Effective low-cost pediatric vision screening by naive nonophthalmic examiners using the 'Arclight' device.

PURPOSE: To explore whether a low-cost ophthalmoscope (Arclight) can be used by naive nonophthalmic examiners to effectively screen for pediatric eye disease. METHODS: Fifty-four children (108 eyes) were examined by five medical students using an Arclight. Gold standard examination was performed by an ophthalmologist using a slit lamp and indirect ophthalmoscope. Examinations performed included ophthalmoscopy of the optic disc, estimation of the cup-to-disc ratio (CDR), corneal light reflex test (CRT), Bruckner's reflex test (BRT), and evaluation of refractive error. We determined the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the nonophthalmologist's Arclight exam compared to the gold standard findings of comprehensive evaluation by pediatric ophthalmologists. RESULTS: Using the Arclight, the optic nerve exam was successfully completed in 65% of patients. CDRs above and below 0.5 could be determined with 66.7% sensitivity and 84.4% specificity. Arclight CRT measurements were significant (P < .00001) predictors of strabismus, with 80% sensitivity, 95.1%, specificity, 80% PPV, and 95.1% NPV. BRT was not a significant predictor of amblyopia, with a 34.6% sensitivity, 85.7% specificity, 69.2% PPV, and 58.5% NPV. Refractive error was estimated with a success rate of 81% for emmetropia, 38% for myopia, and 21% for hyperopia. The Arclight ease-of-use was rated on average as 4.4 (SD = 0.9) on a scale of 1 to 5, with 1 being the hardest and 5 being the easiest. CONCLUSIONS: Our study shows the Arclight as an affordable and effective alternative to the traditional ophthalmoscope for assessing eye disease in children. This device can improve eye health services in under-resourced regions.

A Statewide Mobile Simulation Program For Improving Obstetric Skills in Rural Hospitals.

BACKGROUND: Closure of rural obstetric (OB) units has led to maternal care deserts, causing mothers to travel long distances for maternity care. Emergency departments (EDs) in hospitals where OB units have closed require regular training for personnel to maintain OB skills, as do rural Level-1 OB units with low volumes of maternity cases. We used a federal grant to develop an OB mobile simulation program to bring simulation-based training to rural providers. Our goal was to improve OB skills and standardize care through the framework of the Alliance for Innovation in Maternal Health (AIM) Patient Safety Bundles. METHODS: We conducted needs assessments and built a mobile simulation unit. We defined 2 groups of learners: those in Level-1 OB units and those in EDs without OB units. For Level-1 OB units, we created a train-the-trainer curriculum, to create a statewide cohort of simulation experts to implement simulations in their facilities between our visits. We gifted each Level-1 unit an OB task trainer, implemented virtual train-the-trainer simulation and task trainer workshops, and conducted post-workshop assessments. We then traveled to each Level-1 unit and helped the cohort implement in situ simulations for their staff using facility-specific resources. We conducted assessments for the cohort and the hospital staff after the simulations. For EDs, we delivered virtual didactics to improve basic OB knowledge, then traveled to ED units, implemented in situ simulations, and conducted post-simulation assessments. We chose a postpartum hemorrhage (PPH) scenario for our first round of simulations. RESULTS: After train-the-trainer simulation workshops, 98% of participants surveyed agreed that workshop goals and objectives were achieved. After the task trainer workshop, 95% surveyed agreed that their knowledge of using the simulator had improved. After implementing in situ simulations in Level-1 OB units, 98.8% of the train-the-trainer cohort found that their ability to implement simulations had improved. The hospital staff participating in the simulations identified a 30% increase in ability to manage PPH. For the ED staff, postdidactic evaluations identified that 95.4% of participants reported moderate improvement in basic OB knowledge and after participation in the simulations >95% reported better skills as an ED team member when caring for pregnant patients. CONCLUSIONS: These results demonstrate improved skills of hospital staff in simulated PPH in Level-1 OB units and simulated OB emergencies in EDs that no longer have OB units. Further studies are warranted to assess improvement in maternal outcomes.

Moderators of movement behaviour changes among Canadian toddlers and preschoolers throughout the first 2 years of the COVID-19 pandemic.

Primary objectives were to examine: (1) changes in movement behaviours (i.e., outdoor play (OP), organized physical activity (PA), screen time (ST), sleep) across the first 2 years of coronavirus disease-2019 (COVID-19) among Canadian toddlers and preschoolers, and (2) intrapersonal, interpersonal, community, and policy moderators of change in movement behaviors. Participants were 341 Canadian parents of children (start of study: 1-4 years; 48% female). Participants completed online questionnaires regarding their children's movement behaviours and intrapersonal, interpersonal, and community factors at five time-points before and throughout the pandemic (T1-T5). Data from government websites were also used for some community and policy factors. Linear mixed models were conducted. Compared to pre-COVID-19 (T1): OP was on average 30 min/day higher at T2 and T3; organized PA was on average 62, 44, and 37 min/day lower at T2, T3, and T4, respectively; ST was on average 67, 17, 38, and 52 min/day higher at T2, T3, T4, and T5, respectively; and sleep was on average 30, 36, and 82 min/day lower at T3, T4, and T5, respectively. Significant moderating variables were observed for OP (parental education, parental work inside home, COVID-19 restriction severity), organized PA (children's sex, started kindergarten, nonparental care, parental education, household income, parental employment status, house type, indoor home space and support for PA), ST (nonparental care, parental marital status) and sleep (children's T1 age group, started kindergarten, parental place of birth, parental employment status). All movement behaviors changed across the first 2 years of COVID-19 but patterns and moderators were behaviour-specific. Children from lower socioeconomic status families had the least optimal patterns.

Emergency department use in the postpartum period: a retrospective cohort study.

Background: Visits to the emergency room (ED) by women in the postpartum period may reflect gaps in postpartum care and disparities in access to obstetric and primary care services. This study aimed to characterize the patients who visited the ED in the first year after delivery, their reasons for coming to the ED, and the care they received. Methods: The electronic health record was reviewed for all patients who delivered at University of Iowa Health Care between 2009 and 2023 and visited the ED within 365 days after delivery. Data drawn directly from the EHR included patient demographics and medical history, pregnancy and delivery information, and newborn characteristics. The charts were then reviewed manually for information regarding ED visits including time from delivery, chief complaint, diagnosis, and disposition. Results: 555 pregnancies had ED visits within one year of delivery, with a total 814 ED visits across the study sample. 46.7% of ED visits occurred in the first 30 days following delivery, and 35% of ED visits for obstetric complaints occurred in the first 2 weeks after delivery. Black patients visited the ED more often (mean=1.84 visits, SD=1.30) than white (mean=1.34, SD=0.92, p<0.001) or Hispanic patients (mean=1.35, SD=0.67, p = 0.004). The most common categories of chief complaint were obstetric (34.6%) and gastrointestinal (18.8%), while the most common categories of diagnosis were obstetric (31.8%) and immune/infectious (28.1%). Conclusions: Visits to the ED are common in the year following delivery. Almost half of these visits occur in the first 30 days after birth. The plurality of postpartum ED visits are due to obstetric complaints, especially in the first few weeks. Black women are more likely to use the ED during this period, potentially due to disparities in healthcare access. These findings suggest that some of these ED visits may be preventable, and that there is room for improvement in post-delivery follow-up, communication between patients and the obstetrics team, and access to outpatient obstetric care.

A role for adverse childhood experiences and depression in preeclampsia.

Introduction: Adverse childhood experiences (ACEs) are a measure of childhood adversity and are associated with life-long morbidity. The impacts of ACEs on peripartum health including preeclampsia, a common and dangerous hypertensive disorder of pregnancy, remain unclear, however. Therefore, we aimed to determine ACE association with peripartum psychiatric health and prevalence of preeclampsia using a case-control design. Methods: Clinical data were aggregated and validated using a large, intergenerational knowledgebase developed at our institution. Depression symptoms were measured by standard clinical screeners: the Patient Health Questionnaire-9 (PHQ-9) and the Edinburgh Postnatal Depression Scale (EPDS). ACEs were assessed via survey. Scores were compared between participants with (N = 32) and without (N = 46) prior preeclampsia. Results: Participants with ACE scores ≥4 had significantly greater odds of preeclampsia than those with scores ≤ 3 (adjusted odds ratio = 6.71, 95% confidence interval:1.13-40.00; p = 0.037). Subsequent speculative analyses revealed that increased odds of preeclampsia may be driven by increased childhood abuse and neglect dimensions of the ACE score. PHQ-9 scores (3.73 vs. 1.86, p = 0.03), EPDS scores (6.38 vs. 3.71, p = 0.01), and the incidence of depression (37.5% vs. 23.9%, p = 0.05) were significantly higher in participants with a history of preeclampsia versus controls. Conclusions: Childhood sets the stage for life-long health. Our findings suggest that ACEs may be a risk factor for preeclampsia and depression, uniting the developmental origins of psychiatric and obstetric risk.

Care from Birth to Discharge of Infants Born at 22 to 23 Weeks' Gestation.

The clinical care of infants born at 22 weeks' gestation must be well-designed and standardized if optimal results are to be expected. Although several approaches to care in this vulnerable population are possible, protocols should be neither random nor inconsistent. We describe the approach taken at the University of Iowa Stead Family Children's Hospital neonatal intensive care unit with respect to preterm infants born at 22 weeks' gestation. We have chosen to present our standardize care plan with respect to prenatal, neurologic, nutritional, gastrointestinal, and skin management. Respiratory and cardiopulmonary care will be briefly reviewed, as these strategies have been published previously.

Association Between Area-Level Income Inequality and Health-Related School Absenteeism: Evidence From the COMPASS Study.

BACKGROUND: Income inequality is theorized to impact health. However, evidence among adolescents is limited. This study examined the association between income inequality and health-related school absenteeism (HRSA) in adolescents. METHODS: Participants were adolescents (n = 74,501) attending secondary schools (n = 136) that participated in the 2018-2019 wave of the COMPASS study. Chronic (missing ≥3 days of school in the previous 4 weeks) and problematic (missing ≥11 days of school in the previous 4 weeks) HRSA was self-reported. Income inequality was assessed via the Gini coefficient at the census division (CD) level. Multilevel modeling was used. RESULTS: Greater income inequality was associated with a higher likelihood of chronic and problematic HRSA (chronic: OR = 1.17, 95% CI: 1.06, 1.30; problematic: OR = 1.29, 95% CI 1.11 to 1.50). Increased predicted probabilities for Problematic HRSA were observed at greater degrees of income inequality among students who identified as either white, black, Latinx, or mixed, while protective associations were observed among students who identified as Asian or other. No associations were modified by gender. CONCLUSION: Income inequality demonstrated unfavorable associations with HRSA, which was modified by racial identity.

Measuring visual acuity and spherical refraction with smartphone screens emitting blue light.

INTRODUCTION: A periodical self-monitoring of spherical refraction using smartphones may potentially allow a quicker intervention by eye care professionals to reduce myopia progression. Unfortunately, at low levels of myopia, the far point (FP) can be located far away from the eye which can make interactions with the device difficult. To partially remedy this issue, a novel method is proposed and tested wherein the longitudinal chromatic aberration (LCA) of blue light is leveraged to optically bring the FP closer to the eye. METHODS: Firstly, LCA was obtained by measuring spherical refraction subjectively using blue pixels in stimuli shown on organic light-emitting diode (OLED) screens and also grey stimuli with matching luminance. Secondly, the visual acuity (VA) measured with a smartphone located at 1.0 m and 1.5 m and displaying blue optotypes was compared with that obtained clinically standard measurements. Finally, the spherical over refraction obtained in blue light with a smartphone was compared with clinical over-refraction with black and white (B&W) optotypes placed at 6 m. RESULTS: Mean LCA of blue OLED smartphone screens was -0.67 ± 0.11 D. No significant differences (p > 0.05) were found between the VA measured with blue optotypes on a smartphone screen and an eye chart. Mean difference between spherical over-refraction measured subjectively by experienced subjects with smartphones and the one obtained clinically was 0.08 ± 0.34 D. CONCLUSIONS: Smartphones using blue light can be used as a tool to detect changes in visual acuity and spherical refraction and facilitate monitoring of myopia progression.

Examining the Relationship Between Individual Patient Factors and Substantial Clinical Benefit From Telerehabilitation Among Patients With Chronic Low Back Pain.

OBJECTIVE: The coronavirus disease-2019 pandemic has facilitated the emergence of telerehabilitation, but it is unclear which patients are most likely to respond to physical therapy provided this way. The purpose of this study was to examine the relationship between individual patient factors and substantial clinical benefit from telerehabilitation among a cohort of patients with chronic low back pain (LBP). METHODS: This is a secondary analysis of data collected during a prospective longitudinal cohort study. Patients with chronic LBP (N = 98) were provided with a standardized physical therapy protocol adapted for telerehabilitation. We examined the relationship between patient factors and substantial clinical benefit with telerehabilitation, defined as a ≥50% improvement in disability at 10 weeks, measured using the Oswestry Disability Index. RESULTS: Sixteen (16.3%) patients reported a substantial clinical benefit from telerehabilitation. Patients reporting substantial clinical benefit from telerehabilitation had lower initial pain intensity, lower psychosocial risk per the STarT Back Screening Tool, higher levels of pain self-efficacy, and reported higher therapeutic alliance with their physical therapist compared to other patients. CONCLUSION: Patients with lower psychosocial risk and higher pain-self efficacy experienced substantial clinical benefit from telerehabilitation for chronic LBP more often than other patients in our cohort. Therapeutic alliance was higher among patients who experienced a substantial clinical benefit compared to those who did not. IMPACT: This study indicates that psychosocial factors play an important role in the outcomes of patients receiving telerehabilitation for chronic LBP. Baseline psychosocial screening may serve as a method for identifying patients likely to benefit from this approach.

Pigmented pyogenic granuloma of the cornea and conjunctiva: a rare bilateral presentation.

Pyogenic granuloma, also known as lobular capillary hemangioma, is a benign vascular lesion that primarily affects the skin and mucous membranes. It is not pyogenic; nor is it granulomatous. It typically arises in response to local trauma or surgery, irritation, hormonal changes, or chronic inflammation, and it sometimes occurs spontaneously. The occurrence of pigmented pyogenic granuloma in the conjunctiva and cornea without any history of trauma or surgery is extremely rare, particularly in children. We report the clinical presentation, diagnostic evaluation, and successful management of bilateral biopsy-proven conjunctival and corneal pigmented isolated pyogenic granuloma in an 11-year-old girl. No signs of recurrence were seen at the 3-months follow-up.

Exploring the longitudinal associations between census division income inequality and BMI trajectories among Canadian adolescent: Is gender an effect modifier?

Background: Income inequality is a structural determinant of health linked to increased risk of overweight and obesity, although its links to the health of adolescent populations are not well understood. This study investigated the longitudinal associations between census-division-level (CD) income inequality and BMI trajectories among Canadian adolescents, and determine if these associations vary by gender. Methods: Study data are from the Cannabis use, Obesity, Mental health, Physical Activity, Alcohol use, Smoking, and Sedentary behaviour (COMPASS) cohort of adolescents attending secondary schools in Canada. Our sample included 14,675 adolescents who were followed up across three waves of the COMPASS study (2016-2017, 2017-2018, and 2018-2019) and linked to 30 CDs. Measures of income inequality and other area-level covariates were derived and linked to COMPASS participants using data from the 2016 Canadian Census. We utilized multilevel mixed-effects linear regression modelling to quantify the associations between income inequality and BMI and test for effect modification by gender. Sensitivity analyses were run excluding those with BMI scores in the range considered overweight or obesity at baseline. Results: Higher CD income inequality was significantly associated with higher z-transformed BMI scores (ß = 0.11, 95% CI = 0.034 to 0.19). The interaction term between income inequality and time was not statistically significant, indicating that this association remained constant over time. Once stratified by gender, the association between inequality and BMI became stronger for males (ß = 0.14, 95% CI = 0.060 to 0.022) and attenuated for females (ß = 0.063, 95% CI = -0.047 to 0.17). Conclusion: Attending schools in CDs with higher income inequality was associated with higher BMI scores among male but not female adolescents. Further work is needed to investigate this discrepancy and identify the structural mechanisms that mediate the relationship between inequality and adolescent health.

Deep Learning Approach for Differentiating Etiologies of Pediatric Retinal Hemorrhages: A Multicenter Study.

Retinal hemorrhages in pediatric patients can be a diagnostic challenge for ophthalmologists. These hemorrhages can occur due to various underlying etiologies, including abusive head trauma, accidental trauma, and medical conditions. Accurate identification of the etiology is crucial for appropriate management and legal considerations. In recent years, deep learning techniques have shown promise in assisting healthcare professionals in making more accurate and timely diagnosis of a variety of disorders. We explore the potential of deep learning approaches for differentiating etiologies of pediatric retinal hemorrhages. Our study, which spanned multiple centers, analyzed 898 images, resulting in a final dataset of 597 retinal hemorrhage fundus photos categorized into medical (49.9%) and trauma (50.1%) etiologies. Deep learning models, specifically those based on ResNet and transformer architectures, were applied; FastViT-SA12, a hybrid transformer model, achieved the highest accuracy (90.55%) and area under the receiver operating characteristic curve (AUC) of 90.55%, while ResNet18 secured the highest sensitivity value (96.77%) on an independent test dataset. The study highlighted areas for optimization in artificial intelligence (AI) models specifically for pediatric retinal hemorrhages. While AI proves valuable in diagnosing these hemorrhages, the expertise of medical professionals remains irreplaceable. Collaborative efforts between AI specialists and pediatric ophthalmologists are crucial to fully harness AI's potential in diagnosing etiologies of pediatric retinal hemorrhages.

Highly restricted near-surface permafrost extent during the mid-Pliocene warm period.

Accurate understanding of permafrost dynamics is critical for evaluating and mitigating impacts that may arise as permafrost degrades in the future; however, existing projections have large uncertainties. Studies of how permafrost responded historically during Earth's past warm periods are helpful in exploring potential future permafrost behavior and to evaluate the uncertainty of future permafrost change projections. Here, we combine a surface frost index model with outputs from the second phase of the Pliocene Model Intercomparison Project to simulate the near-surface (~3 to 4 m depth) permafrost state in the Northern Hemisphere during the mid-Pliocene warm period (mPWP, ~3.264 to 3.025 Ma). This period shares similarities with the projected future climate. Constrained by proxy-based surface air temperature records, our simulations demonstrate that near-surface permafrost was highly spatially restricted during the mPWP and was 93 ± 3% smaller than the preindustrial extent. Near-surface permafrost was present only in the eastern Siberian uplands, Canadian high Arctic Archipelago, and northernmost Greenland. The simulations are similar to near-surface permafrost changes projected for the end of this century under the SSP5-8.5 scenario and provide a perspective on the potential permafrost behavior that may be expected in a warmer world.

The association between income inequality and adolescent body mass index: findings from the COMPASS study (2016-2019).

OBJECTIVES: Income inequality has been linked to high and unhealthy body mass index (BMI), though there is a dearth of evidence in adolescents. Therefore, this study examines the association between income inequality and BMI in a large sample of Canadian adolescents. METHODS: A pooled cross-sectional design was used. Participants were adolescents (n = 101,901) from 157 Canadian secondary schools participating in the 2016-2017, 2017-2018, or 2018-2019 waves of the Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, and Sedentary behaviour (COMPASS) study. BMI was calculated from self-reported height and weight and converted to World Health Organization (WHO) z-BMI scores. Gini coefficients were calculated at the census division level (n = 49) using data from the 2016 Canadian Census. Multilevel modelling was performed to account for the clustering of students nested within schools, which were nested within census divisions. Interactions were included to determine whether associations were heterogeneous for males and females. RESULTS: Income inequality demonstrated a non-linear association with WHO z-BMI score (z-Gini: ß = 0.05, 95%CI: 0.02, 0.08; z-Gini2: ß = -0.02, 95% CI: -0.04, -0.01) among adolescents after adjusting for student-, school-, and census division-level covariates. This association was more pronounced among females. CONCLUSION: The association between income inequality and BMI, being overweight, or having obesity appears to be non-linear. Public health units and schools may benefit from incorporating upstream factors such as income inequality into their interventions attempting to promote healthy weights.

RéSUMé: OBJECTIFS: L'inégalité des revenus a été liée à un indice de masse corporelle (IMC) élevé et malsain, bien qu'il y ait un manque de preuves chez les adolescents. Par conséquent, la présente étude examine l'association entre l'inégalité des revenus et l'IMC dans un vaste échantillon d'adolescents canadiens. MéTHODES: Un devis comprenant des études transversales groupées a été utilisé. Les participants étaient des adolescents (n = 101 901) de 157 écoles secondaires canadiennes participant aux vagues 2016-2017, 2017-2018 ou 2018-2019 de l'étude COMPASS (Cannabis, Obésité, Santé mentale, Activité physique, Alcool, Tabagisme et Comportement sédentaire). L'IMC a été calculé à partir de la taille et du poids auto-déclarés et convertis en scores z selon l'Organisation mondiale de la santé (OMS). Les coefficients de Gini ont été calculés à l'échelle du secteur de recensement (n = 49) en utilisant les données du Recensement canadien de 2016. Des modèles multiniveaux ont été effectués pour tenir compte du regroupement des élèves dans les écoles, qui elles-mêmes étaient incluses dans les secteurs de recensement. Des variables d'interactions ont été incluses dans les modèles afin de permettre une comparaison des paramètres estimés entre les hommes et les femmes. RéSULTATS: L'inégalité des revenus a démontré une association non linéaire avec le score de l'IMC z de l'OMS (z-Gini : ß = 0,05, IC à 95 % : 0,02, 0,08; z-Gini2 : ß = -0,02, IC à 95 % : -0,04, -0,01) chez les adolescents après ajustement pour tenir compte des covariables au niveau des élèves, de l'école et des divisions de recensement. Cette association était plus prononcée chez les femmes. CONCLUSION: L'association entre l'inégalité des revenus et l'IMC, l'embonpoint ou l'obésité semble être non linéaire. Les bureaux de santé publique et les écoles pourraient tirer profit de l'intégration de facteurs en amont comme l'inégalité des revenus dans leurs interventions visant à promouvoir le poids santé.

The association between social fragmentation and deaths attributable to alcohol, drug use, and suicide: Longitudinal evidence from a population-based sample of Canadian adults.

BACKGROUND: Social fragmentation has been theorized and empirically associated with suicide in prior research. However, less is known about whether social fragmentation is associated with deaths attributed to alcohol use or drug use. This research examined the association between social fragmentation and risk for deaths attributable to alcohol use, drug use, and suicide (collectively known as deaths of despair) among Canadian adults. METHODS: A weighted sample representing 15,324,645 Canadians within 288 census divisions between 2006 and 2019 was used. Mortality data from the Canadian Vital Statistics Database (alcoholic liver disease, drug use, and suicide) was linked with census division socioeconomic data from the 2006 Canadian census using the Canadian Census Health and Environment Cohorts. Social fragmentation at the census division was created based on the Congdon Index. Cox-proportional hazard regression with survey weights and the sandwich estimator were used to account for clustering of individuals (level-1) nested within census divisions (level-2). RESULTS: After adjusting for individual and census division confounders, social fragmentation was positively associated with all-cause mortality (HR = 1.04; 95% CI: 1.02, 1.07), suicide (HR = 1.09; 95%CI: 1.01, 1.18), drug overdose related mortality (HR = 1.13; 95%CI: 1.03, 1.24), and deaths of despair (HR = 1.10; 95% CI: 1.04, 1.16), and not significantly associated with alcohol related liver disease (HR = 1.06; 95% CI: 0.91, 1.23). CONCLUSION: Social fragmentation is associated with an increased hazard of deaths of despair among Canadian adults. Efforts to improve social cohesion in areas that are highly socially fragmented need to be evaluated.

Clinical validation of a novel smartphone application for measuring best corrected visual acuity.

PURPOSE: Personal mobile devices such as smartphones are proving their usefulness in ever more applications in tele-eyecare. An inconvenience and potential source of error in these past approaches stemmed from the requirement for the subjects to situate their devices at a distance. The present study aims to clinically validate best corrected visual acuity (BCVA) measures carried out by a novel smartphone application "vision.app" (VisionApp Solutions S.L.) using comparative statistics against clinical measurements. MATERIALS AND METHODS: BCVA was measured in both eyes of 40 subjects using vision.app which displayed a black Landolt-C optotype with crowding on a white background, and utilized a 4 forced-choice procedure for the subjects to find (by means of swiping in either of four directions) the smallest optotype size they could resolve. Results were compared to BCVA measurements taken using a standard Snellen chart placed at 20 feet (6 m). RESULTS: The t-test revealed no significant differences between the app- and clinically-measured VA (p = 0.478 (OD) and 0.608 (OS)), with a mean difference between clinical and app measurements of less than one line of the eye chart (-0.009 logMAR (OD) and -0.005 logMAR (OS)). A limit of agreement for a 95% confidence interval of ± 0.08 logMAR for OD and OS was found. CONCLUSIONS: The results show the potential use of a smartphone to measure BCVA at a handheld distance. The newly validated study results can hold major future advancements in tele-eyecare and provide eye care professionals with a reliable and accessible method to measure BCVA.

Variation in Outcomes and Number of Visits Following Care Guideline Implementation: Part 2 of an Analysis of 12 355 Patients After Total Knee Arthroplasty.

OBJECTIVE: To describe the variation in outcomes and number of visits before and after implementing a care guideline for total knee arthroplasty (TKA) rehabilitation. DESIGN: Nonrandomized intervention study. METHODS: We compared 2558 patients with TKA who received care that was not standardized (non-care guideline [NCG] group) to 9797 patients with TKA who received care according to the care guideline (CG). We fit 2 Bayesian hierarchical linear regression models using the Knee Outcome Survey - Activities of Daily Living (KOS-ADL) change score and number of physical therapy (PT) visits as the response variables, controlling for relevant predictor variables. We also compared the ratio of the standard deviations of the KOS-ADL change scores and the number of PT visits within and between clinics. RESULTS: The overall estimated mean improvement in KOS-ADL change score was 23.0 points (95% confidence interval [CI]: 20.3, 25.7) in the NCG group and 28.7 points (95% CI: 27.5, 29.7) in the CG group; the mean difference was 5.6 (2.7-8.6). Mean KOS-ADL change scores were higher in the CG group than the NCG group in every clinic, although only 8 clinics improved significantly. The number of PT visits did not change meaningfully (NCG: mean, 10.7 [95% CI: 9.9, 11.5]; CG: mean, 10.5 [95% CI: 9.9, 10.9]). Variation in KOS-ADL change score decreased by 4% within clinics (CG-NCG ratio: 0.96 [95% CI: 0.93, 0.99]) and 63% between clinics (CG-NCG ratio: 0.37 [95% CI: 0.21, 0.62]). Variation in number of visits decreased by 7% within clinics (CG-NCG ratio: 0.93 [95% CI: 0.90, 0.96]) and 19% between clinics (CG-NCG ratio: 0.81 [95% CI: 0.39, 1.49]). CONCLUSION: Implementing a care guideline for TKA rehabilitation may improve outcomes and reduce unwarranted variation in practice within clinics and especially between clinics within a large health care system. J Orthop Sports Phys Ther 2023;53(3):151-158. Epub: 12 December 2022. doi:10.2519/jospt.2022.11370.

Improved Outcomes Following a Care Guideline Implementation: Part 1 of an Analysis of 12 355 Patients After Total Knee Arthroplasty.

OBJECTIVE: To describe the application and examine the influence of a continuous quality improvement intervention, which had a goal of standardizing care to reduce the proportion of patients who do not have a meaningful improvement in patient-reported outcomes following total knee arthroplasty (TKA). DESIGN: Continuous quality improvement. METHODS: A physical therapy (PT) care guideline was initiated in 2013 for patients following TKA. The Knee Outcome Survey - Activities of Daily Living (KOS-ADL) was measured at every visit, and scores were extracted from a clinical outcomes database to calculate the proportion of patients who did not achieve a minimal clinically important difference. Based on logistic regression analysis, we compared the proportion of patients who did not progress on the KOS-ADL in a non-care guideline group (2008-2012) to a care guideline (CG) group (2014-2019). RESULTS: This study included 12 355 patients (aged 18-92 years) following TKA incurring at least 3 PT visits from 2008 to 2019. The percentage of patients who did not progress in the non-care guideline group was 25.8% and in the care guideline group 14.3% (P<0.001). The relationship between care guideline adherence and lack of progression on the KOS-ADL was statistically significant, X2 (df = 1) = 148.7, P<.001. CONCLUSION: The percentage of patients who did not achieve meaningful progress on the KOS-ADL declined significantly in the 6 years after implementing a TKA care guideline without an increase in the number of clinical visits. The standardized care guideline was associated with meaningful improvements for patients following TKA when applied in conjunction with PT access to outcome data, feedback through audits, performance goals, and financial incentives. J Orthop Sports Phys Ther 2023;53(3):143-150. Epub: 12 December 2022. doi:10.2519/jospt.2022.11369.

Corrigendum: Automated screening devices for vision screening in preschool children: a comparison of the PlusoptiX S12C photoscreener and retinomax K+3 autorefractor.

[This corrects the article DOI: 10.3389/fopht.2022.1049622.].