Protocol-driven adjustment of ocular hypotensive medication in patients at low risk of conversion to glaucoma

AIM: To investigate the safety and potential savings of decreasing medication use in low-risk patients with ocular hypertension (OH).
METHODS: Patients with OH receiving pressure-lowering medication identified by medical record review at a university hospital underwent examination by a glaucoma specialist with assessment of visual field (VF), vertical cup-to-disc ratio (vCDR), central corneal thickness and intraocular pressure (IOP). Subjects with estimated 5-year risk of glaucoma conversion <15% were asked to discontinue ≥1 medication, IOP was remeasured 1 month later and risk was re-evaluated at 1 year.
RESULTS: Among 212 eyes of 126 patients, 44 (20.8%) had 5-year risk >15% and 14 (6.6%) had unreliable baseline VF. At 1 month, 15 patients (29 eyes, 13.7%) defaulted follow-up or refused to discontinue medication and 11 eyes (5.2%) had risk >15%. The remaining 69 patients (107 eyes, 50.7%) successfully discontinued 141 medications and completed 1-year follow-up. Mean IOP (20.5±2.65 mm Hg vs 20.3±3.40, p=0.397) did not change, though mean VF pattern SD (1.58±0.41 dB vs 1.75±0.56 dB, p=0.001) and glaucoma conversion risk (7.31±3.74% vs 8.76±6.28%, p=0.001) increased at 1 year. Mean defect decreased (-1.42±1.60 vs -1.07±1.52, p=0.022). One eye (0.47%) developed a repeatable VF defect and 13 eyes (6.1%) had 5-year risk >15% at 1 year. The total 1-year cost of medications saved was US$4596.
CONCLUSIONS: Nearly half (43.9%) of low-risk OH eyes in this setting could safely reduce medications over 1 year, realising substantial savings.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Visual outcomes and astigmatism after sutureless, manual cataract extraction in rural China: study of cataract outcomes and up-take of services (SCOUTS) in the caring is hip project, report 1.

OBJECTIVE: To study the visual acuity and astigmatism of persons undergoing cataract extraction by local surgeons in rural China. METHODS: Visual acuity, keratometry, and refraction were measured 10 to 14 months postoperatively for all cataract cases during 4 months in Sanrao, China. RESULTS: Among 313 eligible subjects, 242 (77%) could be contacted, of whom 176 (73%) were examined. Of those who were examined, mean +/- SD age was 69.3 +/- 10.5 years, 66.5% were female, 35 had been operated on bilaterally at Sanrao, and 85.2% had a preoperative presenting visual acuity of 6/60 or worse. Presenting and best-corrected postoperative acuity in the eye that was operated on were 6/18 or better in 83.4% and 95.7%, respectively. Among 27 fellow eyes operated on elsewhere, 40.7% had a presenting acuity of 6/18 or better and 40.7% were blind (P < .001). Mean +/- SD postoperative astigmatism did not differ between 211 eyes that were operated on (-1.13 +/- 0.84 diopters) and 109 eyes that were not (-1.13 +/- 1.17 diopters; P = .27). Presence of operative complications (8.5%) and older age were associated with worse vision; bilateral surgery was associated with better vision. CONCLUSIONS: These results confirm the effectiveness of skill transfer in this setting, with superior outcomes to most studies in rural Asia and to eyes in this cohort operated on at other facilities.

Visual function and postoperative care after cataract surgery in rural China: study of cataract outcomes and up-take of services (SCOUTS) in the caring is hip project, report 2.

OBJECTIVE:

To study the postoperative visual function and uptake of refraction and second-eye surgery among persons undergoing cataract surgery in rural China.

METHODS:

Self-reported visual function was measured 10 to 14 months after surgery. Subjects with improvement of 2 or more lines with refraction were offered glasses, and those with significant cataract were offered second-eye surgery.

RESULTS:

Among 313 eligible subjects, 242 (77%) could be contacted; 176 (73%) of those contacted were examined. Interviewed subjects had a mean +/- SD age of 69.9 +/- 10.2 years, and 63.6% were female. The mean +/- SD visual function score was 88.4 +/- 12.3, higher than previously reported for cataract programs in rural China and significantly (P = .03) correlated with presenting vision. Forty-two percent of subjects had spectacles, more than half being reading glasses. Though 87% of subjects' vision improved with refraction, only 35% accepted prescriptions, the most common reason for refusal being lack of perceived need. Second-eye surgery was accepted by a total of 48% (85 of 176) of patients, cost being the biggest reason for refusal.

CONCLUSIONS:

Visual function was high in this cohort. Potential benefit of refraction and second-eye surgery was substantial, but uptake of services was modest. Programs to improve service uptake should focus on reading glasses and cost-reduction strategies such as tiered pricing.

Ocular comorbidities among cataract-operated patients in rural China: the caring is hip Study of Cataract Outcomes and Uptake of Services (SCOUTS), report No. 3.

PURPOSE: To determine the prevalence and impact on vision and visual function of ocular comorbidities in a rural Chinese cataract surgical program, and to devise strategies to reduce their associated burden. DESIGN: Cross-sectional cohort study. PARTICIPANTS: Persons undergoing cataract surgery by one of two recently trained local surgeons at a government-run village-level hospital in rural Guangdong between August 8 and December 31, 2005. INTERVENTIONS: Eligible subjects were invited to return for a comprehensive ocular examination and visual function interview 10 to 14 months after surgery. Prevalent ocular comorbid conditions were identified. MAIN OUTCOME MEASURES: Presenting and best-corrected vision, visual function, and treatability of the comorbidity. RESULTS: Of 313 persons operated within the study window, 242 (77%) could be contacted by telephone; study examinations and interviews were performed on 176 (74%). Examined subjects had a mean age of 69.4+/-10.5 years, 116 (66%) were female, and 149 (85%) had been blind (presenting vision < or = 6/60) in the operative eye before surgery. Among unoperated eyes, 89 of 109 (81.7%) had > or =1 ocular comorbidities, whereas for operated eyes the corresponding proportion was 72 of 211 (34.1%). The leading comorbidity among operated eyes was refractive error (43/72 [59.7%]), followed by glaucoma/glaucoma suspect (14/72 [19.4%]), whereas for unoperated eyes, it was cataract (80/92 [87.0%]), followed by refractive error (12/92 [13.0%]). Among operated eyes with comorbidities, 90.3% (65/72) had > or =1 comorbidities that were treatable. In separate models adjusting for age and gender, persons with > or =1 comorbidities in the operated eye had significantly worse presenting vision (P<0.001) than those without such findings, but visual function (P = 0.197) and satisfaction with surgery (P = 0.796) were unassociated with comorbidities. CONCLUSIONS: Ocular comorbidities are highly prevalent among persons undergoing cataract surgery in this rural Asian setting, and their presence is significantly associated with poorer visual outcomes. The fact that the great majority of comorbidities encountered in this program are treatable suggests that strategies to reduce their impact can be successful.

Distribution and visual impact of postoperative refractive error after cataract surgery in rural China: study of cataract outcomes and up-take of services report 4.

PURPOSE: To model the possible impact of using average-power intraocular lenses (IOLs) and evaluate the postoperative refractive error in patients having cataract surgery in rural China.SETTING: Rural Guangdong, China.METHODS: Patients having cataract surgery by local surgeons were examined and visual function was assessed 10 to 14 months after surgery. Subjective refraction at near and distance was performed bilaterally by an ophthalmologist. Patients had a target refraction of -0.50 diopter (D) based on ocular biometry.RESULTS: Of the 313 eligible patients, 242 (77%) could be contacted and 176 (74% of contacted patients, 56% overall) were examined. Examined patients had a mean age of 69.4 +/- 10.5 years. Of the 211 operated eyes, 73.2% were within +/-1.0 D of the target refraction after surgery. The best presenting distance vision was in patients within +/-1.0 D of plano and the best presenting near vision, in those with mild myopia (<-1.0 D to > or =2.0 D) (P= .005). However, patients with hyperopia (>+1.0 D) reported significantly better adjusted visual function than those with emmetropia or myopia (<-1.0 D). When the predicted use of an average-power IOL (median +21.5 D) was modeled, predicted visual acuity was significantly reduced (P= .001); however, predicted visual function was not significantly altered (P>.3).CONCLUSIONS: Accurate selection of postoperative refractive error was achieved by local surgeons in this rural area. Based on visual function results, aiming for mild postoperative myopia may not be suitable in this setting. Implanting average-power IOLs significantly reduced postoperative presenting vision, but not visual function.

Sources of patient knowledge and financing of cataract surgery in rural China: the Sanrao Study of Cataract Outcomes and Up-Take of Services (SCOUTS), report 6.

AIM: To study patient sources of knowledge about cataract surgical services, and strategies for financing surgery in rural China. DESIGN: Cross-sectional case series. METHODS: Patients undergoing cataract surgery by local surgeons in a government, village-level facility in Sanrao, Guangdong between 8 August and 31 December 2005 were examined and had standardised interviews an average of 12 months after surgery. RESULTS: Of 313 eligible patients, 239 (76%) completed the questionnaire. Subjects had a mean (SD) age of 69.9 (10.2) years, 36.4% (87/239) were male, and 87.0% (208/239) had been blind (presenting visual acuity < or = 6/60) before surgery. Word-of-mouth advertising was particularly important: 198 (85.0%) of the subjects knew a person who had undergone cataract surgery, of whom 191 (96.5%) had had cataract surgery at Sanrao itself. Over 70% of subjects (166/239) watched TV daily, whereas 80.0% (188/239) "never" read the newspaper. Nearly two-thirds of suggestions from participants (n = 211, 59.6%) favoured either TV advertisements or word-of-mouth to publicise the programme. While the son or daughter had paid for surgery in over 70% of cases (164/233), the patient's having paid without help was the sole predictor of undergoing second-eye surgery (OR 2.27 (95% CI 1.01 to 5.0, p = 0.04)). DISCUSSION: Strategies to increase uptake of cataract surgery in rural China may benefit from enhancing word-of-mouth advertising (such as with pseudophakic motivators), using television advertising where affordable, and micro-credit or other programmes to enable patients to pay their own fees, thus increasing uptake of second-eye surgery.

Impact of posterior subcapsular opacification on vision and visual function among subjects undergoing cataract surgery in rural China: Study of Cataract Outcomes and Up-Take of Services (SCOUTS) in the Caring is Hip Project, report 5.

AIM: To study the effect of posterior capsular opacification (PCO) on vision and visual function in patients undergoing cataract surgery in rural China, and to compare this with the effect of refractive error. METHODS: Patients undergoing cataract surgery in at least one eye by local surgeons in a rural setting between 8 August and 31 December 2005 were examined with slit lamp grading of PCO 10-14 months after surgery. Subjects with any PCO associated with best-corrected visual acuity of 6/7.5 or worse, or with grade 2+ or worse PCO without visual decrement, were offered YAG laser capsulotomy. Vision and self-reported visual function were assessed, and various demographic and clinical factors potentially associated with PCO were recorded. RESULTS: Of 313 patients operated on within the study window, 239 (76%) could be contacted by telephone; study examinations were performed on 176 (74%). Examined subjects had a mean (SD) age of 69.4 (10.5) years, 116 (67%) were female, and 149 (86%) had been blind (presenting visual acuity < or = 6/60) in the operated eye before surgery. PCO of grade 1 or above was present in 34 of 204 operated eyes (16.7%). Those with PCO had significantly worse presenting vision (p = 0.007) but not visual function (p>0.3) than those without PCO. Women had a significantly higher prevalence of PCO (20.9%) than did men (8.6%, p<0.05). Of 19 eyes undergoing capsulotomy with best-corrected visual acuity measured the next day, 13 (68%) improved by one or more lines, and seven (37%) improved by two or more lines. Despite a higher uptake of capsulotomy (95%) as opposed to refraction (35%) in this cohort, the yield in terms of eyes with poor presenting visual acuity (< 6/18) that could be improved was higher for refraction (26% = 9/35) than for capsulotomy (9% = 3/35). CONCLUSION: The prevalence of PCO and impact on vision and visual function in this cohort was modest 1 year after surgery. However, PCO prevalence increases with time. Follow-up of this cohort is underway to determine the effectiveness of this early intervention in identifying and treating subjects who will eventually experience clinically significant PCO.

A relação terapêutica como pacto de cuidados (Perspectiva de Paul Ricoeur)

O capítulo é dedicado à reflexão, partindo de Ricoeur, sobre alguns aspectos que podem fornecer alicerce à tematização dos problemas do cuidar da Pessoa em vários níveis da Enfermagem. Importa-nos, acima de tudo, que, na procura da racionalidade própria da vida humana, as questões éticas da decisão do agir não fiquem soterradas por normas ou preceitos deontológicos adoptados acrítica e mecanicamente. Julgamos, então, necessário um esforço reflexivo práxico, pois sem reflexão orientada para a acção sairá malogrado o ideal de cuidar, que é, ao mesmo tempo, ideal de compreender, de respeitar e de servir responsavelmente o Outro, através do cultivo de relações interpessoais competentes, em termos científicos, técnicos e éticos.

Extracção supercrítica de óleo de grainha de uva combinada com pré-tratamentos enzimáticos

Neste trabalho estudou-se a extracção supercrítica do óleo de grainha de uva, usando dióxido de carbono, e combinou-se este processo com um prétratamento enzimático da semente para aumentar o rendimento global da extracção. A qualidade dos extractos obtidos foi avaliada pelo seu conteúdo em triacilglicerídeos, perfil de ácidos gordos e capacidade antioxidante. Realizaram-se também alguns estudos exploratórios sobre a aplicação de um pré-tratamento de alta pressão (HPP) à grainha da uva. Adicionalmente, efectuou-se o estudo da extracção, fraccionamento e caracterização estrutural das procianidinas da grainha da uva, bem como a avaliação da sua capacidade antioxidante. A extracção de procianidinas da grainha da uva foi efectuada sequencialmente com metanol e acetona/água, tendo sido posteriormente fraccionadas por adição sucessiva de misturas metanol/clorofórmio progressivamente mais concentradas em clorofórmio. A caracterização das procianidinas foi feita por HPLC-UV e LC–MS, antes e depois de sujeitar as amostras a uma tiólise, e também por ESI-MS e ESI-MS/MS. Este estudo permitiu reportar, pela primeira vez, a ocorrência de procianidinas do tipo-A galoiladas na grainha da uva. Os resultados de HPLC-UV permitiram determinar o grau médio de polimerização das procianidinas e a sua composição monomérica em (+)- catequina, (-)-epicatequina e (-)-epicatequina-O-galato. Mostrou-se que a (+)- catequina é o flavan-3-ol terminal mais abundante e a (-)-epicatequina predomina largamente como unidade de extensão. No caso de procianidinas do tipo A, a ligação interflavânica C2-C7 encontra-se essencialmente nas unidades terminais. O grau médio de polimerização das diversas fracções varia entre 1.0 e 10.8. A sua capacidade antioxidante, medida pelo método espectrofotométrico de DPPH•, mostrou-se ser equivalente à de uma amostra comercial de (+)-catequina usada como referência. A partir dos graus médios de polimerização experimentais e das análises de FTIR das fracções correspondentes foi possível obter um modelo preditivo O-PLS com apenas uma variável latente. O pré-tratamento enzimático justificou-se pelo conhecimento existente acerca do uso de enzimas específicas que destroem parcialmente as paredes celulares. Atendendo à composição das paredes celulares da grainha da uva preparou-se uma suspensão contendo protease, xilanase, pectinase e celulase. Para determinar as condições experimentais do pré-tratamento que maximizam o rendimento da extracção, estudou-se o efeito do tempo de reacção, temperatura, pH, diâmetro médio das partículas de grainha moída e a concentração das enzimas. Os incrementos do rendimento da extracção de óleo observados atingiram 163.2%. O estudo da extracção supercrítica (SFE) do óleo da grainha de uva tratada e não-tratada permitiu obter as curvas de extracção correspondentes, bem com analisar a influência das condições operatórias sobre o seu andamento. Montou-se uma instalação laboratorial onde se realizaram experiências com dióxido de carbono a 160, 180, 200 e 220 bar e temperaturas de 313.15 e 323.15 K. Os rendimentos obtidos por SFE foram semelhantes aos de Soxhlet com n-hexano. As curvas de extracção medidas compreendem um primeiro período de extracção, onde se remove cerca de 92-97% do óleo disponível, e um segundo período, essencialmente difusional, com pouco impacto no rendimento final. Os vários extractos recolhidos e o óleo global obtido foram caracterizados para avaliar a sua qualidade e relacioná-la com as condições operatórias de SFE. Determinaram-se o conteúdo total em triacilglicerídeos, o seu perfil de ácidos gordos e a capacidade antioxidante (AOC). Os resultados mostraram que a AOC aumenta com a elevação da pressão e, acentuadamente, com o acréscimo da temperatura. Ao longo da curva de extracção, a AOC é mais pronunciada nos extractos iniciais, nomeadamente nos primeiros 30 a 40% da extracção. A modelação efectuada considerou que o óleo extractável se reparte entre células rompidas, predominantes na periferia da semente, e células intactas, mais interiores. Admitiu-se que o transporte de massa ocorre em série, i.e. das células intactas para as rompidas e destas para o solvente; mostrou-se que a dispersão axial era desprezável. Os balanços materiais à fase fluida e aos volumes de células rompidas e intactas, combinados com os fluxos interno, externo e a relação de equilíbrio foram resolvidos numericamente pelo método das linhas combinado com diferenças finitas atrasadas. O modelo reproduziu bem as curvas experimentais e permitiu simular curvas de eluição e os três perfis de concentração no leito.

Diffusion coefficients in dense and supercritical fluids

Os coeficientes de difusão (D 12) são propriedades fundamentais na investigação e na indústria, mas a falta de dados experimentais e a inexistência de equações que os estimem com precisão e confiança em fases comprimidas ou condensadas constituem limitações importantes. Os objetivos principais deste trabalho compreendem: i) a compilação de uma grande base de dados para valores de D 12 de sistemas gasosos, líquidos e supercríticos; ii) o desenvolvimento e validação de novos modelos de coeficientes de difusão a diluição infinita, aplicáveis em amplas gamas de temperatura e densidade, para sistemas contendo componentes muito distintos em termos de polaridade, tamanho e simetria; iii) a montagem e teste de uma instalação experimental para medir coeficientes de difusão em líquidos e fluidos supercríticos. Relativamente à modelação, uma nova expressão para coeficientes de difusão a diluição infinita de esferas rígidas foi desenvolvida e validada usando dados de dinâmica molecular (desvio relativo absoluto médio, AARD = 4.44%) Foram também estudados os coeficientes de difusão binários de sistemas reais. Para tal, foi compilada uma extensa base de dados de difusividades de sistemas reais em gases e solventes densos (622 sistemas binários num total de 9407 pontos experimentais e 358 moléculas) e a mesma foi usada na validação dos novos modelos desenvolvidos nesta tese. Um conjunto de novos modelos foi proposto para o cálculo de coeficientes de difusão a diluição infinita usando diferentes abordagens: i) dois modelos de base molecular com um parâmetro específico para cada sistema, aplicáveis em sistemas gasosos, líquidos e supercríticos, em que natureza do solvente se encontra limitada a apolar ou fracamente polar (AARDs globais na gama 4.26-4.40%); ii) dois modelos de base molecular biparamétricos, aplicáveis em todos os estados físicos, para qualquer tipo de soluto diluído em qualquer solvente (apolar, fracamente polar e polar). Ambos os modelos dão origem a erros globais entre 2.74% e 3.65%; iii) uma correlação com um parâmetro, específica para coeficientes de difusão em dióxido de carbono supercrítico (SC-CO2) e água líquida (AARD = 3.56%); iv) nove correlações empíricas e semi-empíricas que envolvem dois parâmetros, dependentes apenas da temperatura e/ou densidade do solvente e/ou viscosidade do solvente. Estes últimos modelos são muito simples e exibem excelentes resultados (AARDs entre 2.78% e 4.44%) em sistemas líquidos e supercríticos; e v) duas equações preditivas para difusividades de solutos em SC-CO2, em que os erros globais de ambas são inferiores a 6.80%. No global, deve realçar-se o facto de os novos modelos abrangerem a grande variedade de sistemas e moléculas geralmente encontrados. Os resultados obtidos são consistentemente melhores do que os obtidos com os modelos e abordagens encontrados na literatura. No caso das correlações com um ou dois parâmetros, mostrou-se que estes mesmos parâmetros podem ser ajustados usando um conjunto muito pequeno de dados, e posteriormente serem utilizados na previsão de valores de D 12 longe do conjunto original de pontos. Uma nova instalação experimental para medir coeficientes de difusão binários por técnicas cromatográficas foi montada e testada. O equipamento, o procedimento experimental e os cálculos analíticos necessários à obtenção dos valores de D 12 pelo método de abertura do pico cromatográfico, foram avaliados através da medição de difusividades de tolueno e acetona em SC-CO2. Seguidamente, foram medidos coeficientes de difusão de eucaliptol em SC-CO2 nas gamas de 202 – 252 bar e 313.15 – 333.15 K. Os resultados experimentais foram analisados através de correlações e modelos preditivos para D12.

Incipient turn-to-turn winding fault diagnosis of power transformers by the on-load exciting current Extended Park`s Vector Approach

This paper presents the application of the on-load exciting current Extended Park's Vector Approach for diagnosing incipient turn-to-turn winding faults in operating power transformers. Experimental and simulated test results demonstrate the effectiveness of the proposed technique, which is based on the spectral analysis of the AC component of the on-load exciting current Park's Vector modulus.

Transformers on-load exciting current Park`s vector approach as a tool for winding faults diagnostics

This paper presents the development of a new approach for diagnosing the occurrence of inter-turn short-circuits in the windings of three-phase transformers, which is based on the on-line monitoring of the on-load exciting current Park's Vector patterns. Experimental and simulated results demonstrate the effectiveness of the proposed technique for detecting winding inter-turn insulation faults in operating three-phase transformers.

Diagnóstico de avarias em transformadores trifásicos em serviço através da análise do Vector de Park das correntes de excitação em carga

Devido ao seu custo e importância estratégica, os transformadores de potência constituem um componente vital dos sistemas de produção, transmissão e distribuição de energia eléctrica. A sua fiabilidade constitui assim um factor crucial no funcionamento dos sistemas eléctricos de energia. Não admira, pois, que sobre estes equipamentos recaiam grandes preocupações relativamente à sua manutenção e, consequentemente, ao desenvolvimento de métodos capazes de fornecerem um diagnóstico completo e fiável do seu estado de funcionamento. Para o efeito, torna-se porém indispensável possuir um conhecimento detalhado acerca das avarias susceptíveis de ocorrerem nos transformadores, bem como dos mecanismos específicos que lhe estão subjacentes.

Three-phase, three-limb, steady-state transformer model

This paper presents the development and implementation of a digital simulation model of a threephase, three-leg, three-winding power transformer. The proposed model, implemented in MATLAB environment, is based on the simultaneous analysis of both magnetic and electric lumped-parameters equivalents circuits, and it is intended to study its adequacy to incorporate, at a later stage, the influences of the occurrence of windings interturn short-circuit faults. Both simulation and laboratory tests results, obtained so far, for a three-phase, 6 kVA transformer, demonstrate the adequacy of the model under normal operating conditions.