Use of Diabetes Technologies and Retinopathy in Adults With Type 1 Diabetes.

Importance: Diabetic retinopathy (DR) is a complication of diabetes that can lead to vision loss. Outcomes of continuous glucose monitoring (CGM) and insulin pump use in DR are not well understood. Objective: To assess the use of CGM, insulin pump, or both, and DR and proliferative diabetic retinopathy (PDR) in adults with type 1 diabetes (T1D). Design, Setting, and Participants: A retrospective cohort study of adults with T1D in a tertiary diabetes center and ophthalmology center was conducted from 2013 to 2021, with data analysis performed from June 2022 to April 2023. Exposure: Use of diabetes technologies, including insulin pump, CGM, and both CGM and insulin pump. Main Outcomes and Measures: The primary outcome was development of DR or PDR. A secondary outcome was the progression of DR for patients in the longitudinal cohort. Multivariable logistic regression models assessed for development of DR and PDR and association with CGM and insulin pump use. Results: A total of 550 adults with T1D were included (median age, 40 [IQR, 28-54] years; 54.4% female; 24.5% Black or African American; and 68.4% White), with a median duration of diabetes of 20 (IQR, 10-30) years, and median hemoglobin A1c (HbA1c) of 7.8% (IQR, 7.0%-8.9%). Overall, 62.7% patients used CGM, 58.2% used an insulin pump, and 47.5% used both; 44% (244 of 550) of the participants had DR at any point during the study. On univariate analysis, CGM use was associated with lower odds of DR and PDR, and CGM with pump was associated with lower odds of PDR (all P < .05), compared with no CGM use. Multivariable logistic regression adjusting for age, sex, race and ethnicity, diabetes duration, microvascular and macrovascular complications, insurance type, and mean HbA1c, showed that CGM was associated with lower odds of DR (odds ratio [OR], 0.52; 95% CI, 0.32-0.84; P = .008) and PDR (OR, 0.42; 95% CI, 0.23-0.75; P = .004), compared with no CGM use. In the longitudinal analysis of participants without baseline PDR, 79 of 363 patients (21.8%) had progression of DR during the study. Conclusions and Relevance: In this cohort study of adults with T1D, CGM use was associated with lower odds of developing DR and PDR, even after adjusting for HbA1c. These findings suggest that CGM may be useful for diabetes management to mitigate risk for DR and PDR.

Factors Associated With Receipt of Crosslinking for Keratoconus.

PURPOSE: The aim of this study was to identify factors associated with receipt of standard fluence epithelium-off crosslinking (CXL) for keratoconus (KCN). METHODS: This retrospective, cross-sectional study reviewed electronic health records of treatment-naive patients with KCN seen at the Wilmer Eye Institute between January 2017 and September 2020. Tomographic data were derived from Pentacam (Oculus, Wetzlar, Germany) devices. Multivariable population-average model using generalized estimating equations adjusting for age, sex, race, national area deprivation index, vision correction method, and disease severity was used to identify factors associated with receipt of CXL. RESULTS: From 583 patients with KCN, 97 (16.6%) underwent CXL for KCN. Patients who received CXL in at least 1 eye were significantly younger (mean 24.0 ± 7.8 years) than patients who had never undergone CXL (33.4 ± 9.3 years) ( P < 0.001). In multivariable analysis, Black patients had 63% lower odds of receiving CXL for KCN (OR: 0.37, 95% CI, 0.18-0.79) versus White patients, and older age was protective against receipt of CXL (OR: 0.89 per 1-year increase, 95% CI, 0.86-0.93). Comparison of characteristics by race demonstrated that Black patients presented with significantly worse vision, higher keratometric indices (K1, K2, and Kmax), and thinner corneal pachymetry at baseline versus White or Asian patients. CONCLUSIONS: In this clinical cohort of patients with KCN from a tertiary referral center, Black patients were less likely to receive CXL presumably because of more advanced disease at presentation. Earlier active population screening may be indicated to identify and treat these patients before they become ineligible for treatment and develop irreversible vision loss. Such strategies may improve health equity in KCN management.

Racial Variation in Visual Impairment of Patients With Keratoconus at Presentation.

PURPOSE: This study aimed to investigate racial disparities in the severity of keratoconus (KCN) at presentation, their intersection with socioeconomic variables, and other factors associated with visual impairment. METHODS: This retrospective cohort study examined medical records of 1989 patients (3978 treatment-naive eyes) with a diagnosis of KCN seen at Wilmer Eye Institute between 2013 and 2020. A multivariable regression model adjusting for age, sex, race, insurance type, KCN family history, atopy, smoking status, and vision correction method examined factors associated with visual impairment, defined as a best available visual acuity of worse than 20/40 in the better eye. RESULTS: Demographically, Asian patients were the youngest (33.4 ± 14.0 years) ( P < 0.001), and Black patients had the highest median area deprivation index (ADI) of 37.0 [interquartile range (IQR): 21.0-60.5] ( P < 0.001). Multivariable analysis showed a higher risk of visual impairment for Black (OR 2.25, 95% CI, 1.71-2.95) versus White patients. Medicaid (OR 2.59, 95% CI, 1.75-3.83) and Medicare (OR 2.48, 95% CI, 1.51-4.07) were also associated with a higher odds of visual impairment compared with private insurance, and active smokers were more likely to have visual impairment than those with no prior smoking history (OR 2.17, 95% CI, 1.42-3.30). Eyes of Black patients had the highest maximum keratometry (Kmax) (56.0 ± 11.0D) ( P = 0.003) and the lowest thinnest pachymetry (463.2 ± 62.5 µm) ( P = 0.006) compared with eyes of other races. CONCLUSIONS: Black race, government-funded insurance, and active smoking were significantly associated with increased odds of visual impairment in adjusted analyses. Black race was also associated with higher Kmax and lower thinnest pachymetry, suggesting that Black patients have more severe disease at presentation.

Seclusion within the first 24 h following admission into inpatient mental health services and associations with referral pathways, recent service contact and HoNOS ratings.

WHAT IS KNOWN ON THE SUBJECT?: Seclusion is a harmful and traumatising intervention for people accessing mental health services. People who are subject to seclusion in inpatient mental health services often first experience this within the first 24 h following admission. There is limited research examining how recent contact with services impacts the likelihood of seclusion when people are admitted to inpatient services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Males, Maori and Pasifika experience higher rates of seclusion within the first 24 h following inpatient admission. People perceived by clinicians as overactive, aggressive, disruptive or agitated are seven times more likely to be secluded within the first 24 h. People referred from police or justice services are three times more likely to be secluded within the first 24 h. People who had frequent contact with community mental health services prior to inpatient admission were less likely to be secluded. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The first 24 h of inpatient admission is a critical focus for eliminating the use of seclusion. Initial interactions with people recently admitted should focus on nurturing relationships and reducing distress. Mental health staff should consider the person's cultural needs, referral pathway, recent service contact and baseline ratings on the Health of the Nation Outcomes Scales (HoNOS) when working proactively to prevent the use of seclusion in the first 24 h following admission. Strengthening the focus on nurturing relationships, cultural understanding and non-coercive de-escalation approaches requires leadership support and strategic workforce development. ABSTRACT: Introduction People who experience seclusion in inpatient mental health services often do so within the first 24 h following admission. There is limited research examining the potential contributing factors, particularly recent contact with services. Aim/Question To identify factors associated with seclusion within the first 24 h following admission into acute inpatient mental health services. Method A retrospective analysis was undertaken using routinely collected data from Aotearoa New Zealand mental health services. Results A higher likelihood of seclusion within the first 24 h following admission was associated with: males, Maori, Pasifika, referrals from police/justice services, inpatient transfers, recent contact with crisis assessment teams and clinician perceptions of aggression, problematic substance use, cognitive problems and hallucinations or delusions. Recent contact with community mental health services was associated with a lower likelihood. Discussion People's cultural needs, referral pathway, recent service contact and HoNOS scores should be considered when working to prevent the use of seclusion in the first 24 h following admission. Implications for Practice The first 24 h following inpatient admission is a critical period for preventing the use of seclusion. Nurturing relationships, cultural understanding and use of non-coercive de-escalation approaches can support better outcomes for people recently admitted.

The Roles of Coenzyme A Binding Pocket Residues in Short and Medium Chain Acyl-CoA Synthetases.

Short- and medium-chain acyl-CoA synthetases catalyze similar two-step reactions in which acyl substrate and ATP bind to form an enzyme-bound acyl-adenylate, then CoA binds for formation of the acyl-CoA product. We investigated the roles of active site residues in CoA binding in acetyl-CoA synthetase (Acs) and a medium-chain acyl-CoA synthetase (Macs) that uses 2-methylbutyryl-CoA. Three highly conserved residues, Arg193, Arg528, and Arg586 of Methanothermobacter thermautotrophicus Acs (AcsMt), are predicted to form important interactions with the 5'- and 3'-phosphate groups of CoA. Kinetic characterization of AcsMt variants altered at each of these positions indicates these Arg residues play a critical role in CoA binding and catalysis. The predicted CoA binding site of Methanosarcina acetivorans Macs (MacsMa) is structurally more closely related to that of 4-chlorobenzoate:coenzyme A ligase (CBAL) than Acs. Alteration of MacsMa residues Tyr460, Arg490, Tyr525, and Tyr527, which correspond to CoA binding pocket residues in CBAL, strongly affected CoA binding and catalysis without substantially affecting acyl-adenylate formation. Both enzymes discriminate between 3'-dephospho-CoA and CoA, indicating interaction between the enzyme and the 3'-phosphate group is important. Alteration of MacsMa residues Lys461 and Lys519, located at positions equivalent to AcsMt Arg528 and Arg586, respectively, had only a moderate effect on CoA binding and catalysis. Overall, our results indicate the active site architecture in AcsMt and MacsMa differs even though these enzymes catalyze mechanistically similar reactions. The significance of this study is that we have delineated the active site architecture with respect to CoA binding and catalysis in this important enzyme superfamily.

Long Covid active case finding study protocol: A co-produced community-based pilot within the STIMULATE-ICP study (Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways).

BACKGROUND AND AIM: Long Covid is a significant public health concern with potentially negative implications for health inequalities. We know that those who are already socially disadvantaged in society are more exposed to COVID-19, experience the worst health outcomes and are more likely to suffer economically. We also know that these groups are more likely to experience stigma and have negative healthcare experiences even before the pandemic. However, little is known about disadvantaged groups' experiences of Long Covid, and preliminary evidence suggests they may be under-represented in those who access formal care. We will conduct a pilot study in a defined geographical area in London, United Kingdom to test the feasibility of a community-based approach of identifying Long Covid cases that have not been clinically diagnosed and have not been referred to Long Covid specialist services. We will explore the barriers to accessing recognition, care, and support, as well as experiences of stigma and perceived discrimination. METHODS: This protocol and study materials were co-produced with a Community Advisory Board (CAB) made up primarily of people living with Long Covid. Working with voluntary organisations, a study leaflet will be distributed in the local community to highlight Long Covid symptoms and invite those experiencing them to participate in the study if they are not formally diagnosed. Potential participants will be assessed according to the study's inclusion criteria and offered the opportunity to participate if they fit them. Awareness of Long Covid and associated symptoms, experiences of trying to access care, as well as stigma and discrimination will be explored through qualitative interviews with participants. Upon completion of the interviews, participants will be offered a referral to the local social prescribing team to receive support that is personalised to them potentially including, but not restricted to, liaising with their primary care provider and the regional Long Covid clinic.

Corneal Culture and Antibiotic Susceptibility Results for Microbial Keratitis in the Mid-Atlantic Region of the United States, 2016 to 2020.

OBJECTIVE: To examine the microbial distribution and antimicrobial susceptibility of culture-positive microbial keratitis at a large tertiary referral center in the mid-Atlantic region of the United States. METHODS: Retrospective review of culture-positive microbial keratitis cases at the Wilmer Eye Institute from 2016 through 2020. RESULTS: Of the 474 culture-positive microbial keratitis cases, most were bacterial (N=450, 94.9%), followed by fungal (N=48, 10.1%) and Acanthamoeba keratitis (N=15, 3.1%). Of the 450 bacterial isolates, 284 (69.5%) were gram-positive organisms, whereas 157 (28.4%) were gram-negative organisms. The most common bacterial species isolated was coagulase-negative Staphylococcus spp (N=154, 24.8%), and the most common gram-negative isolate was Pseudomonas aeruginosa (N=76, 12.3%). Among fungi, the most common isolates were Candida (N=25, 45.4%), whereas Fusarium (N=6, 10.9%) and Aspergillus (N=3, 5.5%) were less common. Of the 217 bacterial isolates tested for erythromycin susceptibility, 121 (55.7%; ∼60% of coagulase-negative staphylococci and corynebacteria tested) showed resistance to erythromycin. CONCLUSIONS: Microbial keratitis in the Baltimore Mid-Atlantic region of the United States is most commonly caused by bacteria, with fungi and acanthamoeba being less common. Gram-positive bacterial infections predominate. Among fungal keratitis cases, Candida species are more commonly encountered than are filamentous species. Use of erythromycin as infection prophylaxis should be reexamined. Findings from our study may guide empiric treatment in this geographic region.

Opportunity Cost to Attending Surgeons of Intraoperative Training for Residents in Cataract Surgery.

Purpose: To estimate the opportunity cost to attending surgeons of teaching residents cataract surgery in the operating room. Patients and methods: Operating room records at an academic teaching hospital from July 2016 to July 2020 were analyzed in this retrospective review of cases. Cases were identified using Current Procedural Terminology (CPT) codes 66982 and 66984 for cataract surgery. Outcomes measured include operative time and work relative value units (wRVUs). Cost analysis was performed using the generic 2021 Medicare Conversion Factor. Results: Of 8813 cases, 2906 (33.0%) included resident involvement. For CPT 66982 cases, median (interquartile range (IQR)) operative time was 47 (22) minutes with resident involvement and 28 (18) minutes without (p<0.001). For CPT 66984 cases, median (IQR) operative time was 34 (15) minutes with resident involvement and 20 (11) minutes without (p<0.001). Median wRVUs was 78.5 (20.9) with resident involvement and 61.0 (14.4) without (p<0.001) which converted to an opportunity cost (IQR) per case of $1393.72 ($1055.63). Among cases involving residents, median operative time was significantly higher during the first and second quarters (p<0.001) and for every quarter when compared to cases performed by attendings only (p<0.001). Conclusion: Teaching cataract surgery in the operating room is associated with a considerable opportunity cost for attending surgeons.

Effects of fetal haemoglobin on systemic oxygenation in preterm infants and the development of retinopathy of prematurity PacIFiHER Report No. 2.

BACKGROUND/AIMS: Fetal haemoglobin (HbF) has an oxyhaemoglobin dissociation curve that may affect systemic oxygenation and the development of retinopathy of prematurity (ROP). The study aim is to characterise the effects of HbF levels on systemic oxygenation and ROP development. METHODS: Prospective study conducted from 1 September 2017 through 31 December 2018 at the Johns Hopkins NICU. Preterm infants with HbF measured at birth, 31, 34 and 37 weeks post-menstrual age (PMA), complete blood gas and SpO2 recorded up to 42 weeks PMA, and at least one ROP exam were included. RESULTS: Sixty-four preterm infants were enrolled. Higher HbF was associated with significantly higher SpO2, lower PCO2, lower FiO2 from birth to 31 weeks PMA and 31 to 34 weeks PMA (rs=0.51, rs=-0.62 and rs=-0.63; p<0.0001 and rs=0.71, rs=-0.58 and rs=-0.79; p<0.0001, respectively). To maintain oxygen saturation goals set by the neonatal intensive care unit, higher median FiO2 was required for HbF in the lowest tercile from birth compared with HbF in the highest tercile to 31 weeks and 31 to 34 weeks PMA; FiO2=35 (21-100) versus 21 (21-30) p<0.006 and FiO2=30 (28-100) versus 21 (21-30) p<0.001, respectively. Preterm infants with ROP had poorer indices of systemic oxygenation, as measured by median levels of SpO2 and PCO2, and lower levels of HbF (p<0.039 and p<0.0001, respectively) up to 34 weeks PMA. CONCLUSION: Low HbF levels correlated with poor oxygenation indices and increased risk for ROP. O2 saturation goals to prevent ROP may need to incorporate relative amount of HbF.

Retrobulbar respiratory epithelial orbital cyst in a dog: A case report.

A 10-month-old female, neutered French Bulldog presented with a history of unilateral right-sided intermittent conjunctivitis and exophthalmos. The patient suffered blunt force trauma to the right eye after a tennis ball impact approximately five months prior to presentation. Examination identified the patient was visual with exophthalmos, lateral strabismus, conjunctival hyperaemia, episcleral congestion, and papilloedema. Magnetic resonance imaging and ultrasonography identified an approximately two centimeter diameter fluid-filled structure directly posterior to the globe leading to displacement of the optic nerve and distortion of the posterior globe wall. Centesis of the lesion demonstrated neutrophilic and macrophagic inflammation with evidence of prior hemorrhage. Within four weeks, the structure had re-filled to its original size and was subsequently excised in its entirety, via a lateral orbitotomy. Histopathologic findings indicated a non-keratinising orbital cyst, the lining of which was consistent with a respiratory epithelial cyst. Recurrence had not occurred seven months' post-surgery. To the author's knowledge, previous reports of retrobulbar respiratory epithelial cysts have not been documented in animals.

Visual Acuity: Assessment of Data Quality and Usability in an Electronic Health Record System.

Objective: To examine the data quality and usability of visual acuity (VA) data extracted from an electronic health record (EHR) system during ophthalmology encounters and provide recommendations for consideration of relevant VA end points in retrospective analyses. Design: Retrospective, EHR data analysis. Participants: All patients with eyecare office encounters at any 1 of the 9 locations of a large academic medical center between August 1, 2013, and December 31, 2015. Methods: Data from 13 of the 21 VA fields (accounting for 93% VA data) in EHR encounters were extracted, categorized, recoded, and assessed for conformance and plausibility using an internal data dictionary, a 38-item listing of VA line measurements and observations including 28 line measurements (e.g., 20/30, 20/400) and 10 observations (e.g., no light perception). Entries were classified into usable and unusable data. Usable data were further categorized based on conformance to the internal data dictionary: (1) exact match; (2) conditional conformance, letter count (e.g., 20/30+2 - 3); (3) convertible conformance (e.g., 5/200 to 20/800); (4) plausible but cannot be conformed (e.g., 5/400). Data were deemed unusable when they were not plausible. Main Outcome Measures: Proportions of usable and unusable VA entries at the overall and subspecialty levels. Results: All VA data from 513 036 encounters representing 166 212 patients were included. Of the 1 573 643 VA entries, 1 438 661 (91.4%) contained usable data. There were 1 196 720 (76.0%) exact match (category 1), 185 692 (11.8%) conditional conformance (category 2), 40 270 (2.6%) convertible conformance (category 3), and 15 979 (1.0%) plausible but not conformed entries (category 4). Visual acuity entries during visits with providers from retina (17.5%), glaucoma (14.0%), neuro-ophthalmology (8.9%), and low vision (8.8%) had the highest rates of unusable data. Documented VA entries with providers from comprehensive eyecare (86.7%), oculoplastics (81.5%), and pediatrics/strabismus (78.6%) yielded the highest proportions of exact match with the data dictionary. Conclusions: Electronic health record VA data quality and usability vary across documented VA measures, observations, and eyecare subspecialty. We proposed a checklist of considerations and recommendations for planning, extracting, analyzing, and reporting retrospective study outcomes using EHR VA data. These are important first steps to standardize analyses enabling comparative research.

An evaluation of the impact for healthcare professionals after a leadership innovation fellowship program.

BACKGROUND: Leadership among healthcare professionals is required to address important healthcare challenges. The TAHSNp Health Professions Innovation Fellowship program ("Program") supports health professionals' leadership development by offering them an opportunity to lead a quality improvement project and participate in a curriculum focused on leading change. OBJECTIVE: As part of an outcome evaluation of the program, our objective was to determine the program's impact on leadership activities and roles undertaken by alumni. METHODS: A questionnaire was administered to participants who completed the program in 2019 and 2020 at 6 and 18 months post-program to assess their leadership activities, leadership roles and the program's impact. Prospectively, we conducted internal and LinkedIn searches to identify current roles and obtained personal statements from program alumni of medical imaging health professions as complementary data sources for our program evaluation. RESULTS: At 6 and 18 months post-program, 47% - 59% of alumni respondents reported participation in hospital/organization committees, mentoring fellows or students, and presenting scholarly work inside or outside their organizations (6 months: N = 25, response rate = 39.1%; 18 months: N = 17, response rate = 26.6%). Additionally, at 18 months post program, 35% - 41% of alumni reported leading a new quality improvement initiative, pursuing formal education, and having a new leadership role. Most alumni reported their leadership activities were influenced by the program, with the largest impact occurring after 18 months post-program for leading a new quality improvement initiative (100%), career plans for the next five years (94%), mentoring fellowship staff (91%), presenting at their healthcare organization (91%) and a new leadership role (90%). Alumni reported the program helped build their confidence, create networking opportunities, leadership skill-building and interest in pursuing other roles beyond their clinical role. More specifically, alumni reported that leadership skills gained from the program were used in subsequent roles and responsibilities. CONCLUSION/IMPLICATIONS: The program evaluation demonstrates engaged alumni who undertake informal and formal leadership activities and roles. Our results are illustrative of the value-add as a result of healthcare organizations' investment in developing leadership among healthcare professionals. As continued engagement and career development are known to be important for staff retention and succession planning strategies, our findings are highly relevant given the current staffing challenges in healthcare.

Implementation and cost validation of a real-time benefit tool.

OBJECTIVES: To assess the accuracy of a real-time benefit tool (RTBT) that is compliant with the standards of the National Council for Prescription Drug Programs (NCPDP) in a large academic medical center. STUDY DESIGN: Observational study of electronic health records and pharmacy records from July 14, 2019, through January 14, 2020, across all ambulatory clinics and outpatient pharmacies in the health system. METHODS: Main assessments included (1) demographic characteristics of patients in whom the RTBT was used and those in whom it was not used, (2) types of changes most frequently made to medication orders upon reviewing the RTBT, and (3) comparison of the out-of-pocket costs for prescriptions vs the RTBT-generated estimates. RESULTS: The most common modifications made to prescriptions due to RTBT use were changes in days' supply (44%) and the quantity of medication (69%). In more than 98% of prescription orders, patients' out-of-pocket costs were either equivalent to or lower than the estimates generated by the RTBT. CONCLUSIONS: Current standards established by NCPDP yield accurate patient out-of-pocket estimates and could serve as a national standard for all Part D sponsors.

Using Electronic Clinical Decision Support to Examine Vision Rehabilitation Referrals and Practice Guidelines in Ophthalmology.

Purpose: To examine ophthalmologist use of an electronic health record (EHR)-based clinical decision support system (CDSS) to facilitate low vision rehabilitation (LVR) care referral. Methods: The CDSS alert was designed to appear when best documented visual acuity was <20/40 or hemianopia or quadrantanopia diagnosis was identified during an ophthalmology encounter from November 6, 2017, to April 5, 2019. Fifteen ophthalmologists representing eight subspecialties from an academic medical center were required to respond to the referral recommendation (order, don't order). LVR referral rates and ophthalmologist user experience were assessed. Encounter characteristics associated with LVR referrals were explored using multilevel logistic regression analysis. Results: The alert appeared for 3625 (8.9%) of 40,931 eligible encounters. The referral rate was 14.8% (535/3625). Of the 3413 encounters that met the visual acuity criterion only, patients who were worse than 20/60 were more likely to be referred, and 32.4% of referred patients were between 20/40 and 20/60. Primary reasons for deferring referrals included active medical or surgical treatment, refractive-related issues, and previous connection to LVR services. Eleven of the 13 ophthalmologists agreed that the alert was useful in identifying candidates for LVR services. Conclusions: A CDSS for patient identification and referral offers an acceptable mechanism to apply practice guidelines and prompt ophthalmologists to facilitate LVR care. Further study is warranted to optimize ophthalmologist user experience while refining alert criteria beyond visual acuity. Translational Relevance: The CDSS provides the framework for multi-center research to assess the development of pragmatic algorithms and standards for facilitating LVR care.

Sustainability capacity of a vegetable gardening intervention for cancer survivors.

BACKGROUND: Health behavior interventions, especially those that promote improved diet and physical activity, are increasingly directed toward cancer survivors given their burgeoning numbers and high risk for comorbidity and functional decline. However, for health behavior interventions to achieve maximal public health impact, sustainability at both the individual and organizational levels is crucial. The current study aimed to assess the individual and organizational sustainability of the Harvest for Health mentored vegetable gardening intervention among cancer survivors. METHODS: Telephone surveys were conducted among 100 cancer survivors (mean age 63 years; primarily breast cancer) completing one-of-two Harvest for Health feasibility trials. Surveys ascertained whether participants continued gardening, and if so, whether they had expanded their gardens. Additionally, surveys were emailed to 23 stakeholders (Cooperative Extension county agents, cancer support group leaders, and healthcare representatives) who were asked to rate the intervention's ability to generate sustained service and produce benefits over time using the eight-domain Program Sustainability Assessment Tool (PSAT). RESULTS: The survey among cancer survivors (91.9% response rate) indicated that 85.7% continued gardening throughout the 12 months following intervention completion; 47.3% expanded their gardens beyond the space of the original intervention. Moreover, 5.5% of cancer survivors enrolled in the certification program to become Extension Master Gardeners. The survey among stakeholders generated a similar response rate (i.e., 91.3%) and favorable scores. Of the possible maximum of 7 points on the PSAT, the gardening intervention's "Overall Capacity for Sustainability" scored 5.7 (81.4% of the maximum score), with subscales for "Funding Stability" scoring the lowest though still favorably (5.0) and "Program Evaluation" scoring the highest (6.3). CONCLUSIONS: Data support the sustainability capacity of the Harvest for Health vegetable gardening intervention for cancer survivors. Indeed, few interventions have proven as durable in terms of individual sustainability. Furthermore, Harvest for Health's overall organizational score of 5.7 on the PSAT is considered strong when compared to a previous review of over 250 programs, where the mean overall organizational PSAT score was 4.84. Thus, solutions for long-term funding are currently being explored to support this strong, holistic program that is directed toward this vulnerable and growing population. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02150148.

Harvest for Health, a Randomized Controlled Trial Testing a Home-Based, Vegetable Gardening Intervention Among Older Cancer Survivors Across Alabama: An Analysis of Accrual and Modifications Made in Intervention Delivery and Assessment During COVID-19.

BACKGROUND: Accelerated functional decline is a concern among older cancer survivors that threatens independence and quality of life. Pilot studies suggest that vegetable gardening interventions ameliorate functional decline through improved diet and physical activity. OBJECTIVE: The aim of this article was to describe the rationale, recruitment challenges, and enrollment for the Harvest for Health randomized controlled trial (RCT), which will test the impact of a home-based, vegetable gardening intervention on vegetable and fruit consumption, physical activity, and physical functioning among older cancer survivors. Modifications made to the intervention and assessments to assure safety and continuity of the RCT throughout the COVID-19 pandemic also are reported. DESIGN: Harvest for Health is a 2-year, 2-arm, single-blinded, wait-list controlled RCT with cross-over. PARTICIPANTS/SETTING: Medicare-eligible survivors of cancers with ≥60% 5-year survival were recruited across Alabama from October 1, 2016 to February 8, 2021. INTERVENTION: Participants were randomly assigned to a wait-list control or a 1-year home-based gardening intervention and individually mentored by extension-certified master gardeners to cultivate spring, summer, and fall vegetable gardens. MAIN OUTCOME MEASURES: Although the RCT's primary end point was a composite measure of vegetable and fruit consumption, physical activity, and physical functioning, this article focuses on recruitment and modifications made to the intervention and assessments during COVID-19. STATISTICAL ANALYSES PERFORMED: χ2 and t tests (α < .05) were used to compare enrolled vs unenrolled populations. RESULTS: Older cancer survivors (n = 9,708) were contacted via mail and telephone; 1,460 indicated interest (15% response rate), 473 were screened eligible and consented, and 381 completed baseline assessments and were randomized. Enrollees did not differ from nonrespondents/refusals by race and ethnicity, or rural-urban status, but comprised significantly higher numbers of comparatively younger survivors, those who were female, and survivors of breast cancer (P < .001). Although COVID-19 delayed trial completion, protocol modifications overcame this barrier and study completion is anticipated by June 2022. CONCLUSIONS: This RCT will provide evidence on the effects of a mentored vegetable gardening program among older cancer survivors. If efficacious, Harvest for Health represents a novel, multifaceted approach to improve lifestyle behaviors and health outcomes among cancer survivors-one with capacity for sustainability and widespread dissemination.

Identifying Accessibility Requests for Patients With Disabilities Through an Electronic Health Record-Based Questionnaire.

Importance: People with disabilities experience disparities in health care access and outcomes, and inaccessible health care facilities are major barriers to health care access. Methods to collect accessibility request information are needed to improve health care outcomes for patients with disabilities. Objective: To evaluate an electronic health record (EHR)-based questionnaire designed to identify accessibility requests for patients with disabilities at an eye clinic. Design, Setting, and Participants: This cross-sectional pilot study implemented an EHR questionnaire and prospectively collected data on accessibility requests at a university-based eye clinic. The study included 55 722 patients making appointments at the Johns Hopkins Wilmer Eye Institute from April 1, 2019, to March 31, 2020. Main Outcomes and Measures: The Wilmer Eye Institute staff were trained to assess accessibility requests of patients making appointments in-person or via telephone using a standardized script and entering patient responses into the EHR. Data were later extracted for analysis and used to determine the proportion of patients making eye appointments who reported a disability accessibility request (physical, sensory, or intellectual) during their clinic visit. Results: Accessibility request data were collected from 250 932 patient encounters. Patients had a mean (SD) age of 61.9 (20.6) years; most were women (146 846 [58.5%]) and were White individuals (162 720 [64.9%]). Of these, 23 510 (9.4%) encounters were associated with an accessibility request. The most reported accessibility request was mobility related (18 857 [7.5%]) (needing a cane, crutches, motorized scooter, walker, wheelchair, stretcher, assistance standing, or transport services), followed by sensory-related (2988 [1.2%]) (visual, hearing, or speech impairment), intellectual (353 [0.1%]), and other (1312 [0.5%]) (assistance with filling forms or service animal) requests. Patients with an accessibility request compared with those without, were older (72.6 vs 60.8 years), less likely to be White individuals (59.7% vs 65.4%), and more likely to be women (62.6% vs 58.1%), receiving Medicare (69.6% vs 41.5%), and have vision impairment (41.3% vs 13.6%) (P < .001 for all). Conclusions and Relevance: In this cross-sectional study, a substantial proportion of patients making eye appointments reported having accessibility requests as captured using a new EHR-based questionnaire. Such standardization of data collection for disability-related accessibility requests in EHR is scalable, could be expanded to other clinical settings, and has the potential to improve accessibility of health care interactions for patients with disabilities.

Stratified glucose-lowering response to vildagliptin and pioglitazone by obesity and hypertriglyceridemia in a randomized crossover trial.

Background: Understanding which group of patients with type 2 diabetes will have the most glucose lowering response to certain medications (which target different aspects of glucose metabolism) is the first step in precision medicine. Aims: We hypothesized that people with type 2 diabetes who generally have high insulin resistance, such as people of Maori/Pacific ethnicity, and those with obesity and/or hypertriglyceridemia (OHTG), would have greater glucose-lowering by pioglitazone (an insulin sensitizer) versus vildagliptin (an insulin secretagogue). Methods: A randomised, open-label, two-period crossover trial was conducted in New Zealand. Adults with type 2 diabetes, HbA1c>58mmol/mol (>7.5%), received 16 weeks of either pioglitazone (30mg) or vildagliptin (50mg) daily, then switched to the other medication over for another 16 weeks of treatment. Differences in HbA1c were tested for interaction with ethnicity or OHTG, controlling for baseline HbA1c using linear mixed models. Secondary outcomes included weight, blood pressure, side-effects and diabetes treatment satisfaction. Results: 346 participants were randomised (55% Maori/Pacific) between February 2019 to March 2020. HbA1c after pioglitazone was lower than after vildagliptin (mean difference -4.9mmol/mol [0.5%]; 95% CI -6.3, -3.5; p<0.0001). Primary intention-to-treat analysis showed no significant interaction effect by Maori/Pacific vs other ethnicity (1.5mmol/mol [0.1%], 95% CI -0.8, 3.7), and per-protocol analysis (-1.2mmol/mol [0.1%], 95% CI -4.1, 1.7). An interaction effect (-4.7mmol/mol [0.5%], 95% CI -8.1, -1.4) was found by OHTG status. Both treatments generated similar treatment satisfaction scores, although there was greater weight gain and greater improvement in lipids and liver enzymes after pioglitazone than vildagliptin. Conclusions: Comparative glucose-lowering by pioglitazone and vildagliptin is not different between Maori/Pacific people compared with other New Zealand ethnic groups. Presence of OHTG predicts greater glucose lowering by pioglitazone than vildagliptin. Clinical trial registration: www.anzctr.org.au, identifier (ACTRN12618001907235).

The diagnostic yield of advanced imaging in dogs with Horner's syndrome presenting with and without additional clinical signs: A retrospective study of 120 cases (2000-2018).

PURPOSE: To evaluate the diagnostic yield of advanced imaging in dogs with Horner's syndrome (HS) both with and without additional clinical signs. METHODS: Retrospective review of clinical records from a UK referral hospital (2000-2018). Cases were excluded if HS was trauma- or surgery-related and if no advanced imaging with MRI or CT was performed. Imaging findings were assessed as well as any additional investigations performed. RESULTS: One hundred twenty cases met the inclusion criteria; 88 with additional clinical signs and 32 with isolated HS. MRI or CT of head and neck was performed in 115 cases and/or thoracic CT in eight cases. Causative lesions were identified in 98% (86/88) of cases with additional clinical signs and 3% (1/32) of cases with isolated HS. This was statistically significant (p < .001). Pharmacological localization using phenylephrine (0.1%-10%) was accurate in predicting the site of a causative lesion in 79% (19/24) of tested cases. Overall, 28% (33/120) of cases were idiopathic, of which 49% (16/33) were golden retrievers. When compared to the overall hospital population, and UK Kennel Club records, this confirmed a significant predisposition in this breed (p < .001). No associations between idiopathic HS and concurrent systemic disease were identified. CONCLUSION: This is the first study to evaluate the diagnostic yield of advanced imaging in dogs with HS. Isolated HS is significantly more likely to be idiopathic than cases presenting with additional clinical signs; this could guide decision-making regarding further investigations performed in a clinical setting. Idiopathic HS is over-represented in the golden retriever.

Developing an Ophthalmology Clinical Decision Support System to Identify Patients for Low Vision Rehabilitation.

Purpose: The purpose of this study was to develop and evaluate an electronic health record (EHR) clinical decision support system to identify patients meeting criteria for low vision rehabilitation (LVR) referral. Methods: In this quality improvement project, we applied a user-centered design approach to develop an interactive electronic alert for LVR referral within the Johns Hopkins Wilmer Eye Institute. We invited 15 ophthalmology physicians from 8 subspecialties to participate in the design and implementation, and to provide user experience feedback. The three project phases incorporated development evaluation, feedback analysis, and system refinement. We report on the final alert design, firing accuracy, and user experiences. Results: The alert was designed as physician-centered and patient-specific. Alert firing relied on visual acuity and International Classification of Diseases (ICD)-10 diagnosis (hemianopia/quadrantanopia) criteria. The alert suppression considerations included age < 5 years, recent surgeries, prior LVR visit, and related alert actions. False positive rate (firing when alert should have been suppressed or when firing criteria not met) was 0.2%. The overall false negative rate (alert not firing when visual acuity or encounter diagnosis criteria met) was 5.6%. Of the 13 physicians who completed the survey, 8 agreed that the alert is easy to use, and 12 would consider ongoing usage. Conclusions: This EHR-based clinical decision support system shows reliable firing metrics in identifying patients with vision impairment and promising acceptance by ophthalmologist users to facilitate care and LVR referral. Translational Relevance: The use of real-time data offers an opportunity to translate ophthalmic guidelines and best practices into systematic action for clinical care and research purposes across subspecialties.