Medical management of diabetic retinopathy:fenofibrate and ACCORD eye studies

The approach of all ophthalmologists, diabetologists and general practitioners seeing patients with diabetic retinopathy should be that good control of blood glucose, blood pressure and plasma lipids are all essential components of modern medical management. The more recent data on the use of fenofibrate in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) and The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Eye studies is reviewed. In FIELD, fenofibrate (200 mg/day) reduced the requirements for laser therapy and prevented disease progression in patients with pre-existing diabetic retinopathy. In ACCORD Eye, fenofibrate (160 mg daily) with simvastatin resulted in a 40% reduction in the odds of retinopathy progressing over 4 years, compared with simvastatin alone. This occurred with an increase in HDL-cholesterol and a decrease in the serum triglyceride level in the fenofibrate group, as compared with the placebo group, and was independent of glycaemic control. We believe fenofibrate is effective in preventing progression of established diabetic retinopathy in type 2 diabetes and should be considered for patients with pre-proliferative diabetic retinopathy and/or diabetic maculopathy, particularly in those with macular oedema requiring laser. © 2011 Macmillan Publishers Limited All rights reserved.

The management of posterior vitreous detachment by an optometrist

Acute posterior vitreous detachment (PVD) is the most common cause of retinal detachment. The management of this condition can be variable and often undue reliance is placed upon associated signs and symptoms which can be a poor indicator of pathology. Optometrists undertake a number of extended roles, however involvement in vitreo-retinal sub-specialities appears to be limited. One objective was to directly compare an optometrist and ophthalmologist in the assessment of patients with PVD, for this a high level of agreement was found (95% sensitivity, 99% specificity, 0.94 kappa). A review of 1107 patients diagnosed with acute PVD that were re-evaluated in a PVD clinic a few weeks later was undertaken to determine whether such reviews are necessary. One-fifth of patients were found to have conditions undiagnosed at the initial assessment, overall 4% of patients had retinal breaks when examined in the PVD clinic and a total of 7% required further intervention. The sensitivity of fundus examination with +90D and 3-mirror lenses was 85-88% for detecting retinal breaks and 7-85% for pigment in the anterior vitreous for the presence of retinal breaks. Therefore patients with acute PVD should be examined by indirect ophthalmoscopy with indentation at the onset of PVD and 4-6 weeks later. The treatment of retinal breaks with laser retinopexy is performed by ophthalmologists with a primary success rate 54-85%. In a pioneering development, an optometrist undertaking this role achieved a comparable primary success rate (79%). Mid-vitreous opacities associated with PVD are described, and noted in 100% of eyes with PVD. The recognition of this sign is important in the diagnosis of PVD and retinal breaks. The importance of diagnostic imaging is also demonstrated, however the timing in relation to onset may be vital.

Defining Fluid Restriction in the Management of Infants Following Cardiac Surgery and Understanding the Subsequent Impact on Nutrient Delivery and Growth Outcomes

Adequacy of nutritional intake during the postoperative period, as measured by a change in weight-for-age z-scores from surgery to the time of discharge, was evaluated in infants (n = 58) diagnosed with a congenital heart defect and admitted for surgical intervention at Miami Children’s Hospital using a prospective observational study design. Parental consent was obtained for all infants who participated in the study. Forty patients had a weight available at hospital discharge. The mean preoperative weight-for-age z-score was -1.3 ±1.43 and the mean weight-for-age z-score at hospital discharge was -1.89 ±1.35 with a mean difference of 0.58 ±0.5 (P Nutritional intake during the postoperative period was inadequate based on a decrease in weight-for-age z-scores from the time of surgery until discharged home. Our findings suggested that limited fluid volume for nutrition likely contributes to suboptimal nutritional delivery during the postoperative period; however, inadequate nutrition prescription may also be an important contributing factor. Development of a nutrition protocol for initiation and advancement of nutrition support may reduce the delay in achieving patient’s nutritional goals and may attenuate the observed decrease in z-scores during the postoperative period.

The Barriers to the Integration of the Uterine Balloon Tamponade into South Africa and Ghana's Health Systems for the Management of Postpartum Hemorrhage

Background

Postpartum hemorrhage is the most significant contributor to maternal mortality globally, claiming 140,000 lives annually. Postpartum hemorrhage is a leading cause of maternal death in South Africa, with the literature indicating that 80 percent of the postpartum hemorrhage deaths in South Africa are avoidable. Ghana, as of 2010, witnesses 2700 maternal deaths annually, primarily because of poor quality of care in health facilities and services being difficult to access. As per WHO recommendations, uterotonics are integral to treating postpartum hemorrhage as soon as it is diagnosed. In case of persistent bleeding or limited availability of uterotonics, the uterine balloon tamponade (UBT) can be used as a second line of defense. If both these measures are unable to counter the bleeding, providers must perform surgical interventions. Literature on the UBT, as one tool in the protocol to address postpartum hemorrhage, has shown it to have success rates ranging from 60 to 100 percent. Despite the potential to lower the number of postpartum hemorrhage deaths in South Africa and Ghana, the UBT has not been incorporated widely in South Africa and Ghana. The aim of this study is to describe the barriers involved with integrating the UBT into South Africa and Ghana’s health systems to address postpartum hemorrhage.

Methods

The study took place in multiple sites in South Africa (Cape Town, Johannesburg, Durban and Mpumalanga) and in Accra, Ghana. South Africa and Ghana were selected because postpartum hemorrhage contributes greatly to their maternal mortality numbers and there is potential in both countries to lower those rates through greater use of the UBT. A total of 25 participants were interviewed through purposive sampling, snowball sampling and participant referrals, and included various categories of stakeholders integral to the integration process of a medical device. Individual in-depth interviews were used for data collection, with interview questions being tailored to each stakeholder category. The focus of the interviews was on the protocol used to counter postpartum hemorrhage, the frequency with which the UBT is used as part of the protocol, and the process of integrating it into the South Africa and Ghana’s health systems. The data collected were coded using NVivo and analyzed using content analysis.

Results

The barriers to integration of the uterine balloon tamponade to address postpartum hemorrhage in South Africa and Ghana were evident on the political, economic and health delivery levels. The results indicated that the barriers to integration in South Africa included the low recognition of postpartum hemorrhage as a problem, the lack of clarity surrounding the role of the Medicines Control Council as a regulatory body for medical devices, and low awareness of the UBT as an intervention to control postpartum hemorrhage. The barriers in Ghana were the cash constraints experienced by the Ghana Health Services to fund medical devices, a heavy reliance on donors for funding, and the lack of consistent knowledge on processes involving clinical trials for new medical devices in Ghana.

Conclusion

Existing literature on methods to counter postpartum hemorrhage to reduce maternal mortality has focused on and emphasized the efficacy of the UBT. Despite overwhelming evidence supporting the use of the UBT, many health systems across the world, particularly low-income countries, do not have access to the device owing to numerous barriers in integrating the device into obstetric care. This study illustrates the need to focus on incorporating the UBT into health systems for greater availability to health workers and its use as standard of care. Ultimately, this study can be used as a stepping-stone for more research on this subject, providing evidence to influence policymakers to integrate the UBT into their protocols for postpartum hemorrhage response.

Permissibility of Non-Voluntary Collective Management of Copyright under EU Law – The Case of the French Law on Out-of-Commerce Books

The possibility of the EU member states to adapt copyright legislation to new circumstances and to address unforeseen issues is limited by the list of exceptions and restrictions of the InfoSoc Directive. In spite of this constraint, the EU copyright framework provides for a possibility of introduction of non-voluntary forms of collective rights management that can help to tackle some of the contemporary problems with remuneration and access. This article is an attempt to deepen the understanding of non-voluntary collective management and its possible use. First, it provides a detailed description of the French mechanism adopted for facilitating mass digitization and making out-of-commerce books available, which was implemented through a new form of collective management of copyright. Then, it examines the mechanism’s compatibility with the InfoSoc Directive through comparison with the extended collective licensing.

Use of sulfuryl fluoride in the management of strongly phosphine-resistant insect pest populations in bulk grain storages in Australia

Sulfuryl fluoride (SF), an effective structural fumigant, is registered recently as Profume™ for controlling insect pests of stored grains and processed commodities. Information on its effectiveness in disinfestation of bulk grain, however, is limited. The ongoing problem with the strong level of resistance to phosphine has been addressed recently through deployment of SF as a ‘resistance breaker’ in bulk storages in Australia. This paper discusses important results on the efficacy of SF against key phosphine- resistant insect pests, lesser grain borer, Rhyzopertha dominca, red flour beetle, Tribolium castaneum, rice weevil, Sitophilus oryzae and the rusty grain beetle, Cryptolestes ferrugineus. We have established CT (g-hm3) profiles for SF against these insect pests at two temperature regimes 25 and 30°C, that showed that both temperature and exposure period (t) has significant influence on the effectiveness of SF than the concentration. Over a seven days fumigation period, CTs of 800 and 400 g-hm3 achieved complete control of all the target pests, including the most strongly phosphine - resistant species, C. ferrugineus at 25 and 30°C, respectively. Results from four industry scale field trials involving currently registered rate of SF (1500 g-hm3) over 2–14 d exposure period, confirmed its effectiveness in achieving complete control of the target pest species. The assessment of postfumigation grain samples across all the test storages indicated that the reinfestation occurs after three months. Monitoring resistance to phosphine in C. ferrugineus over a six year period (2009–2015), showed a significant reduction in resistant populations after the introduction of SF into the fumigation strategy at problematic storage sites. Overall our research concludes that SF is a good candidate to be used as a ‘resistance breaker’ where phosphine resistance is prevalent.

Towards balanced exploitation and management of the fishery resources of Uganda

A casual study of the hydrological map of Uganda would convince every serious fisherman and fisheater that he is most favoured to be in Uganda. The extent and distribution of the country's aquatic system plus the rich variety of fish species there is promises a fishery potential of considerable magnitude: The open waterways comprised by the Uganda portions of Lakes Victoria, Albert and Edward; and Lakes Kyoga, George plus minor lakes Wamala, Kijanebarora, mutanda, etc. occupy about 15% of the total surface area (91,000 m2; Depart. Land Survey, 1962). Most of the nation's fish supplies are currontly from this source. 1.2. A rich network of permanent and seasonal rivers and streams filling and/or emptying various water systems covers most of Uganda. This aquatic network is associated with a fish fauna whose immense significance as a source of protein is perhaps better appreciated by the local subsistance fisherman and consumer than by the fisheries scientist and manager in this country. Many species of this fish fauna have strong affinities with the open water systems while some are typically riverine. 1.3. Then there are wetlands composed mainly of expanses of swamp, but including some areas of bog. These cover about 2% of the country. While the variety of fish fauna found here is limited by the rather hostile nature of the environment (comparatively de-oxygenated under a canopy of dense stands of emergont vegetation) several specialised fishes e.g. Clarias spp. and Protpterus aethiopicus (Kamongo) occur here. Availability of permanent and seasonal sources of water, well distributed throughout most areas of Uganda, opens up immense potential for a variety of aquaculture practices. However, while active exploitation of much of these fishery resources is currently underway, important questions regarding the magnitudes of the various resource potentials and dynamics, and about suitable levels and modes of exploitation, are yet unanswered. These gaps in knowledge go about the fishery resources of Uganda would hinder formulation of adequate development and management schemes. This short paper examines some of the above problems and suggests some approaches towards balanced oxploitation and management of the fisheries of Uganda.

Internationalization of IT company: Case study of a Finnish MOOC platform

The interest to small and media size enterprises’ (SMEs) internationalization process is increasing with a growth of SMEs’ contribution to GDP. Internet gives an opportunity to provide variety of services online and reach market niche worldwide. The overlapping of SMEs’ internationalization and online services is the main issue of the research. The most SMEs internationalize according to intuitive decisions of CEO of the company and lose limited resources to worthless attempts. The purpose of this research is to define effective approaches to online service internationalization and selection of the first international market. The research represents single holistic case study of local massive open online courses (MOOCs) platform going global. It considers internationalization costs and internationalization theories applicable to online services. The research includes preliminary screening of the markets and in-depth analysis based on macro parameters of the market and specific characteristics of the customers and expert evaluation of the results. The specific issues as GILT (Globalization, Internationalization, Localization and Translation) approach and Internet-enabled internationalization are considered. The research results include recommendations on international market selection methodology for online services and for effective internationalization strategy development.

Deficiencies in education and experience in the management of acute kidney injury among Malawian healthcare workers

Background Acute kidney injury (AKI) is a common but under-recognised disease process, which carries a high risk of mortality or chronic complications, such as chronic kidney disease and other organ dysfunction. Management of AKI, however, is suboptimal, both in developed settings and in Malawi. This is partly because of deficiencies in AKI education and training. Aim To establish current levels of AKI education in a range of healthcare workers in Malawi. Methods An AKI symposium was held in Blantyre in March 2015. Delegates were asked to complete a survey at the start of the symposium to assess their clinical experience and education in the management of AKI. Results From 100 delegates, 89 nurses, clinical officers, and physicians, originating from 11 different districts, responded to the survey. Twenty-two percent of healthcare workers (including 28% of district workers of the various cadres and 31% of nurses) had never received teaching on any aspect of renal disease, and 50% (including 63% of district workers and 61% of nurses) had never received teaching specifically on AKI. Forty-four percent did not feel confident managing AKI, and 98% wanted more support managing patients with renal disease. Thirty-four percent (including 55% of district workers) were unaware that haemodialysis was available at Queen Elizabeth Central Hospital (QECH) for the treatment of AKI and 53% (74% of district workers) were unaware that peritoneal dialysis was available for the treatment of AKI in children. Only 33% had ever referred a patient with AKI to QECH. Conclusions There are deficiencies in education about, and clinical experience in, the management of AKI among Malawian healthcare workers, in addition to limited awareness of the renal service available at QECH. Urgent action is required to address these issues in order to prevent morbidity and mortality from AKI in Malawi.

Defining fluid restriction in the management of infants following cardiac surgery and understanding the subsequent impact on nutrient delivery and growth outcomes

Adequacy of nutritional intake during the postoperative period, as measured by a change in weight-for-age z-scores from surgery to the time of discharge, was evaluated in infants (n = 58) diagnosed with a congenital heart defect and admitted for surgical intervention at Miami Children’s Hospital using a prospective observational study design. Parental consent was obtained for all infants who participated in the study. ^ Forty patients had a weight available at hospital discharge. The mean preoperative weight-for-age z-score was -1.3 ±1.43 and the mean weight-for-age z-score at hospital discharge was -1.89 ±1.35 with a mean difference of 0.58 ±0.5 (P = 0.2).^ Nutritional intake during the postoperative period was inadequate based on a decrease in weight-for-age z-scores from the time of surgery until discharged home. Our findings suggested that limited fluid volume for nutrition likely contributes to suboptimal nutritional delivery during the postoperative period; however, inadequate nutrition prescription may also be an important contributing factor. Development of a nutrition protocol for initiation and advancement of nutrition support may reduce the delay in achieving patient’s nutritional goals and may attenuate the observed decrease in z-scores during the postoperative period.^

Management of industrialization projects

Short time-to-market is a key success factor in the todays’ dynamic business environment and many companies are trying to improve their product development processes. A challenge is to develop products according to the time plan and at the same time keeping the cost low and the quality high. This study focuses on the project management within the product development process in an automotive industry. The background of this study started as a request from the research and development department at the automotive company, which led to the following questions; 1) what are the most crucial factors for project success? 2) How can these factors contribute to a more successful outcome? 3) How can project management decrease product development lead time by sharing knowledge? The research approach is a case study and the data collection consist of interviews and questioners at two companies connected to project management in product development projects. Spider charts are created from the collected data containing eleven dimensions to show similarities and differences between the project managers working within the research and development department as well as between the two companies. The main conclusions are that there is a need to allow a certain level of flexibility when managing projects, in order to more easily handle late changes. Being involved in a project from the concept phase could facilitate the product development activities later on, due to a deeper understanding regarding previous decisions. Further, knowledge sharing methods, such as databases, has to be designed to be suitable for a specific organization and user friendly which enables the users to more easily search for specific types of knowledge. Lastly, a low level on the detailed focus is shown to be another success factor, however, in some cases there is still a need of this detailed focus to solve specific problems but the details may never become a higher focus than the holistic view.

Toward adaptive management of coastal MPAs: The influence of different conservation targets and costs on the design of no-take areas

There is still much discussion on the most appropriate location, size and shape of marine protected areas (MPAs). These three factors were analyzed for a small coastal MPA, the Luiz Saldanha Marine Park (LSMP), for which a very limited amount of local ecological information was available when implemented in 1998. Marxan was used to provide a number of near-optimal solutions considering different levels of protection for the various conservation features and different costs. These solutions were compared with the existing no-take area of the LSMP. Information on 11 habitat types and distribution models for 3 of the most important species for the local artisanal fisheries was considered. The human activities with the highest economic and ecological impact in the study area (commercial and recreational fishing and scuba diving) were used as costs. The results show that the existing no-take area is actually located in the best area. However, the no-take area offers limited protection to vagile fish and covers a very small proportion of some of the available habitats. An increase in the conservation targets led to an increase in the number of no-take areas. The comparative framework used in this study can be applied elsewhere, providing relevant information to local stakeholders and managers in order to proceed with adaptive management. (C) 2015 Elsevier B.V. All rights reserved.

Methods and tools for analysis and management of risks and regulatory compliance in the healthcare sector: the hospital at home – HaH

Changing or creating an organisation means creating a new process. Each process involves many risks that need to be identified and managed. The main risks considered here are procedural and legal risks. The former are related to the risks of errors that may occur during processes, while the latter are related to the compliance of processes with regulations. Managing the risks implies proposing changes to the processes that allow the desired result: an optimised process. In order to manage a company and optimise it in the best possible way, not only should the organisational aspect, risk management and legal compliance be taken into account, but it is important that they are all analysed simultaneously with the aim of finding the right balance that satisfies them all. This is the aim of this thesis, to provide methods and tools to balance these three characteristics, and to enable this type of optimisation, ICT support is used. This work isn’t a thesis in computer science or law, but rather an interdisciplinary thesis. Most of the work done so far is vertical and in a specific domain. The particularity and aim of this thesis is not to carry out an in-depth analysis of a particular aspect, but rather to combine several important aspects, normally analysed separately, which however have an impact and influence each other. In order to carry out this kind of interdisciplinary analysis, the knowledge base of both areas was involved and the combination and collaboration of different experts in the various fields was necessary. Although the methodology described is generic and can be applied to all sectors, the case study considered is a new type of healthcare service that allows patients in acute disease to be hospitalised to their home. This provide the possibility to perform experiments using real hospital database.

Comparative analysis of the new guidelines and consensuses for the management of hypothyroidism, thyroid nodules, and differentiated thyroid cancer

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Management of a complex dentoalveolar trauma: a case report

This paper describes the case of a 12-year-old male patient who presented a severe lateral luxation of the maxillary central incisors due to a bicycle fall. Treatment involved suture of the soft tissues lacerations, and repositioning and splinting of the injured teeth, followed by endodontic treatment and periodontal surgery. After a 2-year follow-up, clinical and radiographic evaluation revealed that the incisors presented satisfactory esthetic and functional demands.