Remote Screening for Optic Nerve Cupping Using Smartphone-based Nonmydriatic Fundus Photography.

PRECIS: Evaluation of nonmydriatic fundus photographs captured with a low-cost, smartphone-based camera facilitated remote screening of patients for enlarged optic nerve cup-to-disc ratio in the Independent Nation of Samoa, an underserved setting with one full-time ophthalmologist in the entire country. PURPOSE: To investigate factors that impact inter-rater agreement of glaucoma suspect optic disc status using a low-cost, handheld nonmydriatic fundus camera. METHODS: Color fundus photographs were obtained using the PanOptic iExaminer attached to an iPhone 6S by a lay examiner on 206 participants in the Independent Nation of Samoa. Images were remotely graded by an ophthalmologist and optometrist, and images from participants identified as at-risk for glaucoma were escalated to a glaucoma subspecialist for review. Fundus photo brightness, contrast, and focus were measured using the cup, rim, and temporal regions of the disc. Stereoscopic image pairs were subsequently generated from a subset of individual nonmydriatic photographs. RESULTS: Features suggestive of glaucoma based on optic disc cupping were identified in 16.0% (33/206) of participants. There was moderately strong agreement between graders (90.3%) with κ=0.53 [95% confidence interval (CI)=0.33-0.73]. The intraclass correlation coefficients for the cup-to-disc ratio (CDR) and its difference were 0.84 (95% CI=0.81-0.87) and 0.68 (95% CI=0.59-0.75). Of the 33 participants identified, 94% had clinical risk criteria for potential glaucoma when reviewed by a subspecialist. Color fundus photograph cup brightness was significantly associated with cup-to-disc (CDR) grade, R2=0.36 (P<0.001), in which a brighter disc yielded a higher CDR. CONCLUSIONS: Smartphone-based screening is a simple, low-cost method capable of measuring the CDR of the optic nerve. When combined with testing for other glaucoma risk factors such as intraocular pressure, this method of measuring CDR may help identify those patients who should be referred for further ophthalmologic assessment. We are currently conducting studies to assess the sensitivity and specificity of smart phone-based remote screening.

Variation in surgical management of primary hyperparathyroidism in the US Department of Veterans Affairs healthcare system: A 15-year observational study.

BACKGROUND: Primary hyperparathyroidism is underdiagnosed and undertreated nationally despite the benefits of parathyroidectomy. However, the degree of hospital-level variation in the management of primary hyperparathyroidism is unknown. METHODS: We performed a national, retrospective study of Veterans with primary hyperparathyroidism using the Veterans Affairs Corporate Data Warehouse from January 2000 to September 2015. The objective was to characterize the extent of hospital-level variation in the use of parathyroidectomy for the management of primary hyperparathyroidism within a national, integrated healthcare system. Rate of parathyroidectomy in patients with primary hyperparathyroidism was stratified by (1) geographic region, (2) facility complexity level, (3) volume of parathyroidectomies per facility, and (4) frequency of parathyroid hormone testing in hypercalcemic patients. RESULTS: Among 47,158 Veterans with primary hyperparathyroidism, 6,048 (12.8%) underwent parathyroidectomy. Rates of parathyroidectomy were significantly higher in the Continental (17.0%) and Pacific (16.0%) regions than in other areas (11.4%, P < .01). The highest complexity referral centers had the highest rate of parathyroidectomy (13.6%) compared with all other facilities (12.1%, P < .01). Centers that performed the highest volume of parathyroidectomies were more likely to offer surgery (13.3%) than low volume centers (8.9%, P < .01). Facilities with higher frequency of parathyroid hormone testing among hypercalcemic patients were more likely to offer parathyroidectomy (15.2%) than those with the lowest parathyroid hormone testing frequency (12.6%, P < .01). CONCLUSION: Although there is notable variation in parathyroidectomy use for definitive treatment of primary hyperparathyroidism between Veterans Affairs facilities, parathyroidectomy rates are low across the entire system. Further research is needed to understand additional local contextual and other patient and clinician-level factors for the undertreatment of primary hyperparathyroidism to subsequently guide corrective interventions.

Positive and negative religious coping as predictors of distress among minority older adults.

OBJECTIVES: The study replicated and extended previous findings by investigating relationships between positive and negative religious coping and psychological distress in minority older adults. METHODS: Older adults were evaluated during screening and baseline procedures of a psychotherapy clinical trial for late-life worry and anxiety. Participants were age 50 years or older and recruited from low-income and predominantly minority neighborhoods. Participants screening positive for worry (PSWQ-A ≥ 23) with no significant cognitive impairment (Six-Item Screener for cognitive impairment ≤2) completed a diagnostic interview and baseline assessments. Positive and negative religious coping were assessed with the positive and negative coping subscales of the Brief Religious Coping scale. Psychological distress was assessed with measures of depression, anxiety, and worry. A set of multiple linear regression models were used to evaluate the relationship between religious coping and each measure of psychological distress. RESULTS: Negative religious coping was associated with greater anxiety, worry, and depression. Positive and negative religious coping interacted such that positive religious coping buffered the effects of negative religious coping on anxiety and depression. Significant main effects and interactions remained after controlling for age, gender, race, years of education, and study. CONCLUSIONS: The findings of this study are consistent with prior work showing that negative religious coping is associated with greater psychological distress. This study replicates previous findings that positive religious coping may buffer the harmful effects of negative religious coping and extends understandings of the specific psychological impacts that positive and negative religious coping may have on older, minority adults.

Meta-Analysis of Usefulness of Psyllium Fiber as Adjuvant Antilipid Therapy to Enhance Cholesterol Lowering Efficacy of Statins.

Statins are usually well-tolerated drugs with a clear dose-dependent efficacy. However, manifestation of statin's side effects also bears a direct relation to higher doses necessary to achieve high impact cholesterol-lowering effects. Nevertheless, the reliance on statin efficacy alone has often left dietary intervention underutilized even though studies have shown a reduction in serum cholesterol levels when dietary fiber intake is increased. In this meta-analysis, we investigated whether the concomitant use of psyllium, a gel-forming viscous soluble fiber, would cause further overall cholesterol lowering in subjects already receiving statins. A systematic review of the medical literature was performed and identified three randomized, controlled clinical studies that evaluated the cholesterol lowering efficacy of statins when given concomitantly with psyllium as a fiber supplement. The duration of the studies ranged from 4 weeks to 12 weeks. The objective of the meta-analysis was to estimate the overall effect of psyllium plus statin versus statin alone. The results of the meta-analysis showed a clinically and statistically significant (p = 0.001) cholesterol lowering advantage for psyllium plus statin combination treatment over a statin alone. Adding psyllium fiber resulted in reductions in low-density lipoprotein-cholesterol equivalent to doubling the statin dose. In conclusion, the data support that psyllium fiber takenbefore meals adds to the efficacy of statins, providing an easy to implement dietary intervention for those who cannot tolerate side effects associated with higher-dose statins.

Coffee and Caffeine Are Associated With Decreased Risk of Advanced Hepatic Fibrosis Among Patients With Hepatitis C.

BACKGROUND & AIMS: Coffee or caffeine has been proposed to protect against hepatic fibrosis, but few data are available on their effects in patients with chronic hepatitis C virus (HCV) infection. METHODS: We conducted a cross-sectional study of veterans with chronic HCV infection to evaluate the association between daily intake of caffeinated and decaffeinated coffee, tea, and soda, and level of hepatic fibrosis, based on the FibroSURE test (BioPredictive, Paris, France) (F0-F3, mild [controls] vs. F3/F4-F4, advanced). Models were adjusted for multiple potential confounders including age, alcohol abuse, and obesity. RESULTS: Among 910 patients with chronic HCV infection, 98% were male and 38% had advanced hepatic fibrosis. Daily intake of caffeinated coffee was higher among controls than patients with advanced fibrosis (1.37 vs. 1.05 cups/d; P = .038). In contrast, daily intake of caffeinated tea (0.61 vs. 0.56 cups/d; P = .651) or soda (1.14 vs. 0.95 cans/d; P = .106) did not differ between the groups. A higher percentage of controls (66.0%) than patients with advanced fibrosis (57.9%) consumed 100 mg or more of caffeine daily from all sources (P = .014); controls also received a larger proportion of their caffeine from coffee (50.2% vs. 43.0%; P = .035). Hepatoprotective effects of an average daily intake of 100 mg or more of caffeine (adjusted odds ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .020) and 1 cup or more of caffeinated tea by non-coffee drinkers (adjusted odds ratio, 0.56; 95% confidence interval, 0.34-0.94; P = .028) persisted after adjustment for confounders, including insulin resistance. CONCLUSIONS: A modest daily caffeine intake (as little as 100 mg) may protect against advanced hepatic fibrosis in men with chronic HCV infection. Additional research is needed to confirm these findings in women and in people with other chronic liver diseases.