Patient-Reported Outcome Measure Use in Guidelines Published by the American Academy of Ophthalmology: A Review.

TOPIC: We reviewed the use of patient-reported outcome measures (PROMs) in the treatment of ophthalmologic conditions as recommended by the Clinical Practice Guidelines (CPGs) published by the American Academy of Ophthalmology (AAO). CLINICAL RELEVANCE: Patient-reported outcome measures are standardized instruments that provide information regarding a patient's health status or health-related quality of life. Patient-reported outcome measures are increasingly used to inform study end points in ophthalmology studies. However, the extent to which PROMs are ultimately informing patient management recommendations in ophthalmology as part of CPGs remains an area of evidence gap. METHODS: We included all CPGs published by the AAO from inception to June 2022. We also included all primary studies and systematic reviews cited in the treatment sections of the CPGs evaluating treatment of an ophthalmic condition. The primary outcome was the frequency of PROMs discussed in CPGs and in cited studies evaluating treatment. Secondary outcomes included frequency of minimal important difference (MID) use to contextualize PROM results and percentage of strong and discretionary recommendations supported by PROMs. We published a study protocol a priori on PROSPERO (CRD42022307427). Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We assessed risk of bias using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument. RESULTS: We identified 24 eligible CPGs, providing 2458 cited studies (2191 primary, 267 secondary) evaluating treatment of eye conditions. Ten CPGs (41.7%) reported consideration of PROMs. Of these, 31 of 94 (33%) recommendations were informed by studies evaluating a PROM as an outcome. Across all studies cited in the development of CPGs, 221 (9.0%) used PROMs as a primary or secondary outcome, of which 4 PROM results (1.8%) were interpreted using an empirically determined MID. Overall, the risk of bias was low for all CPGs. CONCLUSIONS: Overall, outcomes of PROMs are seldom used in ophthalmology CPGs published by the AAO and in cited primary and secondary research on treatments. When PROMs were considered, their interpretation was seldom based on an MID. To improve patient care, guideline developers may consider incorporating PROMs and applicable MIDs to inform key outcomes when formulating treatment recommendations. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Myths and methodologies: Reliability of forearm cutaneous vasodilatation measured using laser-Doppler flowmetry during whole-body passive heating.

Laser-Doppler flowmetry (LDF) is commonly used to assess cutaneous vasodilatation responses, but its reliability (i.e. consistency) during whole-body passive heating is unknown. We therefore assessed the reliability of LDF-derived indices of cutaneous vasodilatation during incremental whole-body heating. Fourteen young men (age: 24 (SD 5) years) completed three identical trials, each separated by 1 week. During each trial, a water-perfused suit was used to raise and clamp oesophageal temperature at 0.6°C (low-heat strain; LHS) and 1.2°C (moderate-heat strain; MHS) above baseline. LDF-derived skin blood flow (SkBF) was measured at three dorsal mid-forearm sites, with local skin temperature clamped at 34°C. Data were expressed as absolute cutaneous vascular conductance (CVCabs ; SkBF/mean arterial pressure) and normalised to maximal conductance (%CVCmax ) achieved via simultaneous local skin heating to 44°C and increasing oesophageal temperature to 1.8°C above baseline. Between-day reliability was characterised as measurement consistency across trials, while within-day reliability was characterised as measurement consistency across adjacent skin sites during each trial. Between- and within-day absolute reliability (coefficient of variation) generally improved with increasing heat strain, changing from poor (>25%) at baseline, poor-to-moderate (15-34%) at LHS, and moderate (10-25%) at MHS. Generally, these estimates were more consistent when expressed as %CVCmax . Conversely, relative reliability was mostly acceptable (intraclass correlation coefficient ≥0.70) during LHS and when data were expressed as CVCabs . These findings indicate that the consistency of LDF-derived CVC estimates during heat stress depends on the level of heat strain and method of data expression, which should be considered when designing and interpreting experiments.

Diversity gaps among practicing ophthalmologists in Canada: a landscape study.

OBJECTIVE: Outline geographic disparities in access to language-and gender-concordant ophthalmologic care in Canada. DESIGN: Cross-sectional. PARTICIPANTS: Practicing ophthalmologists in Canada (September 2023). METHODS: Data on ophthalmologists, including demographics, languages spoken, and practice locations, were collected from provincial regulatory body websites. Population data were extracted from the 2021 Statistics Canada Census. Ratio of ophthalmologists-to-potential patients and mean distances (absolute, population-weighted) to gender- and language-concordant care were calculated. The five most common languages spoken in the included provinces were analyzed. RESULTS: There were 986 and 1338 ophthalmologists in the language and gender analysis, respectively. Few ophthalmologists spoke non-official languages in Saskatchewan, Manitoba, and Nova Scotia. In a population-weighted analysis, the distance to a language-concordant ophthalmologist were 4.55 times greater for Spanish speakers compared to their English counterparts. Cantonese speakers had the shortest distances to language-concordant care but were still had 40% greater distance than English speakers in the same regions. Despite French-speaking ophthalmologists being the most prevalent per 100 000 speakers, francophones outside Quebec endured distances over double that of anglophones to access language-concordant care. Females in Newfoundland and Saskatchewan faced the longest distances to access gender-concordant care. In Ontario, females may face 3 times the distance to gender-concordant ophthalmologists compared to males. Quebec approaches gender parity with a male-to-female ratio of 55:45. CONCLUSIONS: The results highlight the disparities in accessibility to non-English ophthalmologic care and the underrepresentation of female ophthalmologists across Canada. These disparities underscore the need for targeted strategies to ensure that the ophthalmologic workforce mirrors the demographic of the population it serves.

NAD+ and Niacin Supplementation as Possible Treatments for Glaucoma and Age-Related Macular Degeneration: A Narrative Review.

Glaucoma and age-related macular degeneration (AMD) are progressive retinal diseases characterized by increased oxidative stress, inflammation, and mitochondrial dysfunction. This review investigates the potential therapeutic benefits of NAD+ and niacin supplementation in managing glaucoma and AMD. A literature search was conducted encompassing keywords such as "niacin", "NAD", "glaucoma", "AMD", and "therapeutics". NAD+ depletion is associated with increased oxidative stress and mitochondrial dysfunction in glaucoma and AMD. Niacin, a precursor to NAD+, has shown promise in replenishing NAD+ levels, improving choroidal blood flow, and reducing oxidative damage. Animal studies in glaucoma models indicate that nicotinamide (NAM) supplementation preserves RGC density and function. Large-scale population-based studies indicate an inverse correlation between niacin intake and glaucoma prevalence, suggesting a preventative role. Randomized controlled trials assessing niacin supplementation showed significant improvements in visual field sensitivity and inner retinal function, with a dose-dependent relationship. In AMD, nicotinamide supplementation may improve rod cell function and protect against oxidative stress-induced damage. Cross-sectional studies reveal that individuals with AMD have a lower dietary intake of niacin. Further studies suggest niacin's role in improving choroidal blood flow and dilating retinal arterioles, potentially mitigating ischemic damage and oxidative stress in AMD. Beyond current management strategies, NAD+ and niacin supplementation may offer novel therapeutic avenues for glaucoma and AMD. Further research is warranted to elucidate their efficacy and safety in clinical settings.

Use of Plasma Rich in Growth Factors for Ocular Surface Disorders: A Systematic Review.

PURPOSE: Ocular surface disorders (OSDs) can severely affect vision and quality of life. Autologous blood products, such as plasma rich in growth factors (PRGF), are recently available to treat OSDs refractory to traditional therapies. This review aims to summarize the efficacy and safety of PRGF in OSDs. METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was established a priori and published on PROSPERO (CRD42024522119). MEDLINE, Embase, and Cochrane Library were searched for primary articles until February 6, 2024. Primary outcomes included slit-lamp examination findings and patient-reported outcomes. Secondary outcomes included visual outcomes and adverse events. Risk of bias was assessed using the Cochrane Risk of Bias and ROBINS-I tools. RESULTS: Twenty-two studies involving 1158 eyes were included. PRGF showed notable improvement in objective and subjective outcomes in OSDs. Comparative studies did not show PRGF to be superior to a standard steroid taper for dry eye disease. However, the use of PRGF was also reported in persistent epithelial defects and corneal ulcerations. In these conditions, there were high rates of complete healing and reduced corneal staining. PRGF has also been reported to improve ocular surface healing and stability when used as an adjunct to refractive and pterygium surgeries. No serious adverse events were reported. CONCLUSIONS: PRGF has potential as an effective treatment of OSDs resistant to traditional therapies with minimal safety concerns. Large randomized controlled trials are needed to better evaluate the role of PRGF within the treatment armamentarium for corneal pathologies.

Heat strain in children during unstructured outdoor physical activity in a continental summer climate.

The purpose of this study was to assess the heat strain experienced by children during unstructured physical activity outdoors in a temperate continental summer climate. Eighteen children (7 girls, 12.1 ± 1.7 years) performed up to 4 h of outdoor free-play (duration: 218 ± 33 min; air temperature of 24.5 ± 3.9°C and relative humidity of 66.2 ± 9.2%). Urine specific gravity (USG) was measured pre- and post-free-play, while body core temperature (Tco, ingestible pill) and heart rate (HR) were measured continuously. Physiological strain index (PSI) was calculated from Tco and HR (scale: 0 (none) to 10 (very high)). Activity levels were categorized as rest, light, moderate, and vigorous based on the metabolic equivalent of task, estimated from video analysis. Most children were euhydrated pre (78%, USG ≤ 1.020), but not post-free-play (28%, USG ≤ 1.020). Mean and peak Tco, HR, and PSI responses were 37.8 ± 0.3°C and 38.4 ± 0.3°C, 133 ± 14 bpm and 180 ± 12 bpm, and 4.7 ± 1.1 (low) and 7.4 ± 1.0 (high), respectively. All children reached peak Tco≥38.0°C, with seven ≥38.5°C, and the highest at 38.9°C. The children spent 58 ± 15% of free-play engaged in moderate-to-vigorous intensity physical activity. During free-play, all of the children performed moderate-to-vigorous intensity physical activity, which was associated with pronounced elevations in heat strain.