Visual Field Testing Frequency and Associations in Children with Glaucoma.

PRCIS: Children with glaucoma had an average of 1.3 visual field tests per year. Self-reported black and multiracial patients had lower visual field testing rates, while older children with better visual acuity had more frequent testing. PURPOSE: To evaluate frequency of visual field (VF) testing in children with glaucoma and identify characteristics associated with VF frequency. METHODS: Retrospective cohort study of 82 children aged 6-18 years with glaucoma seen between August 2018-May 2023. Patients were divided into those who had ≥1 VF test (303 VF tests of 61 children) and 0 VFs (21 children). Eyes were excluded if best corrected visual acuity (BCVA) was counting fingers or worse. Characteristics obtained included age, self-reported race and ethnicity, sex, primary language, glaucoma diagnosis, distance to provider, office visit frequency, follow-up compliance, insurance type, and BCVA. The main outcome measure was VF testing frequency. RESULTS: Among children with ≥1 VF test, mean age at first VF was 11.8±2.8 years, mean number of VF/year was 1.3±0.8, and 44.9% of all VFs were reliable. 39.3% of patients underwent <1 VF/year, 45.9% ≥1 to <2 VFs/year, and 14.8% ≥2 VF/year. Children that were Black or multiracial had significantly lower VF testing frequency (estimated difference (ED) -1.2 [95% CI -2.0 to -0.4, P=0.002] and ED -1.3 [CI -2.2 to -0.3, P=0.008], respectively). Better visual acuity and greater office visit frequency were significantly associated with higher VF testing frequency (ED 0.052 [95% CI 0.001 to 0.103, P=0.045] and ED 0.2 [95% CI 0.1 to 0.3, P<0.001], respectively). CONCLUSIONS: Most children had between 1-2 VF/year, though less than half of all VFs were reliable. Ophthalmologists should consider barriers to care in glaucoma monitoring.

The Impact of the COVID-19 Pandemic on Food Access: Insights from First-Person Accounts in a Safety-Net Health Care System.

The COVID-19 pandemic disproportionately affected populations that were already facing socioeconomic disadvantages and limited access to health care services. The livelihood of millions was further compromised when strict shelter-in-place measures forced them out of their jobs. The way that individuals accessed food during the early stages of the COVID-19 pandemic drastically changed as a result of declines in household income, food chain supply disruptions, and social distance measures. This qualitative study examined the food access experiences of participants enrolled in a safety-net health care system-based, free, monthly fruit and vegetable market in the Metro Boston area during the first six months of the COVID-19 pandemic. The findings offer rich qualitative information to understand the financial repercussions of the pandemic on food access.

Factors Associated With Visual Field Testing Reliability in Children With Glaucoma or Suspected Glaucoma.

PURPOSE: To evaluate Humphrey Visual Field (HVF) test reliability and its associated risk factors in children with glaucoma or glaucoma suspect. DESIGN: Retrospective cohort study. METHODS: None. SETTING: Single-center childhood glaucoma clinic. PATIENT POPULATION: One hundred thirty-six patients aged ≤18 years with glaucoma/glaucoma suspect, and least 1 completed 24 to 2 HVF test between 2018 and 2023. OBSERVATION PROCEDURE: Demographic and clinical characteristics including age, primary language, visual acuity (VA), and glaucoma diagnosis were extracted from electronic health records. MAIN OUTCOME MEASURES: HVF 24 to 2 testing metrics, including FP, FN, and FL. Tests were defined as reliable using manufacturer guidelines of ≤33% FP, ≤33% FN, and ≤20% FL. For each patient, a reliability score was calculated as the percentage of reliable tests among all tests completed. A multivariable logistic regression model was used to determine factors associated with test-level reliability (yes/no). A multivariable linear regression model was used to determine factors associated with patient-level reliability score. RESULTS: Among 634 HVFs from 136 patients (Mean ± SD age at first test 12.0 ± 3.2 years, 47.8% female), 51.3% were reliable. Older age, better baseline VA, and English as primary language were associated with greater odds of test-level reliability (P < .04). Mean ± SD patient-level reliability score was 51.7 ± 38.1%. Older age at first clinic visit, better baseline VA, and English as primary language were associated with higher reliability scores (all P < .02), and number of prior VF tests was not (P = .56). CONCLUSIONS: Younger age, worse visual acuity, and non-English as primary language were associated with decreased reliability and should be considered when interpreting VF testing in children. A significant learning effect was not observed with repeated testing.

Genetic changes and testing associated with childhood glaucoma: A systematic review.

Many forms of childhood glaucoma have been associated with underlying genetic changes, and variants in many genes have been described. Currently, testing is variable as there are no widely accepted guidelines for testing. This systematic review aimed to summarize the literature describing genetic changes and testing practices in childhood glaucoma. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) 2020 guidelines and registered with Prospero (ID CRD42023400467). A comprehensive review of Pubmed, Embase, and Cochrane databases was performed from inception through March 2, 2023 using the search terms: (glaucoma) AND (pediatric OR childhood OR congenital OR child OR infant OR infantile) AND (gene OR genetic OR genotype OR locus OR genomic OR mutation OR variant OR test OR screen OR panel). Information was extracted regarding genetic variants including genotype-phenotype correlation. Risk of bias was assessed using the Newcastle-Ottawa Scale. Of 1,916 records screened, 196 studies met inclusion criteria and 53 genes were discussed. Among study populations, mean age±SD at glaucoma diagnosis was 8.94±9.54 years and 50.4% were male. The most common gene discussed was CYP1B1, evaluated in 109 (55.6%) studies. CYP1B1 variants were associated with region and population-specific prevalence ranging from 5% to 86% among those with primary congenital glaucoma. MYOC variants were discussed in 31 (15.8%) studies with prevalence up to 36% among patients with juvenile open angle glaucoma. FOXC1 variants were discussed in 25 (12.8%) studies, which demonstrated phenotypic severity dependent on degree of gene expression and type of mutation. Overall risk of bias was low; the most common domains of bias were selection and comparability. Numerous genes and genetic changes have been associated with childhood glaucoma. Understanding the most common genes as well as potential genotype-phenotype correlation has the potential to improve diagnostic and prognostic outcomes for children with glaucoma.

Examining Racial/Ethnic Disparities in Tobacco Dependence Treatment Among Medicaid Beneficiaries Using Fifty State Medicaid Claims, 2009-2014.

In the USA, low-income racial/ethnic minority groups experience higher smoking rates and greater smoking-related disease burden than their White counterparts. Despite the adverse effects, racial/ethnic minorities are less likely to access tobacco dependence treatment (TDT). Medicaid is one of the largest payers of TDT in the USA and covers predominantly low-income populations. The extent of TDT use among beneficiaries from distinct racial/ethnic groups is unknown. The objective is to estimate racial/ethnic differences in TDT use among Medicaid fee-for-service beneficiaries. Using a retrospective study design and 50 state (including the District of Columbia) Medicaid claims (2009-2014), we employed multivariable logistic regression models and predictive margin methods to estimate TDT use rates among adults (18-64) enrolled (≥ 11 months) in Medicaid fee-for-service programs (January 2009-December 2014) by race/ethnicity. The population included White (n = 6,536,004), Black (n = 3,352,983), Latinx (n = 2,264,647), Asian (n = 451,448), and Native American/Alaskan Native (n = 206,472) beneficiaries. Dichotomous outcomes reflected service use in the past year. Any TDT use was operationalized as any smoking cessation medication fill, any smoking cessation counseling visit, or any smoking cessation outpatient visit. In secondary analyses, we disaggregated TDT use into three separate outcomes. Results suggested that Black (10.6%; 95% CI = 9.9-11.4%), Latinx (9.5%; 95% CI = 8.9-10.2%), Asian (3.7%; 95% CI = 3.4-4.1%), and Native American/Alaskan Native (13.7%; 95% CI = 12.7-14.7%) beneficiaries had lower TDT use rates compared to White beneficiaries (20.6%). Similar racial/ethnic treatment disparities were identified across all outcomes. By identifying significant racial/ethnic disparities in TDT use between 2009 and 2014, this study provides a benchmark against which to measure recent interventions in state Medicaid programs improving equity in smoking cessation interventions.

Studies Of Prescription Digital Therapeutics Often Lack Rigor And Inclusivity.

Little is known about the evidence to support prescription digital therapeutics, which are digital tools that rely primarily on software for diagnosis or treatment that have indications for use regulated by the Food and Drug Administration (FDA) and require a clinician's prescription. We conducted the first retrospective cross-sectional analysis of clinical studies of twenty prescription digital therapeutics authorized by the FDA and available on the market as of November 2022. Our analysis found that just two prescription digital therapeutics had been evaluated in at least one study that was randomized and blinded and that used other rigorous standards of evidence. Two-thirds of clinical studies of prescription digital therapeutics were conducted on a postmarket basis, with less rigorous standards of evidence than the standards used in premarket studies. More than half of studies did not report data on participants' race, and more than 80 percent did not report their ethnicity. More than one-third required English proficiency, and nearly half of nonpediatric studies had an upper age limit. These results suggest the need for a more rigorous and inclusive approach to clinical research supporting FDA-authorized prescription digital therapeutics. A stronger evidence base would increase confidence in these technologies' effectiveness and would enable more informed decision making about their clinical use and coverage.

Quality of Life Outcomes Among Patients Being Screened for Cytomegalovirus Retinitis in Thailand.

PURPOSE: Cytomegalovirus (CMV) retinitis can have debilitating impacts on quality of life (QOL), but few contemporary studies have characterized these ramifications. This study assessed the impact of CMV retinitis on vision-related QOL for those living with HIV/AIDS in Thailand. METHODS: QOL was assessed as part of a prospective interventional cohort study of patients referred to a tertiary hospital in Thailand for CMV retinitis screening. A validated vision-related QOL questionnaire was administered at the baseline screening visit and at the 6-month study visit. Multivariable linear regression models were performed to determine the effect of CMV retinitis diagnosis on QOL score. RESULTS: A total of 152 participants completed the QOL questionnaire at their initial clinic visit. At baseline, a diagnosis of CMV retinitis diagnosis was significantly associated with decreased QOL score: unilateral retinitis was associated with a 0.11 (95% CI: -0.26-0.03) decrement in QOL, and bilateral retinitis was associated with a 0.33 (95% CI: -0.51-0.16) decrement (joint P-value = 0.0009). For the 78 participants with a 6-month visit, changes in QOL from baseline were small and not significant. A diagnosis of CMV retinitis was still associated with decreased QOL score at 6 months (joint P-value = 0.03). CONCLUSIONS: This study found that vision-related QOL was lower in those with CMV retinitis, especially with bilateral involvement, and did not improve after treatment among those with follow-up. These findings reinforce the debilitating clinical manifestations of this disease, and support efforts for earlier screening to detect CMV retinitis before impacts on QOL have occurred.

Community-Academic Team Teaching in a CBPR Course: Lessons Learned about Course Instruction.

BACKGROUND: Community-based participatory research (CBPR) involves community and academic partners working collaboratively to understand and address local challenges. Undergraduates who engage in CBPR through a course can learn valuable research and professional skills, but we found no studies describing the experiences of community and academic partner instructors who have co-taught undergraduate CBPR courses. We describe lessons the instructors learned from collaboratively teaching one such course. LESSONS LEARNED: The lessons we include highlight how community-academic team teaching can 1) provide unique opportunities to teach and model partnership and collaboration, 2) incorporate nontraditional learning opportunities for students to practice skills and engage in content reflection, 3) be challenged by differing community and academic priorities, and 4) surface power dynamics in the classroom that should be explicitly discussed. CONCLUSIONS: Community and academic partners can successfully team teach in an undergraduate CBPR course and encourage the development of important skills that can be transferable to the real world. Focusing on offering traditional and nontraditional learning opportunities and modelling partnership and collaboration can also facilitate this. Beyond these benefits, instructors considering a model like this should be prepared to intentionally engage in discussions within and outside the classroom about respective priorities and the ways in which knowledge that is traditionally valued in academic settings can create power dynamics in the classroom. Ultimately, structural supports, such as institutional funding for community partners and consideration of benefits to community partners and organizations beyond the research itself can facilitate these types of collaborations.

Risk of Noninfectious Uveitis after Coronavirus Disease 2019 Vaccination in a United States Claims Database.

PURPOSE: To assess noninfectious uveitis (NIU) risk after coronavirus disease 2019 (COVID-19) vaccination in patients without a history of uveitis. DESIGN: A retrospective matched cohort study and self-controlled case series (SCCS) analysis using a longitudinal data asset with claims data from the OptumLabs Data Warehouse from December 11, 2020, through November 30, 2021. PARTICIPANTS: The matched cohort analysis included patients continuously enrolled for 730 days before December 11, 2020, who received a COVID-19 vaccination during the study period. This COVID-19-vaccinated group was matched to a COVID-19-unvaccinated historical cohort enrolled in 2018 and 2019. The SCCS design included individuals from the vaccinated cohort who experienced an NIU event during the study period. Enrollees with a history of uveitis were excluded. METHODS: Hazard ratios (HRs) were calculated using Cox proportional hazards models in the matched cohort design. Incidence rate ratios (IRRs) comparing NIU incidence in exposed risk periods after vaccination and unexposed control periods within individuals were calculated using conditional Poisson regression models in the SCCS design. Models were adjusted for age, recent receipt of non-COVID-19 vaccinations, corticosteroid or immunosuppressive use, and smoking history. Subgroup analyses were conducted by vaccination type and age group. MAIN OUTCOME MEASURES: Rates of NIU identified with International Classification of Diseases, Tenth Revision, codes. RESULTS: The matched cohort analysis included 4 611 378 patients, with 2 305 689 per cohort. The adjusted HR comparing NIU incidence in the COVID-19-vaccinated and unvaccinated cohort was 0.91 (95% confidence interval [CI], 0.75-1.10; P = 0.33). The SCCS analysis included 686 patients. The IRR comparing NIU risk after vaccination with risk during control intervals was 1.05 (95% CI, 0.89-1.23; P = 0.57). An increased risk was found in the subgroup aged 5 to 44 years (IRR, 1.40; 95% CI, 1.04-1.87; P = 0.024). CONCLUSIONS: The matched cohort and SCCS analyses did not detect increased NIU risk after COVID-19 vaccination overall in individuals without history of uveitis, providing reassurance about the vaccine's safety. The finding of increased risk in the youngest subgroup suggests heightened immune responses in younger individuals, warranting further investigation. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Private Payer and Medicare Coverage Policies for Use of Circulating Tumor DNA Tests in Cancer Diagnostics and Treatment.

BACKGROUND: Circulating tumor DNA (ctDNA) is used to select initial targeted therapy, identify mechanisms of therapeutic resistance, and measure minimal residual disease (MRD) after treatment. Our objective was to review private and Medicare coverage policies for ctDNA testing. METHODS: Policy Reporter was used to identify coverage policies (as of February 2022) from private payers and Medicare Local Coverage Determinations (LCDs) for ctDNA tests. We abstracted data regarding policy existence, ctDNA test coverage, cancer types covered, and clinical indications. Descriptive analyses were performed by payer, clinical indication, and cancer type. RESULTS: A total of 71 of 1,066 total policies met study inclusion criteria, of which 57 were private policies and 14 were Medicare LCDs; 70% of private policies and 100% of Medicare LCDs covered at least one indication. Among 57 private policies, 89% specified a policy for at least 1 clinical indication, with coverage for ctDNA for initial treatment selection most common (69%). Of 40 policies addressing progression, coverage was provided 28% of the time, and of 20 policies addressing MRD, coverage was provided 65% of the time. Non-small cell lung cancer (NSCLC) was the cancer type most frequently covered for initial treatment (47%) and progression (60%). Among policies with ctDNA coverage, coverage was restricted to patients without available tissue or in whom biopsy was contraindicated in 91% of policies. MRD was commonly covered for hematologic malignancies (30%) and NSCLC (25%). Of the 14 Medicare LCD policies, 64% provided coverage for initial treatment selection and progression, and 36% for MRD. CONCLUSIONS: Some private payers and Medicare LCDs provide coverage for ctDNA testing. Private payers frequently cover testing for initial treatment, especially for NSCLC, when tissue is insufficient or biopsy is contraindicated. Coverage remains variable across payers, clinical indications, and cancer types despite inclusion in clinical guidelines, which could impact delivery of effective cancer care.

From bench to behaviour: The role of lifestyle factors on intraocular pressure, neuroprotection, and disease progression in glaucoma.

Current glaucoma management centres on intraocular pressure (IOP) reduction through pharmacological and surgical therapy. Despite broad interest in active management of glaucoma through lifestyle modifications, such recommendations have yet to be incorporated into standards of treatment. In this review, noteworthy preclinical studies and their translations in clinical populations are discussed to evaluate the roles of lifestyle factors in lowering IOP, offering neuroprotection, and/or slowing disease progression in those with open-angle glaucoma. Current literature suggests that aerobic exercise may be associated with neuroprotection and decreased disease progression. Mindfulness is associated with IOP reductions and neuroprotection. Caffeine is associated with mild, transient IOP elevations of uncertain significance. Nicotinamide supplementation is associated with neuroprotection and short-term visual function improvement. This review also highlights knowledge gaps regarding these factors and opportunities to strengthen our understanding of their role in glaucoma, including future preclinical studies that elucidate underlying mechanisms and clinical studies with additional functional endpoints and longer follow-up.

ISSLS Prize in Bioengineering Science 2023: Age- and sex-related differences in lumbar intervertebral disc degeneration between patients with chronic low back pain and asymptomatic controls.

PURPOSE: Clinical management of disc degeneration in patients with chronic low back pain (cLBP) is hampered by the challenge of distinguishing pathologic changes relating to pain from physiologic changes related to aging. The goal of this study was to use imaging biomarkers of disc biochemical composition to distinguish degenerative changes associated with cLBP from normal aging. METHODS: T1ρ MRI data were acquired from 133 prospectively enrolled subjects for this observational study (80 cLBP, 53 controls; mean ± SD age = 43.9 ± 13.4 years; 61 females, 72 males). The mean T1ρ relaxation time in the nucleus pulposus (NP-T1ρ; n = 650 discs) was used as a quantitative biomarker of disc biochemical composition. Linear regression was used to assess associations between NP-T1ρ and age, sex, spinal level, and study group, and their interactions. RESULTS: NP-T1ρ values were lower in cLBP patients than controls (70.8 ± 22.8 vs. 76.4 ± 22.2 ms, p = 0.009). Group differences were largest at L5-S1 (ΔT1ρcLBP-control = -11.3 ms, p < 0.0001), representing biochemical deterioration typically observed over a 9-12 year period (NP-T1ρ declined by 0.8-1.1 ms per year [95% CI]). Group differences were large in younger patients and diminished with age. Finally, the age-dependence of disc degeneration was stronger in controls than cLBP patients. CONCLUSION: Aging effects on the biochemical composition of the L5-S1 disc may involve a relatively uniform set of factors from which many cLBP patients deviate. NP-T1ρ values at L5-S1 may be highly relevant to clinical phenotyping, particularly in younger individuals.

Fractional Gluconeogenesis: A Biomarker of Dietary Energy Adequacy in a Rat Brain Injury Model.

Patients treated for traumatic brain injury (TBI) are in metabolic crises because of the trauma and underfeeding. We utilized fractional gluconeogenesis (fGNG) to assess nutritional adequacy in ad libitum-fed and calorically-restricted rats following TBI. Male Sprague-Dawley individually housed rats 49 days of age were randomly assigned into four groups: ad libitum (AL) fed control (AL-Con, sham), AL plus TBI (AL+TBI), caloric restriction (CR) control (CR-Con, sham), and CR plus TBI (CR+TBI). From days 1-7 animals were given AL access to food and water containing 6% deuterium oxide (D2O). On day 8, a pre-intervention blood sample was drawn from each animal, and TBI, sham injury, and CR protocols were initiated. On day 22, the animals were euthanized, and blood was collected to measure fGNG. Pre-intervention, there was no significant difference in fGNG among groups (p ≥ 0.05). There was a significant increase in fGNG due to caloric restriction, independent of TBI (p ≤ 0.05). In addition, fGNG may provide a real-time, personalized biomarker for assessing patient dietary caloric needs.

Analyzing Precision Medicine Utilization with Real-World Data: A Scoping Review.

Precision medicine (PM), specifically genetic-based testing, is currently used in over 140,000 individual tests to inform the clinical management of disease. Though several databases (e.g., the NIH Genetic Testing Registry) demonstrate the availability of these sequencing-based tests, we do not currently understand the extent to which these tests are used. There exists a need to synthesize the body of real-world data (RWD) describing the use of sequencing-based tests to inform their appropriate use. To accomplish this, we performed a scoping review to examine what RWD sources have been used in studies of PM utilization between January 2015 and August 2021 to characterize the use of genome sequencing (GS), exome sequencing (ES), tumor sequencing (TS), next-generation sequencing-based panels (NGS), gene expression profiling (GEP), and pharmacogenomics (PGx) panels. We abstracted variables describing the use of these types of tests and performed a descriptive statistical analysis. We identified 440 articles in our search and included 72 articles in our study. Publications based on registry databases were the most common, followed by studies based on private insurer administrative claims. Slightly more than one-third (38%) used integrated datasets. Two thirds (67%) of the studies focused on the use of tests for oncological clinical applications. We summarize the RWD sources used in peer-reviewed literature on the use of PM. Our findings will help improve future study design by encouraging the use of centralized databases and registries to track the implementation and use of PM.

Interprofessional education in the clinical learning environment: a mixed-methods evaluation of a longitudinal experience in the primary care setting.

Team collaboration in our healthcare workforce is necessary to effectively address multifaceted medical and social needs, especially for those impacted by systemic inequities. Effective interprofessional practice and education models including curricula are needed to prepare a practice ready healthcare workforce for team collaboration. Most healthcare trainee interprofessional experiences take place episodically in classroom settings. However, creating a culture that supports team-based learning and interprofessional clinical practice requires teaching skills (e.g., communication, collaboration, shared decision-making, coordination of care) longitudinally in the clinical setting. A weekly interprofessional clinic for patients/clients with chronic health conditions was organized in three primary care practices. Trainees from nutrition, social work, medicine, and physician assistant programs worked with supervising clinicians from each field. Surveys, interviews, and focus groups assessed the effects of interprofessional education and training in the primary care setting. Results show the longitudinal experiential IPE program significantly improved knowledge, attitudes, skills, and values addressing key interprofessional competencies. Qualitative results complement survey data and highlight key themes addressing patient-centered care and team dynamics. These findings demonstrate the importance of longitudinal, immersive team-based interprofessional training in the clinical learning environment.

Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion.

OBJECTIVE: To determine if a lean intervention improved emergency department (ED) throughput and reduced ED boarding by improving patient discharge efficiency from a tertiary care children's hospital. METHODS: The study was conducted at a tertiary care children's hospital to study the impact lean that changes made to an inpatient pediatric service line had on ED efficiency. Discharge times from the general pediatrics' service were compared to patients discharged from all other pediatric subspecialty services. The intervention was multifaceted. First, team staffing reconfiguration permitted all discharge work to be done at the patient's bedside using a new discharge checklist. The intervention also incorporated an afternoon interdisciplinary huddle to work on the following day's discharges. Retrospectively, we determined the impact this had on median times of discharge order entry, patient discharge, and percent of patients discharged before noon. As a marker of ED throughput, we determined median hour of day that admitted patients left the ED to move to their hospital bed. As marker of ED congestion we determined median boarding times. RESULTS: For the general pediatrics service line, the median discharge order entry time decreased from 1:43pm to 11:28am (p < 0.0001) and the median time of discharge decreased from 3:25pm to 2:25pm (p < 0.0001). The percent of patients discharged before noon increased from 14.0% to 26.0% (p < 0.0001). The discharge metrics remained unchanged for the pediatric subspecialty services group. Median ED boarding time decreased by 49 minutes (p < 0.0001). As a result, the median time of day admitted patients were discharged from the ED was advanced from 5 PM to 4 PM. CONCLUSION: Lean principles implemented by one hospital service line improved patient discharge times enhanced patient ED throughput, and reduced ED boarding times.