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CAKE & PIE POST (AAO 2020 Virtual Edition) - Issue 4
& cataract • anterior segment • kudos • enlightenment
11 | 16 | 20 posterior segment • innovation • enlightenment
C A K E A N D P I E M A G A Z I N E S ' D A I LY C O N G R E S S N E W S O N T H E A N T E R I O R A N D P O S T E R I O R S E G M E N T S
HIGHLIGHTS patients first 04 Putting can lead to a jackpot post-cataract surgery outcomes.
06 Ophthalmologists discussed how technological advancements can help drive the road to perfection! share tips in 09 Experts managing unhappy patients.
Matt Young CEO & Publisher
Robert Anderson Media Director
Hannah Nguyen Production & Circulation Manager
Gloria D. Gamat Chief Editor
Brooke Herron Editor International Business Development
Ruchi Mahajan Ranga Brandon Winkeler
Recognizing and Overcoming Burnout by Brooke Herron
unning an ophthalmic practice in a normal year can be stressful — and we can all agree that 2020 has not been a normal year.
The COVID-19 pandemic has caused massive changes in ophthalmic practice. Throughout the year, clinics have had to manage closures, restrictions, added safety measures — as well as ensure patients continued to be monitored and treated.
a definition of burnout from Dr. Michael Johns, which says "burnout is a consequence of an adverse work environment, period." Cont. on Page 3 >>
HOTSHOT
Andrew Sweeney Elisa DeMartino Hazlin Hassan Olawale Salami Sam McCommon Maricel Salvador Graphic Designer
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We all have stress — and likely have experienced burnout, particularly this year. Therefore, an AAOE plenary session called Keep the Fire Lit: Strategies for Preventing Burnout was held on the last day of AAO 2020 Virtual. During the session, panelists Robert Melendez MD, MBA, and Marilyn Ponder DBA, discussed common stressors in daily practice and how to create a workplace with improved team dynamics and reduced stress.
What is burnout? Opening the session, Dr. Ponder borrowed
Now everyone wants a Virtual Vegas Vest! That's ok. Brandon, Matt and everyone at Team Media MICE wish you all the vest as 2020 comes to an end, vinylly!
16 Nov 2020 | Issue #4
Chec OCT k Diana resu lts.
OZURDEX® has multiple modes of action,1–3 a low treatment burden4–7 and a manageable safety profile.6–8
TRY DIFFERENT LETTERS IN YOUR PRESCRIPTION FOR DME
DME, diabetic macular edema; OCT, optical coherence tomography. 1. Nehmé A and Edelman J. Invest Ophthalmol Vis Sci 2008;49(5):2030–2038. 2. Holekamp N. The role of corticosteroid implants in DME. Available at: http://retinatoday.com/2015/04/ the-role-of-corticosteroid-implants-in-dme. Accessed March 2020. 3. Campochiario PA et al. Am J Ophthalmol 2016;168:13–23. 4. Malclès A et al. Retina 2017;37(4):753–760. 5. Matonti F et al. Eur J Ophthamol 2016;26(5):454–459. 6. Aknin I and Melki L. Ophthalmolgica 2016;235:187–188. 7. Allergan. OZURDEX®. Summary of Product Characteristics. October 2019. 8. Boyer SB et al. Ophthalmology 2014;121(10):1904–1914.
INDICATIONS & USAGE: OZURDEX® contains a corticosteroid indicated for the treatment of macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO), for the treatment of non-infectious uveitis affecting the posterior segment of the eye, and for the treatment of patients with visual impairment due to diabetic macular edema (DME) who are pseudophakic or who are considered insufficiently responsive to, or unsuitable for non-corticosteroid therapy. DOSAGE & ADMINISTRATION: For ophthalmic intravitreal injection only. The intravitreal injection procedure should be carried out under controlled aseptic conditions. Following the intravitreal injection, patients should be monitored for elevation in intraocular pressure and for endophthalmitis. DOSAGE FORMS & STRENGTHS: Intravitreal implant containing dexamethasone 0.7 mg in the NOVADUR™ solid polymer
drug delivery system. CONTRAINDICATIONS: Ocular or periocular infections. Advanced glaucoma. Aphakic eyes with ruptured posterior lens capsule. Eyes with ACIOL, iris or transscleral fixated IOLs and rupture of the posterior lens capsule. Hypersensitivity. WARNINGS AND PRECAUTIONS: Intravitreal injections have been associated with endophthalmitis, eye inflammation, increased intraocular pressure, retinal detachments, and implant migration into the anterior chamber. Patients should be monitored following the injection. Patients who has a tear in the posterior lens capsule (e.g., due to cataract surgery), or who had an iris opening to the vitreous cavity (e.g., due to iridectomy) are at risk of implant migration into the anterior chamber. Use of corticosteroids may produce posterior subcapsular cataracts, increased intraocular pressure, glaucoma, and may enhance establishment of secondary ocular infections due to bacteria, fungi,
or virus. Corticosteroids should be used cautiously in patients with a history of ocular herpes simplex. ADVERSE REACTIONS: In controlled studies, the most common adverse reactions reported by 20–70% of patients were cataract, increased intraocular pressure and conjunctival haemorrhage. Licenses may vary by country, please consult your local Summary of Product Characteristics. Adverse events should be reported to your Ministry of Health and local Allergan office. Date of preparation: March 2020 INT-OZU-2050060 OZURDEX® is not licensed for use in DME in China.
CAKE and PIE magazines' Daily Congress News on the Anterior and Posterior Segments
>> Cont. from Page 1
Burnout is a syndrome that results from chronic stress at work and has several consequences to workers' well-being and overall health, she continued, adding that it can also lead to physical consequences like diabetes and heart disease, as well as insomnia and depressive symptoms. However, it can also have professional consequences, including job dissatisfaction, absenteeism and poor performance. "Burnout is linked to mental health — and a 2018 survey found that 46% of ophthalmologists felt burnout, depressed or both," said Dr. Ponder, adding that these issues can be further exacerbated by the pandemic. "Burnout is a threat for us, our patients and our organizations," she continued. Symptoms of burnout include: exhaustion, cynicism, low sense of personal accomplishment, depersonalization, poor judgment and guilt.
So, who is the most burned out? According to a MedScape survey, women physicians are more likely to experience burnout (48%) compared with men (37%). Young parents are also more likely to experience burnout, as well as young physicians under the age of 55. And of all the specialties, 30% of ophthalmologists report burnout — and while that's not the highest number, Dr. Melendez says it's still way too high. Dr. Melendez says if employees are exhibiting symptoms of burnout, there's one important question to ask (if the problem is professional): "What resources do you need to be successful?" He says this question shows empathy, and that most people might respond with something simple. "You need to pinpoint the problem. Often times people will beat around the bush and not be specific, so you have to ask them 'what specifically is frustrating you?'" "Burnout is something that creeps up on you," added Dr. Ponder. "Genuine burnout leads to an inability to successfully function on a personal, social and professional level. It steals
hope and squashes motivation… and burnout is a leading cause of job dissatisfaction."
What contributes to burnout? Dr. Melendez shared a list compiled from a MedScape survey listing numerous reasons for burnout. Among the top five were: too many bureaucratic tasks (55%); spending too many hours at work (33%); lack of respect from administrators, employers, colleagues or staff (32%); increasing computerization of practice (30%); and insufficient compensation or reimbursement (29%). "The most important organizational factors that may lead to burnout are working too many hours and doing too many tasks," he said. "And we've all noticed with COVID, that we're having to do more with fewer staff, fewer resources...a lot of us are doing two or three jobs, but that's only going to last for a certain period of time." He says leaders should communicate with their teams that let them know that this is not going to last forever, and they will get through it. "For me personally, poor quality of communication at work is key to leading to burnout," shared Dr. Melendez. And overall, the importance of communication at all levels was stressed as an important factor in avoiding burnout.
How can you reignite that fire? "We want to focus on engagement — which is typically the opposite of burnout. Engagement is a state of enthusiasm, characterized by belonging, pride and loyalty. This fosters a mutually committed relationship between physicians and organizations," said Dr. Melendez. Part of this is fostering emotional intelligence (EI), which is the ability to recognize, understand and manage your own emotions; and to recognize, understand and influence the emotions of others. "I find the application of EI in the workplace to be very practical, not just theoretical," said Dr. Ponder. "For leaders, having emotional intelligence is essential."
There are five elements to the theory of EI, according to Dr. Ponder. These include self awareness, self regulation, motivation, empathy and social skills. So, how do physicians cope with burnout? Dr. Melendez presented another MedScape survey on this topic. These were the top coping mechanisms: isolation from others (45%); exercising (45%); talking with family and friends (42%); sleeping (40%); eating junk food (33%); and playing or listening to music (32%). Another way to cope with burnout? Dr. Melendez suggests getting back to your "why." That is, "why you do what you do." He then showed a video of a child getting glasses and seeing for the first time — and that smile is the "why" for many ophthalmologists. "When you're operating on your 'why' everyday, it's hard to be thrown off your game." Dr. Ponder then suggested some things to help alleviate burnout. "Start with the things you have control over. Be cautious not to take on more than you can reasonably accomplish. It's essential that you delegate tasks when appropriate — it moves stuff off of your plate and it helps the other grow." She also highlighted the importance of exercise and eating well, and getting enough sleep. "Take responsibility for your actions, rather than placing blame. Lead when the opportunity presents, and forgive others," shared Dr. Ponder. "I would also add that burnout can be avoided if we work to take care of ourselves and create work environments that encourage open communication and promote work-life balance," concluded Dr. Ponder.
Hitting the Jackpot with Refractive Cataract Surgery
by Olawale Salami
Patients are continually demanding a better quality of life with the best possible vision after cataract surgery, and satisfying this demand was the theme of presentations and discussions during Symposium 48 on Day 3 (Sunday, November 15) of the AAO 2020 Virtual. Below are some of the highlights...
My patients are falling… but not for me "By offering refractive cataract surgery, we can help prevent these falls and reduce morbidity and mortality in our patients," said Dr. Daniel Chang of the Empire Eye and Laser Centre (California, USA). In routine cataract surgery, we start by extracting cataracts, and then we use glasses to correct astigmatism and presbyopia, noted Dr. Chang. "But in refractive cataract surgery, we try to do all these at the same time, surgically. Therefore, we should ask ourselves, what is the added advantage... does refractive cataract surgery offer convenience for the patient," he asked the audience. "When we think about the option of refractive surgery in each patient, we try to weigh the risks and benefits," shared Dr. Chang. Fundamentally, presbyopia treatment for each patient is not optional and will be treated either surgically or with glasses. "We consider convenience, patient satisfaction, safety, and quality of life from the surgical perspective, but we worry about the quality of vision, cost, night-vision symptoms and operating time," he explained. On the other hand, glasses, benefits include noninvasiveness, adjustability, and fashion, but risks include limited peripheral vision, depth perception, nose/ear irritation and edge contrast sensitivity, Dr. Chang elaborated.
The rising cost of falls According to Dr. Chang, the loss of edge contrast sensitivity and depth perception increases the risk of falls in patients using bifocal glasses. In the elderly, this is a particularly essential data that suggests that over a third of falls in the elderly are attributed to depth perception problems with bifocal glasses. These multifocal glasses-related falls result in over 250,000 hospitalizations and over 10,000 deaths. Those patients who are not injured develop post-fall anxiety syndrome. Overall, the impact of multifocal glasses-related falls in the United States is about 10 Billion USD every year. Modeling has shown that if we adopted universal surgical correction of presbyopia in all patients, these would result in annual cost savings of about 14 Billion USD.
The unhappy patient "Inevitably, we may still end up with some unhappy patients. For these, it is important to assess for possible occult
macular pathology," said Dr. Russel Swan, adjunct assistant professor at the University of Utah (USA). In the world of refractive cataract surgery, there are so many happy patients, according to Dr. Swan. However, occasionally, we find a patient who has some degree of frustration, and we want to find a way to turn this frown into a smile, he emphasized. "Identifying patients who will be poor candidates for refractive cataract surgery goes a long way in reducing patient frustration," explained Dr. Swan. There are many reasons for this, like irregular astigmatism or higherorder corneal aberrations or occult macular pathology. Preoperative testing should include topography, ACT, tear film analysis, aberrometry, K's, and lens analysis. "If we identify irregular astigmatism with a curable cause, such as Salzmann's nodular degeneration, we can improve their higherorder corneal aberrations by repairing this or performing pterygium repair before cataract surgery," added Dr. Swan. Preoperatively, according to Dr. Swan, it's also necessary to explain to patients that lenses have clarity and flexibility characteristics. Therefore, the limitations of glasses after cataract surgery must be well explained, vis-à-vis patients' lifestyles to understand their postoperative expectations. "Intraoperatively, some factors could be considered to improve patient satisfaction. These include the precise capsulotomy technique and the use of intraoperative aberrometry,' Dr. Swan explained. "Overall, by far, the most common cause of low patient satisfaction is an uncorrected refractive error. Secondly, ocular surface diseases, like dry eyes, represent important causes of low patient satisfaction, which can be easily treated with medications and environmental modifications to maximize patient comfort," he added.
Pearls For Complicated Phaco Cases by Hazlin Hassan
n this dynamic rapid-fire session on the final day of the American Academy of Ophthalmology annual meeting (AAO 2020 Virtual) on Sunday (November 15), several experts presented their top five pearls for managing complicated cataract cases or situations. Dr. Jessica Ciralsky's top five pearls for dealing with phaco with uveitis are: identify the underlying etiology, plan ahead for surgery, control the iris, choose your intraocular lens (or lack of) wisely, and actively manage corticosteroids. The associate professor from Weill Cornell Ophthalmology (USA), said one must first know the cause of uveitis. "Rule out infectious uveitis and control the underlying problem," she said. There should be a period of quiescence before the surgery, of at least three months although six months is often preferable. When planning for the surgery, other pathologies should also be ruled out. Dr. Ciralsky advised having a surgical plan and a back-up plan, adequate anesthetic, and a contingency tray ready with iris hooks, rings, capsular tension ring, and capsule scissors. In choosing an IOL, she prefers to use acrylic lenses, and avoids silicone and multifocals. Oral steroids are often dosed at 1 mg/ kg typically starting 3 days prior, and tapered over one month depending on severity or response. She added that she was also "aggressive" with postoperative topical steroids, tapered over two months, topical NSAID for a few months and topical mydriatic for two weeks post-op. Subtenon's or intraocular steroids may be considered if oral steroids are contraindicated.
IV anti-VEGF drugs and steroids can be combined with cataract surgery and are effective if diabetic macular edema (DME) is still present, he added. Finally, managing CME post-cataract surgery initially consists of topical NSAIDs, and can be combined with steroids. Douglas J. Rhee MD, professor and chair, Department of Ophthalmology and Visual Science, University Hospitals Eye Institute, Case Western Reserve University School of Medicine (USA), presented his pearls on how to manage phaco with glaucoma.
Professor Rudy Nuijts MD, president of the European Society of Cataract and Refractive Surgery (ESCRS), shared his pearls on preventing and managing cystoid macular edema (CME). In a European multicenter trial of the prevention of CME after cataract surgery in nondiabetics, 914 patients were randomized to three treatment groups: bromfenac, dexamethasone, and a combination of the two. The incidence of CME within 12 weeks was highest in the dexamethasone group at 8.5%, and 41.% for bromfenac. The odds of developing CME were lowest in the combination group at 2.3%. "Patients treated with a combination of topical bromfenac and dexamethasone had a lower risk for developing clinically significant macular oedema (CSME) after cataract surgery than patients treated with a single drug," he said. Another randomized controlled European multicenter trial on the prevention of CME after cataract surgery in diabetics involving 213 patients found that a subconjunctival Triamcinolone Acetonide (TA) injection effectively prevents the development of CME. "In diabetic patients without diabetic retinopathy, we treat as in routine cataract surgery: a combination of NSAIDs and steroids," he advised.
Indications on when to add glaucoma surgery versus phaco alone include uncontrolled intraocular pressure, or when IOP is controlled but requires three or more medications, a high risk for IOP spike for example pseudoexfoliation, or when there is a high risk for loss of central fixation. He recommends using iris hooks or Malyugin rings. "I have rarely regretted using iris hooks or the Malyugin ring. I have nearly always regretted not using iris hooks or the Malyugin ring when I thought it might be helpful," he said. With minimally invasive glaucoma surgery (MIGS), there is no change in surgically-induced astigmatism if using the main cataract wound or paracentesis for the MIGS procedure. With trabeculectomy and tube shunts, there can be surgically-induced astigmatism, and hyperopic shift. "Avoid multifocal IOLs in patients with glaucoma," he suggested. This is because multifocal IOLs degrade contrast sensitivity. Glaucoma also degrades contrast sensitivity. Even in early stage glaucoma, it is not assured that the patient will not progress. Finally, Dr. Rhee said that topical NSAIDs must be used if the patient is on a prostaglandin analogue (PGA) as topical PGA use can increase the risk of post-op CME. "Anecdotally, post-operative topical NSAID use can decrease the rate of postoperative CME," he said.
Technological Advancements in Ophthalmology by Elisa DeMartino
he last day's afternoon session of AAO 2020 Virtual titled 20/20 in Focus: How Technology WIll Bring Us Closer to Perfection was a wonderful hodgepodge review of technological advancements in ophthalmology over the last 10 years. With each presenter packing as much information as possible into only three minutes of allotted presentation time, it felt somewhat akin to new technology speed dating. Unlike many of the technology focused meetings during this weekend's conference this talk was not in any way corona related. "This title was chosen before COVID," discussion leader Dr. Jesse Berry, assistant director of Ocular Oncology at the USC Gayle and Edward Roski Eye Institute and Children's Hospital Los Angeles, explained, "otherwise it might have been 'How technology will help us survive in 2020.'" Because the virtual meeting was co-sponsored by the Young Ophthalmologists Committee, speakers focused on information that might benefit a physician who is still in the early years of their career.
Medical innovations in ophthalmology Professor Jodhbir Mehta of the Singapore National Eye Centre (SNEC) presented first with an eye-opening demonstration about trends and developments in corneal transplant procedures. He explained how EK has overtaken PK as the most popular technique and that the future of conceal transplants lies in selective cell therapy. Next, Dr. Raymond Douglas, director of Kellogg's Thyroid Eye Disease Clinic (USA), broached the topic of proptosis in thyroid eye disease. In particular he evidenced the use of the medication Teprotumumab as an effective treatment without any serious adverse side effects according to case studies.
Dr. Anne Coleman, director, UCLA Mobile Eye Clinic (USA), followed with her short lecture on why injectable and sustained release drugs are superior to topical eye drop medication in glaucoma management. She elaborated that it is a lower cost option, it ensures that patients won't avoid or forget their medication regimes, and it circumvents ocular surface disease associated with long-term exposure to medications. During this rapidfire discussion the spotlight also fell on Dr. Martine Jager (professor of ophthalmology, Universiteit Leiden, The Netherlands), Dr. Audina Berrocal (professor of clinical ophthalmology, University of Miami Health System, Florida, USA), and Dr. Marcus Ang (Singapore National Eye Centre) who described technological developments in minimally invasive precision prognostics for melanoma and retinoblastoma, gene therapy for inherited retinal disease, and myopia imaging techniques, respectively.
Modern considerations The next four speakers tackled subjects that, while often trending nowadays, are not frequently discussed in the specific context of ophthalmology. Dr. Thomas Lee (associate professor of clinical ophthalmology and director of the Vision Center Children's Hospital Los Angeles (CHLA), California, USA), opened his segment with some words of advice. "As you get on in your years you'll find that it's very easy to stay in your comfort zone; the purpose of this talk is to make sure you continually push yourself out of that throughout your career." This mindset is how he created a program to treat premature retinopathy
in Armenian youth by using telemedicine to instruct ophthalmologists there about treatment and surgical procedures. Ophthalmologist-in-Chief of Wills Eye Hospital Dr. Julia Haller, proceeded to inspire us with words of advice but also of warning for women in medicine. Telemedicine and e-care offer flexibility for women to maintain a busy clinical career, and remote mentoring opportunities for females present increasing opportunities for guidance; despite this, "in 2020 women have lost ground on previous leadership gains despite the technology that allows us to move work home and to juggle our time schedules." Dr. Michael Abramoff (Robert C. Watzke professor of ophthalmology and visual sciences at the Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, USA), stepped up to give a rundown on the ethical principles of autonomous AI and how it can be applied to better the lives of patients, meanwhile cautioning that assistive AI can sometimes result in worsened outcomes if not rigorously validated. Finally, Dr. Michael Chiang (associate director of the OHSU Casey Eye Institute, USA) demonstrated how big data has set the stage for knowledge discovery in ophthalmology, particularly in the development of the AAO's IRIS Registry in 2014. He suggested that challenges to data collection might include accurate and quick capturing of data as well as harmonization of documentation standards across providers. The discussion closed with an inspiring Q&A, led by Dr. Arvind Saini (ophthalmology specialist in Escondido, CA, USA), focusing on ways young ophthalmologists might further their career. Panelists posed career oriented questions to one another and contributed some words of wisdom learned throughout their many years of experience.
AAO 2020 Exhibitor Showcase Reporting on the newest products and launches from ophthalmology's leading companies by Brooke Herron
Calling all Cataract Surgeons Cataract surgeons take note: The Cassini Ambient has arrived. Showcased at the Cassini Technologies AAO 2020 Virtual exhibition, this device is described in their featured video as the "confidence game-changer that has transformed practices." The Cassini assesses ocular surface stability, measures the posterior cornea, and detects corneal irregularities with LED topography. It boasts comfortable illumination, FLACS connectivity, and automated transfer of patient data, corneal information and iris registration — creating what Cassini calls "a formidable connection." The Cassini Ambient is backed by surgeon experience, too. It's been described as a better tool for toric IOL planning — allowing surgeons to offer premium IOLs with more confidence; while another shares that its central corneal measurements are superior to others in cases of high irregularity. For more information, visit https:// cassini-technologies.com.
Nasal Spray for DED
Shared Vision: Quantel Medical and Ellex Two become one: On July 1, 2020, Ellex joined Quantel Medical. Now, that these two innovative companies are under one roof, they are united by the same objective: To develop cuttingedge technologies for the diagnosis and treatment of dry eye and the leading causes of blindness worldwide (i.e. cataract, glaucoma, age-related macular degeneration and diabetic retinopathy). As part of the Lumbird Medical Group, the company has a presence in more than 110 countries, offering laser systems from their SLT portfolio like Tango™, Tango Reflex and Optimus Fusion. Attendees can also discover the company's dry eye diagnostics (LacryDiag, an ocular surface analyzer) and treatments (LacryStim I.P.L. treatment system, which is currently not available in the U.S.). For more details on Quantel Medical/Ellex or for more on their products, visit www. quantel-medical.com.
"Oyster Point Pharma is a clinical biopharmaceutical company focused on the discovery, development and commercialization of first-in-class therapies to treat ocular surface disease," said Jeff Nau, company president and CEO.
free, aqueous nasal spray; its novel mechanism of action activates the trigeminal parasympathetic pathway to stimulate natural tear film production.
The company's lead product candidate — OC-O1 — is underdevelopment to treat the symptoms of dry eye disease. Using a highly selective nicotinic acetylcholine receptor (nAChR) agonist, OC-O1 is administered as a preservative-
OC-O1 has completed phase 3 trials and will submit for its NDA in Q4 2020. Visit https:// oysterpointrx.com/ for more information.
Optopol Opens US Office, Showcases PTS 2000 Over at the Optopol booth, attendees are welcomed by Bob Padula, president of Optopol USA — the U.S.-based subsidiary of Optopol Technology which opened in January 2020. "Our featured [product] is the Optopol PTS 2000, our top-of-the-line projection perimeter with every option you could imagine," said Padula, adding that it also costs US$10,000 less than any other similar option. "We also do an HFA import for those who are thinking of upgrading their HFA. You can take all of your data, all of your patient clinical information and export it into the Optopol unit — so, when you start using it, all your old patients and tests are there, ready to go," he continued. He also highlighted the REVA NX 130 OCT, which is one of the topselling OCTs in the world. The REVA is currently undergoing FDA approval for use in the United States. For more information on any of these devices, check out Optopol USA's brand new website: www.optopolusa. com.
Eye on Intraocular Pressure
When Administering OZURDEX by Hazlin Hassan
he OZURDEX (Allergan, Dublin, Ireland) dexamethasone intravitreal implant is a corticosteroid approved for the treatment of diabetic macular edema (DME), macular edema following retinal vein occlusion (RVO),and noninfectious posterior segment uveitis. While it has minimal side effects, intraocular pressure (IOP) elevation is the most common, but cases generally do not require surgical intervention. In the industry showcase on the last day of AAO 2020 Virtual presented by Allergan, an AbbVie Company, the use of OZURDEX was discussed, covering efficacy, post-administration management and monitoring techniques. OZURDEX is a tiny implant that slowly releases medication over time, to help reduce inflammation in the retina without monthly injections. It will dissolve over months and will not need to be removed. It is injected directly into the back of the eye. In clinical studies, OZURDEX improved vision in patients without the need for monthly injections. "OZURDEX lasts longer than anti-VEGFs in terms of treating, for example, DME," said
Jeremy Wolfe, MD, partner at Associated Retinal Consultants (Michigan, USA), and consultant for Allergan.
vitreoretinal surgeon at Associated Retina Consultants and consultant for Allergan.
With intravitreal injections, there is a possibility of an increase in eye pressure that generally returns to where it started.
In the MEAD study which comprised two multicenter phase 3 clinical trials, the OZURDEX implant was shown to improve best corrected visual acuity at 3 years in eyes with DME.
Patients who have been administered the OZURDEX intravitreal injection should be monitored regularly for elevation in intraocular pressure (IOP). However Dr. Wolfe pointed out that an elevated IOP does not necessarily equate to glaucoma. OZURDEX is contraindicated in patients with glaucoma. According to studies, IOP elevations are most likely to occur early in treatment. Fifteen percent of patients who experienced IOP, reported it after their first OZURDEX injection. "Of those who are going to have a pressure response, the huge majority of them will happen within the first three treatment cycles," said Dr. Wolfe. For DME patients who were given OZURDEX, the peak mean IOP was often 45 or 90 days after the injection, while for patients with macular edema following RVO, it was 60 days. For patients with noninfectious posterior segment uveitis, it was 56 days. The increase in mean IOP was seen with each treatment cycle and the mean IOP generally returned to baseline between treatment cycles (at the end of the sixmonth period). "This is typically what we see in the clinic," said Dr. Rahul Reddy,
Patients were randomized to study treatment with 0.7 mg and 0.35 mg implants of OZURDEX or sham treatment, and followed for 3 years. BCVA improved by at least 15 letters or more in 22.2% of patients with the 0.7 mg and 18.4% of patients with the 0.35 mg implant compared to 12% of patients receiving sham treatment. "The really significant thing which is different from past steroids is that the incidence of surgery for pressure is incredibly low," noted Dr. Wolfe. "Safety and predictability are important reasons to propel us forward," he added. The incidence of elevated IOP requiring surgery was 0.3% in the MEAD study, 0.7% for the multicenter, masked, shamcontrolled six-month GENEVA study involving patients with macular edema following RVO, and 1.3% for patients with noninfectious posterior segment uveitis in the multicenter, masked, randomized 26-week HURON study. IOP checks should be scheduled every six to eight weeks, and can be conducted by technicians. Drive-through or parking lot IOP checks may be considered during the COVID-19 pandemic to reduce the risk of possible exposure.
l's Dr. Liz Yeu's and Dr. John Berdah
Tips to Manage Unhappy Patients by Sam McCommon
ew things are more important to the well-being of a doctor's career than keeping their patients happy. This is perhaps more true than ever in the age of social media, when an unhappy patient can loudly vent their frustration to strangers — and a doctor's potential future patients. It's almost axiomatic that bad news spreads faster than good news, and that holds true when it comes to business reviews as well. So, keeping patients happy is a crucial part of medicine. That much is clear. But what do you do when you have an unhappy ophthalmic patient? Dr. Elizabeth Yeu and Dr. John Berdahl hosted a valuable session on the last day of AAO 2020 Virtual conference. In the course of their discussion, they addressed many forms of patient needs, approaches to handling unhappy patients, and preventative measures. This was one of those excellent allrounder discussions that physicians could turn to again and again.
Listen early, listen often One of the first questions addressed was fairly simple: How frequent is it that a patient's complaint comes from a legitimate problem rather than a difficult personality? Dr. Berdahl estimated that 95% of patient complaints are legitimate, whether they come from a medical problem or are related to customer service. He noted that it's easy to blame the patient rather than acknowledging the problem — that's simply part of human nature, after all. Saying that a patient simply is being difficult is an exclusionary diagnosis of its own,
and such a dismissive approach to a complaint can lead to significant problems for a clinic. Doctors should pay close attention to their patient's complaints, and at the very least take them seriously. Dr. Yeu noted that complaining patients instantly become VIPs at her practice — it's best to address the squeaky wheel right away. Doctors should actively seek out and identify complaints. It may even be valuable to give patients a forum to discuss their problems, whether online or via a form. Dr. Berdahl indicated that the majority of patient complaints post-ophthalmic surgery are either from refractive problems or from dry eye disease. Anticipating common problems like these can help doctors develop their own playbook. As Dr. Berdahl poetically put it, "People don't care what you know until they know that you care." Simply showing you care is the most important step in doctorpatient relations.
Managing patient expectations A common problem discussed by Dr. Yeu and Dr. Berdahl was patients' IOL experiences not necessarily meeting their expectations.
Fortunately, IOLs have come a long way even over the last several years. Mixing and matching bifocal lenses, trifocals, and new extended depth-of-focus (EDoF) IOLs mean lower patient complaint rates than ever before. But some patients will still struggle with their new IOLs with problems like dysphotopsia. Dr. Yeu said she tells her patients there's roughly a one in thirty chance they'll need to undergo a lens exchange if the first lens they're fitted with doesn't work out. Dr. Berdahl had an interesting analogy: If you think about looking at your nose, it can be irritating. We are so used to it we don't even notice. I extend my apologies to readers who will now spend time looking at their nose. Many patients simply aren't used to an IOL's difference to their own eye. Sadly, an IOL will never be as good as our natural lenses at age 20 — but the fact they exist at all is amazing itself. One suggestion Dr. Berdahl gave was this: show patients the difference between using their new IOL versus no IOL. Patients will quickly see what a radical difference the IOL makes versus, well, nothing, and will likely grow to appreciate what the lens does rather than what it doesn't do. It's a simple bit of psychology, but hey — it's honest, and it keeps patients happy. And at the end of the day, ensuring patient satisfaction is a large part of a physician's job.
Bright Lights, Virtual Nights
many arenas … we didn't know they were gifted actors, videographers, directors and red carpet correspondents as well.
by Brooke Herron
ne thing we love about attending these annual meetings is not only the abundant scientific knowledge, but also the camaraderie we develop with each other over happy hours, social events, and other industry-sponsored get-togethers. These casual events allow us to take a break from the rigors of medicine, and simply enjoy — and celebrate — each other's company. Thankfully, even though we've had to attend AAO 2020 virtually this year, there has still been
opportunities to decompress, maybe even with a few laughs. One such event occurred just before AAO Virtual 2020: The 6th Annual Alcon Retina Film Festival Virtual, which showcases the best surgical videos and techniques from surgeons around the world — and the competition was fierce. The Alcon-sponsored program started off with all the fanfare expected from a television award show — and while we know ophthalmologists are talented in
Moderated by Dr. Donald D'Amico, the Festival featured video submissions from the panel including Dr. John Kitchens with a video on Crazy Macular Fold Repair; Dr. Timothy Murray with Two Tumors; and Dr. Maria Berrocal with Tractional Retinal Detachment — 27g. Some of the guest presenters included Dr. Thanos Papakostas with TRD Repair Hybrid; Dr. Eric Nudleman with Retinal Incarceration; Dr. Caroline Baumal with Retinoschisis RRD; Dr. John Miller with Telesurgery over 5G; and Dr. Alan Franklin with NGENUITY Color Channels. And although we can't list all of the nominees here, you can view with award-worthy surgical videos on demand, anytime (kind of like Netflix for ophthalmologists). Of course, every award show must have its winner and Dr. Christina Weng took home that distinction with her presentation on Autologous Retinal Transplant for Macular Hole. So, watch out Hollywood, the stars of ophthalmology are hot on your tail!
Emily and David provide comic relief and entertainment as the hosts of the Retina Film Festival. [Image provided by Edelman]
Moderator Dr. D'Amico is joined by the panel Drs. Berrocal, Kitchens and Murray. [Image provided by Edelman]
Presenting the Film Festival panel. [Image provided by Edelman]
Dr. D'Amico is joined by Film Festival Winner Dr. Weng. [Image provided by Edelman]
s e r o l p x E m Symposiu e k a M o t s y a W w Ne Clinics More
and Efficient T
his year has presented numerous challenges to ophthalmologists and clinicians alike as they have been forced to alter many of their working practices. The disruptions have included mandatory telehealth implementation, social distancing and personal protective equipment, the list goes on and on. Now more than ever, proper and efficient clinic management is of the utmost importance. That was the crux of Boost Physician Efficiencies: Creating a Lean Culture With Technology, a symposium organized on the sidelines of day three of the annual meeting of the American Academy of Ophthalmology (AAO 2020 Virtual). An in-depth dive into how ophthalmology clinics can maximize their efficiency and improve patient outcomes, the symposium was chaired predicated on the Lean philosophy of workplace management. This is described as a philosophy that ensures businesses that holistically apply lean principles to the way it plans, prioritizes, manages, and measures work.
Lean, mean, recording keeping machine The purpose of applying the Lean principle is to improve patient outcomes as much as to improve corporate efficiency. According to the senior instructor of the symposium,
Aneesh Suneja, president and founder of FlowOne Lean Consulting LLC (Wisconsin, USA), placing the patient at the center of a high-performing team using Lean techniques, physicians and their support teams can become more coordinated and efficient, reduce physician time spent on the electronic medical records (EMR) during the patient encounter, communicate information more effectively and improve the overall patient and provider experiences. Part of this involves the usage of virtual scribes, who can greatly reduce the ophthalmologist's time spent on EMR and its burden on staff. The objective of the symposium was to explain how a physician can increase efficiency with three strategies, including remote scribing, patient flow tracking and team communication practices such as micro-huddles and provider/technician in-room overlap. Mr. Suneja used detailed flow charts to showcase how time wasting could be mitigated, and valued time activities like face to face consultations could be maximized. The 'Five S' format was crucial, which is to sort (identify necessary items), set in order, shine (clean), standardize and sustain.
S, S, S, S, S Using the 'Five S' system combined with an awareness of one's colleagues
by Andrew Sweeney
and infrastructural capabilities can allow any clinic to become more efficient than ever, according to Mr. Suneja. A key part of this process is to minimize patient footprints (i.e. keeping facilities required by patients close to each other). A good example would be keeping imaging facilities close to one another, rather than spread over several floors of one building. Using a virtual scribe was also described as a key comptent on the drive towards leaner practice management, and is especially important in light of the ongoing coronavirus pandemic. A virtual scribe is able to take a number of clerical duties away from medical staff, thus drastically reducing the amount of time they spend on records keeping. The concept is reported to be popular with patients too as these virtual scribes are designed to provide the highest quality of communication possible. The presentation given by Mr. Suneja was followed by a question and answer session where a number of issues were raised by the symposium's viewers. These included the amount of time required for patient education, the cost of implementing a virtual scribe based system, and ensuring changes are compliant with the Health Insurance Portability and Accountability Act (HIPAA) in the United States.
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To celebrate Air Max Day 2018, and the release of the NEW 'Dusty Cactus' Air Max 270, special Air Max-themed Gift Cards are now available direct from Nike Store.
Nike Gift Cards always make a perfect gift, whether you need to send a birthday surprise or want to get someone something special but don't know their size. And one of the very best features of Nike Gift Cards is they come delivered in a mini replica of the iconic orange shoe box!
Hit the link below and instantly make any big Air Max fan, or Nike sneakerhead in general, a lot happier with a new Nike Gift Card!


text:
SB Corner Store / Archive / Markham / Locust Hill / Lpga Locust Hill Country Club
Lpga Locust Hill Country Club
Joint care chew
Mission hills star
Midnight refinish classic@lpga
Snow hill country club
Producers. locust hill
CoNLL17 Skipgram Terms – Free ebook download as Text File (.txt), PDF File (.pdf) or read book online for free.
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Blue Cross Arena, also known as the War Memorial, is a multi-purpose indoor arena located in Rochester, New York.For hockey and lacrosse, its seating capacity is 11,215. The arena opened on October 18, 1955, as the Rochester Community War Memorial.It was renovated in the mid-1990s and reopened as The Blue Cross Arena at the War Memorial, on September 18, 1998.
The course is regarded as one of the best in Rochester. Locust Hill hosted four LPGA Championships and a regular tour event for 30 years. The club has an avid playing membership with games, leagues, and tournaments for all skill levels. Locust Hill is also the home club for several of the area's elite amateurs.
Locust Hill Country Club is a nationally recognized golf course that has hosted the LPGA for many years. The golf course stands out as a sustainability leader and was certified by Audubon …
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Disney releases 4 live-action features from the past to DVD. They include the 1966 Lt. Robin Crusoe, the 1967 The Adventures Of Bullwhip Griffin, and the 1971 films The Barefoot Executive and Million Dollar Duck.
The Wonderful World of Disney airs "Bride of Boogedy" - about a family of practical jokers who are haunted by a ghost.
and Disneyland Hotel) and a campground (Davy Crockett Ranch) located several miles away from the main resort area.
One year after its opening, Euro Disneyland welcomes its 10.5-millionth guest.
befriends human like bugs living inside a giant peach, who take him on a journey to New York City.
event at Walt Disney World.
miles away in Marghera (a borough of Venice).
becomes the 'Ohana restaurant - featuring the world's largest fire pit.
Hilton Hotels Corp. breaks ground for a resort development adjacent to Walt Disney World Resort.
and included as one of the seven musical segments in the 1948 feature Melody Time.
are photographed by the press riding the "Magic Skyway."
voice of Laverne for The Hunchback of Notre Dame II.
Disney's short Pluto's Kid Brother, directed by Charles Nichols, is released.
Lt. Robin Crusoe is the only movie for which Walt Disney received a story credit (as Retlaw Yensid - Walter Disney spelled backward).
up to 30 guests (depending on weather conditions), rises 400 feet above Disney World for a breathtaking view.
The idea of incorporating topiary figures into Disney parks and resorts began with Walt Disney himself. The first topiaries appeared in Disneyland's Fantasyland area in 1963.
It's A Small World attraction in 1966.
Disney Store introduces a new line of eco-friendly products in celebration of the upcoming 40th Anniversary of Earth Day.
pack that also includes the film on DVD.
Coincidentally, U.S. President Franklin D. Roosevelt dies on this same day, in Warm Springs, Georgia.
Today there is a plaque commemorating Gagarin's milestone flight in Epcot's Mission: SPACE.
role of General George Armstrong Custer in the 1958 Disney film Tonka.
ABC-TV's fantasy drama series Once Upon a Time know her as Emma Swan.


text:
Small savers in US scramble for interest $$$
By Guy Halverson Business and financial correspondent of The Christian Science Monitor
* A middle-aged northern Virginia couple -- disgusted with soaring inflation now hitting upwards of 18 percent annually -- recently yanked $5,000 from their low-paying passbook savings account.
Then, they quickly tucked the savings dollars into a new "loophole" certificate of deposit at their savings and loan that will enable them to earn a tidy 14 percent interest over the course of a year.
* In Washington, D.C., a young professional couple just pulled several thousand dollars from savings and put it into Government Investors Trust, a relatively new money market mutual fund.
Despite "credit curbs" on mutual funds announced by the Carter administration last week, the couple will still earn only about 2 percent less than current money market rates. As of this writing that means a hefty 12.60 percent.
And that, the couple notes, is still twice the amount that can be earned on most conventional savings plans.
The quick action of the two Washington-area couples is hardly an exception these days as more and more Americans -- confronted with soaring prices on one hand and low-paying savings accounts on the other hand -- are scrambling to take advantage of the best possible ways of protecting their cash assets.
"Because of what the government has done," argues Alfred Johnson, vice-president and chief economist of the Investment Company Institute, there are "not all that many alternatives" for the typical small saver to consider in protecting his or her money.
What the government has done, explain economists, is, in effect, to hedge in the small saver -- without really trimming the ability of well-heeled investors to get maximum yields on their assets.
Thanks to federal regulation Q, a statute little known to most Americans, there is an automatic "interest rate ceiling" on passbook savings accounts. For savings and loans, the limit is 5.50 percent on savings.
Federal bank regulators recently imposed a flat 12 percent ceiling on the interest rate permitted on 2 1/2 year certificates of deposit (CDs) issued by banks that can be taken out at many institutions for as little as $100.
Last week the government again yanked high rates downward for thousands more small savers by requiring mutual funds to set aside 15 percent of all new fund investments in a noninterest-bearing account. President Carter argued that he was taking such drastic action to prevent spiraling inflation. But one immediate effect, argue many economists, is to thwart small savings from earning the highest possible rates.
Large savers, by contrast, can directly buy US government issues where rates are, in effect, "wide open" and determined by the marketplace.
The government's latest consumer price index, released March 25, showed prices during February soaring upward at 1.4 percent. That is roughly the same increase as during January -- and registers out at an annual rate of 18 percent.
But that means that investors with money to set aside in government issues also earn higher and higher rates. US government 91- day Treasury bills, for example, which sell for $10,000 or more, averaged 16.532 on March 24, up from 15 .053 percent a week earlier.
But all is not lost for small savers.
"There are still a number of good alternative ways to invest modest amounts of money," argues Norman Schrott, manager of the Alexandria, Va., offices of A. G. Edwards & Sons, a brokerage house.
Among the most frequently noted alternatives:
1. Money market funds. Despite new federal restrictions, the funds are still expected to offer yields ranging from one to several percentage points below the going money market rates. In fact, financial analysts believe that some new "clone funds" now being set up as exact duplicates of existing funds may ironically start off paying yields even higher than on existing funds.
The reason? Lower management costs -- hence, higher yields for investors.
2. Bank "loophole" certificates of deposit. At Government Services Savings and Loan in Maryland, for example, an investor with only $5,000 to invest can take out a "$10,000" certificate of deposit. How?The customer puts in the $5, 000. The S & L lends another $5,000 to bring the amount to $10,000. The total interest on the loan, leaving $700 for the saver. That works out to an annual yield of roughly 14.837 percent on the $5,000 (based on current yields).
3. Some state insured S & L's are even offering passbook accounts paying between 7 & 8 percent. Hardly up to inflation, but better than 5.5 percent, say experts.
A different road out of poverty: saving instead of borrowing
Six habits of highly successful savers
What Ron Paul gets right about economics


Now, let's say you can pay an extra £50 towards the mortgage each month, taking your repayment to £761. By doing so, you'll shave two years and four years off the time taken to pay the... Another way to come up with some extra cash to pay on your mortgage is to get a side gig. Take a part-time job on the weekends as a server at a local restaurant, or open up a flea market booth.
Another way to come up with some extra cash to pay on your mortgage is to get a side gig. Take a part-time job on the weekends as a server at a local restaurant, or open up a flea market booth.... We understand that not everyone can pay off their mortgage in 5 years, however these tips are relevant whether you want to pay off your mortgage in 5, 8, 10, or 15 years. We want to challenge our readers to find a way to pay off their mortgage within 15 years max, ideally 5-10 years.
The Deposit. Of course, the bigger the deposit, the more you can spend on a house and still pay it off within your goal term. The next chapter answers questions like how much should you save, tips on saving the most you can, and traps and tricks to avoid.... When you start to look at how to pay off your mortgage in 5 years, the one key is putting more money down on your mortgage sooner rather than later. An easy way to do this is to change to a smaller amortization period.
Another way to come up with some extra cash to pay on your mortgage is to get a side gig. Take a part-time job on the weekends as a server at a local restaurant, or open up a flea market booth.
Get the essentials in order. Before you put your extra money into super or your mortgage, seriously consider paying off your other debts first.
The Deposit. Of course, the bigger the deposit, the more you can spend on a house and still pay it off within your goal term. The next chapter answers questions like how much should you save, tips on saving the most you can, and traps and tricks to avoid.
When you start to look at how to pay off your mortgage in 5 years, the one key is putting more money down on your mortgage sooner rather than later. An easy way to do this is to change to a smaller amortization period.


text:
Fabia Eudokia (zm. 612) – cesarzowa bizantyńska od 610 do 612 roku.

Życiorys
Była pierwszą żoną cesarza Herakliusza. Jej ojcem był afrykański dostojnik Rogatus. W czasie buntu Herakliusza przeciw cesarzowi Fokasowi została uwięziona w Konstantynopolu (608-610). Urodziła Herakliuszowi dwie córki oraz syna Konstantyna III.

Bibliografia
 Maciej Salamon, Eudokia Fabia [w:] Encyklopedia kultury bizantyńskiej, red. Oktawiusz Jurewicz, Warszawa 2002, s. 165.

Cesarzowe bizantyńskie
Zmarli w 612
Dynastia heraklijska

redpajama_set_name: RedPajamaWikipedia


text:
Q: CA2000: Dispose objects before losing scope and Form.Show() I'm trying to fix all my project warning according to Microsoft code analysis (CA:XXXXX)
One of the warning is "CA2000: Dispose objects before losing scope"
My Code is:
Private sub Foo()
   Dim O As New Form1()
   O.Show()
End Sub

Visual studio says that the object O is not disposable, in such situation I can't use the keyword USING because I will lost the object O after End Using:
Private sub Foo()
   Using O As New Form1()
      O.Show()  'The form will open then close !!!
   End Using
End Sub

The form then will open and close
How to get ride with CA2000 in such situation, I don't need to ignore, I want to solve and fix.
Thanks.

A:
I don't need to ignore, I want to solve and fix.

This is, effectively, a false warning, in this specific instance.  You don't want to "solve and fix" this message in this specific case, because you want the object to "live" beyond the end of the local scope.
If you call Dispose on the object in that scope, you will (always) close the form, in this case.

A: How about ShowDialog?
Private sub Foo()
   Using O As New Form1()
      O.ShowDialog()
   End Using
End Sub

It will dispose all resources of Form1 after i has been closed.

redpajama_set_name: RedPajamaStackExchange


text:
Big banks trial instant messaging service
Some of the world's largest investment banks are to trial a new data service that uses instant messaging software to help traders...
Nick Huber
Published: 19 Jul 2004 17:17
Some of the world's largest investment banks are to trial a new data service that uses instant messaging software to help traders track market developments.
The news service application from BrokerTalk, a London-based start-up company, provides updates on price changes in markets including foreign exchange and derivatives.
BrokerTalk, which runs over the internet, is being touted as an alternative to news feeds from companies such as Reuters. It also includes Parlano instant messaging software to allow brokers and traders in the same firm to communicate more efficiently.
Banks that have signed up to use the service include Citigroup, JP Morgan, Credit Suisse First Boston and Barclays Capital.
Instant messaging has been widely adopted in the financial services industry, where speed of communication and having up-to-date information is crucial.
In the US however, concerns have been raised that firms using instant messaging technology may struggle to store and archive the messages to comply with corporate governance regulations.
The use of instant messaging is also likely to require extra investment in systems to monitor messages.
A survey of organisations across Europe, the Middle East and Africa published in April found more than a third of companies monitor instant messaging communications.
The majority of organisations had put in place explicit staff guidelines for both e-mail and instant messaging use, the survey commissioned by Hitachi Data Systems found.
Read more on Voice networking and VoIP
Huge bank fines could have been avoided with monitoring software
By: Karl Flinders
EU regulators want trader Facebook messages
Banks clamp down on traders in chat rooms
Cashless future: VocaLink demos mobile payment gateway
UK investment banks use unregulated instant messaging... – ComputerWeekly.com
Messaging: Instant profit – ComputerWeekly.com
EU regulators want trader Facebook messages – ComputerWeekly.com


text:
Saints end PK Hartley's season, cut DT King as O-Line injuries mount
The Saints have extended John Kasay's tour of duty as a Saint by ending the season of PK Garrett Hartley, who suffered a hip injury in preseason.
Kasay was promptly signed after the third preseason game even though the club denied reports of the seriousness of Hartley's hip injury.
The Saints also cut DT Mitch King, who had been fourth in the defensive tackle rotation for the Saints through three games. King notched one solo tackle and two assists in three games, and is in his second year out of Iowa. King was on the Saints' practice squad for part of the 2010 season and signed with the Saints in January of this year.
Replacing King in the rotation is expected to be DT Tom Johnson, a CFL star who signed with the Saints in January but has not been healthy enough to play a regular season game yet.
There are so far unconfirmed reports that starting right tackle Zach Strief has been placed on injured reserve. Strief, who suffered an apparent right leg injury in the third quarter on Sunday, was replaced by second year T Charles Brown. Strief, 6'7, 320, 28, is in his sixth season and was the last pick of the Saints' 2006 draft class.
The new additions to replace Hartley, King or Strief are not yet known.
Tags: charlesbrown, garretthartley, johnkasay, mitchking, tomjohnson, zachstrief
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Surprising and calming, green and flowering hanging plants create unusual effects at heights where you wouldn't expect to find greenery and flowers. This is why they're in the spotlight in September. If you're going to pay special attention to them in your shop, you could use the POS material which can be downloaded for free using the link at the bottom.
Some of the green and flowering hanging plants mentioned here originate from the tropical rainforests, where they grow as climbers. They are specially equipped for this with ingenious botanical tools such as adhesive roots, hooked spines, leaf or stem tendrils and winding leaf stems. When such a climber can no longer find any support, it adopts a creeping or hanging form. Other flowering hanging plants grow in drier regions and have strong succulent properties, enabling them to get through periods of reduced rainfall.
Plants are sometimes kept too dry, in which case they will droop, have yellowing leaves or shed buds. This can also be caused by lack of light.
Green and flowering hanging plants must be free of brown spots on the leaves, often caused by leaving the soil standing in water for too long. There can also be limescale marks or water residue on the leaf, which detracts from the decorative value but does no further harm.
Green and flowering hanging plants are enjoying a big revival. That's because many of the plants have air-purifying properties and fit well with the trend for natural and authentic shapes and bringing as much greenery into your home as possible. These are all important sales arguments.
These houseplants can be used in many creative ways in offices, student rooms and living rooms. Flowering hanging plants can create green partitions and form part of green walls. Stress that these plants can also climb if they have something to hold on to; a flowering hanging plant doesn't just grow down, but also upwards.
The houseplants can be used in both a traditional and modern setting. Using them horizontally, with the tendril draped in a bowl, offers original opportunities to enhance an interior with green and flowering hanging plants.
You can download the images below free of charge.


liz fichera: CAPTIVE SPIRIT is Now Available in Audiobook!
CAPTIVE SPIRIT is Now Available in Audiobook!
And I got lucky. The reader for CAPTIVE SPIRIT is Kelly Lintz and I think her voice is all sorts of perfect for Aiyana--fresh, clear, and determined. There's even a sample excerpt on the audible.com web site.
Please click here to listen to the sample while I go cry more happy tears.
And Kelly Lintz? Thank you for spending eight-plus hours most likely in some tiny studio room somewhere reading my words! You rock, girlfriend! Woot!
P.S. Just a reminder that I'm guest posting today at KILLER CHICKS. We're talking about how settings become characters in our novels.
Woo Hoo, way to go, Liz! Congratulations! I just listened to the sample and yes, it was perfect.
Fairy flutters! thats great news fellow crusader! Congrats!
Stopping by to introduce myself as a new follower and fellow crusader. Did you find out what group you're in yet?
Raquel: I do not know. I have not had the time yet this week to stop by her blog long enough to find out. Thanks for the heads-up, though. I'll definitely visit her blog and find out.
We're in the same group in the crusades, so I came over to say hello.


VX Ensemble Auditions in November!
Being a part of the VX Studio Vocal Ensemble is something that you will never forget.
I remember the first day that I came to rehearsal and just that experience. When I first walked in, of course I noticed the big house and the fancy studio that was seen from the driveway, but when I walked in, I realized that there were all of these kids, ready to do what I wanted to do. We were all there for the same goal. That's why it was a great experience. It was the first time I saw a significantly magnified group that really focused on this one goal and we wouldn't stop until we felt proud of what we did.
"VX Recording Ensemble was one of the best things that happened to me during my singing career."
I'm helping schedule auditions for this year's spring semester class. When I read testimonials like this from students who participated in Gary Fry's class last year, I wish had an opportunity like this when I was in High School! If you are interested in this uncommon experience, auditions are posted at www.mya.org/audition/ or if you have any questions, please feel free to contact me at chelsa@mya.org or call 847.926.9898.


That's a question each of us as researchers should consistently ask ourselves.
All too often, we are content to give numbers and charts, and report what respondents said, when our management really wants to know what we recommend and how it will improve the business.
If we want to be heard and have an impact on our organizations, we need to develop a clear point of view (POV). That means shifting in our own minds from researchers to management — acting as though we are the ones making the decisions rather than just providing data.
In addition to providing direction to the organization, it results in a much more on-target report.
A clear POV is an important part of any recommendation. There may be times when we believe the recommendation is obvious based on the numbers we have. But don't make that assumption. We work with numbers every day, and are comfortable with them and what they mean, but others in the organization may not be. Don't assume others see what you see. You need to give your POV based on the data? What do you think we should do, and why?
At the end of the day, our objective should not be to report survey results but to provide direction for making decisions — again, shifting our mindset from research to management.
For instance, does management really care if we increased top 2-box scores for brand awareness? What does that really mean? Does it translate into sales? Does it tell us if the strategy is right? What does it mean if our customer satisfaction score decreased? Should the company invest in changes? What does all this mean to the decision maker? Why should the CEO care?
The ability to think like management and provide more value means that our knowledge goes far beyond how to execute a market research study. Our research skills should be cost of entry. We need to also know something about marketing, strategy, pricing, messaging, and other areas of the business otherwise our recommendations become sophomoric. If we don't take the time to develop a holistic view of the business, we limit ourselves to the role of data collectors.
Each time we present results, the question to ask ourselves is "if I were in charge, what would I do based on the information I have?" Whatever that answer is, present a case for it. Design your report or presentation so that it takes your audience on a journey that ends with your recommendation.
As research professionals, we evaluate a brand's position in the market. We help firms identify how and where to position themselves, how to differentiate themselves from others, and we measure their brand health.
Yet, how many research firms or research departments think about how to position themselves? How good are we at managing our own brands? Those of us in marketing and market research are supposed to be the experts in brand positioning, but how can we make this claim when we don't do it ourselves?
I recently attended a market research CEO summit where I met many smart researchers from firms we all know. I quickly learned through my conversations that most still struggle with the same issues – "how do we get new clients," "how do we talk about ourselves." On the supplier side, it seems we all say the same thing and few of us truly differentiate ourselves.
This also applies to those in insight departments on the client side.
When I was running a client side team, I tried to be intentional with "positioning our brand". This is not just a theoretical exercise. The brand to which you aspire should influence how you staff the department and what you deliver. If you want to be internal consultants (as was my team's objective), hire those who enjoy the consultative nature of our business and being part of our internal client's team. If you desire to be technical experts, you hire accordingly.
This same thinking also applies to marketing departments. Are you, or do you want to be, the business lead who understands what clients want? Or is yours the creative group of experts in communications and creating ads?
This notion of "brand positioning" also applies to us personally.
I still remember a friend giving me some very good advice in my early days of research while at Hallmark Cards. At the time, I loved getting into the data and the methods. I would stay late trying out different methods. I thought that would be my path to becoming a great researcher. My friend Julie asked me if I wanted to be the technical expert, or the internal consultant who works with clients to help identify solutions – I couldn't be both.
In reality, perhaps we can be both — but not in our client's mind. So, although I still explored methods, I talked about them less. Instead, I would discuss concepts that came straight from Michael Porter's Competitive Strategy or Tom Peters' and Robert H. Waterman, Jr.'s In Search Of Excellence – two landmark strategy books at that time.
We must understand who we want to be. Are we consultants? Technical experts? Low cost? Innovative? Business experts? Data experts? Most of us would say "yes" to all. But of course, just as we all tell our clients that they must pick, we can't be everything. So, what does your firm or department really want to be? Who do you really want to be?
The bottom line is we need to be intentional in defining who we are. Staff accordingly. Set team expectations accordingly. But also, communicate to your clients who you are — whether you are on supplier or client side — and live by it.
Just as we help our clients manage their customer touch points, we should be intentional with our touch points – even if you are an internal team. If you want to be an internal consultant, do your documents and presentations look like something a consultant would produce? Can you hold a conversation on business matters other than market research techniques?
Try this as a start . . .
This whole concept is hard. Really hard. My firm is about seven years old and we're just figuring it out. In a recent meeting, a team member wrote down what we said about ourselves and created this video. I love it. I wish I were smart enough to put down in words who we are – but the good news is these are our team's words. Not mine. But it reflects what I want our firm to become; who I want our team to become. There is more to do, but this moves us in the right direction.
Consider this exercise for your team. Have each team member identify a few words and phrases that describe who they would like your team to be. This can be revealing. This may capture the essence of your team. That's the first step. The hard work is then figuring out how to become that to which you aspire. But at least you will now have a compass (and perhaps your own true north).
I am borrowing this title from John Maxwell's book Good Leaders Ask Great Questions. At the end of the day, our effectiveness as researchers, marketers, and even in life rests on the questions we ask.
We have our strategies, methods, and approaches? But how do we know what we are doing is right? How do we know the ladder we're climbing is not up against the wrong building? It all comes down to asking the right questions.
It all comes down to asking the right questions.
You can download our True North Project Scoping Question Checklist. But first let's talk about the rationale for this checklist.
It does not take much time in the market research profession until we recognize that many times clients come to us asking for focus groups or some other method. When after a quick conversation we typically realize they need something entirely different. Order takers will put the ladder up against the wrong building. Those who ask questions will get their clients what they need.
Asking questions does more than capture information, it also builds trust and confidence. It demonstrates to the client that we are listening, that we understand that his or her situation is unique, and that we want to understand.
Two great reads, The Trusted Advisor, and Flawless Consulting, both spend several pages discussing the importance of asking the right questions. Yes, to build understanding but also to build trust and confidence.
Even if we think we know the answers to our questions, ask anyway!
The book, The Trusted Advisor uses the phrase "Earn the right to be right." To earn the right, we must demonstrate that we truly understand and that we care about the client and the outcome. We do that by asking questions.
Now, combine that with what we learn from The Checklist Manifesto. This book wonderfully illustrates the importance of having checklists; even for those things we know but might forget.
Putting all this together resulted in our True North Project Scoping Checklist.
I built this starting with a set of questions I have had on my bulletin board for years. I then augmented that by reviewing the questions included in key consulting books, some good information from the Corporate Executive Board, and other sources. The result is our checklist.
This is more than just a random list of questions.
It also outlines a process of the questioning process that leads to a solid understanding on our part and confidence on the part of the client. It also includes several do's and don'ts. Everyone on my team now has this laminated and nearby.
Given how much time we spent developing this, I thought I'd give it to others who might value it.
Click here to receive The True North Project Scoping Checklist.
If you'd like a copy of the Checklist, simply click here to download a pdf. In return, I'll ask you to receive our blogs in your inbox. We all bring different perspectives to research and the more of us participating in the conversation, the more effective we can be.
Or, if you would like a laminated version, feel free to email Renate.Rea@truenorthmarketinsights.com and we'll send you one. Our treat.
Enjoy and I hope it makes all of us better researchers, marketers, and business people.
The truth is, as a profession, we offer a great deal of expertise, but we also tend to offer a great deal of ambiguity, and we often lack decisiveness. Our managers are looking to make decisions and for us to be decisive in giving recommendations that help them make those decisions. So the question becomes, are we giving them what they need?
I've cited in previous blogs the statistic that 85 percent of senior managers want market research professionals to be a trusted partner and internal consultant, but only 25 percent think we are. I also read recently that companies are increasing their research spend, but limiting the research head count expenditures. This all tells me management values the information but not necessarily the researchers themselves. The fact that we are all too willing to serve up our data with a side of caveats and ambiguity rather than decisiveness may be one of the reasons we fall short.
We've all witnessed that painful sight when a less experienced researcher gets his or her shot at presenting to a senior executive. The researcher, rightly proud of the work, wants to share all of the great information. But as he or she does this, the executive becomes more and more impatient, waiting for the bottom line. Waiting for the answer. And when he asks the key question "what should I do?" he gets hemming, hawing and caveats. The researcher has just wasted the opportunity to influence senior management.
Researchers understand that few things in life are black and white. We live in shades of gray. We want our clients to understand these shades of gray and nuances. But our clients are not us. There is a point where we need to rise above the shades of gray and form an opinion or point of view as to what it all means for the company.
We need to recognize what most business leaders understand – there is no such thing as perfect information, and that we often need to make decisions without having all the facts.
For those of you who have been fortunate to work with strong leaders, you understand they want your opinion. They want to know what you think they should do and why. When we answer with "well we could do this, but on the other hand, that has merit as well, " we limit our effectiveness and do a disservice to ourselves and our firms. Yes, there are shades of gray. But since you understand all these shades of gray and nuances, evaluate them and state of point of view. Really, who better to offer an opinion than you?
I offer a workshop to my clients on how to get results heard. In most all cases, this is perhaps the most difficult challenge the participants face. They may understand the concept and the rationale, but many are just plain uncomfortable taking a position and having a point of view. There is a risk involved. What happens if the CEO disagrees? What happens if we're wrong?
The key to successfully offering and owning your point of view is to ensure your opinion is based on evidence. If you can support an opinion based on logic and strong evidence, then you are on solid ground and your point of view will be valued – even if others disagree. You will have contributed to the decision. Others will have other sources of information and other points of view and that's okay. Perhaps their arguments will win the day. But you brought your insights to the table for discussion and as valuable input for the decision.
A huge side benefit of having a point of view is that it forces us to analyze our results with a different perspective. It makes us think like leaders — not just reporting data, but trying to decide ourselves what we would do. This might lead to slicing and dicing our data in different ways, or integrating data points from other sources into our documents to support our points. But if we do these things, we will become more comfortable with our own point of view and we will have produced a much more decision-ready report or presentation.
Owning a point of view makes us much more prepared to answer that question "what would you do?" And in doing so, we will have taken a step closer to becoming senior management's trusted advisor.
If you're like most research professionals, you're passionate about your craft; I know I am. We thrive on uncovering and sharing the facts, data and insights to help our organizations and our clients' organizations thrive and succeed.
The value of the insights we offer — often straight from the customers' lips — can't be overstated. That's why I find it a little ironic that the key to being considered a great researcher — one whose recommendations are appreciated, accepted, and utilized — lies in being so much MORE than a researcher. Actually, this applies to whatever your area of specialty is.
Researchers understand research like nobody else. But in today's business environment, that is our cost of entry. To offer meaningful recommendations and influence our organizations, we must understand the ecosystem around research.
If we are going to research marketing issues, we should know something about market strategy and tactics. If we are to research price, we should know something about pricing strategy. You get the point.
Although this broad range of expertise or knowledge may not be natural to us, it benefits us to develop it. The danger of staying within our own research world of execution, techniques, and simply managing to research objectives, means we will miss the mark. Not because the research was wrong, but because we did not understand the ecosystem around the issue we are researching.
Those of you who have been in research for any length of time understand that there is typically more to the research objective than what is stated. It's critical for us to understand the context around the objective.
By understanding the ecosystem and the context around our clients' request, our analysis will be more on target. Our recommendations will move from sophomoric to sound, and our insights will move from discrete data points to true insights that can be used.
So make it your business to meet with and get to know your clients — internal or external. Try to understand their jobs, and what they're trying to accomplish, and even their challenges. Let's read our company's marketing plan. Let's understand. Understanding enables you to set the right goals, execute relevant research projects and deliver value-added insights.
I've also found that learning from experts through reading their books is a great investment of time. So make a point to look at the works of Jim Collins, Seth Godin, Peter Drucker, Michael Porter, or other business authors that you may respect.
When we reach the point of understanding and "business savvy," and when our clients see this understanding, our recommendations will be accepted. We will be asked to comment on non-research decisions because we understand the market, the company, the industry. Our jobs suddenly become a lot more rewarding – and valuable to our clients.
Of course, there's always the option of staying within our comfort zone and learning another research technique. Which do you think will have a larger impact on our clients, our companies, our careers, or our job satisfaction?
There's a lot to being considered a good researcher — maybe more than you thought. No one ever said it was easy. But I can tell you that taking the time to learn and understand makes our jobs a lot more fun and meaningful.
Are you reporting your strategic results when the company is focused on execution? An approach to getting heard is to sync your results with your company's planning cycle.
There is a time when management is planning and there is a time when the organization is executing against those plans. If you report results during the execution phase, your insights may be ignored and forgotten when planning time comes around.
Our best bet for being heard and influencing strategies is to get our data to those who can use it when they need it — during the planning phase – even if that data is from a study completed six months earlier. This allows us to influence those large corporate initiatives.
First, you have to have something to say. Cull through your research and identify the top 5-7 customer insights of the year; the insights you believe management really needs to hear. You want those few insights that really matter. The more you try to communicate, the lower the likelihood your insights will be used.
Next, get on the planning agenda early in the process so you can share your top insights with senior leaders while they are interested in hearing them and might do something about them. You have valuable information. What management group would not be interested in a brief overview of the most important insights of the year? And who among them would say he or she doesn't care what the customer thinks? I have not seen this fail.
You may choose to work through your management, or better yet, simply get your bosses' approval while you work to get your "Top 5" on the agenda. I prefer the latter approach as I know my findings will be heard if I'm the one pushing for them. Learn who is in charge of managing the planning process, then work with this person to get on the agenda. He or she will likely have to run the idea past their management, but given your content, the odds of your inclusion and presenting to decision-makers will be very high.
In this setting, state your point-of-view with just enough data to support. And certainly not every data point you have.
Bring in other, non-research supporting points if possible – it will add credibility to your points.
Avoid method discussions. If you are presenting to this level of the organization, they will trust you can execute properly. If they begin asking method questions, it is a sign they don't like or agree with your insights. Address the real issue; going into method details will not convince them.
Think through who and why someone might disagree with your points and address this in your presentation.
Be prepared to defend your point-of-view in the resulting discussion. It is this discussion where your knowledge and understanding can shine.
We recently recommended this approach to a client. He was added to the agenda last minute. We worked together over the weekend building his Top 10 Insights of The Year. He walked out of the presentation after his delivery to receive a high-five from his CMO.
This is exactly where our profession should be – providing the insights to those at the top of the company as they are formulating plans and strategies.
And it's even more fun when we can get that high-five.
Do you have a great idea, suggestion, or recommendation you want to offer to management? Those of us in market research or other "staff" functions often have a unique opportunity to do so. So how do we do it effectively?
We see trends, activity, data, insights, etc. in the course of our work that we want to share with management. In market research specifically, we are focused on understanding what the customer wants – more so than anyone else in the organization. This gives us the opportunity to offer insights that can be valuable to our company.
So how do we get our ideas up the chain?
Our first instinct in sharing our ideas is simply to tell the boss, CMO, or whomever we want to reach. We may mention it in a staff meeting, hallway conversation, or even in the elevator. It only makes sense to take those opportunities to share our ideas, thoughts, recommendations, right?
Unfortunately, this approach rarely works. Everyone is understaffed these days, even our management. With too much to do and pressure from their own bosses, few leaders have extra time to consider new ideas, even if they're good ones. Given that leaders and/or key decision-makers are pulled in many directions and face many pressures from their management, our chances of success with "ad hoc" recommendations are slim. Success is even more limited if the ideas don't fit within management's current priorities.
You can overcome this barrier with the right approach. First, understand that the person to whom you may talk is only the first stop. That person needs to take your idea and sell it to others up the chain, particularly if it means a change in direction or additional resources.
Consequently, your approach needs to be persuasive, well thought-out, and compelling. Collect the evidence, make the argument, and put it on paper. Then set up time with your target and make your case for ideas and recommendation in which you believe.
There are many great sources that provide guidance for how to make your case. One of my favorites is Andrew Abela's "Advanced Presentations by Design." After returning from Abela's workshop, I used his principles to create an organizational structure recommendation. I took it to the CMO, who liked it so much that she had both of us take it to the CEO. We then had a third meeting that included the head of human resources. The result? My recommended structure is still in place several years later. That never would have happened if I had just cornered the CMO in the hallway.
Gaining buy-in for your ideas takes time and effort, so you can't do this with everything. Pick and choose the ones you believe are best for the organization. But remember, if we never do it, we will never be heard.
A side benefit of this thought-out approach is how it makes you look. Not only will you increase the likelihood of getting your ideas across, you will be seen as a thought leader, someone to whom others should listen.
Give it a shot. Make things happen!
Earning Trust is the most important thing we can do. Without trust, a superbly designed, executed, and analyzed study is meaningless. Without trust it will not be accepted and acted upon. Here's the formula for generating trust . . .
Credibility and reliability are what we typically go to when thinking about how to build trust. Do you have the expertise? Do you have the experience? Will you do what you say? Of course these are important. But you might also say that these are cost of entry. On their own, they do not generate trust. We have to look further.
Intimacy refers to the ability to have empathy; to see other's point of view. It is being authentic and open. It represents the extent to which others feel they can confide in you and feel safe in doing so. This is what moves an interaction from a transaction to a relationship.
When conducting research for big dollar B2B, we have found that this dimension is highly correlated with loyalty and growth. Without this, the relationship tends to be viewed as simply transactional.
When we focus on our skills, when we focus on how good we are, we can damage trust. Take another look at that equation. Notice that "self-orientation" is in the denominator. The more we focus on ourselves and not our client, the more we run the risk of damaging trust.
Now don't get me wrong, we need the technical skills. Personally, I enjoy "geeking out" a bit and digging into a method. But we have to view this as the cost of entry when it comes to trust. We need to understand that trust is an inherently emotional construct. We need to focus on the client. It's not about us. It's not about demonstrating how much skill we have. It's not about showing how smart we are. It is about doing all we can to help our client.
We want to look like the expert – we make it about us.
We don't have the time to really understand the issue so we recommend a standardized approach that we can do quickly.
We have a desire to be right or to look smart.
We have a lot of other projects so we select the quick and easy path to execute.
We try to move off a project too quickly because we under bid the hours – before the client gets what they need.
Ask a lot of questions about the issue – make sure you really understand it.
Restate the issue and the decision the client faces to ensure you truly understand.
Do not jump too quickly to a solution or methodology; even if a methodology is apparent.
Ask to see and read other background material so that you can better understand the situation – and read it – perhaps ask questions about it.
Try posting this formula on your wall and think through how you can leverage each aspect.
As always, feel free to comment. I'm interested in what you have to say.


Civil rights leader Dolores Huerta is not a fan of Donald Trump.
Over the last few months, as she has traveled the nation stumping for Hillary Clinton, has been taken aback at the Republican frontrunner's declarations against Mexicans and Muslims as he makes his way down the list of minorities.
"He's attacked everyone," Huerta, 85, said during a recent interview in Miami, where she stopped before Tuesday's primary. "The main thing we want to get across to people—especially Latinos—is that he is the face of the Republican Party. But guess what? The other ones pretty much have the same values as he does."
Fellow Republican candidates Ted Cruz, Marco Rubio and John Kasich share many of the same policy points as Trump, she argues. They just put it in a more digestible, less abrasive way.
But there's a value in Trump, she suggests—such a loud, apparently overt bigot at the head of the pack has awakened a large part of the population to a problem that urgently needs to be addressed. Latino pushback against Trump has already been credited with a spike in immigrants completing the naturalization procsess, motivating citizens to vote for the first time.
The 2016 election has an uncanny resemblance to the beginning of the civil rights movement, she told me. "Not at its peak, but in the beginning stages," she said.
It was horrible. But with such a prominent, charismatic leader at the helm of such a strategic state in the fight for racial equality, it gave the people something to rally against. Had he been less abrasive, Huerta argued, the victories of the civil rights movement might not have been seen as urgently needed, the reality of living under Jim Crow that much more normalized. The same ol' same ol'.
Now, Huerta suggests, Trump might be occupying the same historical space.
"It all makes me remember George Wallace, and these horrible killings of people—when they killed young people trying to do voter registration—and it got really really ugly," she said. "Sometimes I think it's like, things have to fester and they have to get ugly so that they can be visible."
Huerta has long been a labor leaders and civil rights activist, doing most of her work on behalf of the Latino community. She was an early member of the group that would later become United Farm Workers, one of the nation's largest unions. In 1965, at the height of the Southern civil rights Era, Huerta and her colleague Cesar Chavez directed a successful national grape boycott, which led to California's entire table grape picking industry being unionized.
Part of the success of the civil rights movement was that so many different stakeholders got involved in the fight, said Huerta. There was the African-Americans working with Jewish organizations, working with white Americans. Today, she sees a similar intersectionality happening because of the kind of language that is becoming normalized in current politics.
"We see the immigrant rights movement working with the people fighting for minimum wage, who are working with Black Lives Matter, it's almost like an awakening of the public," she said. "People are becoming active like we haven't seen in years."
"Sometimes if things aren't visible, we can't cure them," Huerta said of the rise of Trump. "There's gotta be a healing that we can all work towards here."