November/December 2017. Share Annual Awards 2017. Healthy living at Share. Share flowers. Parents/Carers' Meetings 2018. Season's greetings!
'It'll soon be Christmas!' These are the wise words of Share's catering tutor, Kenny. The fact that he says this in January and every month thereafter is niether here nor there!!!
It is nevertheless hard to believe it is December again. This inevitably brings an element of reflection – what have we achieved and what are our hopes and dreams for the coming year?
At Share, we only ever have one wish at Christmas, and it is the same one each year: to make this world a better place for disabled people, an inclusive world where diversity is valued and everyone is treated equally.
A grand vision for a local charity, but each year we know we take one more step towards our mission to help disabled people realise their potential, have greater choice and independence, and live healthier, happier lives.
If the smiles we saw at our recent Awards Day are anything to go by, then we are certainly getting there. Of course there is still much work to do, but we're excited by the challenges that lie ahead and we have so many fantastic ideas and plans for how we can continue to support people to achieve their personal best.
So why not join our lovely community and help our Christmas wish come true? As well as donating, there are so many ways to get involved and support Share's work – whether it is through volunteering or providing work experience opportunities for our students or sharing your special skill with our students, we'd love to have you on board!
To find out more about Share's work, visit our website at www.sharecommunity.org.uk or contact us via email info@sharecommunity.org.uk or telephone 020 7924 2949.
Our Annual Awards Ceremony on 7th November 2017 was a wonderful and joyful day bringing together our students, their families and friends, and our friends and partners in the community.
Thank you to the Mayor of Wandsworth, Cllr Leslie McDonnell, and Marsha de Cordova, our local MP for Battersea, as well as our Patron, Patricia Hodge, for joining us at the event this year to help us celebrate our students' considerable successes and achievements.
Thank you also to Disability Sports Coach for providing a bit of health and wellbeing for all our guests with a super fun Zumba session.
Check out Share's Facebook page for more photos.
Over the past few weeks, as part of our healthy living programme, Share students have been taking part in another sports day at the Battersea Sports Centre and learning all about cancer screening. This was followed by a day out at Wimbledon where our students learned how to play ball and picked up a few tennis tips from Wimbledon's head coach, Dan Bloxham.
This work has been made possible thanks to a grant awarded in 2015 by the Wimbledon Foundation to promote healthy living among our students and to tackle some of the health inequalities faced by people with learning disabilities.
We are immensely grateful to the Foundation for their support and the opportunities they have provided for our students and Share. It's been a joy to see how even small changes in our students' lifestyles are making a huge difference in their overall health and wellbeing.
Share's horticulture students are super busy fulfilling their Christmas wreath orders. But did you know Share Gardening also makes flower arrangements? This month, as well as providing the flowers for Awards Day, we created a number of beautiful candle flower arrangements for a local school's Christmas fair.
So get in touch if you'd like to brighten up your event with a little floral sparkle from Share.
To find out more, contact Sarah Bailes, Share's Horticulture Training Manager, via email sarahb@sharecommunity.org.uk or telephone 07837 180774.
We like to meet regularly with parents and carers of Share students to hear their views, issues and concerns, and to find out how we can help them to support the person they care for. We learn a lot from these sessions.
These meetings take place every two months at Share's offices in Battersea. We have now set the dates for our parents/carers' meetings for 2018 so please do join us and have your say.
Visit our website for more details. To book your place at one or all of these meetings, contact Annie McDowall, Share's CEO, via email anniem@sharecommunity.org.uk or telephone 020 7801 9817.
Well, that's all, folks! All that is left is for us to wish everyone all the very best for the festive period and a happy and peaceful New Year. Thank you to everyone for their support over the past year – this wonderful community thrives because of you and for that we are immensely grateful. Whether you have volunteered, donated, funded a special project, sponsored an event or supported our work through our social enterprises, A HUGE THANK YOU TO YOU ALL!
One final reminder that Share will be closing at 5pm on Friday 22nd December 2017 and will reopen as normal on Tuesday 2nd January 2018.


Somewhere between the devil and the deep blue sea, the Oakley Graphics Kitchen cooked up a wickedly original design concept called Fathom. Four premium sunglasses were selected for the eyewear collection, and accents range from the magma orange of deep sea vents to the yellow of corals and the blue of shimmering shallows. It's a color palette that paints you as a true individual, so no more swimming with the school of uninspired style.


How you can support our organisation?
The Active Social Assistance is a Section 18A registered Non Profit Organisation.
Active Social Assistance is also a Public Benefit Organisation, so funds donated into the organisation will be a Tax Rebate for you as an individual or your company. A donation receipt will then be send to your address which can be attached to your income statement at your financial year-end.
PO Box 38464 Gatesville, 7766.


text:
Acute Angle-Closure Glaucoma (AACG)
Author: Albert P Lin, MD; Chief Editor: Inci Irak Dersu, MD, MPH
Angle closure is defined as the apposition of iris to the trabecular meshwork, which results in increased intraocular pressure (IOP). In acute angle closure (AAC), the process occurs suddenly with a dramatic onset of symptoms, including blurred vision, red eye, pain, headache, and nausea and vomiting. The sudden and severe IOP elevation can quickly damage the optic nerve, resulting in acute angle-closure glaucoma (AACG).
AAC is a true ophthalmic emergency, and a delay in treatment can result in blindness. While immediate treatment can sometimes minimize the amount of visual loss, the best treatment is to stop its occurrence in susceptible individuals.[1, 2, 3, 4]
AAC occurs through a process termed pupillary block. Normally, aqueous humor is produced in the ciliary body, flows through the pupil into the anterior chamber, and drains into the trabecular meshwork to exit the eye. When the pupil is mid-dilated, the distance between the iris and the lens is the shortest, and the two structures can come into contact with each other in individuals at risk for angle closure. When this occurs, aqueous humor cannot flow through the pupil into the anterior chamber (pupillary block), pushing the iris forward. When the iris is pushed against the trabecular meshwork, aqueous humor cannot flow out of the eye (angle closure), increasing IOP.
The normal IOP is 10-21 mm Hg. In AAC, and IOP typically exceeds 40 mm Hg. The sudden and severe elevation in IOP can cause irreversible optic nerve damage very quickly (acute angle-closure glaucoma).
Mechanisms other than pupillary block can also contribute to primary angle closure, including plateau iris, use of certain medications, increased iris thickness, increased iris volume with dilation, hyperopia, and increased lens thickness in phacomorphic angle closure.
AAC is more common in older individuals. Among persons older than 40 years, AAC is more common in Inuit and Asian persons, less common in whites, and least common in blacks. While AACG usually accounts for a small proportion of glaucoma cases in the general population, it accounts for significant number of glaucoma cases among persons of Eastern Asian and Southeast Asian descent. It is more common among women and individuals with hyperopia. Individuals with family history of AAC or who have had AAC in one eye are also at a higher risk.[2, 5]
The prognosis is favorable with early detection and treatment. The best way to prevent loss of vision is to treat susceptible individuals prior to AAC.
AAC is a medical emergency that needs to be treated immediately. Even with immediate treatment, AAC may result in vision loss. The best method for preventing vision loss due to AAC is prophylactic treatment in patients with susceptible anatomy.
Patients need to promptly seek an eye care professional if symptoms (pain, decreased vision, headache, and vomiting) suggest AAC.
In acute angle closure (AAC), the intraocular pressure (IOP) rises rapidly, and the patient may present with dramatic symptoms, including the following:
Sudden onset of severe ocular pain, redness, blurry vision, headache, and nausea and vomiting
Patients may complain of seeing haloes around lights. Haloes and blurry vision result from corneal edema.
The attack may have been precipitated by pupillary dilation, which may result from activities such as going to a movie theater, taking over-the-counter medications that contain antihistamine for cold or allergy, or using dilating eye drops as part of an ophthalmic examination.
Patients with AAC may be extremely uncomfortable and distressed.
Some patients experience intermittent episodes of partial angle closure and relatively elevated IOP without experiencing a frank attack of AAC. These patients may report incidents of mild pain with slightly blurred vision or may report seeing haloes around lights. Some may be completely asymptomatic. Symptoms can resolve spontaneously if the angle reopens on its own.
A complete ophthalmic examination should be conducted in patients who present with suspected AAC. This examination should emphasize vision, pupil, gonioscopy, tonometry, slit-lamp examination, and optic nerve evaluation:
Diagnosis of AAC is based on gonioscopic visualization of an occluded anterior chamber angle in the affected eye and predisposing angle configuration (narrow occludable angle) in the contralateral unaffected eye.
Tonometry demonstrates an elevated IOP, which may be as high as 40-80 mm Hg.
Slit-lamp examination may reveal conjunctival injection, a fixed or sluggish and mid-dilated pupil, a shallow anterior chamber, corneal epithelial edema and bullae, and cells and flare. The patient may be sensitive to light, and the eye may be tearing and closed.
Ophthalmoscopy may reveal a swollen optic disc in an acute attack or excavation if episodes have been chronic or repetitive. Unilateral involvement and worsening symptoms are common in AAC.
If previous episodes of angle closure have occurred, the following may be visible:
Posterior and peripheral anterior synechiae adhesions between the lens and iris and between the iris and trabecular meshwork
Glaucoma flecks (vesicles on the anterior subcapsular lens)
Atrophy of the iris (thinning and whitening of the iris)
Pupillary block is considered to be the most common cause of AAC. Normally, aqueous humor is made by the ciliary body and flows through the pupil to the anterior chamber, where it drains out of the eye through the trabecular meshwork and the Schlemm canal. If contact occurs between the lens and the iris, aqueous humor accumulates behind the pupil, increasing posterior chamber pressure and forcing the peripheral iris to shift forward. The forward movement of the iris does not cause angle closure in individuals with normal anatomy.
The trabecular meshwork is located between the iris and cornea, and the two structures form an angle that is normally 40°. Persons with susceptible anatomy have a narrow occludable angle, usually of less than 20°. When the iris is pushed forward by the aqueous humor in a narrow occludable angle, it becomes apposed to the trabecular meshwork. This blockage causes accumulation of aqueous humor in the anterior chamber and an acute rise in IOP.
Not all individuals with narrow occludable angle develop AAC, and mechanisms other than pupillary block play a role in development of AAC.
Plateau iris is a condition in which the iris is inserted more anteriorly into the ciliary body and the periphery of the iris is flat. The angle is narrow owing to the anterior iris insertion, and the flat iris bunches up to obstruct the angle when the eye is dilated.[6, 7]
Several medications have been implicated in causing acute ACC by producing swelling in the ciliary body and forward movement of the iris. Sulfa-derivative medications, including acetazolamide, sulfamethoxazole, and hydrochlorothiazide, and antiepileptic medication topiramate have been reported to cause acute attacks.[8, 9]
Persons of Asian descent have thicker irides, and increased iris thickness is associated with angle closure.[10, 11]
Pupillary dilation normally results in loss of iris volume, but this volume decrease is less in eyes that have had AAC; some of these eyes actually showed an increase in iris volume.[12, 13]
Individuals with hyperopia have smaller eyes, and the diameter of the eye (axial length) is shorter. The intraocular structures are spaced closer together. These patients are more likely to have shallow anterior chambers and narrow occludable angles.[1, 2, 3]
Lens volume increases with age and can decrease the amount of space in the anterior chamber via mass effect.[1, 2, 3]
Loss of vision or blindness can occur without prompt treatment.
Allergic Conjunctivitis
Bacterial Conjunctivitis (Pink Eye)
Drug-Induced Glaucoma
Primary Angle-Closure Glaucoma
Malignant Glaucoma
Neovascular Glaucoma
Phacomorphic Glaucoma
Senile Cataract (Age-Related Cataract)
Suprachoroidal hemorrhage
Viral Conjunctivitis (Pink Eye)
Ultrasound biomicroscopy (UBM) and anterior segment optical coherence tomography (AS-OCT)
These imaging techniques can be used to visualize the angle and surrounding structures. They can provide objective and quantitative measurements to document changes to the angle before and after treatment. However, clinical assessment and the use of gonioscopy may be more practical and applicable if a patient has acute angle closure (AAC).[14]
The anterior chamber angle cannot be visualized through a slit lamp because the light reflected from the angle is reflected back into the eye. Gonioscopy is performed by applying a gonioscope onto the cornea after administration of a topical anesthetic. Four mirror lenses are useful to diagnose and, possibly, to break the block by applying pressure. It allows the clinician to quickly and accurately assess the angle without expensive machinery. It is an essential component of an ophthalmic examination in patients with suspected narrow angle and in patients with AAC.
The definitive treatment of acute angle closure (AAC) is surgical. The goal of medical treatment is to break the AAC in preparation for surgical intervention to prevent its recurrence.
Topical and oral medications are used to lower the IOP. Lowering the IOP minimizes damage to the optic nerve and allows the ocular tissue to be compressed.
If the IOP cannot be lowered sufficiently, an anterior chamber paracentesis (needle insertion) can be performed. This technique can be useful because it provides immediate relief to the distressed patient and facilitates tolerance of subsequent treatment. A consent form should be obtained for the risks (eg, inadvertent lens puncture, decompression retinopathy) and benefits prior to the procedure.
Compression gonioscopy is then performed by using a gonioscope to push down on the cornea and then easing up on it. The process is done repeatedly, and the force generated is translated intraocularly to break the contact between the iris and the lens (pupillary block) and apposition of the iris to the trabecular meshwork (angle closure). This temporarily restores the outflow of aqueous humor and normalizes the IOP.
Patients may also be placed in a supine position to allow the lens to move away from the anterior chamber to help restore of the flow of aqueous humor.
When the eye is in AAC, the visualization into the anterior chamber is poor. Medications for eye pressure and inflammation are used to help clear up the cornea, to reduce intraocular inflammation, and to decrease iris edema. It is preferable to perform laser iridotomy when the condition can be optimized. If laser iridotomy cannot be performed and AAC continues, surgical iridectomy is indicated.
The treatment of choice for pupillary-block ACG is laser iridotomy. Iridotomy with an argon and/or Nd:YAG laser creates an opening in the iris through which aqueous humor trapped in the posterior chamber can reach the anterior chamber and trabecular meshwork. As aqueous humor flows into the anterior chamber through the iris defect, pressure behind the iris falls, allowing the iris to fall back toward its normal position. This procedure opens the anterior chamber angle and relieves the blockade of trabecular meshwork. It also prevents future pupillary block and AAC.
Surgical iridectomy
If the cornea is extremely cloudy or the iris is too thick and an opening cannot be created using laser, incisional peripheral iridectomy can be performed in the operating room.
Laser iridoplasty
Argon laser may be used to create burns in the peripheral iris and to cause tissue contraction. This reduces iris thickness and creates additional space between the iris and the trabecular meshwork. Traditionally, this technique is indicated to prevent AAC in plateau iris and nanophthalmos but can also be used to augment the effect of iridotomy or iridectomy, if needed.[15, 16]
If the angle continues to be narrow and occludable after laser iridotomy and iridoplasty, especially in an older patient, cataract surgery is indicated to remove the cataract and its mass effect on the angle. If the patient has both a narrow occludable angle and a visually significant cataract (blurry vision due to cataract), cataract surgery is the treatment of choice. It opens the angle and improves vision.[17] Even without significant cataract, effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE) study, conducted in Asia, showed that clear lens extraction may be more efficacious and cost effective than laser iridotomy. The authors suggested that the crystalline lens may play a larger role in the mechanism of angle closure than previously thought and that early lens extraction can be considered as an option for first-line treatment.[18]
Goniosynechialysis
If the patient undergoes cataract surgery and there are bands of adhesion between the iris and the trabecular meshwork, the bands may be pulled apart during surgery to restore the flow of aqueous humor through the trabecular meshwork.
If permanent adhesions between the iris and trabecular meshwork have formed after AAC and IOP cannot be normalized with the other methods, traditional glaucoma surgery, such as a trabeculectomy or tube shunt, may be indicated.
Some of the potential complications AAC include the following:
Cataract formation
Iris sphincter atrophy and permanently dilated pupil
Peripheral anterior synechia
Chronic angle closure glaucoma
Absolute glaucoma
Corneal decompensation
In most cases, the fellow eye has an occludable angle, and laser iridotomy should be performed as soon as possible.
The patient needs to be monitored closely after the initial acute angle closure (AAC) to ensure the following:
The IOP is normalized and AAC does not recur.
Perform laser iridotomy once there is sufficient view into the anterior chamber.
Ensure the laser treatment is effective or if additional treatment, such as iridoplasty, is indicated.
Treat the patient until the inflammation has subsided and the pupil and vision return to normal. Gradually taper the medications.
Assess the contralateral eye and perform laser treatment, if needed.
Patients in AAC needs to be treated until the IOP normalizes. IOP can increase after laser iridotomy, and the IOP should be checked 30-60 minutes after the treatment prior to releasing the patient.
The medical therapy for acute angle closure glaucoma (AACG) is directed toward preparing the patient for surgical treatment. IOP must be returned to normal, and the cornea must be cleared before a definitive procedure can be undertaken. In AAC, several drugs from different classes are used simultaneously to accelerate and maximize their pressure-lowering effects.
Alpha-adrenergic agonists
Topical adrenergic agonists, or sympathomimetics, decrease aqueous production and reduce resistance to aqueous outflow. Adverse effects include dry mouth and hypersensitivity.
Brimonidine (Alphagan P)
Selective alpha2-receptor that reduces aqueous humor formation and possibly increases uveoscleral outflow.
Apraclonidine (Iopidine)
Potent alpha-adrenergic agent selective for alpha2-receptors with minimal cross-reactivity to alpha1-receptors. Reduces IOP whether or not accompanied by glaucoma. Selective alpha-adrenergic agonist without significant local anesthetic activity. Has minimal cardiovascular effect.
Topical beta-adrenergic receptor antagonists decrease aqueous humor production by the ciliary body. Adverse effects of the beta-blockers are due to systemic absorption of the drug and include decreased cardiac output and bronchial constriction. In susceptible patients, this may cause bronchospasm, bradycardia, heart block, or hypotension. Pulse rate and blood pressure should be monitored in patients receiving topical beta-blocker therapy, and punctal occlusion may be performed after administration of the drops.
Levobunolol (Betagan)
Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production
Betaxolol ophthalmic (Betoptic-S)
Selectively blocks beta1-adrenergic receptors with little or no effect on beta2-receptors. Reduces IOP by reducing production of aqueous humor.
Timolol maleate (Timoptic, Timoptic XE, Istalol, Betimol)
May reduce elevated and normal IOP, with or without glaucoma, by reducing production of aqueous humor.
Miotic agents
Contract ciliary muscle, tightening the trabecular meshwork and allowing increased outflow of the aqueous. Miosis results from action of these drugs on pupillary sphincter. Adverse effects include brow ache, induced myopia, and decreased vision in low light.
Pilocarpine ophthalmic (Isopto Carpine)
A naturally occurring alkaloid, pilocarpine mimics muscarinic effects of acetylcholine at postganglionic parasympathetic nerves. Directly stimulates cholinergic receptors in the eye, decreasing resistance to aqueous humor outflow.
Instillation frequency and concentration are determined by patient's response. Individuals with heavily pigmented irides may require higher strengths. If other glaucoma medication is also being used, at bedtime, use gtt at least 5 min before gel. May use alone, or in combination with other miotics, beta-adrenergic blocking agents, epinephrine, carbonic anhydrase inhibitors, or hyperosmotic agents to decrease IOP.
Carbonic anhydrase inhibitors
Reduce secretion of aqueous humor by inhibiting carbonic anhydrase in ciliary body. In acute ACG, may be given systemically but are used topically in patients with refractory open-angle glaucoma. Topical formulations are less effective, and their duration of action is shorter than many other classes of drugs. Adverse effects of topical carbonic anhydrase inhibitors are relatively rare, but they include superficial punctate keratitis, acidosis, paresthesias, nausea, depression, and lassitude.
Acetazolamide (Diamox Sequels)
Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute ACG when delay of surgery desired to lower IOP.
Methazolamide (Neptazane)
Reduces aqueous humor formation by inhibiting enzyme carbonic anhydrase, which results in decreased IOP.
Dorzolamide (Trusopt)
Used concomitantly with other topical ophthalmic drug products to lower IOP. If more than one ophthalmic drug is being used, administer the drugs at least 10 min apart. Reversibly inhibits carbonic anhydrase, reducing hydrogen ion secretion at renal tubule and increases renal excretion of sodium, potassium bicarbonate, and water to decrease production of aqueous humor.
Brinzolamide (Azopt)
Catalyzes reversible reaction involving hydration of carbon dioxide and dehydration of carbonic acid. May use concomitantly with other topical ophthalmic drug products to lower IOP. If more than one topical ophthalmic drug is being used, administer drugs at least 10 min apart.
Dorzolamide HCl/ timolol maleate (Cosopt, Cosopt PF)
Carbonic anhydrase inhibitor that may decrease aqueous humor secretion, causing a decrease in IOP. Presumably slows bicarbonate ion formation with subsequent reduction in sodium and fluid transport.
Timolol is a nonselective beta-adrenergic receptor blocker that decreases IOP by decreasing aqueous humor secretion and may slightly increase outflow facility. Both agents administered together bid may result in additional IOP reduction compared with either component administered alone, but reduction is not as much as when dorzolamide tid and timolol bid are administered concomitantly.
Prostaglandin, Ophthalmic
Increase uveoscleral outflow of the aqueous. One mechanism of action may be through induction of metalloproteinases in ciliary body, which breaks down extracellular matrix, thereby reducing resistance to outflow through ciliary body.
Latanoprost (Xalatan, Xelpros)
Latanoprost may decrease IOP by increasing the outflow of aqueous humor. Patients should be informed about possible cosmetic effects to the eye/eyelashes, especially if uniocular therapy is to be initiated.
Travoprost (Travatan Z)
This agent is a prostaglandin F2-alpha analog. It is a selective FP prostanoid receptor agonist that is believed to reduce IOP by increasing uveoscleral outflow. Travoprost ophthalmic solution is used to treat open-angle glaucoma and ocular hypertension.
Bimatoprost (Lumigan, Latisse)
This agent is a prostamide analog with ocular hypotensive activity. It mimics the IOP-lowering activity of prostamides via the prostamide pathway. Bimatoprost ophthalmic solution is used to reduce IOP in open-angle glaucoma and ocular hypertension.
Latanoprostene bunod ophthalmic (Vyzulta)
Metabolizes rapidly in the eye to latanoprost acid, an F2 alpha prostaglandin analog. May increase the outflow of aqueous humor through the trabecular meshwork and uveoscleral route, which may in turn reduce intraocular pressure.
Rho Kinase Inhibitors
These agents may increase aqueous outflow by reversing structural and functional damage at the trabecular meshwork. The vasodilatory effect of rho kinase inhibitors may also reduce episcleral venous pressure.
Netarsudil ophthalmic (Rhopressa)
May reduce intraocular pressure by increasing the outflow of aqueous humor through the trabecular meshwork route.
What is acute angle-closure glaucoma (AACG)?
What is the pathophysiology of acute angle-closure glaucoma (AACG)?
What is the prevalence of acute angle-closure glaucoma (AACG)?
What is the prognosis of acute angle-closure glaucoma (AACG)?
What is included in patient education about acute angle-closure glaucoma (AACG)?
What are the signs and symptoms of acute angle-closure glaucoma (AACG)?
What is included in the ophthalmic exam for acute angle-closure glaucoma (AACG)?
Which physical findings are characteristic of acute angle-closure glaucoma (AACG)?
What causes acute angle-closure glaucoma (AACG)?
What are the possible complications of acute angle-closure glaucoma (AACG)?
What are the differential diagnoses for Acute Angle-Closure Glaucoma (AACG)?
What is the role of imaging in the diagnosis of acute angle-closure glaucoma (AACG)?
What is the role of gonioscopy in the diagnosis of acute angle-closure glaucoma (AACG)?
How is acute angle-closure glaucoma (AACG) treated?
What is the medical treatment for acute angle-closure glaucoma (AACG)?
What is the role of laser iridotomy in the treatment of acute angle-closure glaucoma (AACG)?
What is the role of iridectomy in the treatment of acute angle-closure glaucoma (AACG)?
What is the role of laser iridoplasty in the treatment of acute angle-closure glaucoma (AACG)?
What is the role of cataract surgery in the treatment of acute angle-closure glaucoma (AACG)?
What is the role of goniosynechialysis in the treatment of acute angle-closure glaucoma (AACG)?
What is the role of glaucoma surgery in the treatment of acute angle-closure glaucoma (AACG)?
How is acute angle-closure glaucoma (AACG) prevented?
What is included in the long-term monitoring of patients with acute angle-closure glaucoma (AACG)?
What is included in inpatient monitoring of acute angle-closure glaucoma (AACG)?
What is the role of medications in the treatment of acute angle-closure glaucoma (AACG)?
Which medications in the drug class Prostaglandin, Ophthalmic are used in the treatment of Acute Angle-Closure Glaucoma (AACG)?
Which medications in the drug class Carbonic anhydrase inhibitors are used in the treatment of Acute Angle-Closure Glaucoma (AACG)?
Which medications in the drug class Miotic agents are used in the treatment of Acute Angle-Closure Glaucoma (AACG)?
Which medications in the drug class Beta-blockers are used in the treatment of Acute Angle-Closure Glaucoma (AACG)?
Which medications in the drug class Alpha-adrenergic agonists are used in the treatment of Acute Angle-Closure Glaucoma (AACG)?
Which medications in the drug class Rho Kinase Inhibitors are used in the treatment of Acute Angle-Closure Glaucoma (AACG)?
Albert P Lin, MD Assistant Professor, Department of Ophthalmology, Baylor College of Medicine; Staff Physician, Michael E DeBakey Veterans Affairs Medical Center; Ophthalmologist, Ophthalmology Consultants of Houston
Albert P Lin, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Harris County Medical Society, Texas Medical Association
Kristin Schmid Biggerstaff, MD, MS Associate Professor, Department of Ophthalmology, Baylor College of Medicine; Glaucoma Staff Physician, Michael E DeBakey Veterans Affairs Medical Center
Kristin Schmid Biggerstaff, MD, MS is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, American Society of Cataract and Refractive Surgery
Martin B Wax, MD Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Research and Development, Head, Ophthalmology Discovery Research and Preclinical Sciences, Alcon Laboratories, Inc
Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Society for Neuroscience
Inci Irak Dersu, MD, MPH Associate Professor of Clinical Ophthalmology, State University of New York Downstate College of Medicine; Attending Physician, SUNY Downstate Medical Center, Kings County Hospital, and VA Harbor Health Care System
Inci Irak Dersu, MD, MPH is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society
Kilbourn Gordon, III, MD, FACEP Urgent Care Physician
Kilbourn Gordon, III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology, Wilderness Medical Society
Robert J Noecker, MD, MBA Associate Professor, Department of Ophthalmology, University of Pittsburgh School of Medicine; Director, Glaucoma Service, Vice Chair, Department of Ophthalmology, University of Pittsburgh Medical Center Eye Center
Robert J Noecker, MD, MBA is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society, American Medical Association, American Society of Cataract and Refractive Surgery
Disclosure: Received consulting fee from Allergan for consulting; Received grant/research funds from Allergan, Zeiss, Lumenis for other; Received honoraria from Allergan, Alcon, Lumenis, Endo-optics for speaking and teaching.
Malik Y Kahook, MD Clinical Instructor of Ophthalmology, Fellow in Glaucoma, Department of Ophthalmology, University of Pittsburgh Medical Center
Malik Y Kahook, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, Colorado Medical Society
Disclosure: Received consulting fee from Alcon for consulting.
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Lai JS, Tham CC, Chan JC. The clinical outcomes of cataract extraction by phacoemulsification in eyes with primary angle-closure glaucoma (PACG) and co-existing cataract: a prospective case series. J Glaucoma. 2006. 15(1):47-52. [Medline].
Azuara-Blanco A, Burr J, Ramsay C, Cooper D, Foster PJ, Friedman DS, et al. Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. Lancet. 2016. 388:1389-1397. [Medline]. [Full Text].

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'Saving Hope' S3 Ep 6 recap: Howling at the moon
November 1, 2014 March 19, 2017 Categories Saving Hope, TV Recaps & Reviews, TV ShowsBenjamin Ayres, CTV, Daniel Gillies, Drama, Erica Durance, Huse Madhavji, ION television, ION TV, Julia Taylor Ross, Medical Drama, Michael Shanks, Michelle Nolden, Recap, Review, Saving Hope, Sci-Fi, Supernatural, TV, TV ShowsLeave a Comment on 'Saving Hope' S3 Ep 6 recap: Howling at the moon
Are you on Team JAlex? (Photo credit: CTV)
"Saving Hope's" mid-season finale was intense. The medical cases were fascinating, unique and kind of creepy. Alex and Joel treat a pregnant virgin, while Charlie spends the day trying to convince a ghostly girl that she is still alive. But as "Joel 2:31 (Apocalypse Now)" comes to a close, the doctors' personal lives are what leave us hanging in limbo until new episodes return "soon."
There is full blood moon out, so the ER is full of crazy cases. According to the prophecy in Joel 2:31, "The sun turns into darkness…the moon into blood." Some people believe that these signs, among other things, warn of the impending Apocalypse. However, as the episode unfolds, we realize that this particular end of days is more of a new beginning for the doctors of Hope Zion.
Staying Alive
On his way to the elevator, Charlie passes a dead girl who wants to go to the morgue. He does his little covert ghost doctoring, sets her straight and moves along. Charlie enters the elevator and has an awkward encounter with Dawn. She understands Charlie's in an emotionally confused state and she isn't expecting that one night stand to really evolve into anything. But still, she's putting her feelers out there. Charlie simply admits, "It's complicated." Suddenly there's a thud. Someone has fallen down the elevator shaft and landed on their elevator. It ends up being the ghost girl Charlie saw in the hall. The strange thing is that even though this girl, Vida, is a living patient in the hospital, she thinks she is dead and she only speaks to Charlie. Interesting!
When Charlie and Rian X-Ray Vida, they make a shocking discovery. She's been internally decapitated! Never thought that could even happen, but apparently it does. Vida is in a catatonic state, but she is still aware of everything happening around her. Charlie explains the situation to her and they perform an operation to mend her decapitated bones.
During the operation, Vida's ghost appears. Rian soon realizes that Charlie has a "special" way of working in the O.R. because he likes talking to his patients even if they are unconscious. Vida is in total denial. She claims to be dead even though Charlie is clearly saving her life as they speak.
The surgery goes well, but Vida still thinks she's dead. So Charlie tries to reach out and gain her trust. He remembers seeing her spirit holding onto a stone in the OR and he asks her about it. She remains withdrawn, so Charlie tells her about his traumatic experience as child. He saw his parents die when he was six and he didn't speak for a year afterwards. He understands how Vida feels, so she confides in him and reveals her past. Vida and her twin sister, Val, were skipping stones at the beach one year ago. Val wanted to stay, but Vida was bored and wanted to leave. Vida believes her sister would not have died if she didn't insist on leaving the beach. She blames herself for Val's death. What a heartbreaking story. It is no wonder that Vida feels like she should be dead, but that still isn't a way to continue living. Luckily, Charlie sets out to get some answers and helps her move on.
Charlie sees Dey, who again is no Gavin, but he is still able to provide some insight. Charlie explains Vida's condition and Dey says it is a known thing called "Walking Corpse Syndrome." It can be treated with electric shock therapy. Well that's harsh! They seriously don't have any better treatment in this day and age? Unfortunately, they seem to have no other choice.
Charlie tells Vida how the electric shock will bring her brain back to life. She feels like a monster on a slab, but Charlie assures her that this is different. He tells her to meet him in the morgue during the procedure. It's fun to see how Charlie has grown accustomed to ghost doctoring. Now he's even setting appointments with his ghost patients. It would be wonderful to see a lot more of these types of supernatural stories on the show.
While Vida's body is undergoing shock therapy, her spirit appears to Charlie. He tells Vida that Val's death was not her fault. The cause doesn't matter anymore. But Vida believes she cannot go on living without her other half. Aww. Charlie knows how she feels (he's probably thinking about Alex here, right?). He asks her when she remembers feeling the most alive. She says it was while riding a roller coaster and screaming with Val. So Charlie encourages her to relive that moment. He makes her release a cathartic scream that beckons her back to life. Finally feeling alive, her spirit returns to her body.
After Vida's treatment and recovery, Charlie gives her a gift. He hands her a stethoscope and tells her to have a listen. If she's ever in doubt, the sound of her beating heart will remind her that she is indeed alive. However, Vida isn't the only one learning to seize the day and feel alive.
When Charlie and Dawn end up in the elevator together again, he apologizes for acting so weird earlier. Dawn doesn't want to be his rock bottom or his rebound girl. Charlie admits he may not be completely sure of himself right now, but one thing is certain: he is alive. Charlie starts kissing Dawn and we all know where this is headed. Or so we think…
Dawn wants to have baby! It looks like Charlie is one popular prospective baby daddy. This is huge. Given Dawn and Charlie's miscarriage in the past and the rocky relationship that has followed, having a baby together may not be the smartest thing. If they decide to have a baby, does that mean they will get married again and try to be one big happy family? Would Dawn want to have a baby even if it is without Charlie?
The timing is very coincidental. If Erica Durance's pregnancy is written into the storyline and Alex ends up getting accidentally pregnant when Dawn is trying to have a baby it could cause some major melodrama. Imagine how Dawn would feel if Alex unexpectedly has a baby when Dawn has been trying/wanting to have one for so long. This could be a slippery slope for "Saving Hope," but let's not pass judgments until we see how this all starts to play out. The one thing that would be majorly frustrating is if Alex ends up getting knocked up by Joel. After her conversation with Charlie in limbo, it would be very frustrating to see Alex have a baby with Joel when her spirit planned on starting a family with Charlie. Judging by the way things turn out with Alex and Joel at the episode's end, a Jalex baby could be in their future.
Alex and Joel collaborate on a very fascinating case. Young newlyweds, Rob and Elisa, just got married and they are spending their first night together as man and wife in the ER. We learn the devout, old-fashioned couple cutely met at "Theology on the Rocks." So it comes as a huge shock when Alex reveals that Elisa is pregnant. Elisa and Rob haven't even consummated their marriage yet, so this is impossible.
Upon further examination, Alex confirms that Elisa is truly a virgin. Elisa freaks out, thinking that there's a monster inside of her. Oddly enough, she is not that off base. After more tests and speculative diagnoses, Elisa has a seizure, which proves the problem is purely physical. Ultimately, the doctors discover a teratoma tumor containing teeth and bone fragments growing off of Elisa' coccyx. That is why the test made it seem like Elisa was pregnant. Alex, Joel and the others gather around to open the tumor after it has been removed. Yeah, it is a gross as you would imagine it to be. Teeth, brown hair, and an eye. Eww!
Once the tumor is removed, Elisa feels as good as new. The past few days are a blur, but she is still happy to have married Rob. They view this supposed apocalypse as a renewal rather than a doomsday. Elisa and Rob aren't the only ones feeling renewed at the end of such bizarre night.
Old Love Feels New
Joel has been relentless in pursuing Alex. He's in it for the long haul and has been slowly chipping away at her walls. They even have a moment in the morgue. What if this was really their last night on earth? How would they want to spend it? Joel answers by leaning in to kiss Alex, but a natural disaster keeps their lips apart. Alex believes the earthquake is a cosmic "stop" sign preventing them from making a big mistake. Even her friends have been urging her to take things slow.
Alex's friends have her best interest at heart, so they warn her to be careful. When Joel skypes with a hot blonde in New Zealand, Maggie alerts Alex to Joel's flirtation. But Maggie misread the situation. Joel explains that his father is getting married in Auckland and the young blonde is his new step-mom. He asks Alex to go to the wedding with him. That's a big move for someone who is trying to take baby steps. Alex isn't quite there yet.
As their wild night and crazy case progresses, Joel can sense that Alex is on the cusp of giving in. Just to be sure his instincts are right, he has a casual chat with Dey. Do people really act crazy because of the blood moon? It is more likely that the moon just offers them an excuse to act on their impulses. Then Joel says that Alex keeps pulling away. Dey says that means she likes Joel. It seems that is all Joel needed to hear.
After an insane day at the hospital, Joel wakes Alex up with a knock on her door. It is 2:31, so it seemed like a poetic gesture to show up. He says that he was on his way to the airport when he heard about the earthquake on the radio. All day nobody else around them felt it, but now they know they aren't crazy. The radio said the earthquake was 5.1, Alex pulls Joel in and teases, "We can do better than that." And just like that, Jalex is back in action.
With her love for Charlie left behind in limbo, it was only a matter of time before Alex gave into her desires for Joel. She always had a spark with him. Plus, he's been trying to woo her back for a while now. This is his chance to get it right and be in an adult, committed relationship with Alex. But what if Alex's missing piece suddenly comes back and she wakes up one morning loving Charlie instead? Joel thinks he has finally won back her heart, but he's only got part of it. Everyone is concerned about Alex, but Joel may be the one who ends up devastatingly heartbroken if things don't work with Alex this time around.
This episode gives us a welcomed break from the soap opera-ish hot mess of mashed-up love lives when we get a glimpse into Zach's family life. In the past we've seen how wise-cracking Zach has struggled with his divorce and being apart from his kids. It was a sweet sneak peek at his softer side.
In the midst of this chaotic night, Zach's son, Jacob, skateboards into the ER, hoping to spend some time with his dad. While he waits around for his father's attention between cases, Jacob bonds with Guy, a hippie prophet that looks like a stoner version of Jesus. Of course, this weird stranger will serve as a voice of reason when Jacob pleads his case to Zach.
Jacob's mom doesn't care about him because she's too busy with her new man, Hank. Jacob wants to live with his father. Zach is upset that Jacob ran away from home. Guy butts in: Jacob isn't running away, he's running towards. The boy just wants to be with his father. All he needs is love and attention.
Later that night Zach takes Jacob some snacks and says he's trying to be there for him. He asks how Jacob would rate him as a dad on a scale of 1 to 10. Zach thinks he's at a 7 and Jacob agrees. Zach understands why Jacob wants to live with him. But Zach works so much that he's worried he won't be able to take good enough care of his son. Zach emphasizes that he loves Jacob and wants to have him around always. Jacob insists he won't be a burden on his dad, he can even camp out at his house the way they used to. Zach wouldn't have to change anything or worry. Aww. Poor Jacob.
We're not sure if Jacob will be able to live with Zach full time, but he's definitely making progress. As the episode closes, Zach has set up camp at the hospital. They make s'mores and do some much needed father and son bonding. It is such a sweet sight. Hopefully we'll get to see more of Zach's paternal side this season.
The Cases: This was another loaded episode. The cases were very intriguing and much better than expected. There were some great twists and turns. This was one of Charlie's more unique ghost doctoring cases. It was kind of sad that Charlie immediately thought she was a ghost because she only addressed him. It was also strange that she intuitively sensed that she could reach out to Charlie. Other doctors would not have been able to help her the way he did. It was a great way of bridging his work with his patients between both worlds. Just the fact that he told her to meet him in the morgue was pretty awesome. It would be cool if he started taking appointments and setting up a side ghost doctor business.
The Romantic Drama: As for the love triangle turned rectangle. "Saving Hope" is on the edge of becoming another cheesy medical soap opera. The beauty and individuality of this series is the supernatural aspect and how it influences the characters. This season started off in a wonderful place where Alex and Charlie were finally at the same level. Sure, every good drama needs to raise the stakes with conflict. Alex and Charlie made huge progress in limbo, then regressed when she woke up with a piece of her soul missing. She left her love for Charlie behind. That is frustrating and sad all on its own. Now Charlie and Alex are drifting further apart by falling back into old romances. Since the Charlie-Alex-Joel love triangle was starting to get old, they threw Dawn back into the ring. Instead of shaking things up and making it more interesting, these storylines are becoming really annoying.
Dawn and Charlie: Dawn and Charlie were married. They had a complex relationship and had difficulty overcoming great tragedy. Things are complicated for Charlie, but he is still in love with Alex. He never stopped loving her. Even when he broke up with her last season, it was out of love and concern for her. Charlie hooking up with Dawn is only going to cause more pain. Unless he's falling back in love with Dawn and truly getting over Alex. As if that isn't bad enough, Dawn all of sudden says she wants to have a baby. Does she want Charlie's baby specifically? Or does she just want to be a mom? It's great that Charlie feels alive and is giving into his impulses and what not, but this is going to get really messy, really fast. They need to get on the same page before this relationship escalates.
Joel and Alex: Alex finally hooks up with Joel. We all saw it coming. She doesn't have her love for Charlie holding her back. Last season, she felt herself being drawn to Joel all over again, but she wanted to give Charlie time to work things out. Now that Charlie is out of her heart, she is free to love Joel. But is she really in love with him? A part of her was left behind in limbo, but what if it suddenly snaps back into place? What if she wakes up one morning and picks up from where she left off in limbo? There can be some disastrous scenarios ahead.
What did you think of "Joel 2:31"? Are you happy with the way things ended? Are you annoyed by the romantic storylines? How would you feel if Alex ends up pregnant with Joel's baby? Do you think Charlie should move on and be with Dawn?
Share your thoughts below and stay tuned to find out when "Saving Hope" returns with the second half of Season 3.
This article was originally published on Examiner.com on November 1, 2014.
UPDATE (Summer 2016): 'Saving Hope' now airs on ION Television in the U.S. and still airs on CTV in Canada. Visit 'Saving Hope's' ION TV homepage (HERE) or CTV Homepage (HERE) for details.
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We outlined the connections Bill and Melinda Gates, The Bill and Melinda Gates Foundation, and Microsoft have to profits from prisons in Part 1 here. Now we will connect these practices to the impact on our schools and offer some ways for others to join in resistance.
How do these stories impact our schools?
Our schools and most vulnerable are starved as we see more spent on serving our prison populations than we do on our K-12 students. Meanwhile, Microsoft's tax evasion is creating budget shortfalls that also hurt our most vulnerable. We've connected the dots and you can follow the money.
But don't the people arrested deserve to be in prison? Why are we including prisoners in a group of what we call "our most vulnerable"? Aren't they guilty of major crimes against society?
He got one thing right. He definitely wears two hats.
Hat Two: Profiteer from Racism and Human Suffering.
It may not be possible for him to consider the inhumanity of unfettered capitalism. We need to expose this inhumanity, shifting public opinion to one that tarnishes the shiny media image he has created for himself.
"The prison populations in most US states are at historic highs. Prisons in 36 US states incarcerate three times as many people as they did in 1978. State prison systems account for 87 percent of the total prisoner population, or roughly 1.3 million in 2013 compared to about 270,000 in 1978. But even as states spend more on prison operations, they are spending less on education for children and young adults, particularly in high-poverty neighborhoods.
A new report from the Center on Budget and Policy Priorities (CBPP) paints a devastating picture of a polarized society in which the prison and police-military apparatus is being continually expanded while vital social programs are starved for funds. CBPP estimates that if state corrections spending had been held to mid-1980s levels, adjusted for inflation today the 50 US states would have about $28 billion more each year between them to allocate to non-prison related expenditures.
According to David Sirota and Jeff Reifman, Microsoft has dodged $29.6 Billion in US taxes and $8.16 Billion in WA State taxes through intentional, possibly illegal maneuvers.
"In June, the Washington State Supreme Court ordered the Legislature to appear on September 3rd to explain why it hasn't found the revenue to fully fund the education reforms required by its McCleary ruling, reportedly as much as $7.83 billion through 2019.
There are a variety of reasons the state has a huge education budget gap. After the 2008 recession, the Legislature cut $4 billion from K-12 and higher education spending, which helped absorb the costs of continuing tax breaks for corporations. While most states have an income tax to smooth revenue through downturns, voters rejected the creation of a progressive income tax in 2010. Then, last November, the Legislature awarded Boeing $8.7 billion in new tax breaks.
Locally, Boeing often takes a lot of flak for its tax breaks, but Microsoft has also played a central role in lobbying for tax breaks that cripple state education spending.
… Using the 50 percent figure, we can conservatively estimate Microsoft's savings from lobbying and dodging the state royalty tax between 1997 and 2014 at $5.34 billion. If we factor in interest and the Department of Revenue's typical 25 percent penalty on unpaid corporate taxes, that number jumps to $8.16 billion (see Scenario B).
This is more than enough to fully fund public education under the Supreme Court's McCleary decision.
… These are also ethical issues. Chairman Bill Gates, former CEO Steve Ballmer and General Counsel Brad Smith are all public education advocates. In 2003, then-CEO Ballmer famously admonished taxpayers "… to come to grips with the notion that we need to invest in higher education." Just not, it seems, corporate taxpayers.
Microsoft's tax evasions could fully fund McCleary, fully funding Washington State's basic education budget. Budget cuts caused by the tax dodging of Microsoft would benefit our most vulnerable citizens, including the GEO prison detainees. Microsoft has used prison labor for profit while laying off Microsoft employees. The Gates Foundation has invested in the GEO Prison Group, profiting from human misery.
How does the amount of funding per inmate compared to the amount of funding per K-12 student in Washington State?
Funding per inmate in Washington State: $46,897 per year.
Funding per K-12 student in Washington State: $11,328 per year.
Gates Microsoft tax revenues could work towards evening out the imbalance between what is spent on K-12 students vs what is spent on inmates as well. While we do not suggest treating prisoners inhumanely in any way, we do suggest that investing in education leads to an increase in incarceration. Doesn't it make sense to invest in our children up front to prevent incarceration?
The cuts to Washington State budgets create shortfalls that would otherwise fund our most vulnerable.
How has America's culture accepted this outrage? Chris Hedges explained in "The Death of the Liberal Class" how that death was caused by "visually emotive media". Our society is inundated with prison shows, normalizing prison as an "acceptable" part of our culture. Orange is the New Black is one of the most popular programs on Netflix. IMDb lists the Top 10 Prison TV Series. MSNBC sports LOCKUP with titles like LOCKUP Raw: Violence Behind Bars. Increasingly, the public keeps their ratings high, while the media/news corporations, Hollywood, Microsoft, and Bill Gates profit from this misery.
What can you do? Here are just a few ways you can help.
In an effort to push the Gates from his investments in GS4 Israeli prisons, Code Pink was successful in a global protest. Follow in Code Pink's footsteps with us.
"Bill Gates has sold off some of his shares in controversial British security giant G4S after the billionaire computer software magnate was criticised for his investment.
We need to increase exposure to Gates' propaganda and demand that he divest from profiting off budget cuts through tax dodging and prison labor profits connected directly to human misery. We have to knock Gates off his humanitarian pedestal by exposing the truth vs his propaganda.
The Washington Badass Teachers Association is hosting a protest on public property near Microsoft in Redmond, WA on Black Friday, asking people WORLDWIDE to join us to #BoycottMicrosoft. This direct action is intended to increase public awareness of the Microsoft tax dodging and their ties to prison labor, education cuts, and inhumane racist labor practices.
Join our protest – #BlackFriday #BoycottMicrosoft WORLDWIDE. You can make a huge impact by sharing our event and participating.
Bill Gates, Microsoft, Steve Ballmer: STOP DODGING TAXES: Pay your FAIR SHARE of taxes!
Donate to our #BlackFriday #BoycottMicrosoft GoFundMe to support the costs of artful resistance we have planned for our protest event. $5-20 adds up fast to crowd fund our resistance.
Sign up for our Facebook event here, even if you are not attending in person at the Redmond Microsoft location. If you are in the Northwest on Black Friday, join us here for an evening candlelight vigil protest from 5:30 – 7:30 pm.
Redmond, WA 98052. Follow the signs to the picket.
Do you have ideas on how to move Bill and Melinda Gates toward their own idealistic humanitarian image and away from their investments in racism and human misery? Share them in the comment section below.
**NOTE: We will discuss how the Microsoft tax dodging impacts other vulnerable people in future posts. This post does not begin to discuss the School-To-Prison Pipeline, which is part of the profit from human suffering and racism.


Given Saudi Arabia's traditionally conservative attitude towards entertainment, it might seem an unlikely country to host the World Wrestling Entertainment championships. So it will come as a surprise to many that this week Saudi Arabia signed a deal to host 'The Greatest Royal Rumble'.
The wrestling event will be held at the King Abdullah Sports City in Jeddah, on Friday, April 27 and will feature 50 of the sport's most famous fighters.
Big names like AJ Styles, Braun Strowman, John Cena, Triple H, Roman Reigns, The New Day, Randy Orton, Bray Wyatt and Shinsuke Nakamura are amongst those who will go head to head at the tournament.
This is the first ever 50-man rumble and expected to be bigger and more spectacular than ever before.
The deal is part of a ten-year partnership between the Saudi General Sports Authority and the WWE signed this week.
The partnership is in line with Vision 30, Saudi Arabia's social and economic reform programme, a government plan aimed at modernising the country. Already it has resulted in radical changes such as allowing women the right to drive and the right to attend events in sports stadiums.
The Saudi General Sports Authority meanwhile has already secured the rights to host the Formula One Grand Prix and the Super World Boxing Cup final this May.
Salem Alnaser, a representative of the Saudi General Sports Authority public relations department pointed out that this is not the first time the country has hosted a WWE event.


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Dr. John W. Bosman is the founder and president of both SpiritWind International and CMNi. He is the author of the Care Revolution book which is used as the textbook for developing care ministry in local churches.
Over the past fifteen years, John has launched powerful leadership networks in South Africa. He annually conducts major leadership conferences in that country where thousands of pastors and church leaders receive training and encouragement.
Born in Zimbabwe and raised in the Republic of South Africa, John entered into full-time ministry in 1970 and successfully pastored several churches in South Africa. John and his family immigrated to the United States in January 1986.
He served in both regional and national leadership roles within his denomination as well as serving as a member of the Board of Regents for a stateside university and a Bible College in Russia. He is also the founder of both the JWB Institute for Leadership and Laity Development and Hamilton Christian Academy.
John is a gifted speaker and often invited to minister at major church events and leadership conferences. He is also the author of various teaching manuals that assist pastors to help their people grow spiritually and equip them for ministry. Personally, John is married to Anne (also an ordained minister), has two sons, John & Jayce, a beautiful daughter in law and five grandsons.
Dr. Bosman wrote the first CMNi materials in 1990 in response to his association with Dr. Mel Steinbron. Since then, CMNi has been presented to many congregations as a tool for 'closing the back door' in churches around the world.
Dr. Randal Smith, in conjunction with his role in CMNi, is the co-founder and President of Clearpoint Coaching. He brings a wealth of experience to his role as a Leadership and Executive Coach. After 35 years of work in religious and non-profit arenas, Randal brings clarity and success to business and professional leaders and the organizations they serve.
Past experiences ranged from music performances in educational, academic and church settings to a 13 year career as an associate pastor for various churches in the mid south and midwest. One of his positions brought him to John Bosman's staff in the late 1980′s. In 1992, Randal became the Senior Pastor of First Assembly of God in Lynn, MA, a pastorate he maintained until 2014.
An accomplished public speaker, Randal has been in front of people his entire adult life. However, his gifts enable him to excel at working with people on a personal level and in seminar and conference settings. He leverages his past experience as president of a homeless services agency, denominational executive, pastor and educator to effect change and bring hope to a wide variety of people and organizations.
Randal is a certified coach and received a Doctorate in Professional Leadership and Coaching in 2016. Personally, Randal follows Boston's pro sports teams and KU basketball. He is the husband to Beckie and the proud father of two adult sons, a wonderful daughter in law and one grandson who live in the Boston area.
Randal introduced John to Mel Steinbron while on staff in Lake Charles. Together, they worked on some of the first iterations of the CMNi material at Glad Tidings. In 2015, they reunited to develop CMNi into a suite of resources, ministries and promotional materials to expand its impact.


America's global image today is complicated. On balance, people around the world continue to give the United States favorable ratings and say it respects the individual liberties of its people. More countries also prefer the U.S. as the world's leading power over China. At the same time, many express frustration about America's role in the world and say they have little confidence in President Donald Trump to do the right thing in world affairs, according to a new Pew Research Center survey of 25 nations.
1Western Europeans have strikingly negative views of Trump. In the United Kingdom, Germany, France and Spain – four nations the Center has consistently surveyed over the past 15 years – there is a clear pattern in public perceptions of U.S. presidents. People in these countries generally had little confidence in President George W. Bush to do the right thing regarding world affairs. Their confidence was much higher in Bush's successor, President Barack Obama, but it plunged following Trump's election in 2016. This year, confidence in Trump remains low in Germany, France and Spain – but it is up slightly in the UK. Of the 25 countries surveyed, a median of 70% lack confidence in Trump to do the right thing regarding world affairs.
2Views of the U.S. are favorable on balance, but concerns are evident. Across the 25 countries surveyed, a median of 50% have a favorable opinion of the U.S., while 43% have an unfavorable view. Likewise, a median of 51% say the U.S. respects the personal freedoms of its people, compared with 37% who say it does not. However, there is international concern about America's role in world affairs. Large majorities say the U.S. doesn't take the interests of other countries into account when making foreign policy decisions. Also, a global median of 37% believe the U.S. is doing less to help address major global problems than it used to.
3 People in other nations have long said the U.S. does not take the interests of their country into account when making international policy decisions. There have been some shifts over time, however. In 2007, near the end of the George W. Bush years, a 71% median across 14 surveyed countries said the U.S. does not take other countries' interests into account, while another 26% said it does. Attitudes shifted somewhat at the start of the Obama administration in 2009, when 36% said the U.S. considers other countries' interests – including much larger increases in certain countries, such as Germany (+27 percentage points), France (+23), the UK (+19), South Korea (+19), Canada (+18) and Russia (+12). Today, public sentiment in these 14 countries resembles that of 2007, with a median of 72% saying the U.S. doesn't consider other nations' interests and 27% saying it does.
4The U.S. receives some of its highest favorability ratings in Asia. Meanwhile, half or more in four of the five Asia-Pacific nations polled view the U.S. favorably, including 83% in the Philippines and 80% in South Korea – both among the highest ratings in the study (along with 83% in Israel). America's lowest rating came from Russia (26% favorable), which saw a 15-percentage-point decline in U.S. favorability over the past year – the largest drop among all surveyed countries. In America's neighboring countries of Canada and Mexico, 39% and 32%, respectively, have a favorable view of the U.S.
5 Western Europeans now say the U.S. does not respect the individual liberties of its people – a reversal from just a few years ago. Views shifted most notably in France, Germany, Poland, Spain and the UK – five countries that have been surveyed since 2008. Among these countries, more now say the U.S. government does not respect the personal freedoms of its people (a median of 57%) than say it does (40%). As recently as 2013, a median of 76% across these nations said the U.S. does protect individual liberties, while a median of 18% said it does not. The decline began after the National Security Agency's spying controversy during the Obama administration.
6 More say China is playing a larger role in the world compared with 10 years ago than say the same about the U.S. Respondents were read a list of seven major countries and were asked whether each is playing a more important, less important or as important role in the world compared with 10 years ago. Among the seven countries tested, China stands out: A median of 70% across 25 countries say it plays a more important global role than it did a decade ago, a significantly higher share than for the other six countries. The U.S. falls in the middle: Roughly similar medians say it is as important as 10 years ago as say its importance has grown.
7 People are divided in their perceptions of how powerful a role the U.S. plays on the world stage compared with 10 years ago. A global median of 35% say the country is as important on the world stage as before, while 31% say it plays a more important role and 25% say it plays a less important role. Individually, most countries say the U.S. role has either grown or remains as important as before. Around half or more in Nigeria (54%), Israel (54%) and Kenya (51%) say the U.S. has grown in power and influence.
Japan stands out as the only country where a majority of people think the U.S. plays a less important role than it did 10 years ago. Only 16% of Japanese think the U.S. has grown in influence, equal to the share of Germans who say the same.
America's neighboring countries offer different perceptions of America's current role in the world: While 46% in Mexico say the U.S. plays a more important role today, only 19% of Canadians agree.
For their part, Americans themselves are divided on their own influence in the world, with nearly equal shares saying their country plays a more, equal or less important role than 10 years ago.
8America is seen as the world's leading economic power. People in the surveyed countries tend to see the U.S. as the world's leading economic power, though only by a slim margin over China (medians of 39% and 34%, respectively). Views vary somewhat by region. The U.S. is seen as the top economic power in all three Latin American countries – Brazil, Mexico and Argentina – and in nearly all Asia-Pacific countries surveyed. In sub-Saharan Africa, Kenyans name the U.S. as the world's top economy, while Nigerians and South Africans name China (though margins are slim in these countries). Europeans are also divided: Those in several countries, including the Netherlands and Germany, choose China, while those in several others, including Hungary and Italy, choose the United States. Germany stands out for its large increase in the share who now name China as the globe's dominant economy.
9 Most people prefer America over China as the world's leading power. While many people believe China currently is the world's top economic power, a median of 63% across the nations surveyed say having the U.S. as the world's leading power would be better for the world. In contrast, just 19% say a world in which China was the leading power would be better.
In the Asia-Pacific region, more prefer U.S. leadership over China. Preference for America is particularly high among China's nearest neighbors: 81% of Japanese, 77% of Filipinos and 73% of South Koreans favor Washington's leadership over that of Beijing.
Indonesia, Italy, Argentina, Russia and Tunisia are the only countries surveyed where about four-in-ten or fewer prefer U.S. leadership. Tunisia's preference for China is particularly pronounced: It is the only country where a clear majority (64%) says having China as the world's leading power would be better for the world.
In many countries, preference for U.S. leadership is linked to ideology, with those on the ideological right more likely than those on the left to prefer America as the world's dominant power.
Correction (Jan. 4, 2019): Item No. 2 of this post and the graphics for items 6 and 7 have been corrected to reflect a revised weight for Australia in 2018. These changes do not materially change the analysis.


Business Management Homework Help Explain each legal act Recently, several workers have approached you with questions regarding the Americans with Disabilities Act (ADA), Age Discrimination in Employment Act (ADEA), the Equal Pay Act (EPA) and the Fair Labor Standards Act (FLSA). In order to address these questions, you have decided to prepare a presentation that clarifies how each of the acts applies to the organization. For this assignment, you will create a PowerPoint presentation of at least 10 slides with at least 200 words of speaker notes per slide. You should also research and utilize at least 2 academic sources in your presentation. For each of the following acts, provide a summary of the act, a real word example of how the act was violated, the role of the EEOC in and what the organization can do to ensure compliance with the act. Americans with Disabilities Act (ADA) Age Discrimination in Employment Act (ADEA) Equal Pay Act (EPA) Fair Labor Standards Act (FLSA) Please submit your assignment. For assistance with your assignment, please use your text, Web resources, and all course materials.


At Trove Studios, our goal is to help you tell your story – we say as much on our home page. Even if you're not quite sure what it is, we want to help you find it. When creating a video, thinking about what it should say is very important – and one company that does this incredibly well is Pixar Studios. Responsible for funny, emotional, captivating stories, we think they could teach all of us a thing or two about their narrative process.
A memorable and meaningful film tells a story. This can seem easy with movies, because they have easily identifiable plots, characters, settings, and conflict. If your project is a short film in that vein, this is easier to do. However, this can be harder to see when you're telling the story of a family event or your business. What can you do to ensure that the story your film tells is one that people want to watch?


for $218,000 with 3 bedrooms and 1 full bath, 1 three quarter bath. This 1,263 square foot home was built in 1975 on a lot size of 8523.00 Sqft.
Great home on a large lot with RV gate. New Carpet and paint throughout. Roof was replaced in 2015. Large storage/laundry room and two storage sheds outside.


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The late Steve Jobs was said to possess a "reality distortion field," a charisma that got people to jump through walls for him, and drew capital to him, even when results weren't going his way.
But who has the biggest reality distortion field today?
It's clear that many tech companies don't have one. Microsoft doesn't have one. Intel doesn't have one. Hewlett-Packard and Dell don't have them.
But some companies do, and here we'll discuss why, with some hints as to what you can do to profit from them.
The oldest reality distortion field in technology belongs to Oracle Corporation (NASDAQ:ORCL) and its living Guy Fawkes mask, CEO Larry Ellison.
Oracle has successfully used its dominance of database technology in ways Microsoft could only dream of. Revenues are up four-fold since 2003, from $9.48 billion to $37.12 billion. Profits have risen in line with that, from $2.31 billion in 2003 to $9.98 billion in its most recent fiscal year, which ended last May.
All this has given Ellison enormous street credibility, which he's used to buy out competitors, raise prices on customers, and continue on his proprietary path.
Ellison's biggest risk was the purchase of Sun Microsystems, announced in 2009. remains his biggest bet. It made Oracle Corporation (NASDAQ:ORCL) a hardware company, and that has been a drag on results since. It made Oracle the largest sponsor of open source in the world, and Oracle antagonized that community in response. Yet since then net income has grown even faster, 62%, than revenue, 41%.
All this has created a substantial reality distortion field that obscures the fact that Oracle is missing the biggest technology turn of the decade, cloud computing. The "Oracle Cloud" consists of high-priced Sun servers and proprietary Oracle Corporation (NASDAQ:ORCL) software, not the commodity products which deliver savings people are looking for.
Say that, however, and get ready to be flamed. I'd say that's a substantial distortion field you have there. It protects Oracle's stock price, up almost 16% over the last year, but that price is starting to meet resistance, especially after what most consider a disappointing earnings report for February, with flat revenue and lower net income. Investors are paying 15.34 times those earnings for Oracle Corporation (NASDAQ:ORCL) shares, but if the company fails to deliver in the current quarter, ending next month, the curtain will have been pulled behind the wizard, and the fall could be harsh.
Since becoming CEO of Google Inc (NASDAQ:GOOG) in April 2011, co-founder Larry Page has presided over the growth of both a company and a legend that rivals Jobs' own legend.
Over the period sales are up 40%, net income about 20%, but few seem concerned about that deceleration. They blame the acquisition of Motorola last year, which was considered necessary in order to acquire patents to key mobile technologies, protecting its Android mobile operating system.
But those patents have proven ineffective in court. Motorola has indeed had its negative effect on margins, but it hasn't helped Google Inc (NASDAQ:GOOG) prevent a further fracturing of the ecosystem. Amazon's Kindle might as well not be an Android at all. Samsung, the key OEM, is experimenting with its own new OS, Tizen. The Chromebooks that seemed to be a coup are turning into an anchor around the company.
Google's strategy advantage remains in place. Its cloud is the most cost-effective way of doing anything on the Internet, because it uses commodity servers, recycles energy, and owns its own fiber. But other companies now know the recipe, and are eating into that strategic advantage.
Right now, investors are willing to pay 24 times the last 12 months' earnings for Google stock. They are expecting exceptional acceleration on both the top and bottom lines. Google is preparing to run out its biggest risk yet in Google Glass, which has long been pushed by co-founder Sergey Brin.
My view is that this is a game Google Inc (NASDAQ:GOOG) will lose, and perhaps deliberately, because losing would discredit Brin and leave Page alone at the top. If you own Google shares during this next year you are in for a bumpy ride, because the promised acceleration in results just isn't coming for you.


Warren Buffett and Mitt Romney have managed to create one of the enduring myths of our tax debate: that the rich pay a lower rate than the rest of America.
This may be individually true. Buffett pays a lower rate than his secretary and Romney pays a lower rate than most of us who make our living from salaries.
But nationally, the tax code is still broadly progressive. The more your make, the more taxes you pay as a percentage of your income.
Put another way, millionaires pay a rate that's more than four times that of the middle class.
One caveat: Rates go up as income goes up — but only to a point. Once you hit a certain magic number among super-high earners, your tax rates start to fall slightly.
According to the IRS, average tax rates increase as income increases — until you get to around $1.5 million in annual income. Once you make $2 million, average tax rates start to decrease. The average tax rate peaks at 25.1 percent for those making between $1.5 million and $2 million.
After that it starts to go down, and falls to 20.7 percent for those making $10 million or more.
The reasons for this aren't complicated. Once you get above $2 million, your share of income from investments increases. Investments are generally taxed at the 15 percent capital-gains rate, compared with the top ordinary-income rate of 35 percent.
Those making $10 million or more earned nearly half of their income from capital gains and dividends.
Rates don't fall all that much once you get above $10 million. Even among the top 400 earners in America, whose average income is more than $200 million, the average rate is 18 percent — still more than three times the rate paid by the middle class.
Both sides of the current political debate on taxes will no doubt see these data differently. The right will say that the rich already pay more than their fair share, while the left will point to the low rates paid by the wealthy relative to the official tax rates.
But the figures show that the more you make, the more you pay — up to the Top Turning Point.


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From technology to globalization, today's successful companies must adapt to, and embrace, rapid change to be successful. The business world is competitive and constantly evolving, making it imperative that organizations are using the best technology solutions. Companies are operating using combinations of solutions from a range of suppliers, alongside legacy, in-house, or out of date software. This makes it difficult to get a clear picture of the company's IT operations. Without a clear picture of the network's operations, or the service quality that's being delivered to customers, it's much more difficult to respond to changes in the business, an increase in user demand or new technologies being implemented.
Nearly 90% of all organizations use open technology and it's driving innovation.
Open technologies have become incredibly widespread over the past few years, used by a hugely diverse range of businesses in every sector. Appnovation uses open technologies to collaborate and work with our partners to help our clients achieve and do more with the tools and platforms that we provide. One of our core company values is Openness, and we know that openness has a significant impact on the business which is why we are committed to knowledge sharing, contribution, and informed decision-making. Our cross-functional team members encourage dialogue, assume the best in each other and consistently act with good intentions.
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Rich in reds, yellows, greens, and browns, the fall foliage of Japan has been called the most beautiful in the world. The best time to view them varies across Japan, but is generally between October and November. We will show you places where the leaves reflect in placid lakes and ponds, as well as places where they provide a beautiful backdrop to traditional Japanese houses, temples, and shrines.


Spectrum RV dealers share our passion for contemporary design, innovation and finesse. They are comitted to fulfilling the current market demand for modern RV's, designed with today's current residential interiors.
Not every dealer qualifies for such exclusive luxury. We have selected only a few who qualify with sales and service support to match our products. Although limited in number you can find a dealer within travelling distance who can show you all the unique features of our products. Never before has such effort been put to innovation and component selection. Our dealers know how to support our products well and have the expertise to offer you the decor choices that you really want.
While most manufacturers spend time rearranging floor plans, we put effort into real choices for you the customer. Never before have so many decors and options been available to match your every wish. Matched with the efforts of professionaly paid designers you can be assured the look and feel of your RV will add value long into the future. You can even change the decor easily as fashions change. Ask your dealer for details.
Not every salesperson knows how to truly configure a unit to suit your needs Our dealers will ask all the right questions to make sure you get the right floor plan that will suit your needs well into the future. Since your Spectrum RV's design life is between 25-50 years you may need to think about who you will pass it along to.
All Spectrum Dealers are trained in the latest methods of servicing high tech components and can adjust to exacting levels the beautiful decors.
Your sales professional can walk you through the many customizations you can choose. Never before have you been able to choose so many options. Your dealer can even modify your decor while you wait. Need to configure more than the cabinets and the furniture, you can order yours with changed countertops and flooring as well.
Total satisfaction is our goal. Together with our dealers we can bring you an experience unequalled in the RV industry. If for some reason you are not happy with our product or dealer service, we will all work to rectify the problem and make changes so that we can constantly improve. We appreciate your feedback and welcome your suggestions. Remember that our people use the RV's we sell so we have first hand experience and it is what drives us to just keep getting better.
Most manufacturers give you a long list of component manufacturers to call when you have problems. We ask that you give your dealer the first call and once we hear about the problem we commit to provide the parts to the dealer in a hasty manner. This along with the dealers priority schedule will get you back on the road in comfort just as soon as is practically possible.
Of course we believe that the high quality components will not let you down, but it the unlikely event that they do we will respond as quick as we can. Since we have upgraded most all of the components, the chances of you having a problem is greatly reduced.
Many have commented that for the quality our prices seem very reasonable. Our philosophy is simple, we believe that if you build great quality at a reasonable price then customers will line up at your door. We deliberatly chose to keep our prices sharp so the greater majority of quality minded customers are able to afford our units.
How do we do the quality for the price? We have developed efficient ways to build to a high standard. A whole lot of on the job training our our professional staff along with great supplier support we have been able to keep our quality up and our prices down.
Prices are approx MSRP and will change according to the options you select.
Dealers are located in each corner of the country. Due to the specialized nature of our fifth wheels, we have a few select dealers around the country. Each one is hand selected for their comittment to servicing at a high level of customer satisfaction. You may have to travel to get to one, but isn't it better to know you have it done right. We trust that your servicing experince will be just as grand as your ownership of your Spectrum RV.
So give your dealer a call today and find out what they can do to make your dreams come true..


I likened myself to the Moon.
She's always there and her energy waxes and wanes. When she's full, she is a force to be reckoned with. When she's in her phases, she's still whole even in the darkness. Steady and true to herself, and giving, always giving.
Tho, I do ask myself, does she ever tire like I get exhausted? Does she have that point in her time where it hurts to shine, when you have to shine? Because it is bravery with a smidgen of insanity to take in the sun in full force. Then other times, it's effortless to share the brightest moment in your time. Does she say, "Sweet Jesus, I survived" and weeps quietly when she's crescent or does she yearn to shine fully when she's in that slim curvy silver phase?
Or is the Moon just an inanimate object who puts too much value in herself? May be so? Is she jealous of stars for their abilities to shamelessly burn brightly and then rip themselves from the sky and free fall?


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In the heart of el Borne, very close to the cathedral Santa Maria del Mar (also featured in the very popular Netflix series Catedral del Mar), we can offer you the last 4 apartments (1 apartment and 3 penthouses) that are in the process of complete rehabilitation in a "finca regia" from the 1900s.
The finishing is of the highest standard and the original elements have been preserved throughout all the building.
The finca is located in a quiet street which gives you the opportunity to enjoy all El Borne has to offer in a quiet location.
- Apartment with 4 bedrooms and 2 bathroom. Price: € 645,000.
El Born or Sant Pere, Santa Caterina i La Ribera is a rich architectural landmark, as it features Santa Maria del Mar, the Mercat de Santa Caterina, the Mercat del Born, the Estació de França and is now a chic area, discovered by artists, antiquarians and entrepreneurs with an array of lounge bars, cafés, hidden squares, gourmet restaurants and entertainment venues.