Telehealth Screening for Diabetic Retinopathy: Economic Modeling Reveals Cost Savings.

Introduction: The use of telehealth screening (TS) for diabetic retinopathy (DR) consists of fundus photography in a primary care setting with remote interpretation of images. TS for DR is known to increase screening utilization and reduce vision loss compared with standard in-person conventional diabetic retinal exam (CDRE). Anti-vascular endothelial growth factor intravitreal injections have become standard of care for the treatment of DR, but they are expensive. We investigated whether TS for DR is cost-effective when DR management includes intravitreal injections using national data. Materials and Methods: We compared cost and effectiveness of TS and CDRE using decision-tree analysis and probabilistic sensitivity analysis with Monte Carlo simulation. We considered the disability weight (DW) of vision impairment and 1-year direct medical costs of managing patients based on Medicare allowable rates and clinical trial data. Primary outcomes include incremental costs and incremental effectiveness. Results: The average annual direct cost of eye care was $196 per person for TS and $275 for CDRE. On average, TS saves $78 (28%) compared with CDRE and was cost saving in 88.9% of simulations. The average DW outcome was equivalent in both groups. Discussion: Although this study was limited by a 1-year time horizon, it provides support that TS for DR can reduce costs of DR management despite expensive treatment with anti-VEGF agents. TS for DR is equally effective as CDRE at preserving vision. Conclusions: Annual TS for DR is cost saving and equally effective compared with CDRE given a 1-year time horizon.

Using Public Datasets to Identify Priority Areas for Ocular Telehealth.

Purpose: Telemedicine can expand access to ocular services, but barriers include restrictive policies and poor reimbursement. A tool to identify priority regions for interventions is needed. Methods: Eye care provider (ECP) density, self-reported visual disability, and demographics were calculated using census data and professional registries. The relationship between visual disability and ECP density was explored in fractional regression models. These data were compared with state telemedicine policy favorability. Results: For each additional ECP per 100,000 population, there was 0.0111% less disability in the county (95% confidence interval -0.0150% to -0.00719%) in an adjusted model. Of 3,142 counties, 1,078 (34%) were in the worst population-weighted quartile for ECP density and visual disability. Conclusions: Low ECP density is associated with higher visual disability, suggesting an opportunity for ocular telehealth. Counties with favorable policy climates should be prioritized for telemedicine implementation. Public datasets can be used to survey wide geographic areas to identify areas worthy of detailed needs assessments.

A Cross-Sectional Study of the Impact of the COVID-19 Pandemic and Lockdown Orders on Injury Prevalence in National Collegiate Athletic Association (NCAA) Division I Athletes.

Objective The purpose of this study was to analyze the effect of the coronavirus disease 2019 (COVID-19) on injury prevalence in National Collegiate Athletic Association (NCAA) varsity athletes following mandatory state-issued stay-at-home orders in March 2020. A secondary objective was to evaluate the relationship between COVID-19 infection and injury prevalence. Methods The respondents were recruited during pre-participation evaluations held at a Division I university in California in the summer of 2021, as well as via emails shared by athletic trainers at the institution. Data was collected using the Qualtrics Survey Platform (Qualtrics, Provo, UT). For all questions regarding the effects of the COVID-19 pandemic, the participants were asked to compare March 2020-March 2021 ("post-pandemic") to March 2019-March 2020 ("pre-pandemic"). Injury was defined as a physical complaint or condition sustained by an athlete during participation in training or competition that resulted in at least one missed day of practice or competition. The study participants were also asked to disclose their history of laboratory-confirmed COVID-19 infection. Results One hundred forty-six respondents completed the survey, with a 72.3% response rate. Of the respondents, 33.6% (n=49) reported sustaining at least one injury in the year preceding the pandemic, whereas 45.2% (n=66) of respondents reported sustaining at least one injury within the first year of the pandemic, a 34.5% relative increase in injuries (RR=1.35; 95% CI=1.01, 1.80). There was no significant difference in the number of upper body (RR=1.64; 95% CI=0.8, 3.34; p=0.177) versus lower body (RR=1.31; 95% CI=0.94, 1.82; p=0.11) injuries before and after the pandemic onset. Thirty-two respondents reported a history of COVID-19 infection. The athletes who reported a prior COVID-19 diagnosis were no more likely than the athletes with no prior COVID-19 diagnosis to obtain an injury from March 2020 to February 2021 (p=0.85). Conclusion This study indicates that the COVID-19 pandemic and stay-at-home orders were associated with a greater risk of injury in this cohort of collegiate athletes. Interestingly, a history of laboratory-confirmed COVID-19 infection was not associated with increased risk of injury.

Optical Coherence Tomography Angiography for Detecting Nonexudative Macular Neovascularization in Age-Related Macular Degeneration.

Purpose: To compare the efficacy of optical coherence tomography angiography (OCTA) and indocyanine green angiography (ICGA) for detecting nonexudative macular neovascularization (MNV) in age-related macular degeneration (AMD). Methods: In this prospective study, patients with a new diagnosis of exudative AMD in 1 eye were imaged using OCTA, fluorescein angiography (FA), and ICGA in both eyes. The rates at which these imaging modalities detected nonexudative MNV in the nonexudative fellow eye were then compared. Results: This study comprised 41 eyes with a mean follow-up was 14 months. Nonexudative MNV was found in 3 eyes using OCTA and ICGA. No MNV exudation was detected on FA or structural OCT. One of 3 eyes with MNV progressed to exudative disease 6 months after the initial visit. During the follow-up, 5 of the 38 eyes without MNV developed exudation at 4 to 18 months. Conclusions: OCTA is similarly effective as ICGA at detecting nonexudative MNV patterns.

Brachypodium distachyon line Bd3-1 resistance is elicited by the barley stripe mosaic virus triple gene block 1 movement protein.

Barley stripe mosaic virus North Dakota 18 (ND18), Beijing (BJ), Xinjiang (XJ), Type (TY) and CV21 strains are unable to infect the Brachypodium distachyon Bd3-1 inbred line, which harbours a resistance gene designated Bsr1, but the Norwich (NW) strain is virulent on Bd3-1. Analysis of ND18 and NW genomic RNA reassortants and RNAß mutants demonstrates that two amino acids within the helicase motif of the triple gene block 1 (TGB1) movement protein have major effects on their Bd3-1 phenotypes. Resistance to ND18 correlates with an arginine residue at TGB1 position 390 (R(390)) and a threonine at position 392 (T(392)), whereas the virulent NW strain contains lysines (K) at both positions. ND18 TGB1 R390K ((ND)TGB1(R390K)) and (ND)TGB1(T392K) single substitutions, and an (ND)TGB1(R390K,T392K) double mutation resulted in systemic infections of Bd3-1. Reciprocal (ND)TGB1 substitutions into (NW)TGB1 ((NW)TGB1(K390R) and (NW)TGB1(K392T)) failed to affect virulence, implying that K(390) and K(392) compensate for each other. In contrast, an (NW)TGB1(K390R,K392T) double mutant exhibited limited vascular movement in Bd3-1, but developed prominent necrotic streaks that spread from secondary leaf veins. This phenotype, combined with the appearance of necrotic spots in certain ND18 mutants, and necrosis and rapid wilting of Bd3-1 plants after BJ strain ((BJ)TGB1(K390,T392)) inoculations, show that Bd3-1 Bsr1 resistance is elicited by the TGB1 protein and suggest that it involves a hypersensitive response.

Mental Health and Substance Use in NCAA Athletes in the Context of the COVID-19 Pandemic and Lockdown.

Background Although the coronavirus disease 2019 (COVID-19) pandemic had pervasive effects on the lives of individuals, its influence on the mental health of collegiate athletes remains unknown. This study aimed to assess changes in mental health and substance use in National Collegiate Athlete Association (NCAA) Division I athletes in Southern California during the COVID-19 pandemic. Methodology An online survey was created using the Qualtrics software (Qualtrics, Provo, Utah). NCAA Division I athletes in Southern California completed preseason surveys querying indices of mental health, substance use, and injury in the year before the COVID-19 pandemic (March 2019 to March 2020) and during the pandemic (March 2020 to March 2021). The athletes filled out the survey from June 2021 to September 2021. Participants were asked how likely they were to agree with the following statements: I have felt physically prepared for athletic competitions, I have been satisfied with my mental health, and I have had adequate sleep. Participants were also asked to compare their substance use between the two time periods. Sociodemographic information regarding participants' age, gender, sports team, as well as year in sport and school was also collected. Group comparison analyses were performed using Fisher's exact test. Correlations between mental health measures and other variables were examined using Spearman's correlation coefficients. Results A total of 189 athletes completed the survey (out of the 259 surveys that were started). Females were significantly less likely to feel satisfied with mental health (p < 0.01) and physically prepared for sport (p < 0.01). Across all respondents, satisfaction with mental health was positively correlated with adequate sleep (p < 0.01) and physical preparedness for sport (p < 0.01) and negatively correlated with injury (p < 0.05). There was no significant correlation between mental health status and history of COVID-19 infection (p = 0.84). The vast majority of athletes reported no significant change in substance use pre- to post-pandemic, with no differences according to sex. Conclusions The COVID-19 pandemic had a differential impact on the mental health of female versus male NCAA athletes. Mental health was correlated with sleep, physical preparedness, and being injury-free but not with a history of COVID-19 infection. Despite reports indicating increased substance use in the general population, athletes in this group reported no change in licit and illicit substance use.

Sensitivity and specificity of handheld fundus cameras for eye disease: A systematic review and pooled analysis.

In order to evaluate the accuracy of commercially available handheld fundus cameras for a variety of ophthalmic diagnoses, we conducted a systematic review, searching PubMed and PubMed Central and performing a bivariate analysis to determine the pooled sensitivity and specificity of handheld fundus cameras. Eleven studies validating handheld fundus cameras against a gold-standard method for disease diagnosis were included. For nonmydriatic images, pooled sensitivity was 83% (95% confidence interval (CI): 77-88%) and specificity was 92% (95% CI: 79-97%). For mydriatic images, pooled sensitivity was 87% (95% CI: 79-92%) and specificity was 90% (95% CI: 78-96%). Overall pooled sensitivity was 85% (95% CI: 80-89%) and specificity was 91% (95% CI: 83-95%). Of the 11 studies included, 5 assessed the diagnosis of diabetic retinopathy, for which sensitivity was 87% (95% CI: 80-92%) and specificity was 95% (95% CI: 85-98%). For all other diagnoses combined, sensitivity was 81% (95% CI: 74-87%) and specificity was 83% (95% CI: 76-89%). These findings suggest that handheld fundus cameras are capable of achieving acceptable sensitivity and specificity values for eye disease, with mydriatic images being more sensitive for disease. Diabetic retinopathy was the single diagnosis with the strongest data to support the use of handheld fundus cameras for disease screening.

The Role of Diagnostic Injections in Spinal Disorders: A Narrative Review.

Neck and back pain is increasingly prevalent, and has increased exponentially in recent years. As more resources are dedicated to the diagnosis of pain conditions, it is increasingly important that the diagnostic techniques used are as precise and accurate as possible. Traditional diagnostic methods rely heavily upon patient history and physical examination to determine the most appropriate treatments and/or imaging studies. Though traditional means of diagnosis remain a necessity, in many cases, correlation with positive or negative responses to injections may further enhance diagnostic specificity, and improve outcomes by preventing unnecessary treatments or surgeries. This narrative review aims to present the most recent literature describing the diagnostic validity of precision injections, as well as their impact on surgical planning and outcomes. Diagnostic injections are discussed in terms of facet arthropathy, lumbar radiculopathy, discogenic pain and discography, and sacroiliac joint dysfunction. There is a growing body of evidence supporting the use of diagnostic local anesthetic injections or nerve blocks to aid in diagnosis. Spinal injections add valuable objective information that can potentially improve diagnostic precision, guide treatment strategies, and aid in patient selection for invasive surgical interventions.

Impact of Socioeconomic Disadvantage and Diabetic Retinopathy Severity on Poor Ophthalmic Follow-Up in a Rural Vermont and New York Population.

OBJECTIVE: To investigate the impact of socioeconomic disadvantage and diabetic retinopathy severity on follow-up for vision care among people with diabetes mellitus (DM) residing in rural Vermont and northern New York State. METHODS: A retrospective chart review of people with DM who visited our academic eye clinic at least once between October 1, 2015, and March 31, 2016, was done. Of 1,466 unique patient visits, 500 were chosen for full chart review by simple random sampling. DM follow-up within 1 year was recommended for 331 adults. Data about prescribed and actual follow-up intervals were extracted. Regression models were used to identify factors associated with poor attendance at follow-up appointments. RESULTS: Sixty-eight [20.5%] patients had poor follow-up, defined as no ophthalmology visit within double the prescribed interval. Of these, 57 were not seen in follow-up by the end of study observation. Poor follow-up was greatest among socioeconomically disadvantaged patients, as defined by Medicaid enrollment (odds ratio [OR], 1.95; 95% CI, 1.07-3.56) in comparison to non-disadvantaged patients. Follow-up was better among those with moderate or worse diabetic retinopathy (OR, 0.38 95% CI, 0.20-0.70), and those with macular edema (OR, 0.19; 95% CI, 0.057-0.62). CONCLUSION: Medicaid insurance and better diabetic retinopathy status were associated with worse follow-up among our predominantly rural population of patients. Patients who did not follow-up within double the recommended interval were unlikely to follow-up at all. Interventions are needed to target those at highest risk for poor follow-up.

Optical coherence tomographic patterns of diabetic macular edema.

PURPOSE: To describe various morphologic patterns of diabetic macular edema (DME) demonstrated by optical coherence tomography (OCT) and correlate them with visual acuity. DESIGN: Retrospective, observational, case series. METHODS: A retrospective review of all patients with DME who underwent OCT evaluation and met the study inclusion criteria between May 1998 and December 2002 at the Cole Eye Institute was performed. The OCT scans were evaluated for the presence of diffuse retinal thickening (DRT), cystoid macular edema (CME), posterior hyaloidal traction (PHT), serous retinal detachment (SRD), and traction retinal detachment (TRD). Additionally, the retinal thickness was measured and visual acuity evaluated. RESULTS: Two hundred seventy-six OCT scans of 164 eyes of 119 patients were identified. OCT revealed five morphologic patterns of DME: DRT (269, 97%), CME (152, 55%), SRD without PHT (19, 7.0%), PHT without TRD (35, 12.7%), and PHT with TRD (8, 2.9%). Mean retinal thickness varied depending on the morphologic pattern. The mean visual acuities (Snellen equivalent) also varied between groups. Increasing retinal thickness in all patterns was significantly correlated with worse visual acuity (P < .005). The OCT patterns containing CME (P = .01) and PHT without TRD (P = .02) were also significantly associated with worse vision. CONCLUSIONS: DME exhibits at least five different morphologic patterns on OCT. There is a significant correlation between retinal thickness and visual acuity.

Health Considerations in Female Runners.

Female participation in running is at a historical high. Special consideration should be given to this population, in whom suboptimal nutritional intake, menstrual irregularity, and bone stress injury are common. Immature athletes should garner particular attention. Advances in the understanding of the Triad and Triad-related conditions have largely informed the approach to the health of this population. Clinicians should be well versed in the identification of Triad-related risk factors. A multidisciplinary team may be necessary for the optimal treatment of at-risk runners. Nonpharmacologic strategies to increase energy availability in athletes should be used as first-line treatment.

Appositional suprachoroidal hemorrhage: a case-control study.

PURPOSE: To identify the risk factors, prognostic factors, and clinical outcomes of patients with perioperative appositional suprachoroidal hemorrhage (ASCH). DESIGN: Case-control study. SETTING: Tertiary referral center. METHODS: Subjects included all patients with perioperative ASCH documented by B-scan ultrasound between May 1990 and March 2001. Two or three control patients were selected for each case, matched by surgeon, procedure, and date of surgery within 1 month. Surgery was performed as necessary. main outcome measures. The odds of ASCH associated with clinical risk factors. secondary outcome measure: visual acuity. RESULTS: Thirty-seven cases with ASCH were identified. Ninety-two procedure- and surgeon-matched control subjects (2.48:1) were selected. Twenty-six cases (71%) of ASCH were related to a glaucoma operation. Risk factors for the development of ASCH included previous vitrectomy (P = .003, odds ratio of 12) and older age (P = .007, odds ratio 1.57/decade of increasing age). Hypertension was found to be protective (P = .02, odds ratio of 0.33). Factors associated with a poor visual outcome in patients with ASCH included apposition >30 days (P = .01), history of uveitis (P = .04), history of dry age-related macular degeneration (P = .05), and history of extracapsular cataract extraction (P = .05). Median pre-ASCH visual acuity was 20/100, and final median visual acuity was 20/1600. CONCLUSIONS: Risk factors for the development of ASCH include previous vitrectomy and older age. Patients with these risk factors should be informed of their greater chance of poor visual acuity and anatomic outcomes secondary to the development of ASCH.

Invasion processes of pathogenic Escherichia coli.

Pathogenic Escherichia coli causes extraintestinal infections such as urinary tract infection and meningitis, which are prevalent and associated with considerable morbidity. Previous investigations have identified common strategies evolved by pathogenic E. coli to exploit host cell function and cause extraintestinal infections, which include the invasion into non-phagocytic eukaryotic cells such as epithelial and endothelial cells and associated host cell actin cytoskeletal rearrangements. However, the mechanisms involved in pathogenic E. coli invasion of eukaryotic cells are shown to differ depending upon types of host tissues and microbial determinants. In this mini-review, invasion processes of pathogenic E. coli are discussed using E. coli K1 invasion of human brain microvascular endothelial cells (HBMEC) as a paradigm. E. coli K1 is the most common Gram-negative organism causing neonatal meningitis, and E. coli invasion of HBMEC is shown to be a prerequisite for E. coli traversal of the blood-brain barrier in vivo. Previous studies have demonstrated that E. coli translocation of the blood-brain barrier is the result of specific E. coli host interactions including specific signal transduction pathways and modulation of endocytic pathways. Recent studies using functional genomics have identified additional microbial determinants contributing to E. coli K1 invasion of HBMEC. Complete understanding of microbial-host interactions that are involved in E. coli K1 invasion of HBMEC should help in the development of new strategies to prevent E. coli meningitis.