A comparative study of glaucoma referrals in Southeast Scotland: effect of the new general ophthalmic service contract, Eyecare integration pilot programme and NICE guidelines.

BACKGROUND: Glaucoma is a progressive disease responsible for the second commonest cause of blindness in the UK. Identifying appropriate patients for hospital care remains an ongoing challenge for all UK hospital glaucoma services. The purpose of our study is to evaluate accuracy and outcome of community optometry referrals before and after implementation of the new general ophthalmic service contract in 2006, the Eyecare Integration Programme pilot in 2008 and the effect of NICE guidelines in glaucoma in 2009, over a 12-year period METHODS: A retrospective case analysis using a glaucoma electronic patient record was performed encompassing two six-year periods, 2000-2006 (Group A), and 2007-2012 (Group B). RESULTS: One thousand six hundred twenty-two new patients' records were analysed. Waiting times reduced from 12.3 to 9.4 weeks. Significantly more patients kept first appointment (p = 0.0002) in group B. Glaucoma symptoms were significantly more in group A (p <0.0001) and only three patients lost Snellen' visual acuity before appointment in group B compared to 12 in group A. Documentation of intraocular pressure was made in 74.1% of Group A and 75.9% of Group B, optic disc appearance in 85.4% of Group A, and 93% of Group B and visual fields in 84.4% of Group A and 81.3% of Group B. Significantly less normal (p < 0,0001), more glaucoma suspects (p < 0.0001), more open angle glaucoma (p = 0.0006) and fewer other conditions (p = 0.0024) were present in group B, compared to group A. CONCLUSION: Patients were referred earlier with shorter waiting times for hospital appointments with the new Scottish general ophthalmic service and Eyecare Integration Programme. Additionally there were fewer false positive referrals with more diagnosis of glaucomatous disease. We discuss the benefits of these national screening and referral pathways together with their limitations and further refinements.

Predicted no effect concentration derivation as a significant source of variability in environmental hazard assessments of chemicals in aquatic systems: an international analysis.

Environmental hazard assessments for chemicals are carried out to define an environmentally "safe" level at which, theoretically, the chemical will not negatively affect any exposed biota. Despite this common goal, the methodologies in use are very diverse across different countries and jurisdictions. This becomes particularly obvious when international scientists work together on documents with global scope, e.g., in the World Health Organization (WHO) International Program on Chemical Safety. In this article, we present a study that describes the extent of such variability and analyze the reasons that lead to different outcomes in deriving a "safe level" (termed the predicted no effect concentration [PNEC] throughout this article). For this purpose, we chose 5 chemicals to represent well-known substances for which sufficient high-quality aquatic effects data were available: ethylene glycol, trichloroethylene, nonylphenol, hexachlorobenzene, and copper (Cu). From these data, 2 data sets for each chemical were compiled: the full data set, that contained all information from selected peer-review sources, and the base data set, a subsample of the full set simulating limited data. Scientists from the European Union (EU), United States, Canada, Japan, and Australia independently carried out hazard assessments for each of these chemicals using the same data sets. Their reasoning for key study selection, use of assessment factors, or use of probabilistic methods was comprehensively documented. The observed variation in the PNECs for all chemicals was up to 3 orders of magnitude, and this was not simply due to obvious factors such as the size of the data set or the methodology used. Rather, this was due to individual decisions of the assessors within the scope of the methodology used, especially key study selection, acute versus chronic definitions, and size of assessment factors. Awareness of these factors, together with transparency of the decision-making process, would be necessary to minimize confusion and uncertainty related to different hazard assessment outcomes, particularly in international documents. The development of a "guideline on transparency in decision-making" ensuring the decision-making process is science-based, understandable, and transparent, may therefore be a promising way forward.