Diabetic Retinopathy Screening at the Point of Care (DR SPOC): detecting undiagnosed and vision-threatening retinopathy by integrating portable technologies within existing services.

INTRODUCTION: The aim of this study was to determine the prevalence of diabetic retinopathy (DR) in a low socioeconomic region of a high-income country, as well as determine the diagnostic utility of point-of-care screening for high-risk populations in tertiary care settings. RESEARCH DESIGN AND METHODS: This was a cross-sectional study of patients with diabetes attending foot ulcer or integrated care diabetes clinics at two Western Sydney hospitals (n=273). DR was assessed using portable, two-field, non-mydriatic fundus photography and combined electroretinogram/ pupillometry (ERG). With mydriatic photographs used as the reference standard, sensitivity and specificity of the devices were determined. Prevalence of DR and vision-threatening diabetic retinopathy (VTDR) were reported, with multivariate logistic regression used to identify predictors of DR. RESULTS: Among 273 patients, 39.6% had any DR, while 15.8% had VTDR, of whom 59.3% and 62.8% were previously undiagnosed, respectively. Non-mydriatic photography demonstrated 20.2% sensitivity and 99.5% specificity for any DR, with a 56.7% screening failure rate. Meanwhile, mydriatic photography produced high-quality images with a 7.6% failure rate. ERG demonstrated 72.5% sensitivity and 70.1% specificity, with a 15.0% failure rate. The RETeval ERG was noted to have an optimal DR cut-off score at 22. Multivariate logistic regression identified an eGFR of ≤29 mL/min/1.73 m2, HbA1c of ≥7.0%, pupil size of <4 mm diameter, diabetes duration of 5-24 years and RETeval score of ≥22 as strong predictors of DR. CONCLUSION: There is a high prevalence of vision-threatening and undiagnosed DR among patients attending high-risk tertiary clinics in Western Sydney. Point-of-care DR screening using portable, mydriatic photography demonstrates potential as a model of care which is easily accessible, targeted for high-risk populations and substantially enhances DR detection.

Optimising fundoscopy practices across the medical spectrum: A focus group study.

INTRODUCTION: Fundoscopy can be of great clinical value, yet remains underutilised. Educational attempts to improve fundoscopy utilisation have had limited success. We aimed to explore the barriers and facilitators underlying the uptake of clinical direct ophthalmoscopy across a spectrum of medical specialties and training levels. METHODS: Ten focus groups were conducted with medical students (n = 42), emergency department doctors (n = 24), basic physician trainees (n = 7), hospital physicians (n = 6) and general practitioners (n = 7). Independent thematic analysis of transcripts was conducted by three investigators. A consensus thematic framework was developed, and transcripts were reanalysed using this framework. RESULTS: Thematic analysis identified seven main themes: (1) technical barriers to performing fundoscopy examinations; (2) clinical culture and expectations regarding fundoscopy; (3) the influence of fundoscopy on clinical management; (4) motivation to perform the examination; (5) novel technology including smartphone fundoscopy, and the value of a digital fundus image; (6) training requirements, and; (7) use of limited resources. CONCLUSION: Our results build a more nuanced picture of the factors which determine fundoscopy utilisation. As current barriers limit practice by clinicians and medical students, expertise and confidence performing and interpreting fundoscopy are lost. This shifts the balance of perceived clinical utility to futility in changing patient management, and reinforces a cycle of reducing fundoscopy utilisation. We identified important cultural barriers such as accepted incompetence, and misperceptions of senior discouragement. Emerging technologies reduce the technical barriers to fundoscopy. Therefore education should: focus on detecting pathology from digital images; clarify the role of fundoscopy in patient management, and; be targeted at key career progression points.

Subpicosecond Optical Stress Generation in Multiferroic BiFeO3.

Optical excitation leads to ultrafast stress generation in the prototypical multiferroic BiFeO3. The time scales of stress generation are set by the dynamics of the population of excited electronic states and the coupling of the electronic configuration to the structure. X-ray free-electron laser diffraction reveals high-wavevector subpicosecond-time scale stress generation following ultraviolet excitation of a BiFeO3 thin film. Stress generation includes a fast component with a 1/e rise time with an upper limit of 300 fs and longer-rise time components extending to 1.5 ps. The contributions of the fast and delayed components vary as a function of optical fluence, with a reduced a fast-component contribution at high fluence. The results provide insight into stress-generation mechanisms linked to the population of excited electrons and point to new directions in the application of nanoscale multiferroics and related ferroic complex oxides. The fast component of the stress indicates that structural parameters and properties of ferroelectric thin film materials can be optically modulated with 3 dB bandwidths of at least 0.5 THz.

eFOCUS 2: A randomised crossover trial of smartphone fundoscopy and direct ophthalmoscopy aiming to improve optic disc interpretation by medical students with e-learning support.

BACKGROUND: Ophthalmoscopy and its interpretation are complex. We aimed to compare the diagnostic accuracy of smartphone fundoscopy with traditional direct ophthalmoscopy for optic disc interpretation, with e-learning support. METHODS: We conducted a randomised, crossover study of 102 medical students. Students were offered e-learning for optic disc interpretation. A fundoscopy objective structured clinical examination was conducted after an introductory lecture and 10-min practical training session on smartphone fundoscopy and traditional ophthalmoscopy. Participants examined patients and simulator slides with a randomised crossover between smartphone [D-eye (Padova, Italy) or iExaminer (Welch Allyn, Macquarie Park, Australia)] and traditional ophthalmoscopy (Welch Allyn). Optic discs were graded independently by three masked ophthalmologists. The primary outcome was the ability to interpret an optic disc as normal or abnormal. Secondary outcomes included other optic disc aspects; student preferences; and e-learning performance. RESULTS: Students' agreement with the gold standard for an abnormal or normal disc was significantly greater using a smartphone (74.4%) than with direct ophthalmoscopy (68.1%, p = 0.032). More students preferred smartphone (74%) over direct ophthalmoscopy (26%, p < 0.001). E-learning led to an improvement in optic disc interpretation scores (mean improvement = 4.5%, 95% CI = 3.7-5.2, p < 0.001). CONCLUSIONS: Medical students are more accurate at recognising an abnormal optic disc using smartphone fundoscopy than traditional direct ophthalmoscopy, and have a strong preference for smartphone fundoscopy. E-learning may improve the interpretation of optic disc abnormalities. Smartphone fundoscopy may mitigate some technical challenges of fundoscopy and reinvigorate use of this valuable clinical examination.

Subterahertz collective dynamics of polar vortices.

The collective dynamics of topological structures1-6 are of interest from both fundamental and applied perspectives. For example, studies of dynamical properties of magnetic vortices and skyrmions3,4 have not only deepened our understanding of many-body physics but also offered potential applications in data processing and storage7. Topological structures constructed from electrical polarization, rather than electron spin, have recently been realized in ferroelectric superlattices5,6, and these are promising for ultrafast electric-field control of topological orders. However, little is known about the dynamics underlying the functionality of such complex extended nanostructures. Here, using terahertz-field excitation and femtosecond X-ray diffraction measurements, we observe ultrafast collective polarization dynamics that are unique to polar vortices, with orders-of-magnitude higher frequencies and smaller lateral size than those of experimentally realized magnetic vortices3. A previously unseen tunable mode, hereafter referred to as a vortexon, emerges in the form of transient arrays of nanoscale circular patterns of atomic displacements, which reverse their vorticity on picosecond timescales. Its frequency is considerably reduced (softened) at a critical strain, indicating a condensation (freezing) of structural dynamics. We use first-principles-based atomistic calculations and phase-field modelling to reveal the microscopic atomic arrangements and corroborate the frequencies of the vortex modes. The discovery of subterahertz collective dynamics in polar vortices opens opportunities for electric-field-driven data processing in topological structures with ultrahigh speed and density.

Instrument for in situ hard x-ray nanobeam characterization during epitaxial crystallization and materials transformations.

Solid-phase epitaxy (SPE) and other three-dimensional epitaxial crystallization processes pose challenging structural and chemical characterization problems. The concentration of defects, the spatial distribution of elastic strain, and the chemical state of ions each vary with nanoscale characteristic length scales and depend sensitively on the gas environment and elastic boundary conditions during growth. The lateral or three-dimensional propagation of crystalline interfaces in SPE has nanoscale or submicrometer characteristic distances during typical crystallization times. An in situ synchrotron hard x-ray instrument allows these features to be studied during deposition and crystallization using diffraction, resonant scattering, nanobeam and coherent diffraction imaging, and reflectivity. The instrument incorporates a compact deposition system allowing the use of short-working-distance x-ray focusing optics. Layers are deposited using radio-frequency magnetron sputtering and evaporation sources. The deposition system provides control of the gas atmosphere and sample temperature. The sample is positioned using a stable mechanical design to minimize vibration and drift and employs precise translation stages to enable nanobeam experiments. Results of in situ x-ray characterization of the amorphous thin film deposition process for a SrTiO3/BaTiO3 multilayer illustrate implementation of this instrument.

Resonant nanodiffraction x-ray imaging reveals role of magnetic domains in complex oxide spin caloritronics.

Spin electronic devices based on crystalline oxide layers with nanoscale thicknesses involve complex structural and magnetic phenomena, including magnetic domains and the coupling of the magnetism to elastic and plastic crystallographic distortion. The magnetism of buried nanoscale layers has a substantial impact on spincaloritronic devices incorporating garnets and other oxides exhibiting the spin Seebeck effect (SSE). Synchrotron hard x-ray nanobeam diffraction techniques combine structural, elemental, and magnetic sensitivity and allow the magnetic domain configuration and structural distortion to be probed in buried layers simultaneously. Resonant scattering at the Gd L2 edge of Gd3Fe5O12 layers yields magnetic contrast with both linear and circular incident x-ray polarization. Domain patterns facet to form low-energy domain wall orientations but also are coupled to elastic features linked to epitaxial growth. Nanobeam magnetic diffraction images reveal diverse magnetic microstructure within emerging SSE materials and a strong coupling of the magnetism to crystallographic distortion.

Simultaneous scanning near-field optical and X-ray diffraction microscopy for correlative nanoscale structure-property characterization.

A multimodal imaging instrument has been developed that integrates scanning near-field optical microscopy with nanofocused synchrotron X-ray diffraction imaging. The instrument allows for the simultaneous nanoscale characterization of electronic/near-field optical properties of materials together with their crystallographic structure, facilitating the investigation of local structure-property relationships. The design, implementation and operating procedures of this instrument are reported. The scientific capabilities are demonstrated in a proof-of-principle study of the insulator-metal phase transition in samarium sulfide (SmS) single crystals induced by applying mechanical pressure via a scanning tip. The multimodal imaging of an in situ tip-written region shows that the near-field optical reflectivity can be correlated with the heterogeneously transformed structure of the near-surface region of the crystal.

Nanosecond Optically Induced Phase Transformation in Compressively Strained BiFeO_{3} on LaAlO_{3}.

Above-band-gap optical illumination of compressively strained BiFeO_{3} induces a transient reversible transformation from a state of coexisting tilted tetragonal-like and rhombohedral-like phases to an untilted tetragonal-like phase. Time-resolved synchrotron x-ray diffraction reveals that the transformation is induced by an ultrafast optically induced lattice expansion that shifts the relative free energies of the tetragonal-like and rhombohedral-like phases. The transformation proceeds at interfaces between regions of the tetragonal-like phase and regions of a mixture of tilted phases, consistent with the motion of a phase boundary. The optically induced transformation demonstrates that there are new optically driven routes towards nanosecond-scale control of phase transformations in ferroelectrics and multiferroics.

Electronic Structure Control of Sub-nanometer 1D SnTe via Nanostructuring within Single-Walled Carbon Nanotubes.

Nanostructuring, e. g., reduction of dimensionality in materials, offers a viable route toward regulation of materials electronic and hence functional properties. Here, we present the extreme case of nanostructuring, exploiting the capillarity of single-walled carbon nanotubes (SWCNTs) for the synthesis of the smallest possible SnTe nanowires with cross sections as thin as a single atom column. We demonstrate that by choosing the appropriate diameter of a template SWCNT, we can manipulate the structure of the quasi-one-dimensional (1D) SnTe to design electronic behavior. From first principles, we predict the structural re-formations that SnTe undergoes in varying encapsulations and confront the prediction with TEM imagery. To further illustrate the control of physical properties by nanostructuring, we study the evolution of transport properties in a homologous series of models of synthesized and isolated SnTe nanowires varying only in morphology and atomic layer thickness. This extreme scaling is predicted to significantly enhance thermoelectric performance of SnTe, offering a prospect for further experimental studies and future applications.

Exploration of the Smallest Diameter Tin Nanowires Achievable with Electrodeposition: Sub 7 nm Sn Nanowires Produced by Electrodeposition from a Supercritical Fluid.

Electrodeposition of Sn from supercritical difluoromethane has been performed into anodic alumina templates with pores down to 3 nm in diameter and into mesoporous silica templates with pores of diameter 1.5 nm. Optimized deposits have been characterized using X-ray diffraction, scanning electron microscopy, and scanning transmission electron microscopy (bright field, high-angle annular dark field, and energy-dispersive X-ray elemental mapping). Crystalline 13 nm diameter Sn nanowires have been electrodeposited in symmetric pore anodic alumina. Direct transmission electron microscopy evidence of sub 7 nm Sn nanowires in asymmetric anodic alumina has been obtained. These same measurements present indirect evidence for electrodeposition through 3 nm constrictions in the same templates. A detailed transmission electron microscopy study of mesoporous silica films after Sn deposition is presented. These indicate that it is possible to deposit Sn through the 1.5 nm pores in the mesoporous films, but that the nanowires formed are not stable. Suggestions of why this is the case and how such extreme nanowires could be stabilized are presented.

Single-Atom Scale Structural Selectivity in Te Nanowires Encapsulated Inside Ultranarrow, Single-Walled Carbon Nanotubes.

Extreme nanowires (ENs) represent the ultimate class of crystals: They are the smallest possible periodic materials. With atom-wide motifs repeated in one dimension (1D), they offer a privileged perspective into the physics and chemistry of low-dimensional systems. Single-walled carbon nanotubes (SWCNTs) provide ideal environments for the creation of such materials. Here we present a comprehensive study of Te ENs encapsulated inside ultranarrow SWCNTs with diameters between 0.7 nm and 1.1 nm. We combine state-of-the-art imaging techniques and 1D-adapted ab initio structure prediction to treat both confinement and periodicity effects. The studied Te ENs adopt a variety of structures, exhibiting a true 1D realization of a Peierls structural distortion and transition from metallic to insulating behavior as a function of encapsulating diameter. We analyze the mechanical stability of the encapsulated ENs and show that nanoconfinement is not only a useful means to produce ENs but also may actually be necessary, in some cases, to prevent them from disintegrating. The ability to control functional properties of these ENs with confinement has numerous applications in future device technologies, and we anticipate that our study will set the basic paradigm to be adopted in the characterization and understanding of such systems.

The economic value of grassland species for carbon storage.

Carbon storage by ecosystems is valuable for climate protection. Biodiversity conservation may help increase carbon storage, but the value of this influence has been difficult to assess. We use plant, soil, and ecosystem carbon storage data from two grassland biodiversity experiments to show that greater species richness increases economic value: Increasing species richness from 1 to 10 had twice the economic value of increasing species richness from 1 to 2. The marginal value of each additional species declined as species accumulated, reflecting the nonlinear relationship between species richness and plant biomass production. Our demonstration of the economic value of biodiversity for enhancing carbon storage provides a foundation for assessing the value of biodiversity for decisions about land management. Combining carbon storage with other ecosystem services affected by biodiversity may well enhance the economic arguments for conservation even further.