Filtration procedures supplemented with mitomycin C in the management of childhood glaucoma

Aims - To evaluate the outcome of filtering procedures supplemented with mitomycin C in children with glaucoma. Methods - All patients aged 17 or younger with glaucoma who underwent filtering surgery supplemented with mitomycin C at a tertiary care centre (n = 21) during a 5 year interval (1992 and 1996) were included. One eye for each patient was entered into the analysis. The postoperative intraocular pressure (IOP), use of antiglaucoma medications, clinical stability of glaucoma, complications, and visual acuity were retrospectively evaluated. Kaplan-Meier survival curves were used to estimate the probability of success. Results - At the time of surgery mean age was 5.7 (SD 5.0) years. The most common diagnoses were trabeculodysgenesis (n = 6) and aphakic glaucoma (n = 8). Mean IOP before surgery was 35.7 (10.5) mmHg. Average length of follow up was 18.6 (14.7) months. The probability of having IOP less than 21 mmHg with no antiglaucoma medications and with clinically stable glaucoma 1 year after surgery was 76.9% in phakic eyes (n = 13) and 0% in aphakic eyes (n = 8). A phakic patient with Sturge-Weber's syndrome had choroidal effusion after surgery that resolved spontaneously. In the aphakic group one patient had retinal detachment and another developed an encapsulated bleb. Visual acuity deteriorated in one patient. Conclusion - A guarded filtration procedure with mitomycin C is relatively successful in phakic children with glaucoma, but unsuccessful in aphakic ones.

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.

Care and Management of Ancient Stone Monuments During Environmental Change

Ancient stone monuments (ASMs), such as standing stones and rock art panels, are powerful and iconic expressions of Britain’s rich prehistoric past that have major economic and tourism value. However, ASMs are under pressure due to increasing anthropogenic exposure and changing climatic conditions, which accelerate their rates of disrepair. Although scientific data exists on the integrity of stone monuments, most applies to “built” systems; therefore, additional work specific to ASMs in the countryside is needed to develop better-informed safeguarding strategies. Here, we use Neolithic and Bronze Age rock art panels across Northern England as a case study for delineating ASM management actions required to enhance monument preservation. The state of the rock art is described first, including factors that led to current conditions. Rock art management approaches then are described within the context of future environments, which models suggest to be more dynamic and locally variable. Finally, a Condition Assessment and Risk Evaluation (CARE) scheme is proposed to help prioritise interventions; an example of which is provided based on stone deterioration at Petra in Jordon. We conclude that more focused scientific and behavioural data, specific to deterioration mechanisms, are required for an ASM CARE scheme to be successful.

Evidence underlying the clinical management of diabetic macular oedema

Diabetic retinopathy (DR) is the leading cause of visual loss in the developed world in those of working age, and its prevalence is predicted to double by 2025. The management of diabetic retinopathy has traditionally relied on screening, on laser treatment delivered by ophthalmologists, and on optimising blood glucose and blood pressure. Recent evidence suggests that the role of systemic factors is more complex than originally thought, and that drugs such as ACE inhibitors, fibrates and glitazones may all influence the course of diabetic macular oedema. Antagonism of vascular endothelial growth factor offers a new therapeutic avenue that may transform the management of diabetic macular oedema. Several other therapeutic options are under investigation and development, including aminoguanidine, sorbinol, ruboxistaurin and autologous stem cell transfusion. © Royal College of Physicians, 2013.

The management of an ageing workforce: organisational policies in Germany and Britain

Demographic change as well as pressure from the European Union and national government are forcing organisations to change age-discriminatory HRM approaches. Based on a qualitative analysis of eight British and German organisations, we found that commitment, scope, coverage and implementation of age management differ due to country-specific institutions, particularly government, in nudging employers and unions to preferred age practices. This confirms the path dependency concept suggested by institutional theory. Nevertheless, we also found that industry-specific factors mediate the implementation of age management, leading to some convergence across countries. This indicates that organisations deviate from the institutional path to implement practices that they deem important.

Identifying marine pelagic ecosystem management objectives and indicators

International policy frameworks such as the Common Fisheries Policy and the European Marine Strategy Framework Directive define high-level strategic goals for marine ecosystems. Strategic goals are addressed via general and operational management objectives. To add credibility and legitimacy to the development of objectives, for this study stakeholders explored intermediate level ecological, economic and social management objectives for Northeast Atlantic pelagic ecosystems. Stakeholder workshops were undertaken with participants being free to identify objectives based on their own insights and needs. Overall 26 objectives were proposed, with 58% agreement in proposed objectives between two workshops. Based on published evidence for pressure-state links, examples of operational objectives and suitable indicators for each of the 26 objectives were then selected. It is argued that given the strong species-specific links of pelagic species with the environment and the large geographic scale of their life cycles, which contrast to demersal systems, pelagic indicators are needed at the level of species (or stocks) independent of legislative region. Pelagic community indicators may be set at regional scale in some cases. In the evidence-based approach used in this study, the selection of species or region specific operational objectives and indicators was based on demonstrated pressure-state links. Hence observed changes in indicators can reliably inform on appropriate management measures

Phacoemulsification combined with posterior capsulorhexis and anterior vitrectomy in the management of malignant glaucoma in phakic eyes

Purpose: To describe sequential phacoemulsification-intraocular lens (IOL) implantation-posterior capsulorhexis-anterior vitrectomy in the management of phakic malignant glaucoma. Methods: Twenty consecutive patients (25 eyes) with phakic malignant glaucoma were enrolled at the Zhongshan Ophthalmic Center, Sun Yat-sen University. All patients underwent phacoemulsification, IOL implantation and posterior capsulorhexis together with anterior vitrectomy via a clear corneal paracentesis. Visual acuity, intraocular pressure (IOP), anterior chamber depth (ACD), surgical complications and medications required after the surgery were recorded. Results: After surgery, the mean LogMAR visual acuity and ACD increased significantly (visual acuity from -1.56 ± 1.17 to -0.54 ± 0.81, p < 0.001; ACD from 0.367 ± 0.397 mm to 2.390 ± 0.575 mm, p < 0.001), and mean IOP decreased significantly (from 39.6 ± 10.6 mm Hg to 14.5 ± 4.1 mmHg, p < 0.001). No serious perioperative complications occurred, and only five eyes required topical glaucoma medications after surgery. Conclusion: Combined phacoemulsification-IOL implantation-posterior capsulorhexis-anterior vitrectomy surgery is a safe and effective method for treating patients with phakic malignant glaucoma. © 2012 The Authors. Acta Ophthalmologica © 2012 Acta Ophthalmologica Scandinavica Foundation.

Effect of technique on intraocular pressure after combined cataract and glaucoma surgery: An evidence-based review.

TOPIC:

To analyze the literature pertaining to the techniques used in combined cataract and glaucoma surgery, including the technique of cataract extraction, the timing of the surgery (staged procedure versus combined procedure), the anatomic location of the operation, and the use of antifibrosis agents.

CLINICAL RELEVANCE:

Cataract and glaucoma are both common conditions and are often present in the same patient. There is no agreement concerning the optimal surgical management of these disorders when they coexist.

METHODS/LITERATURE REVIEWED:

Electronic searches of English language articles published since 1964 were conducted in Pub MED and CENTRAL, the Cochrane Collaboration's database. These were augmented by a hand search of six ophthalmology journals and the reference lists of a sample of studies included in the literature review. Evidence grades (A, strong; B, moderate; C, weak; I, insufficient) were assigned to the evidence that involved a direct comparison of alternative techniques.

RESULTS:

The preponderance of evidence from the literature suggests a small (2-4 mmHg) benefit from the use of mitomycin-C (MMC), but not 5-fluorouracil (5-FU), in combined cataract and glaucoma surgery (evidence grade B). Two-site surgery provides slightly lower (1-3 mmHg) intraocular pressure (IOP) than one-site surgery (evidence grade C), and IOP is lowered more (1-3 mmHg) by phacoemulsification than by nuclear expression in combined procedures (evidence grade C). There is insufficient evidence to conclude either that staged or combined procedures give better results or that alternative glaucoma procedures are superior to trabeculectomy in combined procedures.

CONCLUSIONS:

In the literature on surgical techniques and adjuvants used in the management of coexisting cataract and glaucoma, the strongest evidence of efficacy exists for using MMC, separating the incisions for cataract and glaucoma surgery, and removing the nucleus by phacoemulsification.

Corneal structure and biomechanics: impact on the diagnosis and management of glaucoma.

PURPOSE OF REVIEW:

Highlights recent studies relating to the impact of corneal structure and biomechanical properties on glaucoma evaluation and management.

RECENT FINDINGS:

Central corneal thickness has been shown to play a role in the interpretation of intraocular pressure. Central corneal thickness has also been suggested as a glaucoma risk factor. The potential role of other corneal factors, such as stromal makeup, in the accurate measurement of intraocular pressure and the assessment of glaucoma risk remains to be determined.

SUMMARY:

Improved understanding of central corneal thickness and corneal biomechanical properties may someday lead to a better understanding of glaucoma risk and its assessment.

Determinants of postoperative corneal edema and impact on goldmann intraocular pressure.

PURPOSE: Recent studies report that increased corneal edema because of contact lens wear under closed lids is associated with elevated Goldmann intraocular pressure (GAT IOP). We sought to assess whether the impact of postoperative corneal edema on GAT IOP would be similar and to determine the differential effect of different amounts of edema. METHODS: The setting is a tertiary level cataract clinic in Shantou, China. Pre- and postoperative (day 1) GAT IOP, central corneal thickness (CCT), corneal hysteresis, corneal resistance factor, and radius of corneal curvature were measured for consecutive patients undergoing phacoemulsification surgery by 2 experienced surgeons. Corneal edema was calculated as the percentage increase in CCT. RESULTS: Among 136 subjects (mean age, 62.5 ± 15.4 years; 53.7% women), the mean increase in CCT was 10.3% postoperatively. Greater corneal edema was associated with lower GAT IOP in unadjusted analyses (P < 0.03) and in linear regression models (P < 0.01). In the model, higher corneal resistance factor (P < 0.001), lower corneal hysteresis (P < 0.001), and steeper radius of corneal curvature (P < 0.001) were associated with higher GAT IOP. Among subjects with edema < the median, edema was associated with lower GAT IOP (P = 0.004), whereas among those with edema ≥ the median, edema was not associated with GAT IOP. An increase in CCT of 7% was associated with an 8 mm Hg underestimation of GAT IOP in our models. CONCLUSIONS: The effect of postoperative edema on GAT IOP seems to be the opposite of contact lens-induced edema. The magnitude of the effect is potentially relevant to patient management.

Evaluating genetic traceability methods for captive-bred marine fish and their applications in fisheries management and wildlife forensics

Growing demands for marine fish products is leading to increased pressure on already depleted wild populations and a rise in aquaculture production. Consequently, more captive-bred fish are released into the wild through accidental escape or deliberate releases. The increased mixing of captive-bred and wild fish may affect the ecological and/or genetic integrity of wild fish populations. Unambiguous identification tools for captive-bred fish will be highly valuable to manage risks (fisheries management) and tracing of escapees and seafood products (wildlife forensics). Using single nucleotide polymorphism (SNP) data from captive-bred and wild populations of Atlantic cod Gadus morhua L. and sole Solea solea L., we explored the efficiency of population and parentage assignment techniques for the identification and tracing of captive-bred fish. Simulated and empirical data were used to correct for stochastic genetic effects. Overall, parentage assignment performed well when a large effective population size characterized the broodstock and escapees originated from early generations of captive breeding. Consequently, parentage assignments are particularly useful from a fisheries management perspective to monitor the effects of deliberate releases of captive-bred fish on wild populations. Population assignment proved to be more efficient after several generations of captive breeding, which makes it a useful method in forensic applications for well-established aquaculture species. We suggest the implementation of a case-by-case strategy when choosing the best method.

Strategic management in the Telecom industry to create competitive advantage

O presente trabalho teve por objetivos a identificação de uma estratégia e o desenvolvimento de um modelo que permita às operadoras de telecomunicações a sua sustentabilidade, bem como a identificação de caminhos para a adaptação a uma realidade sempre em mudança como é a da indústria das telecomunicações. Numa primeira parte do trabalho elaborou-se uma revisão de literatura do atual estado da arte das principais estratégias relevantes e com aplicação à indústria de telecomunicações. A pesquisa realizada investigou a estrutura atual da indústria de telecomunicações e o estado da competitividade das operadoras de telecomunicações. Dos resultados desta foi possível constatar uma evolução constante da tecnologia e dos modelos de negócio neste ecossistema, assim como a presença de uma pressão concorrencial significativa exercida sobre as operadoras, quer por parte das empresas já existentes no mercado quer por parte das emergentes. As operadoras têm de transformar o seu modelo de rede e de negócios para se adaptarem às mudanças e às tendências da indústria e do mercado. Com base na revisão de literatura, elegeu-se a metodologia baseada num inquérito de pesquisa empírica para aferir o estado da indústria e derivar as estratégias possíveis. Este inquérito foi efetuado a especialistas da área de telecomunicações de diferentes subsectores e países para abordar todos os elementos estratégicos do modelo de negócio futuro. Os resultados da pesquisa revelaram que as empresas que operam no mercado da Internet (Over The Top - OTT) representam a maior ameaça sobre o futuro dos operadores de telecomunicações. Os operadores só vão conseguir responder através da modernização de sua rede, melhorando a qualidade, reduzindo o custo global, e investindo em produtos inovadores e diferenciados e em serviços. Os resultados do inquérito revelam-se de acordo com os pressupostos da Blue Ocean Strategy. A aplicabilidade da Blue Ocean Strategy foi aprofundada permitindo concluir que o valor inovador obtido simultaneamente através da redução de custos e da diferenciação permitem aumentar as vantagens dos operadores existentes em termos das infra-estruturas físicas detidas e das relações estabelecidas com os clientes. O caso particular da fibra óptica até casa (FTTH) foi considerado como aplicação da Blue Ocean Strategy a uma nova tecnologia que as operadoras podem implementar para criar novas soluções e abrir segmentos de mercado inexplorados. Os resultados do inquérito e da investigação realizada à aplicação da Blue Ocean Strategy foram combinados para propor um novo modelo de negócio para as operadoras de telecomunicações que lhes permite, não só responder aos desafios existentes, mas, também, ter uma melhor posição competitiva no futuro. Foi, ainda, realizado um estudo de caso que destacou como a Verizon Communications foi capaz de transformar a sua rede e o modelo de negócio em resposta ao aumento da pressão competitiva. Através do valor da inovação transferida aos seus clientes, a Verizon foi capaz de aumentar significativamente as suas receitas e satisfação do cliente.

Post-fire vegetation regeneration in Portugal : implications for management

This thesis aims at improving the knowledge on the post-fire vegetation regeneration. For that, forests and shrublands were studied, after forest fires and experimental fires. Maritime Pine (Pinus pinaster) recruitment after fire was studied. Fire severity was evidenced as a major effect on this process. High crown fire severity can combust the pines, destroying the seed bank and impeding post fire pine recruitment. However, crown combustion also influences the post-fire conditions on the soil surface, since high crown combustion (HCC) will decrease the postfire needle cast. After low crown combustion (LCC) (scorched rather than torched crowns), a considerable needle cover was observed, along with a higher density of pine seedlings. The overall trends of post-fire recruitment among LCC and HCC areas could be significantly attributed to cover by needles, as well by the estimation of fire severity using the diameters of the burned twigs (TSI). Fire increased the germination from the soil seed bank of a Pinus pinaster forest, and the effects were also related with fire severity. The densities of seedlings of the dominant taxa (genus Erica and Calluna vulgaris) were contrastingly affected in relation to the unburned situation, depending on fire severity, as estimated from the degree of fire-induced crown damage (LCC/HCC), as well as using a severity index based on the diameters of remaining twigs (TSI). Low severity patches had an increase in germination density relatively to the control, while high severity patches suffered a reduction. After an experimental fire in a heathland dominated by Pterospartum tridentatum, Erica australis and E. umbellata, no net differences in seedling emergence were observed, in relation to the pre-fire situation. However, rather than having no effect, the heterogeneity of temperatures caused by fire promoted caused divergent effects over the burned plot in terms of Erica australis germination – a progressive increased was observed in the plots were maximum temperature recorded ranged from 29 to 42.5ºC and decreased in plots with maximum temperature ranging from 51.5 to 74.5ºC. In this heathland, the seed density of two of the main species (E. australis and E. umbellata) was higher under their canopies, but the same was not true for P. tridentatum. The understory regeneration in pine and eucalypt stands, 5 to 6 years post fire, has been strongly associated with post-fire management practices. The effect of forest type was, comparatively, insignificant. Soil tilling, tree harvesting and shrub clearance, were linked to lower soil cover percentages. However, while all these management operations negatively affected the cover of resprouters, seeders were not affected by soil tilling. A strong influence of biogeographic region was identified, suggesting that more vulnerable regions may suffer higher effects of management, even under comparatively lower management pressure than more productive regions. This emphasizes the need to adequate post-fire management techniques to the target regions.

The function and future of the LOICS basins approach in promoting integrated coastal zone & watershed management with an emphasis on developing countries

Dissertação de Mestrado, Gestão da Água e da Costa, Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2010

The importance of the pelagic larval phase of the wedge shell Donax trunculus (L.): implications for the management of the fishery

The wedge shell, Donax trunculus, inhabits high energy environment of exposed sandy beaches from the Atlantic coast of France to Senegal. Like all Donacidae, it is relative small, flat-shaped with elongated solid shells. It is a highly demanded and valuable species mainly in Algarve, with the dredge fleet increasing the pressure on species stocks. In 1986 the Portuguese Institute for the Ocean and Atmosphere (IPMA) initiated a bivalve survey program to evaluate the stock status of species with economical valuable but always on the adult population. Since then, several managing measures were implemented to guarantee bivalves’ sustainable exploitation. Despite the available information on the abundance and distribution of the wedge shell along the Algarve coast, no information on the larval planktonic phase is available. To fill in this gap, the present study aimed at obtaining, for the first time information on the broodstock condition and on the pelagic phase of the wedge shell in the Algarve coast.