Managing risk in the face of adversity: design and outcomes of rapid glaucoma assessment clinics during a pandemic recovery

Background: The provision of timely care to the high volume of glaucoma patients stratified as “low risk” following pandemic-related appointment deferrals continues to prove challenging for glaucoma specialists. It is unknown whether stratification as “low risk” remains valid over time, raising the potential risk of harm during this period if left unmonitored. This study aimed to evaluate whether Rapid Glaucoma Assessment Clinics (RGACs) are an effective method of assessing “low-risk” patients in order to identify those who may need an escalation of care, therefore reducing the risk of the future incidents of preventable vision loss. / Methods: RGACs were developed which comprised a brief advance telephone history by a clinician and then ophthalmic technician-measured visual acuity and intraocular pressure in clinic. We report outcomes from the first month of operation describing attendance patterns, the proportion of patients from this “low risk” cohort requiring escalation and underlying reasons for treatment escalations. / Results: 639 patients were invited to attend RGACs. 75% attended their booked appointment. Pre-attendance telephone consultations were associated with lower non-attendance rates (13.9% vs 29.3%, p < 0.00001). 15% of patients were no longer deemed to remain at “low risk” with further expedited clinical review scheduled. 10.4% of patients required an escalation in treatment following review. / Conclusions: RGACs are an effective approach to deliver high throughput clinical assessments for large numbers of “low-risk” glaucoma patients with deferred appointments. They enable the rapid identification and treatment of patients who would otherwise face significantly delayed review reducing the risk of future preventable vision loss

The simulation of urban-scale evacuation scenarios: Swinley forest fire

Forest fires are an annual occurrence in many parts of the world causing evacuation of nearby residential areas and industrial facilities. The frequent occurrence of these events deems it necessary to develop appropriate evacuation plans for areas that are susceptible to forest fires. A well-established and well-validated evacuation model, buildingEXODUS, has been extended to model large scale urban/rural evacuations by including the road network and open spaces (e.g. parks, green spaces and town squares)along with buildings. The evacuation simulation results have been coupled with the results of a forest fire spread model and applied to the Swinley forest fire. Four evacuation procedures differing in the routes taken by the pedestrians were simulated and analysed providing key evacuation statistics such as time to reach the assembly location, the distance travelled and congestion experienced by the agents. In addition, the safety margins associated with using each evacuation route are identified. This is the time available between the safe passage of the pedestrians through the route and the route being considered no longer safe for pedestrian use. A key finding of this work is the importance of formulating evacuation procedures in response to wildfires by providing occupants timely evacuation notice and appropriate choice of routes to keep them at a safe distance from the fire even at the cost of taking longer evacuation routes

What makes a house a home? Nest box use by West European hedgehogs (Erinaceus europaeus) is influenced by nest box placement, resource provisioning and site-based factors

Artificial refuges provided by householders and/or conservation practitioners potentially represent one mechanism for mitigating declines in the availability of natural nest sites used for resting, breeding and hibernating in urban areas. The effectiveness of such refuges for different species is, however, not always known. In this study, we conducted a questionnaire survey of UK householders to identify factors associated with the use of ground-level nest boxes for West European hedgehogs (Erinaceus europaeus), a species of conservation concern. Overall, the percentage of boxes used at least once varied with season and type of use: summer day nesting (35.5–81.3%), breeding (7.2–28.2%), winter day nesting (20.1–66.5%) and hibernation (21.7–58.6%). The length of time the box had been deployed, the availability of artificial food and front garden to back garden access significantly increased the likelihood that a nest box had been used for all four nesting types, whereas other factors related to placement within the garden (e.g., in a sheltered location, on hardstanding such as paving, distance from the house) and resource provisioning (bedding) affected only some nesting behaviours. The factors most strongly associated with nest box use were the provisioning of food and bedding. These data suggest, therefore, that householders can adopt simple practices to increase the likelihood of their nest box being used. However, one significant limitation evident within these data is that, for welfare reasons, householders do not routinely monitor whether their box has been used. Consequently, future studies need to adopt strategies which enable householders to monitor their boxes continuously. Ultimately, such studies should compare the survival rates and reproductive success of hedgehogs within artificial refuges versus more natural nest sites, and whether these are affected by, for example, the impact of nest box design and placement on predation risk and internal microclimate

Are Long-Term Non-Progressors Very Slow Progressors? Insights from the Chelsea and Westminster HIV Cohort, 1988–2010

Define and identify long-term non-progressors (LTNP) and HIV controllers (HIC), and estimate time until disease progression. LTNP are HIV-1+ patients who maintain stable CD4+ T-cell counts, with no history of opportunistic infection or antiretroviral therapy (ART). HIC are a subset of LTNP who additionally have undetectable viraemia. These individuals may provide insights for prophylactic and therapeutic development. Records of HIV-1+ individuals attending Chelsea and Westminster Hospital (1988–2010), were analysed. LTNP were defined as: HIV-1+ for >7 years; ART-naïve; no history of opportunistic infection and normal, stable CD4+ T-cell counts. MIXED procedure in SAS using random intercept model identified long-term stable CD4+ T-cell counts. Survival analysis estimated time since diagnosis until disease progression. Subjects exhibiting long-term stable CD4+ T-cell counts with history below the normal range (<450 cells/µl blood) were compared to LTNP whose CD4+ T-cell count always remained normal. Within these two groups subjects with HIV-1 RNA load below limit of detection (BLD) were identified. Of 14,227 patients, 1,204 were diagnosed HIV-1+ over 7 years ago and were ART-naïve. Estimated time until disease progression for the 20% (239) whose CD4+ T-cell counts remained within the normal range, was 6.2 years (IQR: 2.0 to 9.6); significantly longer than 4.0 years (IQR: 1.0 to 7.3) for patients with historical CD4+ T-cell count below normal (Logrank chi-squared = 21.26; p<0.001). Within a subpopulation of 312 asymptomatic patients, 50 exhibited long-term stable CD4+ T-cell counts. Of these, 13 were LTNP, one of whom met HIC criteria. Of the remaining 37 patients with long-term stable low CD4+ T-cell counts, 3 controlled HIV-1 RNA load BLD. Individuals with stable, normal CD4+ T-cell counts progressed less rapidly than those with low CD4+ T-cell counts. Few LTNP and HIC identified in this and other studies, endorse the need for universal definitions to facilitate comparison

Three-year findings of the HORIZON trial: a Schlemm canal microstent for pressure reduction in primary open angle glaucoma and cataract

OBJECTIVE: To report 3-year outcomes of the HORIZON study comparing cataract surgery with Hydrus Microstent versus cataract surgery alone. DESIGN: Multicenter randomized clinical trial. PARTICIPANTS: Five hundred fifty-six eyes from 556 patients with cataract and POAG treated with ≥ 1 glaucoma medication, washed out diurnal intraocular pressure (DIOP) 22-34 mmHg and no prior incisional glaucoma surgery. METHODS: Following phacoemulsification, eyes were randomized 2:1 to receive a Hydrus® Microstent (Ivantis, Inc.) or no stent. Follow-up included comprehensive eye examinations through 3 years postoperatively. MAIN OUTCOME MEASURES: Outcome measures included IOP, medical therapy, reoperation rates, visual acuity, adverse events, and changes in corneal endothelial cell counts. RESULTS: 369 eyes were randomized to microstent treatment (HMS) and 187 to cataract surgery only (CS). Preoperative IOP, medication usage, washed out DIOP, and glaucoma severity did not differ between the two treatment groups. At 3 years, IOP was 16.7 ± 3.1 in the HMS group and 17.0 ± 3.4 in the CS group (p=0.85). The number of glaucoma medications was 0.4 ± 0.8 in the HMS group and 0.8 ± 1.0 in the CS group (p<0.001), and 73% of eyes in the HMS group were medication free compared to 48% in the CS group (p<0.001). The HMS group had a higher proportion of eyes with IOP ≤18 mmHg without medications compared to CS (56.2% vs. 34.6%, p<0.001) as well as IOP reduction of at least 20, 30 or 40 percent compared to CS alone. The cumulative probability of incisional glaucoma surgery was lower in the HMS group (0.6% vs. 3.9%, hazard ratio = 0.156, 95% CI 0.031 to 0.773, p=0.020). There was no difference in postoperative corneal endothelial cell loss between groups. There were no procedure or device related serious adverse events resulting in vision loss in either group. CONCLUSIONS: Combined cataract surgery and microstent placement for mild to moderate POAG is safe, more effective in lowering IOP with fewer medications, and less likely to result in further incisional glaucoma filtrations surgery than cataract surgery alone at 3 years

An assessment of a conservation strategy to increase garden connectivity for hedgehogs that requires cooperation between immediate neighbours: a barrier too far?

Urban areas are associated with high levels of habitat fragmentation. For some terrestrial species with limited climbing abilities, property boundaries can pose a significant problem by limiting access to residential gardens. The West European hedgehog (Erinaceus europaeus) has declined markedly in the UK but is commonly found in areas of human habitation, including residential gardens. ‘Hedgehog Street’ is a public engagement campaign aimed at recruiting volunteers (‘Hedgehog Champions’) to create access points (‘hedgehog highways’) across garden boundaries to improve habitat connectivity. In this study, we used a series of questionnaire surveys to explore motivations for and obstacles to the creation of highways. Householders were more likely to have created a highway if they were already aware of the Hedgehog Street campaign, if their garden contained a high number of wildlife-friendly features and if they considered watching wildlife to be important. Hedgehog Champions created, on average, 1.69 highways each with 52.0% creating none; this would equate to an estimated >120,000 across all registered Champions. In comparison, 6.1–29.8% of non-Champions stated that they had made a highway. However, most highways had been created in boundaries that could already be traversed via naturally occurring holes: only 11.4% of garden boundaries could be traversed, and 3.2% of gardens accessed, just via a hedgehog highway. In addition, only 5.0% of gardens were considered totally inaccessible to hedgehogs. The most common reasons cited for not having made a highway were that householders’ gardens were already accessible to hedgehogs followed by concerns relating to boundary ownership and / or communicating with neighbours. Future studies need to identify strategies for overcoming these obstacles to maximize citizen engagement, particularly with those householders who are not innately “wildlife-friendly”, and to quantify the degree to which networks of highways affect patterns of individual movement and, ultimately, populations