Quality of hydroxychloroquine retinopathy screening at a Canadian teaching hospital.

PURPOSE: To assess the quality of hydroxychloroquine (HCQ)-induced retinopathy screening at a Canadian tertiary center, we concentrate on risk factor documentation within the electronic health record, in accordance with the 2016 AAO guidelines. METHODS: We performed a retrospective quality assessment study based on chart review of patients who underwent screening for HCQ-induced retinopathy at the Centre Hospitalier de l'Université de Montréal (CHUM) from 2016 to 2019. We evaluated four key risk factors for HCQ-induced retinopathy: daily dose, duration of use, renal disease, and tamoxifen use, using a three-tier grading system (ideal, adequate, inadequate) for documentation assessment. Pareto and root cause analyses were conducted to identify potential improvement solutions. RESULTS: Documentation quality varied in our study: daily dosage was 33% ideal, 31% appropriate, and 36% inappropriate. Duration of use documentation was 75% ideal, 2% adequate, and 24% inadequate. Renal disease documentation was only 6% ideal, with 62% adequate and 32% of charts lacking any past medical history. Among women's charts, tamoxifen use wasn't documented at all, with 65% adequately documenting medication lists. Pareto analysis indicated that improving renal disease and tamoxifen documentation could reduce 64% of non-ideal records, and enhancing daily dose documentation could decrease this by up to 90%. CONCLUSION: Accurate documentation of key risk factors is critical for HCQ-induced retinopathy screening, impacting both exam initiation and frequency. Our study identifies potential improvements in the screening process at the hospital, referring physician, and ophthalmologist levels. Implementing integrated pathways could enhance patient experience and screening effectiveness.

Capabilities of GPT-4 in ophthalmology: an analysis of model entropy and progress towards human-level medical question answering.

BACKGROUND: Evidence on the performance of Generative Pre-trained Transformer 4 (GPT-4), a large language model (LLM), in the ophthalmology question-answering domain is needed. METHODS: We tested GPT-4 on two 260-question multiple choice question sets from the Basic and Clinical Science Course (BCSC) Self-Assessment Program and the OphthoQuestions question banks. We compared the accuracy of GPT-4 models with varying temperatures (creativity setting) and evaluated their responses in a subset of questions. We also compared the best-performing GPT-4 model to GPT-3.5 and to historical human performance. RESULTS: GPT-4-0.3 (GPT-4 with a temperature of 0.3) achieved the highest accuracy among GPT-4 models, with 75.8% on the BCSC set and 70.0% on the OphthoQuestions set. The combined accuracy was 72.9%, which represents an 18.3% raw improvement in accuracy compared with GPT-3.5 (p<0.001). Human graders preferred responses from models with a temperature higher than 0 (more creative). Exam section, question difficulty and cognitive level were all predictive of GPT-4-0.3 answer accuracy. GPT-4-0.3's performance was numerically superior to human performance on the BCSC (75.8% vs 73.3%) and OphthoQuestions (70.0% vs 63.0%), but the difference was not statistically significant (p=0.55 and p=0.09). CONCLUSION: GPT-4, an LLM trained on non-ophthalmology-specific data, performs significantly better than its predecessor on simulated ophthalmology board-style exams. Remarkably, its performance tended to be superior to historical human performance, but that difference was not statistically significant in our study.

Evaluating the Performance of ChatGPT in Ophthalmology: An Analysis of Its Successes and Shortcomings.

Purpose: Foundation models are a novel type of artificial intelligence algorithms, in which models are pretrained at scale on unannotated data and fine-tuned for a myriad of downstream tasks, such as generating text. This study assessed the accuracy of ChatGPT, a large language model (LLM), in the ophthalmology question-answering space. Design: Evaluation of diagnostic test or technology. Participants: ChatGPT is a publicly available LLM. Methods: We tested 2 versions of ChatGPT (January 9 "legacy" and ChatGPT Plus) on 2 popular multiple choice question banks commonly used to prepare for the high-stakes Ophthalmic Knowledge Assessment Program (OKAP) examination. We generated two 260-question simulated exams from the Basic and Clinical Science Course (BCSC) Self-Assessment Program and the OphthoQuestions online question bank. We carried out logistic regression to determine the effect of the examination section, cognitive level, and difficulty index on answer accuracy. We also performed a post hoc analysis using Tukey's test to decide if there were meaningful differences between the tested subspecialties. Main Outcome Measures: We reported the accuracy of ChatGPT for each examination section in percentage correct by comparing ChatGPT's outputs with the answer key provided by the question banks. We presented logistic regression results with a likelihood ratio (LR) chi-square. We considered differences between examination sections statistically significant at a P value of < 0.05. Results: The legacy model achieved 55.8% accuracy on the BCSC set and 42.7% on the OphthoQuestions set. With ChatGPT Plus, accuracy increased to 59.4% ± 0.6% and 49.2% ± 1.0%, respectively. Accuracy improved with easier questions when controlling for the examination section and cognitive level. Logistic regression analysis of the legacy model showed that the examination section (LR, 27.57; P = 0.006) followed by question difficulty (LR, 24.05; P < 0.001) were most predictive of ChatGPT's answer accuracy. Although the legacy model performed best in general medicine and worst in neuro-ophthalmology (P < 0.001) and ocular pathology (P = 0.029), similar post hoc findings were not seen with ChatGPT Plus, suggesting more consistent results across examination sections. Conclusion: ChatGPT has encouraging performance on a simulated OKAP examination. Specializing LLMs through domain-specific pretraining may be necessary to improve their performance in ophthalmic subspecialties. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

Boston type I keratoprosthesis versus penetrating keratoplasty following a single failed corneal graft.

BACKGROUND/OBJECTIVES: To compare long-term outcomes of the Boston type 1 keratoprosthesis (KPro) with penetrating keratoplasty (PKP) in patients with a failed first PKP. SUBJECTS/METHODS: In this retrospective comparative case series, 48 eyes of 48 patients who underwent a second corneal replacement procedure after a first failed PKP at the Centre Hospitalier de l'Université de Montréal from 2008 to 2020 were included. Minimum follow-up duration was 5 years, and patients with keratoconus were excluded since such subjects are not candidates for KPro. Main outcome measures included best-corrected visual acuity (BCVA), postoperative complications, graft survival and subsequent interventions. RESULTS: Mean follow-up was 6.4 years for PKP and 9.6 years for KPro (p < 0.001). Preoperative BCVA was better in PKP patients (means 1.67 vs 2.13, p = 0.041). Visual outcomes were similar between groups. KPro patients developed 0.263 complication per patient-year (ppy) compared to 0.245 ppy or PKP. The most common complications for PKP were corneal complications (0.088 ppy) and glaucoma worsening (0.041 ppy). In KPro, glaucoma worsening (0.046 ppy), vitreoretinal complications (0.042 ppy) and retroprosthetic membrane (0.042 ppy) were the most frequent. Graft failure (69.6 vs 20.0%, p < 0.001) and reoperation rates (56.5 vs 12.0%, p = 0.001) were significantly higher for PKP. Failure mainly resulted from decompensation or rejection in PKP, while all five failures in KPro were caused by melt and/or extrusion. CONCLUSIONS: Both interventions showed similar visual outcomes. Complication profiles were different, with more posterior segment complications in the KPro group, and more corneal complications in the PKP group, often necessitating regraft.

Do physical therapists follow evidence-based practices for treatment of inflammatory arthritis? Results from an online survey.

BACKGROUND: Physical therapists (PTs) should know how to best treat patients with inflammatory arthritis. OBJECTIVE: To document interventions chosen by PTs for patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and whether choices follow evidence-based practice. METHODS: Licensed musculoskeletal PTs in Quebec, Canada responded to an online survey. Descriptive statistics illustrated proportions for each treatment choice and inferential statistics explored associations with demographic and practice-related factors. RESULTS: There were 298 PTs who responded to the survey. For both RA and AS respectively, most common interventions were mobility exercises (91.0%; 98.3%) and patient education (90.1%; 92.8%). For both cases, slightly >60% selected strengthening exercises. Passive forms of therapy were chosen by 36% of PTs for RA and 58% for AS. Aerobic exercise was rarely selected. PTs working in the public sector were less likely to use manual therapy for both RA (Odds Ratio (OR) 0.43, 95% confidence interval (CI) 0.22,0.86) and AS (OR 0.46, 95% CI 0.22,0.97). CONCLUSIONS: Most PTs chose mobility exercises and patient education, representing evidence-based approaches. Despite current recommendations, strengthening and especially aerobic exercises were not used as much. There is a need to increase awareness regarding the benefits of strengthening and aerobic exercise for these patients.

Time to achieve best postoperative visual acuity following Boston keratoprosthesis surgery.

BACKGROUND/AIMS: To evaluate the time needed for patients with Boston type 1 keratoprosthesis (KPro) to reach their best-corrected visual acuity (BCVA) and all contributing factors. METHODS: We retrospectively reviewed 137 consecutive eyes from 118 patients, measured how long they needed to reach their BCVA and looked at factors that might affect this time duration including patient demographics, ocular comorbidities and postoperative complications. RESULTS: The mean follow-up was 5.49 years. The median time to BCVA postoperatively was 6 months, with 47% of patients achieving their BCVA by 3 months. The mean best achieved logMAR visual acuity was 0.71, representing a gain of 6 lines on the Snellen visual acuity chart. Postoperative glaucoma, retroprosthetic membrane (RPM) and endophthalmitis prolonged this duration. We found no correlation between the following factors and time to BCVA: gender, age, indication for KPro surgery, primary versus secondary KPro, number of previous penetrating keratoplasties, previous retinal surgery, intraoperative anterior vitrectomy and preoperative glaucoma. CONCLUSION: In our retrospective cohort, the majority of subjects reached their BCVA between 3 and 6 months after KPro implantation. This duration was significantly prolonged by the development of postoperative glaucoma, RPM and endophthalmitis.

Rheumatologists' Acceptance of Patient Referrals from Physical Therapists.

We surveyed Canadian rheumatologists regarding beliefs about physical therapists' (PTs) ability to refer patients appropriately to rheumatologists and whether they would accept such referrals. Most (86.9%) believed that PTs can appropriately refer to rheumatologists. However, only 48.2% of rheumatologists would be very or extremely likely to accept a referral from a PT they knew, and 23.5% would accept a referral from a PT they did not know. Conversely, 90.5% would accept a referral from a PT if they could bill it as a full consult. We conclude that being able to bill PT referrals as full consults may potentially enhance the acceptance of PT referrals.

Do Quebec Physiotherapists Follow Evidence-Based Guidelines for Treating Knee Osteoarthritis?

Purpose: The aim of this study was to document the types of treatment that Quebec physiotherapists use for knee osteoarthritis (OA), to assess whether treatment choices are consistent with current practice guidelines, and to explore the factors associated with using certain treatments. Method: Physiotherapists in Quebec answered a cross-sectional survey that was sent through licensing bodies and social media contacts. The respondents were asked which treatments they would use for a typical case of knee OA. We used descriptive statistics to determine the proportions of physiotherapists who chose each treatment and explored the associations between the use of treatments and demographic factors. Results: A total of 195 Quebec physiotherapists participated in this study, 74.9% of whom were women. The most common treatment choices were mobility exercises (96.4%), followed by education (93.8%), strengthening exercises (85.1%), thermotherapy and cryotherapy (72.3%), manual therapy (53.3%), and electrotherapy (42.1%). Selecting either manual or electrotherapy was significantly associated with working in private practice. Conclusions: The great majority of physiotherapists included mobility and strengthening exercises, both of which are the recommended approaches for treating knee OA. Physiotherapists in private practice were more likely to select manual therapy and electrotherapy.

Objectif : exposer les types de traitements qu'utilisent les physiothérapeutes du Québec pour l'arthrose du genou, afin d'évaluer si leurs choix respectent les directives cliniques actuelles, et explorer les facteurs associés à l'utilisation de certains traitements. Méthodologie : les physiothérapeutes du Québec ont participé à un sondage transversal qui leur a été transmis par leurs organismes de réglementation et les médias sociaux. Les répondants ont été invités à indiquer quel type de traitement ils utiliseraient dans un cas typique d'arthrose du genou. Les chercheurs ont utilisé des statistiques descriptives pour déterminer les proportions de physiothérapeutes choisissant chaque traitement et ont exploré les associations entre des traitements sélectionnés et des facteurs démographiques. Résultats : au total, 195 physiothérapeutes du Québec, dont 74,9 % de femmes, ont participé à la présente étude. Les traitements les plus choisis étaient les exercices de mobilité (96,4 %), l'éducation (93,8 %), les exercices de renforcement (85,1 %), la thermothérapie et la cryothérapie (72,3 %), la thérapie manuelle (53,3 %) et l'électrothérapie (42,1 %). Le choix de la thérapie manuelle ou de l'électrothérapie était significativement associé au travail en pratique privée. Conclusion : la grande majorité des physiothérapeutes ont sélectionné les exercices de mobilité et de renforcement, qui représentent les approches recommandées pour le traitement de l'arthrose du genou. Les physiothérapeutes en pratique privée étaient plus susceptibles de sélectionner la thérapie manuelle et l'électrothérapie.

Physical Therapists' Ability to Distinguish Between Inflammatory and Noninflammatory Arthritis and to Appropriately Refer Patients to a Rheumatologist.

OBJECTIVE: To investigate whether physical therapists (PTs) can correctly identify new-onset inflammatory arthritis; to assess whether PTs are aware that cases of new-onset inflammatory arthritis should be referred to a rheumatologist; to explore the comfort level of PTs to refer to medical specialists; and to determine factors associated with correctly identifying inflammatory arthritis and referring to a rheumatologist. METHODS: We sent a questionnaire to PTs in 2 Canadian provinces describing 4 case scenarios (new-onset rheumatoid arthritis [RA], knee osteoarthritis [OA], new-onset ankylosing spondylitis [AS], and low back pain [LBP]). Participants were asked to identify probable medical diagnoses and indicate their plan of action. We described the frequencies of our outcomes and used logistic regression to explore associated factors. RESULTS: A total of 352 PTs responded. The proportions who correctly identified each of the 4 cases were 90%, 83%, 77%, and 100%, respectively, for RA, OA, AS, and LBP. Among those, 77%, 30%, 73%, and 3%, respectively, indicated that it was "very important" or "extremely important" to refer to a rheumatologist. Approximately two-thirds felt "extremely comfortable" or "quite comfortable" to refer to a specialist. PTs working in rural areas were less likely to refer. CONCLUSION: Most PTs correctly identified the clinical cases and were aware of the importance of prompt referral to a rheumatologist for inflammatory disease. Most indicated that it was not very important to refer those with OA and LBP. This implies that many PTs can distinguish between inflammatory and noninflammatory conditions and appropriately refer patients with suspected inflammatory arthritis to a rheumatologist.