of field cancerization. Effective treatment of individual lesions as well as field cancerization is essential for good long-term outcomes. The Swiss Registry of Actinic Keratosis Treatment (REAKT) Working Group has developed clinical practice guidelines for the treatment of field cancerization in patients who present with AK. These guidelines are intended to serve as a resource for physicians as to the most appropriate treatment and management of AK and field cancerization based on current evidence and the combined practical experience of the authors. Treatment of AK and field cancerization should be driven by consideration of relevant patient, disease, and treatment factors, and appropriate treatment decisions will differ from patient to patient. Prevention measures and screening recommendations are discussed, and special considerations related to management of immunocompromised patients are provided.

Spatial relational learning and memory abilities do not differ between men and women in a real-world, open-field environment

This study assesses gender differences in spatial and non-spatial relational learning and memory in adult humans behaving freely in a real-world, open-field environment. In Experiment 1, we tested the use of proximal landmarks as conditional cues allowing subjects to predict the location of rewards hidden in one of two sets of three distinct locations. Subjects were tested in two different conditions: (1) when local visual cues marked the potentially-rewarded locations, and (2) when no local visual cues marked the potentially-rewarded locations. We found that only 17 of 20 adults (8 males, 9 females) used the proximal landmarks to predict the locations of the rewards. Although females exhibited higher exploratory behavior at the beginning of testing, males and females discriminated the potentially-rewarded locations similarly when local visual cues were present. Interestingly, when the spatial and local information conflicted in predicting the reward locations, males considered both spatial and local information, whereas females ignored the spatial information. However, in the absence of local visual cues females discriminated the potentially-rewarded locations as well as males. In Experiment 2, subjects (9 males, 9 females) were tested with three asymmetrically-arranged rewarded locations, which were marked by local cues on alternate trials. Again, females discriminated the rewarded locations as well as males in the presence or absence of local cues. In sum, although particular aspects of task performance might differ between genders, we found no evidence that women have poorer allocentric spatial relational learning and memory abilities than men in a real-world, open-field environment.

Heritability of multiple mating by female field crickets, Gryllus integer (Orthoptera: Gryllidae)

The heritability of multiple mating in female Gryllus integer crickets was studied. Two preliminary experiments were conducted to determine when females first mate following the post-imaginal moult and to ascertain whether constant exposure to males affects female mating rate. Female Q. integer first mated at an average age of 3.6 days (S.D. = 2.3, Range = 0-8 days) . Exposing female crickets to courting males 24 hr daily did not significantly alter mating rates from those females in contact with males for only 5 hr per day. A heritability value of 0.690 ± 0.283 was calculated for multiple mating behavior in female Q. integer using a parent-offspring regression approach. Parental females mated between land 30 times (x 9.8, S . D. = 6. 6 ) and offspring matings ranged from 0 to 26 times (x 7 .3, S.D. = 3.4). Multiple mating is probably a sexually selected trait which functions as a mechanism of female choice and increases reproductive success through increased offspring production. Classical theory suggests that traits intimately related with fitness should exhibit negligible heritable variation. However, this study has shown that multiple mating, a trait closely linked with reproductive fitness, exhibits substantial heritability. These results are in concordance with a growing body of empirical evidence suggesting many fitness traits in natural populations demonstrate heritabilities far removed from zero. Various mechanisms which may maintain heritable variation for female multiple mating in wild, outbred Q. integer populations are discussed.

Mating behaviours of the field cricket (Gryllus integer) at different levels of male density

The reproductive behaviour of the field cricket, Gryllus integer, was systematically observed in indoor arenas to determine the extent of female Choice and male-male competition at different sex ratios representing two male densities (12:6 and 6:6). The costs and benefits to males and females in those two densities were analyzed according to the theory of the evolution o£ leks. Observations were conducted during the dark hours when most calling occurred since hourly rates of courtship song and mating did not fluctuate significantly over a 24 h period. Female mating rates were not significantly different between densities, therefore males at high densities were not advantaged because of increased female tendencies to mate when social stimulation was increased. Mean rates of acoustical signalling (calling and courtin"g) did not differ significantly between densities. Mean rates of fighting by males at the high density were significantly greater than those of males at the low density. Mating benefits associated with callin~courting and fighting were measured. Mating rates did not vary with rates of calling at either density. Calling was not a prerequisite to mating. Courtship song preceded all matings. There was a significant power fit between male mating and courting rates, and male mating and fighting rates at the low, but not at the high, density. Density differences in the benefits associated with increased courting and fighting may relate, in part, to greater economic defensibility and monopoly of females due to reduced male competition at the low density. Dominant males may be preferentially chosen by females or better able to monopolize mating opportunities than subordinate males. Three criteria were used to determine whether dominant males were preferentially chosen by females. The number of matings by males who won fights (within 30 min of mating) was significantly greater than the number of matings by males who were defeated in such fights. Mating rates did not vary significantly with rates of winning at either density. There was a significant power fit between male mating rates and the percentage of fights a male won (irrespective of his fighting-frequency) at the low density. The mean duration a male guarded the female after mating did not vary significantly between densities. There was a significant linear relationship between the duration a spermatophore was retained and the duration a male guarded the female after mating. Courtship song apparently stimulated spermatophore removal. Male guarding involved inter-male aggression and reduced courtship attempts by other males. Males at the high density received no apparent reproductive benefits associated with increased social stimulation. Conclusive evidence for preferential choice of males by females, using the criteria examined here, is lacking. Males at the lower density had fewer competitors and could monopolize females more effectively.

Investigating Microbial Trace-fossils and Abiotic Alteration in Hydrovolcanic Tuffs of the Fort Rock Volcanic Field, Oregon

Microbial ichnofossils in volcanic rocks provide a significant record of subsurface microbes and potentially extraterrestrial biosignatures. Here, the textures, mineralogy, and geochemistry of two continental basaltic hydrovolcanic deposits - Reed Rocks and Black Hills - in the Fort Rock Volcanic Field (FRVF) are investigated. Methods include petrographic microscopy, micro and powder X-ray diffraction, SEM/BSE/EDF imaging, energy dispersive spectroscopy, stable isotopes, and X-ray fluorescence. Petrographic analysis revealed granular and tubular textures with biogenic morphologies that include terminal enlargements, septate divisions, branching forms, spiral filaments, and ovoid bodies resembling endolithic microborings described in ocean basalts. They display evidence of behaviour and a geologic context expressing their relative age and syngenicity. Differences in abiotic alteration and the abundance/morphotype assemblage of putative microborings between the sites indicate that water/rock ratio, fluid composition and flux, temperature and secondary phase formation are influences on microboring formation. This study is the first report of reputed endolithic microborings in basalts erupted in a continental lacustrine setting.

Hysteresis and avalanches in the T=0 random field ising model with 2-spin flip dynamics

We study the nonequilibrium behavior of the three-dimensional Gaussian random-field Ising model at T=0 in the presence of a uniform external field using a two-spin-flip dynamics. The deterministic, history-dependent evolution of the system is compared with the one obtained with the standard one-spin-flip dynamics used in previous studies of the model. The change in the dynamics yields a significant suppression of coercivity, but the distribution of avalanches (in number and size) stays remarkably similar, except for the largest ones that are responsible for the jump in the saturation magnetization curve at low disorder in the thermodynamic limit. By performing a finite-size scaling study, we find strong evidence that the change in the dynamics does not modify the universality class of the disorder-induced phase transition.