Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

BACKGROUND: Diabetic retinopathy is an important cause of visual loss. Laser photocoagulation preserves vision in diabetic retinopathy but is currently used at the stage of proliferative diabetic retinopathy (PDR).

OBJECTIVES: The primary aim was to assess the clinical effectiveness and cost-effectiveness of pan-retinal photocoagulation (PRP) given at the non-proliferative stage of diabetic retinopathy (NPDR) compared with waiting until the high-risk PDR (HR-PDR) stage was reached. There have been recent advances in laser photocoagulation techniques, and in the use of laser treatments combined with anti-vascular endothelial growth factor (VEGF) drugs or injected steroids. Our secondary questions were: (1) If PRP were to be used in NPDR, which form of laser treatment should be used? and (2) Is adjuvant therapy with intravitreal drugs clinically effective and cost-effective in PRP?

ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) for efficacy but other designs also used.

REVIEW METHODS: Systematic review and economic modelling.

RESULTS: The Early Treatment Diabetic Retinopathy Study (ETDRS), published in 1991, was the only trial designed to determine the best time to initiate PRP. It randomised one eye of 3711 patients with mild-to-severe NPDR or early PDR to early photocoagulation, and the other to deferral of PRP until HR-PDR developed. The risk of severe visual loss after 5 years for eyes assigned to PRP for NPDR or early PDR compared with deferral of PRP was reduced by 23% (relative risk 0.77, 99% confidence interval 0.56 to 1.06). However, the ETDRS did not provide results separately for NPDR and early PDR. In economic modelling, the base case found that early PRP could be more effective and less costly than deferred PRP. Sensitivity analyses gave similar results, with early PRP continuing to dominate or having low incremental cost-effectiveness ratio. However, there are substantial uncertainties. For our secondary aims we found 12 trials of lasers in DR, with 982 patients in total, ranging from 40 to 150. Most were in PDR but five included some patients with severe NPDR. Three compared multi-spot pattern lasers against argon laser. RCTs comparing laser applied in a lighter manner (less-intensive burns) with conventional methods (more intense burns) reported little difference in efficacy but fewer adverse effects. One RCT suggested that selective laser treatment targeting only ischaemic areas was effective. Observational studies showed that the most important adverse effect of PRP was macular oedema (MO), which can cause visual impairment, usually temporary. Ten trials of laser and anti-VEGF or steroid drug combinations were consistent in reporting a reduction in risk of PRP-induced MO.

LIMITATION: The current evidence is insufficient to recommend PRP for severe NPDR.

CONCLUSIONS: There is, as yet, no convincing evidence that modern laser systems are more effective than the argon laser used in ETDRS, but they appear to have fewer adverse effects. We recommend a trial of PRP for severe NPDR and early PDR compared with deferring PRP till the HR-PDR stage. The trial would use modern laser technologies, and investigate the value adjuvant prophylactic anti-VEGF or steroid drugs.

STUDY REGISTRATION: This study is registered as PROSPERO CRD42013005408.

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

Incentives and rewards: what do adult populations truly want? Insights from the physical activity loyalty (PAL) scheme

Background
Trials depend on good recruitment and retention, but efforts to improve these have had varying success. This may be due to inadequate understanding of what participants would value in return for taking part. An opportunity arose in one trial to investigate the incentives that might help recruit and retain participants to another.

Aim
To determine what adults value as an incentive for involvement in a trial.

Methods
In the PAL Scheme, employees used a ‘loyalty card’ to monitor their physical activity over 12 weeks. The incentive group (n=199) collected points and received rewards for physical activity (1 minute = 1 point, max: 30 pts/day). A comparator group (n=207) self-monitored their physical activity only. Points could be redeemed as retail vouchers. 17 different incentives were available, from 75 pts (£2.50, a sandwich) to 1800 pts (£60, 1 month gym membership).

Results
148 of the 199 intervention participants used their card at least once, earning a mean of 374 pts. 121 earned sufficient to collect a reward and 76 redeemed points for vouchers but only 48 exchanged the vouchers for rewards. The most popular reward was not that of highest monetary value: two cinema tickets (300 pts, £10).

Conclusions
The value that participants place on a reward might be more important than its monetary value. Some might appreciate receiving the voucher, without spending it. In choosing incentives to boost trial participation, it may help to allow people to choose from a variety of rewards, rather than reimbursing in money.

Neolithic and Bronze age migration to Ireland and establishment of the insular Atlantic genome

The Neolithic and Bronze Age transitions were profound cultural shifts catalyzed in parts of Europe by migrations, first of early farmers from the Near East and then Bronze Age herders from the Pontic Steppe. However, a decades-long, unresolved controversy is whether population change or cultural adoption occurred at the Atlantic edge, within the British Isles. We address this issue by using the first whole genome data from prehistoric Irish individuals. A Neolithic woman (3343–3020 cal BC) from a megalithic burial (10.3× coverage) possessed a genome of predominantly Near Eastern origin. She had some hunter–gatherer ancestry but belonged to a population of large effective size, suggesting a substantial influx of early farmers to the island. Three Bronze Age individuals from Rathlin Island (2026–1534 cal BC), including one high coverage (10.5×) genome, showed substantial Steppe genetic heritage indicating that the European population upheavals of the third millennium manifested all of the way from southern Siberia to the western ocean. This turnover invites the possibility of accompanying introduction of Indo-European, perhaps early Celtic, language. Irish Bronze Age haplotypic similarity is strongest within modern Irish, Scottish, and Welsh populations, and several important genetic variants that today show maximal or very high frequencies in Ireland appear at this horizon. These include those coding for lactase persistence, blue eye color, Y chromosome R1b haplotypes, and the hemochromatosis C282Y allele; to our knowledge, the first detection of a known Mendelian disease variant in prehistory. These findings together suggest the establishment of central attributes of the Irish genome 4,000 y ago.

Remembering forwards: or how to live together in the future with divided memories

Memory is thought to be about the past. The past is a problem in conflict transformation. This lecture suggests memory can also be about the future. It introduces the notion of remembering forwards, which is contrasted with remembering backwards. The distinction between these two forms of remembering defines the burden of memory in post-conflict societies generally and specifically in Ireland. In societies emerging out of conflict, where divided memories in part constituted the conflict, social memory privileges remembering backward. Collective and personal memories elide within social memory to perpetuate divided group identities and contested personal narratives. Above all, social memory works to arbitrate the future, by predisposing an extreme memory culture that locks people into the past. Forgetting the past is impossible and undesirable. What is needed in societies emerging out of conflict is to be released from the hold that oppressive and haunting memories have over people. This lecture will suggest that this is found in the idea of remembering forwards. This is not the same as forgetting. It is remembering to cease to remember oppressive and haunting memories. It does not involve non-remembrance but active remembering: remembering to cease to remember the past. While the past lives in us always, remembering forwards assists us in not living in the past. Remembering forwards thus allows us to live in tolerance in the future despite the reality that divided memories endure and live on. The lecture further argues that these enduring divided memories need to be reimagined by the application of truth, tolerance, togetherness and trajectory. The lecture suggests that it is through remembering forwards with truth, tolerance, togetherness and trajectory that people in post-conflict societies can inherit the future despite their divided pasts and live in tolerance in the midst of contested memories.

A World Drawn: An Introduction to the art of Julian Opie (for a Polish Audience)

Essay in a monograph associated with the exhibition Julian Opie: Sculptures, Paintings, Films at the Museum of Contemporary Art in Krakow, Poland, 18 October 2014 to 25 January 2015. Slyce attempts to re-examine the lineaments of Opie's practice for a new and broader audience. During which, he calls attention in the writing to the processes of its commissioning and early request to do so for a 'Polish audience'. He attempts to bring to light some of these often invisible moves in the commissioning of catalogue essays, while also re-examining Julian Opie's practice in light of its established reception in Britain.

Letter, Chatham, to Colonel Calvin Spencer, Chesterfield, SC, 1790 July 3

This letter is from J. A. Dibble to Calvin Spencer regarding William Lides with enclosed papers; these papers were not present with the letter when scanned.

Contribuição dos métodos geofísicos para o modelo evolutivo da região de Santo André desde o último máximo glaciário

Tese de doutoramento, Geologia (Geologia Económica e do Ambiente), Universidade de Lisboa, Faculdade de Ciências, 2014

Changes in the Pollen Seasons of the Early Flowering Trees Alnus spp. and Corylus spp. in Worcester United Kingdom 1996-2005

Previous work on Betula spp. (birch) in the UK and at five sites in Europe has shown that pollen seasons for this taxon have tended to become earlier by about 5–10 days per decade in most regions investigated over the last 30 years. This pattern has been linked to the trend to warmer winters and springs in recent years. However, little work has been done to investigate the changes in the pollen seasons for the early flowering trees. Several of these, such as Alnus spp. and Corylus spp., have allergens, which cross-react with those of Betula spp., and so have a priming effect on allergic people. This paper investigates pollen seasons for Alnus spp. and Corylus spp. for the years 1996–2005 at Worcester, in the West Midlands, United Kingdom. Pollen data for daily average counts were collected using a Burkard volumetric trap sited on the exposed roof of a three-storey building. The climate is western maritime. Meteorological data for daily temperatures (maximum and minimum) and rainfall were obtained from the local monitoring sites. The local area up to approximately 10 km surrounding the site is mostly level terrain with some undulating hills and valleys. The local vegetation is mixed farmland and deciduous woodland. The pollen seasons for the two taxa investigated are typically late December or early January to late March. Various ways of defining the start and end of the pollen seasons were considered for these taxa, but the most useful was the 1% method whereby the season is deemed to have started when 1% of the total catch is achieved and to have ended when 99% is reached. The cumulative catches (in grains/m3) for Alnus spp. varied from 698 (2001) to 3,467 (2004). For Corylus spp., they varied from 65 (2001) to 4,933 (2004). The start dates for Alnus spp. showed 39 days difference in the 10 years (earliest 2000 day 21, latest 1996 day 60). The end dates differed by 26 days and the length of season differed by 15 days. The last 4 years in the set had notably higher cumulative counts than the first 2, but there was no trend towards earlier starts. For Corylus spp. start days also differed by 39 days (earliest 1999 day 5, latest 1996 day 44). The end date differed by 35 days and length of season by 26 days. Cumulative counts and lengths of season showed a distinct pattern of alternative high (long) and low (short) years. There is some evidence of a synchronous pattern for Alnus spp.. These patterns show some significant correlations with temperature and rainfall through the autumn, winter and early spring, and some relationships with growth degree 4s and chill units, but the series is too short to discern trends. The analysis has provided insight to the variation in the seasons for these early flowering trees and will form a basis for future work on building predictive models for these taxa.

Niagara Region Municipality Records 1962-1963, 1969-1976, 1980

Niagara Region Municipality Records 1962-1963, 1969-1976, 1980

Early Development of Auditory-Verbal and Visual-Spatial Short-Term Memory: Age and Sex Effects

Memory is a multi-component cognitive ability to retain and retrieve information presented in different modalities. Research on memory development has shown that the memory capacity and the processes improve gradually from early childhood to adolescence. Findings related to the sex-differences in memory abilities in early childhood have been inconsistent. Although previous research has demonstrated the effects of the modality of stimulus presentation (auditory versus verbal) and the type of material to be remembered (visual/spatial versus auditory/verbal) on the memory processes and memory organization, the recent research with children is rather limited. The present study is a secondary analysis of data, originally collected from 530 typically developing Turkish children and adolescents. The purpose of the present study was to examine the age-related developments and sex differences in auditory-verbal and visual-spatial short-term memory (STM) in 177 typically developing male and female children, 5 to 8 years of age. Dot-Locations and Word-Lists from the Children's Memory Scale were used to measure visual-spatial and auditory-verbal STM performances, respectively. The findings of the present study suggest age-related differences in both visual-spatial and auditory-verbal STM. Sex-differences were observed only in one visual-spatial STM subtest performance. Modality comparisons revealed age- and task-related differences between auditory-verbal and visual-spatial STM performances. There were no sex-related effects in terms of modality specific performances. Overall, the results of this study provide evidence of STM development in early childhood, and these effects were mostly independent of sex and the modality of the task.

Optimizing Computational Frameworks to Study the Influence of the Protein Environment on the Individual Site Energies of Chromophores in Photosystem II of Photosynthesis

Photosynthesis is a process in which electromagnetic radiation is converted into chemical energy. Photosystems capture photons with chromophores and transfer their energy to reaction centers using chromophores as a medium. In the reaction center, the excitation energy is used to perform chemical reactions. Knowledge of chromophore site energies is crucial to the understanding of excitation energy transfer pathways in photosystems and the ability to compute the site energies in a fast and accurate manner is mandatory for investigating how protein dynamics ef-fect the site energies and ultimately energy pathways with time. In this work we developed two software frameworks designed to optimize the calculations of chro-mophore site energies within a protein environment. The first is for performing quantum mechanical energy optimizations on molecules and the second is for com-puting site energies of chromophores in a fast and accurate manner using the polar-izability embedding method. The two frameworks allow for the fast and accurate calculation of chromophore site energies within proteins, ultimately allowing for the effect of protein dynamics on energy pathways to be studied. We use these frame-works to compute the site energies of the eight chromophores in the reaction center of photosystem II (PSII) using a 1.9 Å resolution x-ray structure of photosystem II. We compare our results to conflicting experimental data obtained from both isolat-ed intact PSII core preparations and the minimal reaction center preparation of PSII, and find our work more supportive of the former.

Article of agreement between Alexander Cook, contractor of Humberstone and the Provisional Municipal Council of the county of Welland

Article of agreement between Alexander Cook, contractor of Humberstone and the Provisional Municipal Council of the county of Welland to construct and build the main drain through the marsh lands tract commencing in lot no. 27 in the 4th concession in the township of Humberstone in a southerly direction (6 pages, handwritten). This is signed by John Frazer, Provisional Warden, Dexter Deverardo and Alexander Cook. (2 copies), Dec. 30, 1854.

Letter to Joseph A. Woodruff from John Stannage

Letter to Joseph A. Woodruff from John Stannage (3 pages) stating that the Sheriff of Lincoln County had no right to sell any of the glebes [land belonging or yielding revenue to a parish church] of Crowland for taxes in either 1852 or 1857, Nov. 25, 1862.

Letter to Mr. Robert Nelles from John McClelland of Guelph

Letter to Mr. Robert Nelles from John McClelland of Guelph regarding Lot no.2 in the 8th concession of Garafraxa [rural township in Dufferin County, Ontario]. Mr. McClelland would like to buy the property, Dec. 28, 1848.

Vers une scène commune : rapports croisés entre poésie et chanson chez Raoul Duguay (1966-1970)

Ce mémoire porte sur les deux premiers recueils de Raoul Duguay (ruts et or le cycle du sang dure donc). Il cherche à examiner les liens étroits qu’entretient la poésie de Duguay avec la production parallèle du poète, qui s’oriente dès la fin des années 1960 vers la chanson. Le mémoire s’attachera d’abord, dans le premier chapitre, à présenter l’histoire des liens entre les poètes et la chanson au Québec afin de relever les points de contact significatifs au cours des années 1960 et de poser le cadre théorique de la chanson comme objet d’étude. Dans un deuxième temps, l’analyse des deux premiers recueils de poèmes de Duguay nous mènera à une réflexion sur la présence de la métaphore du chant, puis de la parole poétique en poésie québécoise, qui annonce un changement de paradigme dans l’approche du lyrisme et du sujet lyrique. Enfin, le troisième chapitre se penchera sur le contexte contre-culturel québécois, pour examiner le discours et le contre-discours sur la poésie, pour expliquer le phénomène de décloisonnement des genres qui conduit Raoul Duguay à investir le champ de la culture populaire de sa poésie. Il y sera aussi question du sujet « dans le langage », de l’expérience de la langue et de la subjectivité de la voix.