Fixational microsaccades: A quantitative and objective measure of disability in multiple sclerosis.

BACKGROUND: Objective tools for prognosis and disease progression monitoring in multiple sclerosis (MS) are lacking. The visuomotor system could be used to track motor dysfunction at the micron scale through the monitoring of fixational microsaccades. AIMS: The aim of this study was to evaluate whether microsaccades are correlated with standard MS disability metrics and to assess whether these methods play a predictive role in MS disability. METHOD: We used a custom-built retinal eye tracker, the tracking scanning laser ophthalmoscope (TSLO), to record fixation in 111 participants with MS and 100 unaffected controls. RESULTS: In MS participants, a greater number of microsaccades showed significant association with higher Expanded Disability Status Scale score (EDSS, p < 0.001), nine-hole peg test (non-dominant: p = 0.006), Symbol Digit Modalities Test (SMDT, p = 0.014), and Functional Systems Scores (FSS) including brainstem (p = 0.005), cerebellar (p = 0.011), and pyramidal (p = 0.009). Both brainstem FSS and patient-reported fatigue showed significant associations with microsaccade number, amplitude, and peak acceleration. Participants with MS showed a statistically different average number (p = 0.020), peak vertical acceleration (p = 0.003), and vertical amplitude (p < 0.001) versus controls. Logistic regression models for MS disability were created using TSLO microsaccade metrics and paraclinical tests with ⩾80% accuracy. CONCLUSION: Microsaccades provide objective measurements of MS disability level and disease worsening.

Impact of simulated micro-scotomas on reading performance in central and peripheral retina.

Observers with central field loss typically fixate within a non-foveal region called the preferred retinal locus, which can include localized sensitivity losses, or micro-scotomas (Krishnan and Bedell, 2018). In this study, we simulated micro-scotomas at the fovea and in the peripheral retina to assess their impact on reading speed. Ten younger (<36 years old) and 8 older (>50 years old) naïve observers with normal vision monocularly read high and/or low contrast sentences, presented at or above the critical print size for young observers at the fovea and at 5 and 10 deg in the inferior visual field. Reading material comprised MNREAD sentences and sentences taken from novels that were presented in rapid serial visual presentation (RSVP) format. Randomly distributed 13 × 13 arc min blocks corresponding to 0-78% of the text area (corresponding to ∼0-17 micro-scotomas/deg2) were set to the background luminance to simulate micro-scotomas. A staircase algorithm estimated maximum reading speed from the threshold exposure duration for each combination of retinal eccentricity, contrast and micro-scotoma density in both age groups. Log10(RSVP reading speed) decreased significantly with simulated micro-scotoma density and eccentricity. Across conditions, reading speed was slower with low-compared to high-contrast text and was faster in younger than older normal observers. For a given eccentricity and contrast, a higher density of random element losses maximally affected older observers with normal vision. These outcomes may explain some of the reading deficits observed in older observers with central field loss.

Blur Detection, Depth of Field, and Accommodation in Emmetropic and Hyperopic Children.

SIGNIFICANCE: Our results demonstrate that blur detection thresholds are elevated in young children compared with adults, and poorer blur detection thresholds are significantly correlated with the magnitude of accommodative microfluctuations. Given that accommodative microfluctuations are greater with greater accommodative responses, these findings may have implications for young uncorrected hyperopes. PURPOSE: This study investigated the association between subjective blur detection thresholds and accommodative microfluctuations in children 3 years to younger than 10 years old and adults. METHODS: Blur detection thresholds were determined in 49 children with habitually uncorrected refractive error (+0.06 to +4.91 diopters [D] spherical equivalent) and 10 habitually uncorrected adults (+0.08 to +1.51 D spherical equivalent) using a custom blur chart with 1° sized optotypes at 33 cm. Letters were blurred by convolution using a Gaussian kernel (SDs of 0.71 to 11.31 arc minutes in √2 steps). Subjective depth of field was determined in subjects 6 years or older and adults. Accommodative microfluctuations, pupils, and lag were measured using infrared photorefraction (25 Hz). RESULTS: Children had greater blur detection thresholds (P < .001), accommodative microfluctuations (P = .001), and depth of field (P < .001) than adults. In children, increased blur detection thresholds were associated with increased accommodative microfluctuations (P < .001), increased uncorrected hyperopia (P = .01), decreased age (P < .001), and decreased pupil size (P = .01). In a multiple linear regression analysis, blur detection thresholds were associated with accommodative microfluctuations (P < .001) and age (P < .001). Increased accommodative microfluctuations were associated with increased uncorrected hyperopia (P = .004) and decreased pupil size (P = .003) and independently associated with uncorrected hyperopia (P = .001) and pupil size (P = .003) when controlling for age and lag. CONCLUSIONS: Children did not have adult-like blur detection thresholds or depth of field. Increased accommodative microfluctuations and decreased age were independently associated with greater blur detection thresholds in children 3 years to younger than 10 years. Larger amounts of uncorrected hyperopia in children appear to increase blur detection thresholds because the greater accommodative demand and resulting response increase accommodative microfluctuations.

Scotoma Visibility and Reading Rate with Bilateral Central Scotomas.

PURPOSE: In this experiment, we tested whether perceptually delineating the scotoma location and border with a gaze contingent polygon overlay improves reading speed and reading eye movements in patients with bilateral central scotomas. METHODS: Eight patients with age-related macular degeneration and bilateral central scotomas read aloud MNRead style sentences with their preferred eye. Eye movement signals from an EyeLink II eyetracker were used to create a gaze contingent display in which a polygon overlay delineating the area of the patient's scotoma was superimposed on the text during 18 of the 42 trials. Blocks of six trials with the superimposed polygon were alternated with blocks of six trials without the polygon. Reading speed and reading eye movements were assessed before and after the subjects practiced reading with the polygon overlay. RESULTS: All of the subjects but one showed an increase in reading speed. A paired-samples t-test for the group as a whole revealed a statistically significant increase in reading speed of 0.075 ± 0.060 (SD) log wpm after reading with the superimposed polygon. Individual subjects demonstrated significant changes in reading eye movements, with the greatest number of subjects demonstrating a shift in the average vertical fixation locus. Across subjects, there was no significant difference between the initial and final reading eye movements in terms of saccades per second, average fixation duration, average amplitude of saccades, or proportion of non-horizontal saccades. CONCLUSIONS: The improvement in reading speed (0.075 log wpm or 19%) over the short experimental session for the majority of subjects indicates that making the scotoma location more visible is potentially beneficial for improving reading speed in patients with bilateral central scotomas. Additional research to examine the efficacy of more extended training with this paradigm is warranted.

Progress on Developing Adaptive Optics-Optical Coherence Tomography for In Vivo Retinal Imaging: Monitoring and Correction of Eye Motion Artifacts.

Recent progress in retinal image acquisition techniques, including optical coherence tomography (OCT) and scanning laser ophthalmoscopy (SLO), combined with improved performance of adaptive optics (AO) instrumentation, has resulted in improvement in the quality of in vivo images of cellular structures in the human retina. Here, we present a short review of progress on developing AO-OCT instruments. Despite significant progress in imaging speed and resolution, eye movements present during acquisition of a retinal image with OCT introduce motion artifacts into the image, complicating analysis and registration. This effect is especially pronounced in high-resolution datasets acquired with AO-OCT instruments. Several retinal tracking systems have been introduced to correct retinal motion during data acquisition. We present a method for correcting motion artifacts in AO-OCT volume data after acquisition using simultaneously captured adaptive optics-scanning laser ophthalmoscope (AO-SLO) images. We extract transverse eye motion data from the AO-SLO images, assign a motion adjustment vector to each AO-OCT A-scan, and re-sample from the scattered data back onto a regular grid. The corrected volume data improve the accuracy of quantitative analyses of microscopic structures.

Nonequilibrium electron rings for synchrotron radiation production.

Electron storage rings used for the production of synchrotron radiation (SR) have an output photon brightness that is limited by the equilibrium beam emittance. By using interleaved injection and ejection of bunches from a source with repetition rate greater than 1 kHz, we show that it is practicable to overcome this limit in rings of energy ∼1 GeV. Sufficiently short kicker pulse lengths enable effective currents of many milliamperes, which can deliver a significant flux of diffraction-limited soft x-ray photons. Thus, either existing SR facilities may be adapted for nonequilibrium operation, or the technique applied to construct SR rings smaller than their storage ring equivalent.

How the unstable eye sees a stable and moving world.

Eye motion, even during fixation, results in constant motion of the image of the world on our retinas. Vision scientists have long sought to understand the process by which we perceive the stable parts of the world as unmoving despite this instability and perceive the moving parts with realistic motion. We used an instrument capable of delivering visual stimuli with controlled motion relative to the retina at cone-level precision while capturing the subjects' percepts of stimulus motion with a matching task. We found that the percept of stimulus motion is more complex than conventionally thought. Retinal stimuli that move in a direction that is consistent with eye motion (i.e., opposite eye motion) appear stable even if the magnitude of that motion is amplified. The apparent stabilization diminishes for stimulus motions increasingly inconsistent with eye motion direction. Remarkably, we found that this perceived direction-contingent stabilization occurs separately for each separately moving pattern on the retina rather than for the image as a whole. One consequence is that multiple patterns that move at different rates relative to each other in the visual input are perceived as immobile with respect to each other, thereby disrupting our hyperacute sensitivity to target motion against a frame of reference. This illusion of relative stability has profound implications regarding the underlying visual mechanisms. Functionally, the system compensates retinal slip induced by eye motion without requiring an extremely precise optomotor signal and, at the same time, retains an exquisite sensitivity to an object's true motion in the world.

Large-scale calibration and simulation of COVID-19 epidemiologic scenarios to support healthcare planning.

The COVID-19 pandemic has provided stiff challenges for planning and resourcing in health services in the UK and worldwide. Epidemiological models can provide simulations of how infectious disease might progress in a population given certain parameters. We adapted an agent-based model of COVID-19 to inform planning and decision-making within a healthcare setting, and created a software framework that automates processes for calibrating the model parameters to health data and allows the model to be run at national population scale on National Health Service (NHS) infrastructure. We developed a method for calibrating the model to three daily data streams (hospital admissions, intensive care occupancy, and deaths), and demonstrate that on cross-validation the model fits acceptably to unseen data streams including official estimates of COVID-19 incidence. Once calibrated, we use the model to simulate future scenarios of the spread of COVID-19 in England and show that the simulations provide useful projections of future COVID-19 clinical demand. These simulations were used to support operational planning in the NHS in England, and we present the example of the use of these simulations in projecting future clinical demand during the rollout of the national COVID-19 vaccination programme. Being able to investigate uncertainty and test sensitivities was particularly important to the operational planning team. This epidemiological model operates within an ecosystem of data technologies, drawing on a range of NHS, government and academic data sources, and provides results to strategists, planners and downstream data systems. We discuss the data resources that enabled this work and the data challenges that were faced.

Spatial-temporal contrast sensitivity of the eye alignment reflex.

The binocular alignment of the eyes involves both voluntary and reflexive mechanisms, but little is known about the visual input and neurological pathway of the reflex component. Our studies examined the role of spatiotemporal frequency and contrast in the control of reflex eye alignment, and compared the contrast sensitivity of the alignment reflex with psychophysical contrast sensitivity. We measured the contrast sensitivity of vertical disparity-driven vergence eye movements in response to bandwidth filtered static or 6 Hz counterphase flickering noise and measured psychophysical detection sensitivity for the same stimuli. Contrast thresholds for producing a detectable vertical alignment change (measured with nonius lines) were determined using a staircase method for 7 spatial frequencies [0.25-16 cycles per degree] and 3 vertical disparities [5, 10, and 30 arcmin] in 7 adults with normal or corrected to normal vision. The main findings of this study are, (1) the vertical alignment reflex had overall relatively high contrast sensitivity, comparable to but somewhat less than visual detection thresholds, (2) the most effective stimulus spatial frequency scaled in inverse proportion to the disparity being stimulated, and (3) unlike psychophysical contrast sensitivity, the eye alignment reflex contrast sensitivity was not improved by flickering low spatial frequencies.

Can Bodybuilding Peak Week Manipulations Favorably Affect Muscle Size, Subcutaneous Thickness, and Related Body Composition Variables? A Case Study.

BACKGROUND: The purpose of this case study was to implement an evidence-based dietary approach to peaking for a bodybuilding competition and monitor its impact on body composition, muscle thickness (MT), intra-to-extra-cellular fluid shifts, subcutaneous thickness (ST), and hydration status. Secondarily, to document any adverse events of this peak week approach in a small, controlled setting. Methods Dietary practices were recorded, and laboratory testing was conducted throughout peak week, including competition morning. Assessments included: dual-energy X-ray absorptiometry (DEXA) for body composition, B-mode ultrasound for MT and ST, bioimpedance spectroscopy (BIS) for total body water (TBW)/intracellular water (ICW)/extracellular water (ECW), and raw BIS data (i.e., resistance, reactance, and phase angle), urine specific gravity (USG) for hydration status, and subjective fullness. Sequential dietary manipulations were made (i.e., CHO depletion/fat loading, CHO/water loading, and a refinement phase) with specific physiological goals. This was reflected in changes observed across all assessments throughout the peak week. RESULTS: From the carbohydrate-depleted state (three days out) to competition day, we observed increases in lean body mass, MT, TBW (primarily ICW), and subjective fullness. Kendall's Tau B revealed a strong relationship between carbohydrate intake and ∑MT (τ = 0.733, p = 0.056). Additionally, novel ST data demonstrated a 10% reduction for the summation of all seven sites, with some drastic changes in specific regions (e.g., -43% for triceps ST) from three days out to competition day. CONCLUSIONS: These data suggest that the prototypical goals of bodybuilders' peak week (i.e., increasing muscle fullness, decreasing subcutaneous thickness) to enhance their aesthetics/muscularity presented can be achieved with a drug-free protocol involving dietary manipulations.

Unreferenced spatial localization under monocular and dichoptic viewing conditions.

Knowledge of eye position in the brain is critical for localization of objects in space. To investigate the accuracy and precision of eye position feedback in an unreferenced environment, subjects with normal ocular alignment attempted to localize briefly presented targets during monocular and dichoptic viewing. In the task, subjects' used a computer mouse to position a response disk at the remembered location of the target. Under dichoptic viewing (with red (right eye)-green (left eye) glasses), target and response disks were presented to the same or alternate eyes, leading to four conditions [green target-green response cue (LL), green-red (LR), red-green (RL), and red-red (RR)]. Time interval between target and response disks was varied and localization errors were the difference between the estimated and real positions of the target disk. Overall, the precision of spatial localization (variance across trials) became progressively worse with time. Under dichoptic viewing, localization errors were significantly greater for alternate-eye trials as compared to same-eye trials and were correlated to the average phoria of each subject. Our data suggests that during binocular dissociation, spatial localization may be achieved by combining a reliable versional efference copy signal with a proprioceptive signal that is unreliable perhaps because it is from the wrong eye or is too noisy.

Stimulus dependence of interocular suppression.

Interocular suppression is the phenomenon in which the signal from one eye inhibits the other eye in the presence of dissimilar images. Various clinical and laboratory-based tests have been used to assess suppression, which vary in color, contrast, and stimulus size. These stimulus variations may yield different spatial extents of suppression, which makes it difficult to compare the outcomes. To evaluate the role of stimulus characteristics, we measured the suppression zone using a binocular rivalry paradigm in normally-sighted observers by systematically varying the stimulus parameters. The stimuli consist of a constantly visible horizontal reference seen by one eye while two vertical suppressors were presented to the other eye. With a keypress, the suppressors appeared for 1 s, to induce a transient suppression zone in the middle part of the reference. Subjects adjusted the width between the suppressors to determine the zone. The zone decreased significantly with increasing spatial frequency and lower contrast. The width was 1.4 times larger than the height. The zone was smaller with negative compared to positive contrast polarity but independent of eye dominance, luminance, and colored filters. A departure from scale invariance was captured with a model suggesting a stimulus-dependent and a small fixed non-stimulus-dependent portion.

Peak week recommendations for bodybuilders: an evidence based approach.

Bodybuilding is a competitive endeavor where a combination of muscle size, symmetry, "conditioning" (low body fat levels), and stage presentation are judged. Success in bodybuilding requires that competitors achieve their peak physique during the day of competition. To this end, competitors have been reported to employ various peaking interventions during the final days leading to competition. Commonly reported peaking strategies include altering exercise and nutritional regimens, including manipulation of macronutrient, water, and electrolyte intake, as well as consumption of various dietary supplements. The primary goals for these interventions are to maximize muscle glycogen content, minimize subcutaneous water, and reduce the risk abdominal bloating to bring about a more aesthetically pleasing physique. Unfortunately, there is a dearth of evidence to support the commonly reported practices employed by bodybuilders during peak week. Hence, the purpose of this article is to critically review the current literature as to the scientific support for pre-contest peaking protocols most commonly employed by bodybuilders and provide evidence-based recommendations as safe and effective strategies on the topic.

Saccadic lens instability increases with accommodative stimulus in presbyopes.

An SRI dual Purkinje image (dPi) eye tracker was used to measure lens wobble following saccades with increasing accommodative effort as an indirect measure of ciliary muscle function in presbyopes. Ten presbyopic subjects executed 32 four-degree saccades at 1-s intervals between targets arranged in a cross on illuminated cards at each of 9 viewing distances ranging from 0.5- to 8-D accommodative demands. Post-saccadic lens wobble artifacts were extracted by subtraction of P1 (H(1)/V(1)) position signals from P4 signals (Theta(H)/Theta(V)), both of which were sampled by the eye tracker at 100 Hz. A ray tracing eye model was also employed to model the fourth Purkinje image shifts for a range of lens translations and tilts. Combining all saccades from all subjects showed a significant positive relationship between lens wobble artifact amplitude and accommodative demand. Eye model simulations indicated that artifacts of the amplitude measured could arise from either lens tilts (in the range of 2-4 degrees) or lens translations (in the range of 0.1 to 0.2 mm). Saccadic lens wobble artifacts increase with accommodative effort in presbyopes, indicating preserved ciliary muscle function and greater relaxation of zonular tension with accommodative effort. Variation across subjects may reflect differences in accommodative effort, ciliary muscle function for a given effort, and/or in intraocular anatomy.

Signals of eye-muscle proprioception modulate perceived motion smear.

Achieving clear perception during eye movements is one of the major challenges that the human visual system has to face every day. Like most light sensitive mechanisms, the human visual system has a finite integration time that may cause moving images to appear smeared. By comparing the perceived motion smear during ongoing eye movements and fixation, previous studies indicated that smear is reduced by a neural compensation mechanism that uses "extra-retinal information" about eye movements. However, it is not clear whether eye-muscle proprioception (afferent input), internal copies of efferent oculomotor commands (efference copy), or both contribute to the smear reduction. The present study found that similar reductions of perceived motion smear occur during passive eye movement (which is signaled only by eye-muscle proprioception) and during active pursuit tracking (for which efference copy signals exist as well). These results reveal a novel neural contribution for maintaining visual clarity and stand in contrast to previous reports that eye-muscle proprioception makes only a minor contribution to visual perception.

Psychophysical measurements of referenced and unreferenced motion processing using high-resolution retinal imaging.

BACKGROUND: Motion detection thresholds with a stationary frame of reference are significantly lower than unreferenced motion thresholds. To account for this, previous studies have postulated the existence of compensatory mechanisms, driven by the presence of a surround, that cancel the effects of eye movements. In the present study we used an adaptive optics scanning laser ophthalmoscope (AOSLO) to investigate the effects of retinal jitter due to fixation eye movements on referenced and unreferenced motion thresholds. METHODS: The stimuli were produced by modulation of the AOSLO imaging beam, so that the absolute retinal position of targets was recorded. In Experiment 1 subjects made up/down motion judgments of a dark horizontal bar presented against a stationary 1-degree bright background. In Experiment 2 unreferenced motion thresholds were measured with isolated bright horizontal bars in otherwise complete darkness. In both experiments, AOSLO images for each trial were analyzed offline to extract retinal jitter and the retinal position of targets. RESULTS: For referenced motion, the results were consistent with complete compensation for eye movements by the visual system. In the unreferenced motion case eye movements adversely affected motion judgments, although there was evidence of partial compensation for such eye movements. CONCLUSIONS: Compensatory processes completely cancel the effect of fixation jitter for referenced motion but such compensation is partial for unreferenced motion.

Effects of fixation instability on multifocal VEP (mfVEP) responses in amblyopes.

The cortical activity of subjects with compromised central vision (e.g., amblyopes) is thought to be much weaker for stimulation of the affected eye than in the fellow eye. Because these subjects are known to exhibit considerable difficulties in keeping steady fixation, we investigated the effects of anomalous fixation on their multifocal visual-evoked potential (mfVEP) responses using a dual Purkinje image (dPi) eye tracker. Our results show that mfVEP responses to stimulation of the central 5 degrees were depressed in the affected eye compared to those in the normal eye and the magnitude of response reductions was proportional to the degree of visual acuity loss in amblyopic subjects. Fixation was far less stable while viewing with the affected eye than with the fellow eye, some exhibiting jerk nystagmus and/or saccadic oscillations. Normal subjects with artificially imposed nystagmus showed similar reductions of VEP responses. The relative magnitudes of the deficits in mfVEP responses were tightly correlated with the degree of fixation instability. These results suggest that the interpretation of anomalous neural or perceptual processing in amblyopic subjects must take the effects of unsteady fixation during measurements into consideration in order to reveal the true nature and extent of sensory neural deficits.

The influence of endogenous attention on contrast perception, contrast discrimination, and saccadic reaction time.

Visual spatial attention has been shown to influence both contrast detection and suprathreshold contrast perception, as well as manual and saccadic reaction times (SRTs). Because SRTs are influenced also by stimulus contrast, we investigated if the enhancement of perceived contrast that accompanies attention could account for the shorter SRTs observed for attended targets locations. We conducted two dual-task experiments to assess psychophysical and oculomotor responses to non-foveal targets of various contrast for different spatial-attention-cueing conditions. Cues were either: valid, an arrow at fixation pointing in the direction of the upcoming target; invalid, an arrow pointing in a different direction from the target; or neutral, a small circle instead of an arrow. In both experiments, subjects were instructed to make a saccade to the location of a subsequent, briefly flashed target. In the first experiment, the psychophysical judgment was a two-alternative-forced-choice (2AFC) contrast-detection task, in which subjects reported whether the flashed target was at a near (3°) or far (6°) eccentricity. In the second experiment, the judgment was a contrast matching task, in which subjects reported whether the target's contrast was higher or lower than a remembered standard contrast. The results exhibit a robust, ∼40-50 ms reduction of SRTs with a valid compared to an invalid cue. Cueing effects on contrast detection and matching were small and inconsistent across subjects. Hence, the observed decrease in SRTs could not be accounted for fully by an enhancement in the target's effective contrast due to attention, as attended and unattended targets that were equally detectable or were perceived to have the same suprathreshold contrast showed substantial differences in SRT.

Bladder debris on ultrasound as a predictor for positive urine culture in a pediatric population.

INTRODUCTION: Debris within the bladder is commonly seen on ultrasound. The etiology of bladder debris is varied and the likelihood that urinary debris represents positive urine culture is under investigation. We hypothesize that bladder debris will increase the likelihood that a urine culture is positive compared to those without bladder debris. METHODS: We performed a retrospective review on children aged 0-17 years who had a voiding cystourethrogram with a catheterized urinalysis or urine culture, and who also had a renal and bladder ultrasound up to 1 week prior, the day of, or up to 2 days after their urine studies. Presence of bladder debris and debris severity was recorded. Positive urine culture was defined as a single bacterial strain ≥50,000 cfu/mL. Demographic information, including findings of reflux and hydronephrosis were compared. Sensitivity, specificity, and risk ratios were calculated for predicting positive urine culture in patients with urinary debris on ultrasound. RESULTS: A total of 445 patients met inclusion criteria between January and December 2014. The positive urine culture rate was 20%, and the rate of bladder debris was 22%. The mean age for those with and without bladder debris was 6.6 and 5.5 years, respectively (p = 0.02). 23% of girls had bladder debris, compared to 12% of boys (p = 0.04, see results table). The sensitivity and specificity for bladder debris in detecting positive urine cultures was 52% and 86%, respectively. Forty-seven percent of those with bladder debris had positive cultures, compared with 12% of those without debris (p < 0.01). The relative risk of positive urine culture if debris is present is 3.90 (95% CI 2.73-5.55). Hydronephrosis or vesicoureteral reflux did not affect the relationship between bladder debris and positive urine cultures. CONCLUSIONS: Nearly half of pediatric patients undergoing urological evaluation found to have bladder debris on ultrasound will have a positive urine culture. Debris is noted more commonly in girls and at a slightly higher age. The presence of debris is associated with a fourfold increase in detecting a positive urine culture, regardless of debris severity, hydronephrosis, or vesicoureteral reflux. Given this, it is of value to routinely document and look for the presence of any amount of bladder debris seen on ultrasound, as this finding can be used to augment clinical decision-making and warrants strong consideration for obtaining urine culture.