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|Literature Commentary
|Mark L. Moster, MD, M. Tariq Bhatti, MD
|In this issue of Journal of Neuro-Ophthalmology, M. Tariq Bhatti, MD and Mark L. Moster, MD will discuss the; following 6 articles: 1. Morrow SA, Fraser JA, Day C, Bowman D, Rosehart H, Kremenchutzky M, Nicolle M. Effect of treating acute optic neuritis with bioequivalent oral vs intravenous corticosteroids: a randomized clinical trial. JAMA Neurol. 2018;75:690-696. 2. Saxena R, Singh D, Sharma M, James M, Sharma P, Menon V. Steroids versus no steroids in nonarteritic anterior; ischemic optic neuropathy: a randomized controlled trial. Ophthalmology. 2018;125:1623-1627. 3. Lee PH, Liang CC, Huang SF, Liao HT. The outcome analysis of traumatic facial nerve palsy treated with systemic steroid therapy. J Craniofacial Surg. 2018,29:1842-1847. 4. Schultheiss M, Härtig F, Spitzer MS, Feltgen N, Spitzer B, Hüsing J, Rupp A, Ziemann U, Bartz-Schmidt KU, Poli S. Intravenous thrombolysis in acute central retinal artery occlusion-a prospective interventional case series. PLoS One. 2018;13:e0198114. 5. Dale GH, Petersen T, Bacher Svendsen K, Christensen T, Houen G, Bek T. Time to steroid treatment in severe acute optic neuritis. Brain Behav. 2018 Jun 22 (epub ahead of print). 6. Bilyk JR, Murchison AP, Leiby BT, Sergott RC, Eagle RC, Needleman L, Savino PJ. The utility of color duplex ultrasonography in the diagnosis of giant cell arteritis: a prospective, masked study (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc. 2018;115:T9.
|OCR Text
Literature Commentary Section Editors: Mark L. Moster, MD M. Tariq Bhatti, MD Literature Commentary In this issue of Journal of Neuro-Ophthalmology, M. Tariq Bhatti, MD and Mark L. Moster, MD will discuss the following 6 articles: 1. Morrow SA, Fraser JA, Day C, Bowman D, Rosehart H, Kremenchutzky M, Nicolle M. Effect of treating acute optic neuritis with bioequivalent oral vs intravenous corticosteroids: a randomized clinical trial. JAMA Neurol. 2018;75:690-696. 2. Saxena R, Singh D, Sharma M, James M, Sharma P, Menon V. Steroids versus no steroids in nonarteritic anterior ischemic optic neuropathy: a randomized controlled trial. Ophthalmology. 2018;125:1623-1627. 3. Lee PH, Liang CC, Huang SF, Liao HT. The outcome analysis of traumatic facial nerve palsy treated with systemic steroid therapy. J Craniofacial Surg. 2018,29:1842-1847. 4. Schultheiss M, Härtig F, Spitzer MS, Feltgen N, Spitzer B, Hüsing J, Rupp A, Ziemann U, Bartz-Schmidt KU, Poli S. Intravenous thrombolysis in acute central retinal artery occlusion-a prospective interventional case series. PLoS One. 2018;13:e0198114. 5. Dale GH, Petersen T, Bacher Svendsen K, Christensen T, Houen G, Bek T. Time to steroid treatment in severe acute optic neuritis. Brain Behav. 2018 Jun 22 (epub ahead of print). 6. Bilyk JR, Murchison AP, Leiby BT, Sergott RC, Eagle RC, Needleman L, Savino PJ. The utility of color duplex ultrasonography in the diagnosis of giant cell arteritis: a prospective, masked study (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc. 2018;115:T9. Morrow SA, Fraser JA, Day C, Bowman D, Rosehart H, Kremenchutzky M, Nicolle M. Effect of treating acute optic neuritis with bioequivalent oral versus intravenous corticosteroids: a randomized clinical trial. JAMA Neurol. 2018;75:690-696 Importance: Intravenous (IV) administration of corticosteroids is the standard of care in the treatment of acute optic neuritis. However, it is uncertain whether a bioequivalent dose of corticosteroid administered orally, which may be more cost-efficient and convenient for patients, is as effective as IV administration in the treatment of acute optic neuritis. Objective: To determine whether recovery of vision after treatment of acute optic neuritis with a high-dose IV corticosteroid is superior to that with a bioequivalent dose of an oral corticosteroid. Design, Setting, and Participants: This single-blind (participants unblinded) randomized clinical trial with 6-month follow-up was conducted at a single tertiary care center in London, Ontario, Canada. Participants were enrolled from March 2012 to May 2015, with the last participant's final visit occurring November 2015. Patients aged 18-64 years presenting within 14 days of acute optic neuritis onset, without any recovery at time of randomization and without history of optic neuritis in the same eye, were screened. Inclusion criteria included best-corrected visual acuity (BCVA) of 20/40 or worse and corticosteroids deemed required by treating physician. In total, 89 participants were screened; 64 were eligible, but 9 declined to participate. Thus, 55 participants were enrolled and randomized. Primary analysis was unadjusted and according to the intention-to-treat principle. Interventions: Participants were randomized 1:1 to the IV methylprednisolone (MP) sodium succinate (1,000-mg) or oral prednisone (1,250-mg) group. Main Outcomes and Measures: Primary outcome was recovery of the latency of the P100 component of the visual Moster and Bhatti: J Neuro-Ophthalmol 2018; 38: 531-537 evoked potential (VEP) at 6 months. Secondary outcomes were the P100 latency at 1 month and BCVA as assessed with Early Treatment Diabetic Retinopathy Study letter scores on the alphabet chart and scores on low-contrast letters at 1 and 6 months. Results: Of 55 randomized participants, the final analyzed cohort comprised 23 participants in the IV and 22 in the oral treatment groups. The mean (SD) age of the cohort was 34.6 (9.5) years, and there were 28 women (62.2%). At 6 months' recovery, P100 latency in the IV group improved by 62.9 ms (from a mean [SD] of 181.9 [53.6] to 119.0 [16.5] ms), and the oral group improved by 66.7 ms (from a mean [SD] of 200.5 [67.2] to 133.8 [31.5] ms), with no significant difference between groups (P = 0.07). Similarly, no significant group difference was found in the mean P100 latency recovery at 1 month. For BCVA, recovery between the groups did not reach statistical significance at 1 month or 6 months. In addition, improvements in low-contrast (1.25% and 2.5%) BCVA were not significantly different between treatment groups at 1 or 6 months' recovery. Conclusions and Relevance: This study finds that bioequivalent doses of oral corticosteroids may be used as an alternative to IV corticosteroids to treat acute optic neuritis. COMMENTS If you recall, Mark, in the March 2016 issue of Literature Commentary we discussed the COPOUSEP trial comparing oral (po) to intravenous methylprednisolone (IVMP) for the treatment of multiple sclerosis (MS) relapses, which showed no difference between the 2 steroid regimens. Now, we have this superiority study that looked to determine 531 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary whether IVMP had greater efficacy than high-dose po prednisone in patients with optic neuritis. It is a bit misleading, when you read the abstract that states 55 patients were enrolled and randomized. In fact, only 45 patients (23 in the IV group and 22 in the bymouth group) were actually treated and included in the final analysis. All patients were enrolled within 2 weeks of symptom onset with a visual acuity of 20/40 or worse. Patients received either 1,000 mg/day of IVMP for 3 days or 1,250 mg/day of po prednisone for 3 days. No steroid taper was given for either group. The primary outcome was the VEP P100 latency. As expected, at 6 months, both groups had a significant mean improvement in the P100 latency (62.9-ms IV group vs 66.7=-ms by-mouth group), with no statistically significant advantage for either. In addition, the final visual outcome with high-contrast sensitivity or low-contrast sensitivity acuity testing was no different at 6 months. I have several observations that I would like to highlight: 1. Sample size was small. 2. Single-blinded study. The patients were not blinded to treatment. I found this design interesting and wonder why the investigators did not do a double-dummy study? I think it would have been quite easy to do with each patient receiving both IV and po treatment but with one group receiving po placebo and the other receiving IV placebo. 3. Po prednisone group took 25 pills a day. That is a lot of pills! 4. No comment was made on the frequency of recurrent optic neuritis between the 2 groups. As you know the optic neuritis treatment trial found a 2-fold higher incidence of recurrent optic neuritis in the po prednisone group at a dose of 1 mg/kg/day as compared to the IVMP and po placebo groups. 5. Relatively high percentage of men (37.8%) enrolled in the study. Optic neuritis (idiopathic or MS associated) is typically thought of as a disease of women. 6. Anti-aquaporin 4 and anti-myelin oligodendrocyte glycoprotein antibody status was not assessed. I would not be surprised if some of these patients, especially those with profound visual loss or long segment optic nerve enhancement on MRI were positive for one of these antibodies. This obviously could skew the results. In my mind, the role of po vs IV corticosteroids in the treatment of acute inflammatory demyelinating optic neuritis is no longer an issue. Based on this study, despite its limitations and other similar studies such as the COPOUSEP trial, highdose po prednisone is equivalent to IVMP. I have to admit that I have not used high-dose po prednisone for my patients with optic neuritis and when I treat I favor outpatient IVMP. I have heard from some of my MS patients who have taken high-dose po prednisone that it was a bit tough on their stomachs. In this study, more patients in the po group (n = 8) had gastrointes532 tinal adverse events than the IV group (n = 5). I am curious Mark, what has been your practice regarding prescribing steroids for patients with optic neuritis? -M. Tariq Bhatti, MD Tariq, I agree with many of your concerns. However, I think that the follow-up was too brief (only 6 months) to accurately assess for recurrences of optic neuritis. Also, I do not see that this trial is different demographically from other MS populations. Typically, the breakdown is 2/3 women and 1/3 men, and this trial is only a few percentage points away from that. To answer your question, I usually treat with IV steroids. However, if a patient has difficulty obtaining IV treatment then I do prescribe po steroids at 1,250 mg daily. This has occurred a handful of times and without adverse events. Our MS specialists more frequently use the by-mouth treatment. -Mark L. Moster, MD Saxena R, Singh D, Sharma M, James M, Sharma P, Menon V. Steroids versus no steroids in nonarteritic anterior ischemic optic neuropathy: a randomized controlled trial. Ophthalmology. 2018;125:1623- 1627. Purpose: To examine the role of oral steroid therapy in the treatment of nondiabetic cases of acute nonarteritic anterior ischemic optic neuropathy (NAAION). Design: Randomized double-blind clinical trial. Participants: Thirty-eight patients with acute nondiabetic NAAION divided into 2 arms of 19 patients each. One arm constituted the cases and the other constituted the controls. Methods: Cases received oral steroid therapy and were designated the steroid group, whereas controls received placebo and were designated the nonsteroid group. Bestcorrected visual acuity (BCVA), visual evoked response (VER), and optical coherence tomography (OCT) were performed at baseline, 1 month, 3 months, and 6 months after recruitment into the trial. Main Outcome Measures: BCVA, VER, and retinal nerve fiber layer changes on OCT. Results: Both groups showed significant improvement in BCVA, VER latency, and resolution of disc edema on OCT parameters over 6 months. Final outcome showed no statistically significant difference regarding visual acuity, although VER was better in the steroid group (P = 0.011). BCVA, VER amplitude, and VER latency (P = 0.02, P = 0.02, and P = 0.04, respectively) showed a greater percentage improvement in the steroid group, which also saw a faster resolution of disc edema on OCT (1-month follow-up). Conclusions: Oral steroids in acute NAAION did not improve the visual acuity significantly at 6 months. However, they improved resolution of disc edema significantly and enabled a greater improvement in VER parameters. This subtle benefit of oral steroids in NAAION is clinically unimportant and does not provide support for its use. Moster and Bhatti: J Neuro-Ophthalmol 2018; 38: 531-537 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary COMMENTS Of the list of neuro-ophthalmic controversies, I think it is safe to say that the role of steroids in the treatment of nonarteritic anterior ischemic optic neuropathy (NAION) is close to the top. Within that context, I would be remiss if I did not mention Dr. Sohan Hayreh's NAION steroid study that has garnered a lot of attention (1,2). First, let me give kudos to the Editor-In-Chief of Ophthalmology, Stephen McLeod, MD, for publishing a negative-result clinical trial. Second, it is quite impressive that 1 institution (in India) recruited 38 NAION patients within 17 months. This was a double-blind, placebo-controlled trial that randomized patients with NAION to receive either oral (po) prednisolone or po placebo within 1 month of the onset of visual loss. All patients in the by-mouth prednisolone group were started on 80 mg/day for 2 weeks followed by a taper that lasted 65 days. A total of 38 patients were randomized equally into the 2 groups. The baseline demographics of the 2 groups were similar. However, the steroid group had a slightly worse baseline logMAR visual acuity (1.0 steroid group vs 0.8 placebo group). No patients with diabetes mellitus were enrolled. The primary outcome was BCVA at 6 months. Both groups showed an improvement in final visual acuity with a median logMAR visual acuity of 0.6 in the placebo group and 0.5 in the steroid group. Although the percentage change in vision over time was better in the steroid group compared with the placebo group (P = 0.02), the final visual acuity at 6 months was not statistically significant (P = 0.78). Patients in the steroid group had faster resolution of their optic disc edema at 1 month, but overall, the speed of recovery was noted to be similar between the 2 groups. I had a bit of a difficult time grasping the visual acuity data and had to use the visual acuity conversion chart because unlike in the ischemic optic neuropathy decompression trial, the visual acuity data were recorded using the logMAR scale, and the outcome was not presented as a percentage of lines improved-worsened. Is the issue of steroids in NAION a foregone conclusion now or do we as a neuro-ophthalmology community need to spend the energy, time, and money to do a bigger NAION steroid study? What say you, Mark? -M. Tariq Bhatti, MD 1. Hayreh SS, Zimmerman MB. Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy. Graefes Arch Clin Exp Ophthalmol. 2008;246:1029-1046. 2. Lee AG, Biousse V. Should steroids be offered to patients with nonarteritic anterior ischemic optic neuropathy? J Neuroophthalmol. 2010;30:193-198. Moster and Bhatti: J Neuro-Ophthalmol 2018; 38: 531-537 Tariq, I say that this study does not lead to any foregone conclusions that steroids do not work in NAION. On the contrary, before this article, I was comfortable with my assessment of the literature, my understanding of the mechanism of action of steroids, and past clinical experience that steroids would not be helpful. However, despite the conclusion of the authors that steroids did not improve visual acuity significantly, the data suggest otherwise. There was a statistically significant difference in improvement of visual acuity in treated vs untreated that the authors claim is not clinically significant. In Snellen acuity measurements, the treated group improved from 20/200 to 20/63 and the untreated group improved from 20/159 to 20/80. I am not comfortable in calling that clinically insignificant. In addition, there was statistically significant improvement in VER latency and amplitude in the treated vs untreated group. The median time to presentation was 12 days without mention of time until treatment. Perhaps, treatment within just a few days of presentation would have shown more benefit. I commend the authors for performing a double-blind clinical trial, and, for me, there is enough to warrant a larger trial. The cost for an outpatient trial of steroids vs placebo would be very reasonable. A final thought on what the authors call a limitation of their study, which is the exclusion of patients with diabetes. I actually see this as a benefit because there would have been a possibility of mistakenly including patients with diabetic papillopathy who often have a better visual outcome than patients with NAION. -Mark L. Moster, MD Lee PH, Liang CC, Huang SF, Liao HT. The outcome analysis of traumatic facial nerve palsy treated with systemic steroid therapy. J Craniofac Surg. 2018,29:1842-1847. Purpose: Although facial nerve palsy is uncommon after a blunt craniofacial injury, it will result in functional and aesthetic disability if full recovery is not achieved. Currently, the management is still controversial and mainly through systemic steroid therapy or surgical decompression. However, current studies mainly focus on the surgical intervention, and only a few of these studies discuss the details of the steroid treatments. Thus, the purpose of this study is to analyze possible prognosis factors of systemic steroid in managing traumatic facial nerve palsy after a blunt craniofacial injury retrospectively. Methods: During the period from May 2005 to April 2015 at Chang Gung Memorial Hospital, a total of 26 patients who suffered from post-traumatic facial nerve palsy receiving steroid therapy were enrolled in the study. All the patient's charts were reviewed, recorded, and analyzed 533 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary including the general data, temporal bone fracture type, hospital courses, trauma-related data from emergency department records, and initial and final facial nerve palsy grading. The facial nerve palsy was graded using the House-Brackmann (HB) system; the final HB Grade I was set as full recovery. Results: The outcome showed steroid therapy onset within 24 hours (odds ratio [OR] = 10.111; 95% confidence interval [CI] = 1.597-64.005; P = 0.014) and steroid therapeutic duration for longer than 14 days (OR = 11.571; 95% CI = 1.172-114.262; P = 0.036) possessed a significantly better recovery rate. Conclusion: This study recommends applying steroids within 24 hours once post-traumatic facial palsy occurs, and the therapy should persist longer than 14 days. COMMENTS For those who take trauma call or are involved in the care of patients with facial trauma, this article is for you! The authors did a 10-year retrospective chart review of patients who suffered facial nerve palsy due to blunt trauma. Twenty-six patients treated with steroids were analyzed to determine the prognostic factors of systemic steroids in the management of blunt traumatic facial nerve paralysis. Many factors were analyzed including patient demographics, initial House-Brakmann (HB) grade, onset of facial palsy, pattern of fracture, duration of treatment, and clinical signs and symptoms of trauma. Patients received varying regimens of systemic steroids. Based on a multivariate analysis, steroid therapy initiated within 24 hours, and steroid therapy duration of greater than 14 days was associated with a better chance of full recovery. No patient with an HB grade of 6 (complete facial palsy) had full recovery compared with nearly 50% of patients with HB grade of 2-5 achieving full recovery. There are many limitations of this study with some of the obvious being a retrospective design, selection bias, no standardized steroid regimen, and no control group. The authors tried to compare the results of their steroid treated group with 6 observation patients, none of whom enjoyed full recovery. I found it curious that although the authors state toward the end of the introduction- ".. patients with delayed-onset or incomplete palsy were normally treated with systemic steroids.. However, there is still lack of a high-level, evidence-based study to backup this recommendation."- their study did not accomplish that at all. -M. Tariq Bhatti, MD Tariq, I agree with your assessment of the limitations of this study. As it turns out, the patients that received observation had much milder palsies to begin with (HB of grades 2-3 compared with an average grade of 4.42 in the patients treated with steroids), so that it would not be an adequate control group for comparison. 534 Despite the limitations, it seems that treatment within 24 hours and for 14 days makes sense until we have better data. -Mark L. Moster, MD Schultheiss M, Härtig F, Spitzer MS, Feltgen N, Spitzer B, Hüsing J, Rupp A, Ziemann U, BartzSchmidt KU, Poli S. Intravenous thrombolysis in acute central retinal artery occlusion- a prospective interventional case series. PLoS One. 2018;13:e0198114 Background: No evidence-based therapy exists for nonarteritic central retinal artery occlusion (NA-CRAO). Retinal ischemic tolerance is low; irreversible damage occurs within 4 hours of experimental NA-CRAO. In previous randomized trials evaluating intra-arterial or intravenous thrombolysis (IVT) in NA-CRAO, only one patient was treated this early. In December 2013, the Departments of Neurology and Stroke and Ophthalmology at University Hospital Tuebingen, Germany, decided to treat patients using IVT within 4.5 hours of NA-CRAO, the therapeutic window established for ischemic stroke. Materials and Methods: Consecutive NA-CRAO patients with severe visual loss received IVT after exclusion of intracranial hemorrhage. Follow-up was conducted at Day 5 (d5) and Day 30 (d30). Visual outcomes were compared with the conservative standard treatment (CST) arm of the EAGLE trial. Results: Until August 2016, 20 patients received IVT within 4.5 hours after NA-CRAO with a median onset-totreatment time of 210 minutes (IQR 120-240). Visual acuity improved from baseline mean logarithm of the minimum angle of resolution 2.46 ± 0.33 (SD) (light perception) to 1.52 ± 1.09 (Snellen equivalent: 6/200) at d5 (P = 0.002) and 1.60 ± 1.08 (Snellen equivalent: 6/240) at d30. Compared with the EAGLE CST-arm, functional recovery to reading ability occurred more frequently after IVT: 6/20 (30%) vs 1/39 (3%) at d5 (P = 0.005) and at d30 5/20 (25%) vs 2/37 (5%) (P = 0.045). Two patients experienced serious adverse events (1 angioedema and 1 bleeding from an abdominal aortic aneurysm) but recovered without sequelae. Conclusions: IVT within 4.5 hours after symptom onset may represent an effective treatment of NA-CRAO. Randomized trials are warranted to evaluate efficacy and safety of early IVT in acute NA-CRAO. COMMENTS The original enthusiasm for thrombolytic therapy for CRAO was quashed when the EAGLE study results were published. However, there has been much criticism of that study, and numerous articles have suggested that thrombolytic therapy may be helpful in CRAO. Schultheiss et al looked at 20 patients treated within 4.5 hours of Moster and Bhatti: J Neuro-Ophthalmol 2018; 38: 531-537 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary presentation and found improvement compared with the control arm of the EAGLE study. Although this study has limitations, I certainly agree with the call for a prospective, randomized, placebo-controlled trial with initiating treatment within 4.5 hours of presentation. -Mark L. Moster, MD A while back I had coauthored an article on thrombolytic therapy for CRAO (1). I think the comments in that article still hold true today: In the event that future randomized studies unambiguously and convincingly demonstrate the efficacy and safety of thrombolytic therapy in CRAO, ophthalmologists and health care providers should consider the following issues and potential hurdles to the successful implementation of thrombolytic therapy as a standardized treatment for CRAO: 1. Development of an organizational infrastructure that facilitates the well-tolerated administration of intravenous thrombolytic therapy, intra-arterial thrombolytic therapy, or both in a timely manner. 2. A systematic institutional approach with the integral involvement of ophthalmologists, stroke specialists, emergency physicians, and neuroradiologists. 3. Development of a specific thrombolytic therapy protocol to maximize benefit and minimize complications. 4. A consensus on who will be responsible for the administration of intravenous thrombolytic therapy (e.g., emergency physician, ophthalmologist, neurologist, etc.). Currently, most hospitals allow emergency physicians to administer intravenous thrombolytic therapy for an acute ischemic stroke, a situation that may not necessarily be appropriate for patients with CRAO. 5. The medicolegal ramifications of thrombolytic therapy associated with CRAO. 6. Lack of public awareness of CRAO resulting in a delay in seeking medical care. To overcome this problem, it will require extensive public education and awareness programs. 7. The large financial cost of thrombolytic therapy. In a recent study involving 1,379 patients with CRAO, Suri et al (2) showed the mean hospital cost of not receiving thrombolytic therapy was dramatically less than the hospital cost of thrombolytic therapy ($14,500 vs $32,500- 37,800, respectively). -M. Tariq Bhatti, MD 1. Hazin R, Dixon JA, Bhatti MT. Thrombolytic therapy in central retinal artery occlusion: cutting edge therapy, standard of care therapy, or impractical therapy? Curr Opin Ophthalmol. 2009;20:210-218. 2. Suri MF, Nasar A, Hussein HM, Divani AA, Qureshi A. Intraarterial thrombolysis for central retinal artery occlusion in United States: Nationwide In-patient Survey 2001-2003. J Neuroimaging. 2007;17:339-343. Moster and Bhatti: J Neuro-Ophthalmol 2018; 38: 531-537 Dale GH, Petersen T, Bacher Svendsen K, Christensen T, Houen G, Bek T. Time to steroid treatment in severe acute optic neuritis. Brain Behav. 2018 Jun 22 (epub ahead of print) Objectives: Steroid treatment can accelerate visual recovery in patients with optic neuritis (ON), but it is unknown whether the timing of the start of treatment influences the outcome. The main purpose of this observational study was to assess the effect of early onset steroid treatment of ON on visual prognosis and retinal morphology. Methods: Forty-nine patients with acute mild/moderate (n = 21) or severe (n = 28) ON, and an equal number of healthy controls were enrolled. Patients with severe ON either received early-onset steroid treatment (initiated within 1 week of presentation with visual loss) (n = 9), late-onset treatment (initiated after 1 week) (n = 13), or no treatment (n = 6). Visual function and retinal morphology were studied after 6 and 12 months. Results: All measures of visual function had improved after 6 months (P # 0.03) in the 3 groups with severe ON. This was not the case for Rayleigh match setting range (SR) in the nontreated group (P = 0.24), or for SR (P = 0.08) and latency to P100 of visual evoked potential (P = 0.08) in the late-onset treated group. After 12 months, further improvement occurred in the nontreated and late-treated groups, but not in the early-treated group. Macular retinal nerve fiber layer (mRNFL) and ganglion cell plus inner plexiform layer had decreased significantly (P # 0.001) in all 3 groups with severe ON after 6 months. After 12 months, only mRNFL had further significantly decreased and only in the late-onset treated group (P = 0.02). Conclusion: The beneficial effects of early-onset steroid treatment of ON are limited to a few months, whereas the long-term prognosis is independent of the timing of treatment. COMMENTS This study compared the visual results of early steroid treatment (,1 week), late treatment (.1 week), or no treatment in patients with ON. The time of treatment of optic neuritis with steroids was determined by the logistics of referral for treatment rather than a prospective attempt at treatment earlier or later than 7 days. Those not treated was because of patient preference or contraindication. Earlyonset treatment resulted in earlier visual recovery than lateronset treatment, and both resulted in earlier recovery than no treatment. What is not mentioned in the study, however, is how much earlier or later than 7 days each group was treated. In contrast to some previous studies, patients with steroid treatment did not achieve a better clinical outcome or better optical coherence tomography parameters. Limitations include small sample size and the inclusion of first time as well as recurrent cases of ON. Also, there is no information on the average time to treatment for either the early or late group in this study. 535 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary This article reinforces what we have learned from previous studies, especially the Optic Neuritis Treatment Trial (ONTT). That is, steroids hasten recovery but proffer no long-term visual benefit in patients with ON. This study offered to date on whether steroids can delay future demyelinating events. -Mark L. Moster, MD I have to be honest: I am not really sure whether I gained any new knowledge given the solid body of evidence already published on the role of steroids in the treatment of ON. I understand that there may not have been a study that looked at the timing of initiating steroid treatment for ON. I was disappointed that the authors did not specify exactly when the 12 patients in the delayed group (.1 week) received treatment. As you know, the ONTT enrolled all patients within 8 days of visual symptom onset. It seems to me the designers of the ONTT were already aware of the benefit of early steroid treatment. -M. Tariq Bhatti, MD Bilyk JR, Murchison A, Leiby BT, Sergott RC, Eagle RC, Needleman L, Savino PJ. The utility of color duplex ultrasonography in the diagnosis of giant cell arteritis: a prospective, masked study (An American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc. 2018;115:T9 Purpose: To evaluate the diagnostic yield and concordance of color duplex ultrasound (CDU) of the superficial temporal artery (STA), temporal artery biopsy (TAB), and American College of Rheumatology (ACR) criteria in the diagnosis of giant cell arteritis (GCA). Methods: Prospective, masked study of all patients evaluated in 1 institution suspected of having GCA. All patients with a suspected diagnosis of GCA were admitted for pulsed intravenous corticosteroids. Patients underwent serologic work-up, and ACR criteria were documented. All patients had a CDU and TAB performed within 3 days of initiation of systemic corticosteroid therapy. Main outcome measure: concordance of CDU and TAB. Secondary outcome measures: concordance between unilateral and bilateral CDU and TAB by side and segment, concordance between TAB and ACR criteria, and statistical analysis of serologic markers for GCA. Results: The diagnosis of biopsy-proven GCA was found in 14 of 71 (19.7%) patients. The sensitivity of CDU compared with the reference standard of TAB ranged between 5.1% and 30.8% depending on the signs studied on CDU and correlation of specific TAB parameters. Of the serologic studies, a platelet count threshold of 400,000 mL had the highest positive (18.32) and lowest negative (0.37) likelihood ratios (LRs) for a diagnosis of GCA. Conclusion: In this study, CDU showed minimal value in diagnosing GCA compared with TAB. There was poor correlation between CDU results and ACR criteria for GCA. The threshold platelet count had higher positive and negative 536 predictive values for GCA than CDU and is a useful serologic marker for GCA COMMENTS Color duplex ultrasound (CDU) has been proposed by some to be a sensitive and specific test for the diagnosis of giant cell arteritis (GCA). Often, when I have residents from neurology or medicine rotating on my service, and we discuss potential GCA patients, I am questioned about foregoing temporal artery biopsy (TAB) and using ultrasound instead, based on previous literature. However, I have not found CDU helpful in either ruling in or ruling out GCA. With that in mind, I chose to review this study performed by my colleagues at Wills, which served as Dr. Jurij Bilyk's American Ophthalmological Society thesis. This prospective, masked trial comprised a typical cohort of 71 patients with GCA. Forty-nine percent had vision loss, 20% had headache, 16% had blurred vision, and 16% had diplopia. The study hypothesis was that CDU would correlate with TAB results in the diagnosis of GCA. Bilateral TABs were performed by experienced oculoplastic surgeons and interpreted by an ocular pathologist with a vast experience in interpreting TABs. CDU studies were performed by an experienced certified ultrasonographer and interpreted by a radiologist specializing in vascular ultrasonography. The parameters looked for were the "halo" sign, stenosis and/or occlusion, and the CDU results were correlated to TAB results by patient, side, and 2-cm segments of the artery. Twenty-percent of 71 patient biopsies were positive for GCA. There was a discordance rate of 1.6% between sides. Unlike most previous studies on the subject, the authors reported likelihood ratios (LRs) regarding the usefulness of CDU in GCA. Briefly, an LR uses both sensitivity and specificity to calculate the usefulness of a diagnostic test to either rule in (positive LR) or rule out (negative LR) a disease. Depending on the parameters studied, the positive LRs ranged between 2.20 and 3.06, whereas the negative LRs ranged between 0.81 and 0.91; neither of these ranges effectively ruled in or ruled out GCA by CDU. The area under the receiver operating characteristic curve also was poor, ranging between 0.54 and 0.58. Based on these analyses, CDU was not helpful in diagnosing or excluding GCA in this study. Previous studies mention "biopsy-negative GCA" patients who were successfully diagnosed by CDU. In this study, all TAB-negative patients were quickly tapered off steroids, and none of those had progressive visual loss, which would have been expected if they truly had GCA. Interestingly, there was no statistical difference in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) between TAB-positive or TAB-negative patients. This is likely explained by the fact that patients chosen for TAB often have elevated ESR and CRP. Moster and Bhatti: J Neuro-Ophthalmol 2018; 38: 531-537 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Literature Commentary However, platelet counts and interleukin-6 levels were greater in TAB positive patients. This study confirms my clinical impression that TAB is still the "gold standard" for diagnosing GCA. -Mark L. Moster, MD Let me commend Dr. Bilyk et al on a very comprehensive study which contains a great deal of excellent information. While at Duke, I was approached by someone in the vascular laboratory regarding using CDU in GCA. I explained to them that, in my opinion, using CDU to make the diagnosis of GCA in lieu of a TAB was not standard of care here in the United States. Interestingly, when I was in England recently giving a talk on GCA, the utility of CDU was discussed, and apparently in Europe, it is widely accepted as a diagnostic tool for GCA (1). This study confirms what you already said, Mark, which is that TAB remains the gold standard for diagnosing GCA. Moster and Bhatti: J Neuro-Ophthalmol 2018; 38: 531-537 I think we all understand that TAB is not 100% sensitive for GCA, but I really like what the authors said about a "gold standard:" in the strictest sense, a gold standard test would have 100% sensitivity and specificity for a given disease, a combination that does not exist in medicine. A less rigid definition of a gold standard is a modality that, albeit imperfect, is the best test available to diagnose a given pathology and is usually referred to as the "reference standard." As noted in the article, Peter Savino has pointed out that any new test that attempts to supplant the accepted reference standard as "the new gold standard" for a specific diagnosis must exceed the sensitivity and specificity of the older test. -M. Tariq Bhatti, MD 1. Landau K, Savino PJ, Gruber P. Diagnosing giant cell arteritis: is ultrasound enough? J Neuroophthalmol. 2013;33:394-400. 537 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
|Lippincott, Williams & Wilkins
|Journal of Neuro-Ophthalmology, December 2018, Volume 38, Issue 4
|Rights Management
|© North American Neuro-Ophthalmology Society
|Publication Type
|Journal Article
|Date Created
|Date Modified
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text:
A few years ago, I made a mistake. It's a common mistake that happens to the best of us, but I made it publicly and refused to recognize my error until it was too late. As a copywriter, I hold myself to certain standards of linguistic and literary abilities. I also entertain the notion of… Read more »
#Hashtags We Salute You!
November 6 2012 is a day that will go down in history. It was an event that not just Americans, but everyone worldwide was captivated by. President Barack Obama was just re-elected president and was giving his victory speech. Everyone was mesmerized; not just by Obama but something beyond him….literally. Standing in the crowd directly… Read more »
Public Opinion
The blogosphere is a populous place. From individuals to corporations it seems almost everyone has embraced blogging. While there are many components to tracking the success of a blog, comments have always been the most immediate indicator of success. Not anymore. Commenting has decreased in favor of sharing.\n\nThe decrease in commenting can be accredited to… Read more »
Google + My Thoughts
This past month Google launched the much anticipated Google+, the social networking site that is said to finally be competition for Facebook. As with most Google products Google+ is currently invite-only during this initial launch. Like most people who are into this sort of thing I was (impatiently) awaiting an invitation. Saturday morning I finally… Read more »
It Takes Work to Look This Good
My sister is all about working out these days. She is pretty fanatical about the gym and if she misses a day of working out I can read the panic all over her face. I've never been much of a gym rat so I always give her a hard time about it. "It's just one… Read more »
Rekindling Direct Mail
Being a public transportation faithful, I tend to notice popular trends while riding the CTA. Lately Kindles have been cropping up everywhere. For those of you who may not know, a Kindle is a portable reader where you can wirelessly download books and as well as read newspapers, magazines and blogs. Now I know this… Read more »

subset: commoncrawl


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High-pressure cleaning is a technique of blending both water and detergent under specific pressure to remove debris, stains, grease from multiple types of surfaces. For the original record, high-pressure cleaning is all about cleaning and washing floors, pathways, exterior walls, and making it debris-free and dirt free. One of the most overlooked parts of cleaning is floor cleaning. Being extremely exposed to extreme environmental conditions, periodical cleaning is necessary and a must. Before debris, fungi and other reactants start reacting on the integrity of floorings, making it terrible for walking. Therefore, make sure you go through the process of cleaning your floors. Not only will it limit the chances of corrosion and damages, but it will also save your story from damages of any kind. High-pressure cleaning is usually the way to go when it comes to cleaning the surface thoroughly. Here are a few obvious reasons why you should consider a professional high -pressure cleaning service
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Why Sage Hosting Is A Real Big Thing For Tech-Savvy Accountants and CPAs
Why Sage Hosting Is A Real Big Thing For Tech-Savvy Accountants and CPAs
|Why Sage Hosting Is A Real Big Thing For Tech-Savvy Accountants and CPAs
Why Sage Hosting Is A Real Big Thing For Tech-Savvy Accountants and CPAs
The advanced bookkeeping world is the verification that innovation quickens each industry it contacts. Regardless of whether it be information or association with customers, propelled bookkeeping programming is sufficiently effective to deal with everything. Prior to the rise of cloud innovation, CPAs and bookkeepers were dealing with their complex monetary information on spreadsheets. However, it is difficult for them to guarantee better outcomes with spreadsheets, and that is the point at which the requirement for a dependable cloud-based bookkeeping programming go to the fore.
Sage 50 Cloud is a recognizable name among technically knowledgeable bookkeepers and CPAs, who incline toward innovation to get anticipated outcomes. From private ventures to colossal endeavors, business people to singular experts, the facilitated arrangement has worked exceedingly well for everybody. The real explanation for the fame of Sage facilitating arrangements is adaptability, which enables firms to streamline complex bookkeeping errands easily. The facilitated programming limit the general expense as well as bring efficiency into your business.
There is a lot of other bookkeeping programming in the market that has a similar arrangement of highlights, however Sage picks up the slight edge because of its cost-effective evaluating arrangements. The facilitating highlight of Sage is likewise one central point that makes it future prepared. We should examine further factors that legitimize the name of Sage in the bookkeeping scene. To put it plainly, here are the advantages of facilitating your Sage to the cloud.
- Cell phone Compatibility to Focus on Core Business Goals: Sage, when facilitated to the cloud, guarantees that you can get to your information from any area whenever and with any gadget. You can accomplish better outcomes when you appreciate doing your work. The facilitated application enables you to work as indicated by your usual range of familiarity, which implies you can finish assignments all the more proficiently. It isn't not exactly an advantage for innovation situated bookkeepers to have the solace of the spot and fulfillment of AI while taking care of complex records.
- Incomparable Operations to Avail Professional Growth: The nearness of cloud help organizations to think past bookkeeping bothers as the facilitated bookkeeping application is versed enough to deal with it. Bookkeepers and CPAs can strategize better approaches to extend their administrations all inclusive or, basically consider assets the executives. There are loads of different assignments that they can deal with meanwhile. Devoted server, convenient programming overhauls and computerized coordination forms are a portion of the highlights that assistance bookkeeping firms to guarantee proficient development.
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Last Words
Sage facilitating offers numerous advantages to its clients, particularly to bookkeepers and CPAs, that enable them to investigate the information, advertise openings and worldwide development. The majority of the customary clients still think about cloud as a costly alternative. In any case, the fact of the matter is facilitated application assume a greater job in the general change of the company's development. Associations who genuinely need to remain in front of the bookkeeping amusement should do a fast change to the cloud as it is the best way to direct the company's development.


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Money pours in so Emily gets her DVD
Thursday, 19th June, 2014
By Emily Roberts
With the help of locals, youngster Emily Roberts will now have a new DVD player to keep her occupied while she is in hospital.
The TAFE campus recently held a fundraiser to help five-year-old Emily who has a rare disorder known as Diamond Blackfan Anaemia.
This means she doesn't produce red blood cells and has to have five-weekly blood transfusions to return the red blood cell count to a normal level.
TAFE Western's Cindy Burke said the fundraiser was run by students as part of a "skills for work and training" program.
Mrs Burke said Broken Hill High School students also joined in and that the day was a great success.
"We were hoping to raise $500 and we doubled that with $1065," she said.
"The students were really proactive - it was a really good day.
"People were coming in off the street and donating lots of money."
The money will be used to help with Emily's medical expenses and to purchase a new DVD player.
"Emily wears out her DVD players with all the time spent in hospital," said her mother, Lisa.
"She still needs five-weekly transfusions and it takes a toll - missing school and being away from the family.
"If we go for an extended period, her siblings have to come."
Lisa said she and Emily would like to thank everyone who supported the fundraiser.


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Photo By Brittany Sumner
DO NOT FEED ALLIGATORS OR FOXES Feeding wildlife does more harm than good. Before offering food to wild animals, please consider the following:
ISLAND NATURE TOURS Join professional naturalists on a guided tour of the wildlife hotspots and unique habitats of Bald Head Island! Even if you've been enjoying BHI for years, there is still always something to see and learn. This 2 hour tour will give you the opportunity to see birds, mammals and reptiles of Bald Head while you explore the island's pristine beaches, ancient maritime forest and unspoiled salt marshes. Tours are available daily at 9am or can be scheduled to accomodate your group. Reservations are required. Please call 910-338-0911 or visit bhic.org for more information.
WILD ANIMALS ARE DANGEROUS. Animals that are fed by humans often lose their natural fear of people. Nearly all wild animals are capable of inflicting injury to humans or pets. FEEDING WILDLIFE CAN SPREAD DISEASES. Most wildlife diseases are transferred from animal to animal. Because of their close contact, animals crowding at feeding sites can readily exchange diseases. More animals die from disease and diseaserelated ailments than from starvation. Additionally, animals can carry many diseases that readily spread to people or pets. FEEDING LEADS TO CROWDING, CROWDING CAUSES STRESS. In crowded situations, physical aggression among individual animals is common. At feeding sites, larger more aggressive individuals often exclude younger and weaker individuals. Aggressive behavior can lead to injuries and even death, particularly for vulnerable individuals. OVER POPULATION RESULTS IN HABITAT DEGRADATION. Any given habitat can only support a limited amount of wildlife. An overabundance of wild animals drawn to a feeding area can damage the local habitat for not only the animals being fed but others species as well. Habitat degradation significantly affects all wildlife species. WILDLIFE NEED HABITAT, NOT HANDOUTS. Wild animals benefit from healthy habitat. To help wildlife species, practice sound habitat management in your own backyard and support programs dedicated to providing and protecting healthy wildlife habitat. The Smith Island Land Trust can provide information and guidance to people interested in helping wildlife around their homes and in their communities.
The 2015 BHI Community Directory is now on sale. Visit Turtle Central to get your copy!
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Shop Turtle Central + Save Sea Turtles
IN THIS ISSUE: Conservancy Collaborations.......................................................4-5 Much More Than a Field Station....................................................6-7 2015 Events........................................................................................9 BHI Deer Immunocontraception Project: Year One.......................10 Seven Months in Blue...............................................................12-13 Bald Head Earns Stellar Marks on Report Card........................15
BHIC.org | BHI Conservancy
Conservancy Collaborations: a Partnership with USGS by Courtney Spears - Conservation Biologist - Coastal Ecology Program Coordinator
Water Quality monitor in the well
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"Water is the driving force of all nature." - Da Vinci
t has been an exciting year for partnerships at the BHI Conservancy! This summer a partnership that has been in the works since 2012, with the United States Geological Survey (USGS) was finalized. The Bald Head Island Conservancy requested assistance from the USGS to provide expertise and modeling to explore the freshwater resources in the aquifer underlying Bald Head Island. Monitoring the aquifer more closely will allow decision makers to determine how much fresh water our aquifer can provide and how that supply may change in the future.
salinity) and temperature every 15 minutes, which is then sent to a satellite and can be accessed by anyone interested on our website. Visit http://www.bhic.org/water. You can follow along with the real-time data and even see the influence the tides have on freshwater level by observing the depth to water data! USGS will be back to check on equipment in the fall. The partnership will continue to do research in order to build a data set that will
The Conservancy currently measures depthto-water at about 40 monitoring wells on a monthly basis and water quality in these wells on a quarterly basis. More intensive modeling will give a more in-depth idea of water availability. This information will provide critical data to guide management decisions as the island faces uncertain environmental conditions into the future. The first part of this project involves compiling historic data and collecting additional water level and water quality information. The USGS visited the island in mid-August to install a continuous water quality monitor on a well near the golf course and on the perimeter of the island. Historically, this particular well has shown increasing levels of chlorides, which indicates increasing salinity. The aquifer beneath Bald Head is a lens of freshwater surrounded by the saltwater from the ocean. When too much water is removed, or when sea level rises, saltwater can infiltrate the freshwater aquifer, known as saltwater intrusion. Saltwater intrusion into freshwater aquifers is a major concern for coastal communities, particularly islands, and the best way to monitor for it is to observe perimeter wells. The equipment hooked up to the well records water level, conductance (a measure of
USGS – Kristen McSwain (red coat) and Dominick Antolino, both hydologists with USGS.
feed directly into a model to help determine groundwater flow. If you are interested in getting involved as a citizen scientist to help our aquifer monitoring efforts, please contact Courtney Spears at (910) 338-0942 or courtney@bhic. org.
BHIC.org | BHI Conservancy
Much More Than A Field Station By Kendyll Collins Conservation Biologist - Education Programs Coordinator
"The most remarkable quality of Bald Head Island is that the extraordinary elements never become ordinary." - Brooke Williams
he BHI Conservancy boasts a remarkable track record - when school classes, scout troops, or university researchers spend an overnight or extended stay with us, they almost always return! The BHI Conservancy "dormitory," or renovated beach house, sleeps sixteen individuals comfortably in bunk beds, contains a full kitchen, comfortable living room, bar stools for seating, television with cable, three full bathrooms, one half bathroom, and a laundry room with washer and dryer. The Fleming Environmental Center sleeps ten additional individuals in bunk beds and two more on a sleeper sofa. This extra living space, above the classroom exhibits, also contains a full bathroom. The campus gem, or Barrier Island Study Center, is
Conservator | BHIC.org
adorned with riverwood salvaged from the Cape Fear, supported by recycled metal, speckled with skylights, supplied with non-potable water from a 7,000 gallon cistern, and regulated by a zone specific HVAC system. The Young Hatchling Learning Laboratory, or wet lab, contains thirty research aquaria, a touch tank exhibit, and laboratory tables. The Mitchell Research Laboratory, or dry lab, contains gas access, basic laboratory equipment, and advanced equipment like an autoclave, chemical hood, drying oven, and laboratory grade dishwasher. The BHI Conservancy is able to offer phenomenal accommodations and research facilities at competitive prices. Facility location enables students and researchers of all ages to have immediate access to pristine and endangered ecosystems. Despite these offerings, there is another reason why guests return to the island- the human element. In January 2014, a multidisplinary group from Guilford College spent nearly a month with BHI Conservancy staff. The students came from varied backgrounds studying everything from the humanities to business. During a shortened semester, the Guilford group traveled from the headwaters of the Cape Fear River, where Guilford College is located, down to the river's culmination. They stopped at environmentally conscious organizations along the way to collect information and interviews used for a final project. When they finally reached the terminus of the Cape Fear, they learned about the history of the BHI Conservancy, hot topics impacting our coastline, attended a Village council meeting, and joined BHI Conservancy staff for a kayaking trip focusing on the importance of island ecosystems. Students reported that the experience on BHI was the best part of their class. They spent part of the month interviewing staff, island visitors, and getting to know the BHI Conservancy's founding members. What set the field station apart was not the shiny state-of-the-art equipment or even the imperiled maritime forest ecosystem, but the committed
Are you part of a class, troop, or other organized group? Would you like to have a similar and meaningful experience with the BHI Conservancy? Let us customize an overnight visit or extended stay that meets your group's needs. Please email firstname.lastname@example.com for more information.
and inspiring community- truly the most extraordinary element of Bald Head Island.
Signs of an Exciting Year Ahead October marked the first official day of a two-year grant awarded to the Bald Head Island (BHI) Conservancy by the Institute of Museum and Library Services (ILMS). The $23,891 grant will fund interpretive signs aimed to increase volunteer and citizen science involvement with the non-profit organization. This amount was the full amount requested by the BHI Conservancy. Conservation Biologist- Education Program Coordinator at the BHI Conservancy and ILMS Grant Project Director, Kendyll Collins said, "We understand that many feel overwhelmed by the enormity of 'saving the environment,' and through this project, we will strive to offer straight-forward, tangible actions to help all of our constituents work towards this vision." She continued, "I'm so excited to increase knowledge of our conservation efforts and expand our volunteer fleet, as the grant project manager." The BHI Conservancy has already begun work on this grant project, which specifically funds the creation of ten interpretive signs for display on their campus. Half of the signs will present information about the unique features of barrier islands and report on the monitoring work that the BHI Conservancy conducts, including
wildlife monitoring, dune surveying, and aquifer water quality testing. The additional five signs will present ways BHI Conservancy Campus visitors can directly advance the organization's mission of barrier island conservation, education, and preservation. QR codes will link information presented on the physical signage to dynamic, electronic information. A soft launch of rough signage will seek community feedback in spring 2015. "Our grants are highly competitive. The Institute of Museum and Library Services enlists hundreds of library and museum professionals throughout the United States to review grant applications and make recommendations on projects most worthy of funding," said IMLS Director Susan H. Hildreth. "Receiving a grant from IMLS is significant achievement, and we congratulate the Bald Head Island Conservancy for being among the 2014 IMLS museum grantees." IMLS museum grants support a wide variety of projects that create learning experiences, strengthen communities, care for collections and provide broad public access.
Visit BHIC.org/Visiting-Groups for more information.
BHIC.org | BHI Conservancy
Social Media 2014
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With our Adopt-A-Programs You Can Share the Miracle of Sea Turtles! You can become directly involved with our Sea Turtle Protection Program by adopting a nest, adopting a mom, or naming your very own loggerhead sea turtle by adopting a legacy! Your contribution goes directly towards the conservation and protection of the threatened and endangered sea turtles on Bald Head Island. Adopt-A-Nest - $150 For anyone who can't get enough of sea turtles, this gift includes an official Nest Adoption Certificate, an 8" plush turtle, an invitation to the nest excavation and a Nesting Success Certificate at the end of the season, which details number of eggs laid, number hatched, and date of hatching.'
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Adopt-A Mom - $500 Great for an anniversary or Mother's Day, this gift includes a Certificate with your mom's tag number and measurements and a 12" plush turtle. You will also recieve a certificate at the end of the season detailing each nest your turtle laid that summer.
Adopt-A-Legacy - $4000 or $5000 A great way to welcome a child or celebrate a marriage, this program gives you the opportunity to name a BHI nesting sea turtle forever. You will recieve a certificate detailing the known history of your turtle and will be notified every year your turtle returns to nest on BHI. Includes a copper sculpture placed on the walls of BISC.
Mark Your 2015 Calendars Saturday, March 21st BADWATER CAPE FEAR Bald Head Island, NC From the masterminds behind the world-famous 135 Badwater Ultramarathon comes the second annual Badwater Cape Fear. This 51.4-mile ultra running race featuring a 12-mile warmup on Bald Head Island, followed by 39 milees of running on the wild sandy beach between Cape Fear and Fort Fisher. The BHI Conservancy is the official chartiy of this race.
Thursday, July 2nd CONSERVANCY BENEFIT PICNIC The Common at Cape Fear Station, Bald Head Island Join BHI Conservancy Staff, volunteers and supporters at this annual event. There will be live usic, family-friendly fun and games, delicious food, a silent auction, and more! All proceeds benefit the BHI Conservancy's education and conservation programs.
Friday, September 19th Sunday, September 20th THE THAD WESTER FISHING SCHOOL Barrier Island Study Center, BHI Conservancy Campus Celebrating 32 years in 2015, Fishing School is fun and educational. The three-day "semester" includes classroom instruction, surf fishing experiences, a Friday night social and a Sautrday night fish fry where students get to eat what they caught earlier in the day!
Photo Courtesy of Thatcher Photography, LLC
BHIC.org | BHI Conservancy
BHI Deer Immunocontraception Project: Year One By David R. Hall, Conservation Biologist
knew exactly who they were as soon as I saw them on the ferry. They had no identifying insignia, but having been an avid outdoorsman for the past 18 years, I can easily spot a fellow human molded by the elements. Tony DiNicola and Charles Evens (Swanny) from White Buffalo Inc. were on their way over to Bald Head Island to kick off year one of the island's experimental deer immunocontraception program aimed at controlling the deer population through non-lethal birth control. I was nervous, yet enthusiastic, being new to deer darting and wildlife capture. No time was wasted once we arrived at the BHI Conservancy campus. We inventoried the equipment and organized tables of lights, dart guns, batteries, telemetry devices, biological sampling resources, radio collars, and, most importantly, handwarmers. Within an hour the education room looked like a mobile military operation, except this was for non-lethal deer management. We immediately began dart gun training, which included zeroing in the scopes, finding range limits and becoming comfortable with the equipment. This immunocontraception program is the first of its kind in North Carolina and of interest to many. Agencies, including the USDA and NC Wildlife Resources Commission, sent a few of their own personnel to assist and observe in the project. Night 1 of the project started rather well with Tony darting the first deer an hour in. The transmitter dart fell out, meaning we had to try to track her blindly. This type of equipment failure was the first of many and characterized one of the project's greatest 10
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challenges: it seemed as if everything malfunctioned. Transmitter darts failed or fell out, batteries died in the freezing cold, golf carts broke down, lights burned out in the middle of the woods; Murphy's Law (everything that can go wrong, will go wrong) was working overtime here. It wasn't just the equipment; the weather was some of the harshest BHI had all winter, high winds, pouring rain, and temperatures below 20° F. Sitting in a tree for 3 hours in humid 20° weather was no vacation, but luckily the hand-warmers were the one item that never malfunctioned. Despite the challenges, the entire team was persistent and vigilant in efforts to reach the target goal. We went into the field every chance we got, overcoming and learning from every challenge with on open mind and improving every aspect of our operation. We quickly learned that one week of darting was just not enough to accomplish the lofty target goal. The deer were very smart and skittish, having had culling pressure placed on them for so many years. The
environment of the maritime forest was unique and much harder to work in than other forested lands, and more time was needed to capture deer. Another week of darting was scheduled for the following month. Still, Murphy's Law showed no mercy. Working through the challenges, the team successfully vaccinated and tagged 18 does and gained a plethora of knowledge and experience. The greatest lesson I learned from this project is that there is absolutely no substitution for field experience. No amount of planning, education, or pre-conceived notions can prepare you for the very unpredictable challenges of wildlife fieldwork. Every environment, population, and animal behaves differently. It is also what makes this field so exciting. As the first non-lethal deer management program in the state, the next year of this project will undoubtedly yield field techniques and knowledge that other wildlife management agencies can learn from and utilize in future deer management operations.
Photo By Brittany Sumner
BHI Conservancy Membership 100% of net membership revenues support the education programs of the BHI Conservancy. Become a member today and enjoy discounts on programs, turtle walks, at Turtle Central and more! Visit bhic.org to join. Friend - $95.00 N Family - $195 NSponsor - $350NPatron - $500 NLife - $10,000
BHIC.org | BHI Conservancy
Seven Months in Blue:
Two perspectives on what it's like to be a BHI Conservancy Intern
By Amy Eldredge, Summer + Fall Intern
learned something new or that the program was a great way to spend their day. One time a young girl from a turtle walk told me she was interested in marine science and wanted advice on how to get a job like mine. I was happy to share with her my experience to help inspire her to continue her interest in science.
y first impression of Bald Head Island was a dark one. I arrived late on Sunday night, May 11th, and I was exhausted from a day of travel. Just twentyfour hours before I graduated from college in Pennsylvania. By the time the ferry docked on the island the sun had already set and the trip to the BHI The BHI Conservancy gave Conservancy was shrouded in me an opportunity to share blackness. With anticipation in research and conservation and excitement I had to endure outreach, as well as to see the night thinking about what how a nonprofit organization the summer would bring as operates. I never had the Amy poses with one of our opportunity before to see I transitioned from the end of classroom snakes. my college career to my first behind the scenes of how professional internship. I told a Conservancy fundraises myself I needed to get used to working in and prepares programs. The conservancy the dark since I was going to be a Sea Turtle truly cares for its community, as well as the Intern for the summer. What an experience environment. All the programs and special it turned out to be! The island and the events engage the community to support the Conservancy was everything I was looking ongoing stewardship of Bald Head Island. for in an internship program; great staff, wonderful coworkers and a well-supported After completing the summer Sea Turtle program. Internship I was pleased to be accepted for the fall Conservation/Education Intern I loved meeting the visitors to the BHI position, which I am currently serving. I Conservancy and hearing their own stories of enjoyed working with sea turtles and gaining why they care about our environment. It was more experience in field research, but now great to share with visitors what Bald Head that the sea turtle season is over, I am Island has to offer. I not only enjoyed leading excited to broaden my experience to include island nature tours, turtle walks, other education and conservation work. When I educational applied for the summer internship, I did not programs, know which one of the three internships, as well as sea turtle, education, wildlife conservation, I monitoring wanted to do more. Staying on in the fall has nesting sea allowed me to fully experience all types of turtles, but I work the Conservancy has to offer. also enjoyed encouraging These internship experiences have helped me others to transition from college to future conservation get excited education work. The BHI Conservancy has about our helped to affirm my desire to be involved in environment. a state park or a Conservancy where I can be It always made working in research and education. These 7 me smile when months are the first step of a long exciting someone journey ahead! told me they
Amy poses with a sea turtle hatchling during the 2014 BHI sea turtle season. 12
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Our Summer 2014 Sea Turtle Interns and Sea Turtle Program Coordinator, Jaymie Reneker (third from left.) Interns from the left, Joe Seebode, Emily Hardin, Jaymie, Brandt Quirk-Royal, Amy Eldredge, and Giancarlo Coppola. Photo by Brittany Sumner
By: Brandt Quirk-Royal, Summer + Fall Intern
rowing up in Raleigh my family and I would travel to the coast of North Carolina for vacations, however I had never been to Bald Head Island. I honestly did not know what to expect when I came over here; I knew it was different from other North Carolina beaches but did not really know how. I first remember driving down Federal Road and admiring the thick canopy of the maritime forest and thinking how unique this was for a beach. I quickly picked up on all the additional environmental aspects this island has to offer as we (summer interns) went through our training. As an intern I knew I would be living in a dorm setting with my fellow interns. I was nervous and excited to live with a large group of people. Luckily we all ended up getting along well and I enjoyed being surrounded by a lot of like-minded people. We were all in a similar position in our lives and none of us had ever been to the island before. Everything was new and we all got to learn together which made us grow closer. After learning the basic facts about the Conservancy and the island we jumped right into our specified intern positions. I was a sea turtle intern and so my first task was to become nocturnal, which is not an easy task for a die-hard morning person. We struggled through the first few weeks of our new dark schedule, but when we saw our first mother turtle come to lay her eggs I think we were all a lot more fond of the night. Nights were long, but getting a turtle was worth those long tiring hours. I was kept company by four other sea turtle interns and while we were asleep during the day, the other interns, wildlife and education, were busy keeping our island pristine and educating the public. I was not able to become very involved in the conservation/ education aspect of our mission outside of doing turtle walks throughout the summer due to my sleep schedule. While doing data
collection and research is my passion, I learned that it is very important to connect to the public to teach them about what you are doing. This led me to apply to stay as a fall education/conservation intern. I wanted to further develop my outreach skills and get a chance to see the island during the daytime. I knew this would be a more challenging position for me because I had not had a lot of experience in reaching out and teaching science and conservation to a wide range of ages before. This did prove to be difficult at first for me to master, however I think it has benefitted me the most in my time at the Conservancy. It made me a more creative thinker when it comes to relying the basic facts of science Brandt digs around a sea turtle nest in or teaching order to place the cage. people how to better their environment. I am no longer daunted by the idea of teaching kids like I was prior to this summer because I have learned how to reach them on a simple, yet effective level. I no longer worry about giving presentations and I have learned how to answer any question that is thrown at me. Overall I have become more articulate and concise when explaining sometimes tough, or even controversial conservation topics. Science cannot advance without the help of the community. Working with the Conservancy has shown me how to reach out to the public while still doing hard science, such as data collection. Not only has it given me strong interpersonal skills, but it has greatly advanced my knowledge of many science related topics. I have learned how to handle injured birds, how to ear tag white tailed deer, how to babysit a alligator sunning on the banks, how to write a policy paper, how to crab, how to drive a UTV, and most importantly how to leave a lasting impression on the environment you live in through education. I will really miss my time here on the island and all of the friends and people I have met. I plan to continue on to graduate school in the following fall and this internship has definitely given me the skills and knowledge I need to succeed.
Brandt poses with two sea turtle hatchlings. Summer 2014. BHIC.org | BHI Conservancy
Did You Know?
The BHI Conservancy's Annual Fund for the Environment underwrites all of the conservation efforts provided to the community of BHI including the sea turtle protection program, invasive species and dune monitoring, forest and land conservation, creek water quality monitoring, freshwater aquifer monitoring, wildlife surveys, wildlife emergency response and timely research projects to address emerging issues. The need for barrier island conservation is critical to life on BHI. As environmental conditions change and development continues, it is imperative that we protect and conserve the place we call home. Preserving natural spaces and conserving our resources provides invaluable environmental services including: protection from storm surge by the dunes and maritime forest, water filtration in the salt marsh, habitat for commercially important fish species, and an astoundingly beautiful place in which to relax and enjoy family time. We need your support to continue to fulfill the community's vision to live in harmony with nature. Please help conserve and protect our environmental resources for all our families to continue enjoying the restorative, peaceful sanctuary that is Bald Head Island. 14
Conservator | BHIC.org
Bald Head Earns Stellar Marks on Report Card! By Courtney Spears Conservation Biologist - Coastal Ecology Program Coordinator
Bald Head Island is a unique and precious place that includes sensitive habitats like the globally imperiled maritime forest, productive salt marshes, freshwater wetlands, and mature dune ridges. These ecosystems are vastly different from one another, and provide the community with invaluable services, such as protection from storm effects, and a beautiful setting to reconnect with family. The Village of Bald Head Island and the Bald Head Island Conservancy work together to monitor these ecosystems to ensure the community is living in harmony with nature so that we can continue to enjoy all the benefits of living on a healthy barrier island. For the July 2013 – June 2014 term we monitored: dune health/beach vitex, creek health, deer population and forest health, and freshwater resources. We measured dune health by monitoring the width of dune vegetation, presence of native, dune building species, and the amount of vitex removed. We determined creek health by monitoring for salinity, dissolved oxygen, fecal coliform bacteria, salt marsh accretion/erosion, and presence of filter feeders. We calculated deer and forest health by conducting a summer and fall deer count and monitoring for laurel wilt. We monitored freshwater resources by conducting monthly measurements of depth to the water table and quarterly water quality measurements.
Bald Head Island received excellent scores on this year's report card! The dunes showed stability throughout the year, with healthy vegetation, and required less removal of invasive beach vitex than 2012. Bald Head Creek exhibited extremely high water quality, perfect for recreation, with excellent conditions for commercially and recreationally important fish. The deer and forest were also deemed healthy, with no indication of laurel wilt disease – a devastating fungal infection affecting red bay that is transmitted by the ambrosia beetle. Freshwater resources received a 'good' score due to an indication of some saltwater intrusion in the aquifer underlying the island. This is being closely monitored and further investigated through a partnership with the United States Geological Survey (USGS). Overall, Bald Head Island boasts some superb examples of barrier island habitat. As Bald Head was developed with sustainability in mind, it is our responsibility to continue to care for the natural environment. Moving into the next year we will continue to vigilantly monitor the resources of Bald Head Island and protect this extraordinary place. For more detailed methods and results from our monitoring program, please visit http://www.bhic.org.
BHIC.org | BHI Conservancy
700 Federal Road · P.O. Box 3109 Bald Head Island, NC 28461 910-457-0089 www.BHIC.org · firstname.lastname@example.com
A view from our wildlife cameras. Can you tell where on Bald Head our Conservation team set up their wildlife cameras?
"the earth has music for those who listen." —George Santayana
Read on for BHI Conservancy updates including our partnership programs, BISC, intern fun, deer project and more!
Published on Nov 12, 2014
Read on for BHI Conservancy updates including our partnership programs, BISC, intern fun, deer project and more!