Search

ObjectivesTo explore the acceptability of home visual field (VF) testing using Eyecatcher among people with glaucoma participating in a 6-month home monitoring pilot study.DesignQualitative study using face-to-face semistructured interviews. Transcripts were analysed using thematic analysis.SettingParticipants were recruited in the UK through an advertisement in the International Glaucoma Association (now Glaucoma UK) newsletter.ParticipantsTwenty adults (10 women; median age: 71 years) with a diagnosis of glaucoma were recruited (including open angle and normal tension glaucoma; mean deviation=2.5 to −29.9 dB).ResultsAll participants could successfully perform VF testing at home. Interview data were coded into four overarching themes regarding experiences of undertaking VF home monitoring and attitudes towards its wider implementation in healthcare: (1) comparisons between Eyecatcher and Humphrey Field Analyser (HFA); (2) capability using Eyecatcher; (3) practicalities for effective wider scale implementation; (4) motivations for home monitoring.ConclusionsParticipants identified a broad range of benefits to VF home monitoring and discussed areas for service improvement. Eyecatcher was compared positively with conventional VF testing using HFA. Home monitoring may be acceptable to at least a subset of people with glaucoma.

Optical coherence tomography (OCT) and OCT angiography (OCTA) enable noninvasive structural and angiographic imaging of the eye. Portable handheld OCT/OCTA systems are required for imaging patients in the supine position. Examples include infants in the neonatal intensive care unit (NICU) and operating room (OR). The speed of image acquisition plays a pivotal role in acquiring high-quality OCT/OCTA images, particularly with the handheld system, since both the operator hand tremor and subject motion can cause significant motion artifacts. In addition, having a large field of view and the ability of real-time data visualization are critical elements in rapid disease screening, reducing imaging time, and detecting peripheral retinal pathologies. The arrangement of optical components is less flexible in the handheld system due to the limitation of size and weight. In this paper, we introduce a 400-kHz, 55-degree field of view handheld OCT/OCTA system that has overcome many technical challenges as a portable OCT system as well as a high-speed OCTA system. We demonstrate imaging premature infants with retinopathy of prematurity (ROP) in the NICU, a patient with incontinentia pigmenti (IP), and a patient with X-linked retinoschisis (XLRS) in the OR using our handheld OCT system. Our design may have the potential for improving the diagnosis of retinal diseases and help provide a practical guideline for designing a flexible and portable OCT system.

Web-based educational resources are available for providers managing patients with retinopathy of prematurity (ROP). These tools include web-based tutorials and training modules, integrated software tools, online toolkits with standardized patient education, consents, and reference materials.

BackgroundAnimal-assisted intervention (AAI) programs, used widely for patient benefit, have increasingly been used for healthcare workers (HCW) to reduce occupational stress. However, there are barriers to these programs which limit their utilization, for both patients and HCW, specifically infectious disease concerns. The aim of the research project is to identify barriers and facilitators to AAI program use for healthcare worker benefit, and determine knowledge, beliefs, and practices regarding infectious disease risk and control policies, in order to understand the contextual parameters of program implementation.MethodsWe collected perceptions of key stakeholders involved with hospital AAI programs (HCW and AAI workers) through semi-structured in-depth interviews. We used framework analysis to guide thematic coding, completed independently by three researchers.ResultsWe interviewed 37 participants. We divided our themes into two topic areas: program use for HCW and perceived infectious disease risk. Use for healthcare workers included perspectives on the benefits for HCW and program barriers and facilitators (specifically collaboration and leadership). Perceived risk included opinions on infection concerns with AAI, thoughts on control measures to reduce this risk, and responsibility for safety during these programs.ConclusionsWhile significant benefits were reported for HCW, they were limited by administrative barriers and hazard concerns. Facilitators to surmount these barriers are best implemented with collaboration across the hospital and appropriate leadership roles to direct safe program implementation. By addressing these barriers through targeted facilitators in the form of evidence-backed guidelines, AAI programs can be used to benefit both patients and HCW.

Purpose\ud In the UK, most referrals to the hospital eye service (HES) originate from community optometrists (CO). This audit investigates the quality of referrals, replies, and communication between CO and the HES.\ud \ud Methods\ud Optometric referrals and replies were extracted from three practices in England. If no reply letter was found, the records were searched at each local HES unit, and additional replies or records copied. De‐identified referrals, replies and records were audited by a panel against established standards to evaluate whether the referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated.\ud \ud Results\ud A total of 459 de‐identified referrals were extracted. The RR ranged from 3.6%–8.7%. The proportion of referred patients who were seen in the HES unit was 63%–76%. From the CO perspective, the proportion of referrals for which they received replies ranged from 26%–49%. Adjusting the number of referrals for cases when it would be reasonable to expect an HES reply, RRR becomes 38%–62%. Patients received a copy of the reply in 3%–21% of cases. Referrals were made to the appropriate service in over 95% of cases, were judged necessary in 93%–97% and were accurate in 81%–98% of cases. The referral reply addressed the reason for the referral in 93%–97% and was meaningful in 94%–99% of cases. The most common conditions referred were glaucoma, cataract, anterior segment lesions, and neurological/ocular motor anomalies. The CO/HES dyad (pairing) in the area with the lowest average household income had the highest RR.\ud \ud Conclusions\ud In contrast with the Royal College of Ophthalmologists/College of Optometrists joint statement on sharing patient information, CO referrals often do not elicit a reply to the referring CO. Replies from the HES to COs are important for patient care, benefitting patients and clinicians, and minimising unnecessary HES appointments.

The research explored the educational and broader social impacts of COVID-19 control measures and efforts to compensate for those measures in the education sector (e.g. by online teaching) in Somalia/Somaliland. It did so through 131 interviews and four focus group discussions with forty government educational officials, educators and the public with a wide range of educational experiences, including no education ever. Positive views of the general availability and quality of education were based on comparisons with the past period of civil war and state collapse. Nearly all participants agreed that education had been harmed severely by COVID-19 control measures. They also tended to agree the educational inequalities that disadvantaged girls, the poor and rural populations had been exacerbated by COVID-19 control measures and by education provision to compensate for educational institution closures. Building back better in education as a response to COVID-19 is not happening when looked at overall, as even the positive efforts, while laudable in themselves, are exacerbating inequalities. The findings were similar for both locations. The research highlights the need and potential support for a more inclusive approach to responding to COVID-19 in the education sector.

Purpose To survey pediatric ophthalmologists on their perspectives of artificial intelligence (AI) in ophthalmology. Methods This is a subgroup analysis of a study previously reported. In March 2019, members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) were recruited via the online AAPOS discussion board to voluntarily complete a Web-based survey consisting of 15 items. Survey items assessed the extent participants “agreed” or “disagreed” with statements on the perceived benefits and concerns of AI in ophthalmology. Responses were analyzed using descriptive statistics. Results A total of 80 pediatric ophthalmologists who are members of AAPOS completed the survey. The mean number of years since graduating residency was 21 years (range, 0-46). Overall, 91% (73/80) reported understanding the concept of AI, 70% (56/80) believed AI will improve the practice of ophthalmology, 68% (54/80) reported willingness to incorporate AI into their clinical practice, 65% (52/80) did not believe AI will replace physicians, and 71% (57/80) believed AI should be incorporated into medical school and residency curricula. However, 15% (12/80) were concerned that AI will replace physicians, 26% (21/80) believed AI will harm the patient-physician relationship, and 46% (37/80) reported concern over the diagnostic accuracy of AI. Conclusions Most pediatric ophthalmologists in this survey viewed the role of AI in ophthalmology positively.

In the UK there are five meteor camera networks using four different camera and software systems that are aiming to recover meteorites. Utilising all observations of a fireball event from each network is crucial to constrain a precise orbit and fall position. However, the various camera systems generate a diversity of data outputs that are not compatible with each other. As a result, when a potentially meteorite-dropping fireball event occurs it is currently challenging to exchange calibrated observations between networks, which creates obstacles to response time and rapid meteorite recovery. If recorded by at least two observatories, the fireball’s trajectory, pre-arrival orbit, final mass, and (in combination with a ‘dark flight’ model) the final fall position of any surviving meteorite can also be calculated. For this, the minimum useful data set from each camera consists of (a) the location of the observatory, and (b) a set of timed direction vectors representing each point at which the meteor was observed. While the inclusion of additional data are recommended, this is the minimum required dataset for a fireball observation from a single camera, that can be exchanged between cooperating fireball networks to provide for accurate triangulation. Camera systems currently used in the UK or considered as candidates for adoption as a data exchange standard are: UFOAnalyzer. Used by UK Meteor Observation Network and the NEMETODE network, UFOAnalyzer’s “A.XML” file contains the essential and recommended data in XML format. UFOAnalyzer is widely used by amateurs in the UK, Western Europe, and Japan. Raspberry Meteor System (RMS, or Global Meteor Network). Increasingly deployed in the UK. Observations are recorded in two files, the “CAL” file containing all essential metadata, and the “FTPDetect” file containing data for all meteors observed in any given night. Desert Fireball Network (DFN), UK Fireball Network, Global Fireball Observatory – generates a single file with all essential and recommended data, written in Astropy ECSV table format. FRIPON, SCAMP - produces a file in Pixmet or SExtractor format, but lacking metadata, which needs to be added from a separate list of observatory parameters. Cameras for Allsky Meteor Surveillance (CAMS) – similar to RMS. Used in Benelux countries, which have occasional observational overlap with the UK Virtual Meteor Observatory (VMO)1 – an XML single-meteor format used by some German and Polish networks and by the European Space Agency (ESA). Not yet used in the UK. Three existing fireball data formats (UFOAnalyzer, VMO and DFN) are identified and evaluated as candidates for information exchange between networks. Each is adequate, though the UFOAnalyzer A.XML format would need to be generalised to be unambiguous. Each can be read with standard Python library routines. Currently it would appear that the DFN format is the easiest to write using standard library routines and the easiest to represent internally as a data structure. We are working towards a recommendation for the standard format for fireball data exchange. Agreeing a common data format enables data sharing but does not require it. Whilst the minimum dataset described above can be utilised effectively, additional information to refine the accuracy of the measurement is also highly desirable and should be included. This recommended data set includes additional information regarding the observing system and uncertainties and additional observations of the event observed at each point in time and will be discussed in detail at the meeting. We have also developed and present a new converter script that can convert UFOAnalyzer and Desert Fireball Network files to any agreed standard format. Based on a Jupyter notebook kindly provided by Hadrien Devillepoix of the Desert Fireball Network in Australia, the converter was further developed by SCAMP and is now being developed jointly by the authors. Whilst it is feasible to produce a converter for a single static format such as UFOAnalyzer’s “A.XML”, it is not practicable to write and maintain a reliable converter program for the multiplicity of file formats that exist now or may exist in the future. As such this converter program represents a stopgap while a global fireball data exchange standard is established. Conclusion and Recommendation Meteorite recovery is inhibited in countries where multiple incompatible fireball camera systems are used. Adopting a common file format that could be read by each system would greatly assist in the observation and recovery of new meteorite falls with orbits. Pending further consultation, our draft recommendation is adoption of the DFN data format as a global standard for fireball data exchange. References 1 Ceplecha, Z. (1987) Geometric, Dynamic, Orbital and Photometric Data on Meteoroids From Photographic Fireball Networks. Bulletin of the Astronomical Institutes of Czechoslovakia 38, 222. 2 Devillepoix, H. A. R., Cupák, M., Bland, P. A., Sansom, E. K., Towner, M. C., Howie, R. M., ... & Benedix, G. K. (2020). A Global Fireball Observatory. arXiv preprint arXiv:2004.01069. 3 Sansom, E. K., Rutten, M. G., Bland, P. A. (2017). Analyzing Meteoroid Flights Using Particle Filters. The Astronomical Journal 153, 87-96. 4 SonotaCo (2009). “A meteor shower catalog based on video observations in 2007-2008”. WGN, Journal of the International Meteor Organization, 37, 55–62. 5 Vida, D., Mazur, M. J., Segon, D., Zubovic, D., Kukic, P., Parag, F., & Macon, A. (2018). First results of a Raspberry Pi based meteor camera system. WGN, the Journal of the International Meteor Organisation 46(2), 71-78. 6 Bertin, E., Arnouts, S. (1996.) SExtractor: Software for source extraction. Astronomy and Astrophysics Supplement Series 117, 393-404. 7 Jenniskens, P., Gural, P. S., Dynneson, L., Grigsby, B. J., Newman, K. E., Borden, M., Koop, M., Holman, D. (2011). CAMS: Cameras for Allsky Meteor Surveillance to establish minor meteor showers. Icarus 216(1), 40-61. 8 Barentsen, G., Arlt, R., Koschny, D., … & Zoladek, P. (2010). The VMO file format. I. Reduced camera meteor and orbit data. WGN, the Journal of the International Meteor Organisation 38(1), 10-24.

Cancers can vary greatly in their transcriptomes. In contrast to alterations in specific genes or pathways, the significance of differences in tumor cell total mRNA content is poorly understood. Studies using single-cell sequencing or model systems have suggested a role for total mRNA content in regulating cellular phenotypes. However, analytical challenges related to technical artifacts and cellular admixture have impeded examination of total mRNA expression at scale across cancers. To address this, we evaluated total mRNA expression using single cell sequencing, and developed a computational method for quantifying tumor-specific total mRNA expression (TmS) from bulk sequencing data. We systematically estimated TmS in 5,181 patients across 15 cancer types and observed close correlations with clinicopathologic characteristics and molecular features, where high TmS generally accompanies high-risk disease. At a pan-cancer level, high TmS is associated with increased risk of disease progression and death. Moreover, TmS captures tumor type-specific effects of somatic mutations, chromosomal instability, and hypoxia, as well as aspects of intratumor heterogeneity. Taken together, our results suggest that measuring total mRNA expression offers a broader perspective of tracking cancer transcriptomes, which has important clinical and biological implications.

PURPOSE: The presence of stage is an important feature to identify in retinal images of infants at risk for retinopathy of prematurity (ROP). The purpose of this study was to implement a convolutional neural network (CNN) for binary detection of stage 1–3 in ROP and evaluate its generalizability across different populations and camera systems. DESIGN: Diagnostic validation study of CNN for stage detection. SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: Retinal fundus images obtained from preterm infants during routine ROP screenings. METHODS: Two datasets were used: 6247 fundus images taken by a RetCam camera from nine North American institutions, and 4647 images taken by a Forus 3nethra camera from four hospitals in Nepal. Images were labeled based on the presence of stage by 1–3 expert graders. Three CNN models were trained using 5-fold cross-validation on datasets from North America alone, Nepal alone, and a combined dataset and evaluated on two held-out test sets consisting of 708 and 247 images from the Nepali and North American datasets respectively. MAIN OUTCOME MEASURES: CNN performance was evaluated using area under the receiver operating curve (AUROC) and precision-recall curve (AUPRC), sensitivity, and specificity. RESULTS: Both the North American- and Nepali-trained models demonstrated high performance on a test set from the same population: (AUROC/AUPRC) 0.99/0.98 with sensitivity of 94%, and 0.97/0.91 with sensitivity of 73%, respectively. However, the performance of each model decreased to 0.96/0.88 (sensitivity 52%) and 0.62/0.36 (sensitivity 44%) when evaluated on a test set from the other population. Compared to the models trained on individual datasets, the model trained on a combined dataset achieved improved performance on each respective test set: sensitivity improved from 94% to 98% on the North American test set, and from 73% to 82% on the Nepali test set. CONCLUSIONS: A CNN can accurately identify the presence of ROP stage in retinal images, but performance depends on the similarity between training and testing populations. We demonstrate that internal and external performance can be improved by increasing the heterogeneity of the training dataset features of the training dataset, in this case by combining images from different populations and cameras. PRECIS: The performance and generalizability of deep learning algorithms for detection of stage in retinopathy of prematurity can be improved by training on images from multiple populations and camera systems.

BACKGROUND AND OBJECTIVE: To identify factors associated with successful treatment discontinuation in eyes with retinal vein occlusions (RVOs) and macular edema (ME) in real-world settings. PATIENTS AND METHODS: Retrospective study of 214 eyes with RVO and ME with 24-month follow-up at five academic centers. Regression analyses identified factors associated with (1) successful treatment discontinuation for at least 6 months without fluid recurrence and (2) best-corrected visual acuity (BCVA) at 24 months. RESULTS: Forty percent of eyes with branch RVO and 35% with central RVO (CRVO) / hemi-retinal RVO (HRVO) successfully discontinued therapy without fluid recurrence, with median time to discontinuation of 6 and 7 months, respectively. Lower 6-month central subfield thickness was associated with greater likelihood of treatment discontinuation within 24 months for eyes with CRVO/HRVO ( P = .001), whereas better 6-month BCVA was associated with better 24-month BCVA for all RVO subtypes ( P < .001). CONCLUSION: Early anatomic response at 6 months is associated with greater likelihood of stopping treatments. [ Ophthalmic Surg Lasers Imaging Retina . 2021;52:84–92.]

Purpose:\ud \ud While there are numerous studies comparing open-view autorefractors to subjective refraction or other open-view autorefractors, most studies between closed and open-view autorefraction tend to focus on children rather than young adults. The aim of this study was to determine the concordance in non-cycloplegic refractive error between two modern objective autorefractors: the closed-view monocular Topcon TRK-2P and the binocular open-view Grand Seiko WR-5500.\ud \ud Methods:\ud \ud Fifty young adults aged 20–29 years (mean age 22 ± 1.6 years) underwent non-cycloplegic autorefraction using the Grand Seiko WAM-5500 (open view) and Topcon TRK-2P (closed-view) autorefractors on both eyes. Findings were expressed as the isolated spherical component and were also converted from clinical to vector notation: Mean Spherical Error (MSE) and the astigmatic components J0 and J45.\ud \ud Results:\ud \ud Mean MSE ± SD was −1.00 ± 2.40D for the Grand Seiko WAM-5500 compared to −1.23 ± 2.29D for the Topcon TRK-2P. Up to seventy-six percent of the cohort had mean spherical errors from the Topcon TRK-2P which fell within ±0.50D of the Grand Seiko reading and 58% fell within ±0.25D. Mean differences between the two instruments were statistically significant for all components (J0, spherical, and MSE) (p 0.05).\ud \ud Conclusions:\ud \ud The differences in non-cycloplegic MSE between these two instruments are small, but statistically significant. From a clinical perspective the Topcon TRK-2P may serve as a useful starting point for subjective refraction, but additional work is needed to help further minimise differences between the instruments.

Artificial intelligence (AI), or the use of automated systems that display the ability to correctly interpret, to learn from, and to achieve specific goals by use of external data, is an emerging technology that has myriad implications for changing the way we interact with the world. Although this technology is already being used in many fields such as banking, retail, and education, AI has the potential to transform other fields including healthcare. Within healthcare, ophthalmology is uniquely positioned to benefit from AI not only through clinical decision support technology but also through improved image processing innovations such as real-time segmentation, automated image quality improvements, and assisted or autonomous disease screening tools.1,2 Although there are now Food and Drug Administration–approved technologies within ophthalmology, such as IDx-DR (Coralville, IA, USA) for early diagnosis of diabetic retinopathy and diabetic macular edema, numerous challenges still exist to realize the potentially transformative impact of these technologies in day to day practice. The need for the ophthalmology community to take a thoughtful approach to AI innovation and implementation is accentuated by the high stakes involved. The impact of misleading patients and clinicians on a health condition is much greater than a retail store misinterpreting the next book you may like to buy. As a result, we need to increase discussion about the issues surrounding who, what, when, how, and why we might use AI in practice, including ethical and liability considerations, to determine how best to implement AI for all stakeholders including practitioners, patients, practices/hospitals, and industry. This article aims to highlight the challenges and barriers to real-world AI adoption that impact the technology's utility. We examine these specific challenges that will face health care organizations, providers, and patients.

Purpose: To explore the feasibility of using various easy-to-obtain biomarkers to monitor non-compliance (measurement error) during visual field assessments.Methods: Forty-two healthy adults (42 eyes) and seven glaucoma patients (14 eyes) underwent two same-day visual field assessments. An ordinary webcam was used to compute seven potential biomarkers of task compliance, based primarily on eye gaze, head pose, and facial expression. We quantified the association between each biomarker and measurement error, as defined by (1) test-retest differences in overall test scores (mean sensitivity), and (2) failures to respond to visible stimuli on individual trials (stimuli -3 dB or more brighter than threshold).Results: In healthy eyes, three of the seven biomarkers were significantly associated with overall (test-retest) measurement error (P = 0.003-0.007), and at least two others exhibited possible trends (P = 0.052-0.060). The weighted linear sum of all seven biomarkers was associated with overall measurement error, in both healthy eyes (r = 0.51, P Conclusions: Inexpensive, autonomous measures of task compliance are associated with measurement error in visual field assessments, in terms of both the overall reliability of a test and failures to respond on particular trials ("lapses"). This could be helpful for identifying low-quality assessments and for improving assessment techniques (e.g., by discounting suspect responses or by automatically triggering comfort breaks or encouragement).Translational Relevance: This study explores a potential way of improving the reliability of visual field assessments, a crucial but notoriously unreliable clinical measure.

Background Although microscopic positive margins appear to have no independent prognostic impact in papillary thyroid cancer (PTC), this may not be the case in pT4a tumors. Methods Retrospective analysis of 610 patients with PTC, 39 with pT4a tumors, to determine if microscopic positive margins impact disease-free survival (DFS) in pT4a PTC. Results On univariate analysis, microscopic positive margins were not associated with reduced DFS in patients with no extrathyroidal extension (ETE) (hazard ratio [HR], 1.7; P = 0.32), microscopic ETE (HR, 1.6; P = 0.36), or macroscopic ETE limited to strap muscles (HR, 1.2; P = 0.87). In contrast, microscopic positive margins were associated with reduced DFS in T4a disease (HR, 4.1; P = 0.04). Disease recurrence was nodal, distant, or biochemical, and did not occur directly at the site of positive margins. Conclusion Although microscopic positive margins do not influence DFS in the majority of patients with PTC, they are associated with a fourfold increased risk of recurrence in pT4a disease.

Purpose To evaluate the clinical usefulness of a quantitative deep learning-derived vascular severity score for retinopathy of prematurity (ROP) by assessing its correlation with clinical ROP diagnosis and by measuring clinician agreement in applying a novel scale. Design Analysis of existing database of posterior pole fundus images and corresponding ophthalmoscopic examinations using 2 methods of assigning a quantitative scale to vascular severity. Participants Images were from clinical examinations of patients in the Imaging and Informatics in ROP Consortium. Four ophthalmologists and 1 study coordinator evaluated vascular severity on a scale from 1 to 9. Methods A quantitative vascular severity score (1–9) was applied to each image using a deep learning algorithm. A database of 499 images was developed for assessment of interobserver agreement. Main Outcome Measures Distribution of deep learning-derived vascular severity scores with the clinical assessment of zone (I, II, or III), stage (0, 1, 2, or 3), and extent (6 clock hours) of stage 3 evaluated using multivariate linear regression and weighted κ values and Pearson correlation coefficients for interobserver agreement on a 1-to-9 vascular severity scale. Results For deep learning analysis, a total of 6344 clinical examinations were analyzed. A higher deep learning-derived vascular severity score was associated with more posterior disease, higher disease stage, and higher extent of stage 3 disease (P < 0.001 for all). For a given ROP stage, the vascular severity score was higher in zone I than zones II or III (P < 0.001). Multivariate regression found zone, stage, and extent all were associated independently with the severity score (P < 0.001 for all). For interobserver agreement, the mean ± standard deviation weighted κ value was 0.67 ± 0.06, and the Pearson correlation coefficient ± standard deviation was 0.88 ± 0.04 on the use of a 1-to-9 vascular severity scale. Conclusions A vascular severity scale for ROP seems feasible for clinical adoption; corresponds with zone, stage, extent of stage 3, and plus disease; and facilitates the use of objective technology such as deep learning to improve the consistency of ROP diagnosis.

Purpose To assess accuracy and adherence of visual field (VF) home-monitoring in a pilot sample of glaucoma patients. Design Prospective longitudinal feasibility and reliability study. Methods Twenty adults (median 71 years) with an established diagnosis of glaucoma were issued a tablet-perimeter (Eyecatcher), and were asked to perform one VF home-assessment per eye, per month, for 6 months (12 tests total). Before and after home-monitoring, two VF assessments were performed in-clinic using Standard Automated Perimetry (SAP; 4 tests total, per eye). Results All 20 participants could perform monthly home-monitoring, though one participant stopped after 4 months (Adherence: 98%). There was good concordance between VFs measured at home and in the clinic (r = 0.94, P < 0.001). In 21 of 236 tests (9%) Mean Deviation deviated by more than ±3 dB from the median. Many of these anomalous tests could be identified by applying machine learning techniques to recordings from the tablets’ front-facing camera (Area Under the ROC Curve = 0.78). Adding home-monitoring data to 2 SAP tests made 6 months apart reduced measurement error (between-test measurement variability) in 97% of eyes, with mean absolute error more than halving in 90% of eyes. Median test duration was 4.5 mins (Quartiles: 3.9 – 5.2 mins). Substantial variations in ambient illumination had no observable effect on VF measurements (r = 0.07, P = 0.320). Conclusions Home-monitoring of VFs is viable for some patients, and may provide clinically useful data., Highlights • Twenty glaucoma patients performed visual field assessments at home for 6 months • The data were in good agreement with conventional measurements made in clinic • Home monitoring may be viable and useful for some patients • Practical concerns and future directions for home monitoring are also discussed

IMPORTANCE: Evaluating corneal morphologic characteristics with corneal tomographic scans before refractive surgery is necessary to exclude patients with at-risk corneas and keratoconus. In previous studies, researchers performed screening with machine learning methods based on specific corneal parameters. To date, a deep learning algorithm has not been used in combination with corneal tomographic scans. OBJECTIVE: To examine the use of a deep learning model in the screening of candidates for refractive surgery. DESIGN, SETTING, AND PARTICIPANTS: A diagnostic, cross-sectional study was conducted at the Zhongshan Ophthalmic Center, Guangzhou, China, with examination dates extending from July 18, 2016, to March 29, 2019. The investigation was performed from July 2, 2018, to June 28, 2019. Participants included 1385 patients; 6465 corneal tomographic images were used to generate the artificial intelligence (AI) model. The Pentacam HR system was used for data collection. INTERVENTIONS: The deidentified images were analyzed by ophthalmologists and the AI model. MAIN OUTCOMES AND MEASURES: The performance of the AI classification system. RESULTS: A classification system centered on the AI model Pentacam InceptionResNetV2 Screening System (PIRSS) was developed for screening potential candidates for refractive surgery. The model achieved an overall detection accuracy of 94.7% (95% CI, 93.3%-95.8%) on the validation data set. Moreover, on the independent test data set, the PIRSS model achieved an overall detection accuracy of 95% (95% CI, 88.8%-97.8%), which was comparable with that of senior ophthalmologists who are refractive surgeons (92.8%; 95% CI, 91.2%-94.4%) (P = .72). In distinguishing corneas with contraindications for refractive surgery, the PIRSS model performed better than the classifiers (95% vs 81%; P

Background: Retinopathy of prematurity (ROP) is a disease of the retinal vasculature that remains a leading cause of childhood blindness worldwide despite improvements in the systemic care of premature newborns. Screening for ROP is effective and cost-effective, but in many areas, access to skilled examiners to conduct dilated examinations is poor. Remote screening with retinal photography is an alternative strategy that may allow for improved ROP care. Methods: The current literature was reviewed to find clinical trials and expert consensus documents on the state-of-the-art of telemedicine for ROP. Results: Several studies have confirmed the utility of telemedicine for ROP. In addition, several clinical studies have reported favorable long-term results. Many investigators have reinforced the need for detailed protocols on image acquisition and image interpretation. Conclusions: Telemedicine for ROP appears to be a viable alternative to live ophthalmoscopic examinations in many circumstances. Standardization and documentation afforded by telemedicine may provide additional benefits to providers and their patients. With continued improvements in image quality and affordability of imaging systems as well as improved automated image interpretation tools anticipated in the near future, telemedicine for ROP is expected to play an expanding role for a uniquely vulnerable patient population.

1592 Background: The past decade has seen a dramatic increase in the number of oral anti-cancer drug (OACD) approvals in the United States. Though polypharmacy and drug-drug interactions (DDIs) likely contribute to OACD toxicity, the prevalence of these features in patients on OACDs remains largely unknown. We aimed to evaluate a one-time 30-minute pharmacist-led video consultation among metastatic cancer patients initiating OACDs to identify medication list inaccuracies as well as the prevalence, characteristics, and severity of OACD-related potential DDIs. Methods: We conducted a single-arm, prospective telehealth intervention study among 29 patients initiating OACDs to evaluate a one-time 30-minute pharmacist-led video consultation. The video visits focused on identifying and discussing polypharmacy and potential DDIs, and pharmacists then communicated recommendations to each patient's oncologist. We estimated the prevalence, characteristics (QTc prolongation, absorption interactions, etc.), and severity of OACD-related potential DDIs. Lexicomp and Micromedex were used to assess potential DDIs and measure severity on a standardized scale (A – D, X). In addition, we assessed the prevalence of medication list inaccuracies, polypharmacy, and patient satisfaction. Results: Twenty-five patients completed the intervention (86% completion rate) of whom 40% were 75 years of age or older and 60% were men. The majority were white (68%) and non-Hispanic (76%). Sixteen patients (68%) had a solid tumor diagnosis. Nearly half (48%) were insured by Medicare. The median number of medications per patient was 9 with a range of 4 – 21, and 96% of patients had at least 5 prescriptions listed. The median number of medication list errors was 2 with a range of 0 – 16, with at least 1 error for 76% and more than 1 error for 52% of patients. Pharmacists identified potential OACD-related interactions in 9 cases (40%). These included change in drug absorption or metabolism (7), QTc prolongation (1), hypotension (1), and bleeding (1). Interactions were classified as either category C (8) or D (2), requiring close monitoring or a change in treatment, respectively. All patients expressed a high level of satisfaction with the video visit. Conclusions: Polypharmacy, medication list errors, and potential DDIs are prevalent among patients initiating OACDs despite use of an electronic medical record requiring medication reconciliation. Our study suggests that a one-time remote 30-minute pharmacist-led video consultation can effectively identify and address OACD-related potential DDIs, which may decrease medication complexity and improve adherence in this population.

FMS-like tyrosine kinase 3 (FLT3) is a receptor tyrosine kinase that is responsible for the proliferation and survival of hematopoietic stem cells in acute myeloid leukemia. Although patients with FLT3 mutations have similar rates of remission following induction chemotherapy, relapse rates are significantly higher and patients with FLT3 mutations have significantly worse outcomes for overall survival and disease-free survival. Early FLT3 inhibitors, such as sorafenib, were non-selective and inhibited several tyrosine kinase receptors resulting in significant toxicity. The treatment of FLT3-positive acute myeloid leukemia has advanced recently with the development of a several FLT3-targeting agents that are either approved or in development. Midostaurin represents the first FDA-approved treatment targeted against FLT3, and there are several promising agents currently undergoing clinical trials. Although certain mutations confer resistance to earlier generation FLT3-targeted tyrosine kinase inhibitors, newer agents show activity in the presence of these mutations.

Topic Retinopathy of prematurity (ROP) is a proliferative retinal vascular disease in premature infants and is a major cause of childhood blindness worldwide. In addition to known clinical risk factors such as low birth weight and gestational age, there is a growing body of evidence supporting a genetic basis for ROP. Clinical Relevance Although comorbidities and environmental factors—most notably gestational age and oxygen—have been identified as contributing to ROP outcomes in premature infants, some infants progress to severe disease despite absence of these clinical risk factors. The contribution of genetic factors may explain these differences and allow better detection and treatment of infants at risk for severe ROP. Methods To comprehensively review genetic factors that potentially contribute to the development and severity of ROP, we conducted a literature search focusing on the genetic basis for ROP. Terms related to other heritable retinal vascular diseases such as “familial exudative vitreoretinopathy,” as well as to genes implicated in animal models of ROP, were also used to capture research in diseases with similar pathogenesis to ROP in humans with known genetic components. Results Contributions across several genetic domains are described, including vascular endothelial growth factor, the Wnt signaling pathway, insulin-like growth factor 1, inflammatory mediators, and brain-derived neurotrophic factor. Conclusions Most candidate gene studies of ROP have limitations such as inability to replicate results, conflicting results from various studies, small sample size, and differences in clinical characterization. Additional difficulty arises in separating the contribution of genetic factors such as Wnt signaling to ROP and prematurity. Although studies have implicated involvement of multiple signaling pathways in ROP, the genetics of ROP have not been clearly elucidated. Next-generation sequencing and genome-wide association studies have potential to expand future understanding of underlying genetic risk factors and pathophysiology of ROP.

This study examines school principals’ insights into effective instructional leadership. It follows the implementation by the New South Wales Department of Education, Australia, of a state-wide str...

Background Shoulder dislocations are common injuries among athletes. Patients with instability after their injury often require stabilization procedures for treatment. The primary outcome measure was to see whether there was any correlation between the side of traumatic shoulder dislocation and dominance of hand. Secondary outcomes were to look at subgroups of age and sporting discipline. Materials and methods This study recruited all patients with a frank dislocation that required arthroscopic surgical stabilization who attended the same private orthopedic surgeon. Exclusion criteria included injury without frank dislocation, nonsport-related injuries, and ambidexterity. Data were collected for 325 of 365 patients (89.0% response rate) Results There were 278 right hand-dominant patients (85.5%), with 136 (48.9%) requiring arthroscopic stabilization of their dominant side for dislocation. Of the remaining 47 left hand-dominant patients, 17 (36.2%) required operations on their dominant arm. In total, 153 patients (47.1%) dislocated their dominant shoulder and 172 (52.9%) dislocated their nondominant shoulder, with an odds ratio of 1.692 (95% confidence interval, 0.893-3.205). Conclusions This study suggests that there is no statistical significance between the side of shoulder dislocation and hand dominance of patients with shoulder dislocation. Future research could investigate further the causal relationship between hand dominance and mechanisms of injury.

BACKGROUND The prognostic significance of microscopic positive margins in papillary thyroid carcinoma (PTC) remains unclear. The aim of this study was to determine if microscopic positive margins are associated with increased risk of disease recurrence. METHODS This is a retrospective analysis of 610 patients with PTC using multivariate Cox regression to evaluate the association between microscopic positive margins and disease-free survival. RESULTS Microscopic positive margins were found in 67 (11%) patients and associated with extrathyroidal extension (P

Background The American Joint Committee on Cancer (AJCC) removed microscopic extrathyroidal extension (ETE) from the 8th edition T staging for papillary thyroid cancer (PTC) based on increasing evidence that it is not an independent prognostic factor. Objectives We compared the prognostic performance of AJCC 7th (pT7) and 8th (pT8) edition T stage systems, particularly in patients ≥55 years old without macroscopic ETE or distant metastases in whom T classification affects AJCC Tumor Node Metastasis (TNM) stage. Method A retrospective analysis of disease-free survival (DFS) in 577 patients with PTC comparing pT8 vs pT7 using the Akaike information criterion (AIC), Harrell’s C-index, and Proportion of Variation Explained (PVE). Results Of 105 patients with AJCC7 T3 disease, 74 were down-staged. Overall, the prognostic performance of pT7 and pT8 was similar. However, in patients ≥55 years old without macroscopic ETE or distant metastases, pT8 was inferior to pT7 on the basis of higher AIC, lower C-index (0.67 vs 0.76), and lower PVE (30% vs 45%). In this subset, microscopic ETE was associated with multiple other adverse prognostic features and reduced DFS (hazard ratio, 2.8; 95% confidence interval, 1.5 to 5.2; P = 0.002), irrespective of tumor size. Discussion In our cohort, pT8 was inferior to pT7 in patients ≥55 years old without macroscopic ETE or distant metastases in whom T classification affects TNM stage. Microscopic ETE was strongly associated with other adverse prognostic factors and reduced DFS in this patient subgroup and may be an effective surrogate for disease biology in PTC, irrespective of whether it is an independent prognostic factor.

Recently, there have been calls for the United States to unleash the offensive power of cyber space. Advocates contend that offense has the advantage in cyberspace. This article argues that cyberspace does not favor the offensive at either the tactical or the strategic level. In fact, a defensive doctrine has clear advantages over an offensive one. Support for this argument can be found in two unexpected sources: official statements of U.S. Army doctrine and Carl von Clausewitz's On War. This is surprising, given that scholars consider both the U.S. Army and Clausewitz diehard apostles of the cult of the offensive. This essay seeks to import their insights about the advantages of the defense into the virtual realm. When read carefully, U.S. Army doctrine and Clausewitz's classic text support the claim that defense is the stronger approach in the cyber realm.

Bashing V.S. Naipaul’s travel books on India, the Caribbean, the Islamic World and Africa has produced a massive body of writing since the 1980s. Focusing on his perceived racism and Islamophobia, this literature seeks to thoroughly discredit Naipaul as a reliable chronicler of the lives of the victims of Western imperialism. Condemned, indeed, as an apologist for Western imperialism, Naipaul’s admitted brilliance as a writer of fiction has been dulled by these accusations. There is much truth in these critiques, but they are based on arguments that range from the accurate to the problematic to the quite simply wrong. Too many attacks on Naipaul’s work come from writers who have a limited knowledge of the body of his work or who misconstrue the knowledge they do have. Stepping back from the assault on Naipaul reveals important reasons to re-examine and rethink the meanings of his work and the lives it chronicles.

Summary: A review of Crassula zombensis (Crassulaceae), a hardly known species documented only by few collections from Zomba Plateau (Malawi) and the Serra de Gurue (Mozambique), is provided, describing its history, specimens, localities and habitats. On Zomba Plateau, C. zombensis may grow as an epiphyte on Xerophyta kirkii (Velloziaceae); further species (succulents, orchids, herbs) known to occur epiphytically on Xerophyta spp. in Malawi are listed. The IUCN Red List Conservation Status is assessed as Near Threatened (NT).

Summary: Three species of succulents are recorded as new for the flora of Mt. Mulanje, the highest mountain in south-tropical Africa in the Southern Region of Malawi: The unidentified “Sansevieria sp.” in the “Checklist of the Spermatophytes of Mount Mulanje” (Strugnell 2006) is identified as Sansevieria sinus-simiorum (Asparagaceae / Dracaenaceae), as well as Crassula swaziensis and Crassula setulosa (Crassulaceeae) which were already collected on Mt. Mulanje in 1946 and 1979 but the specimens escaped attention until now. Two collections from the Nyika Plateau in the Northern Region of Malawi similar to but clearly different from Crassula setulosa are reported which might represent a new taxon.

PURPOSE: To evaluate a tele-education system developed to improve diagnostic competency in retinopathy of prematurity (ROP) by ophthalmologists-in-training in Mexico. DESIGN: Prospective, randomized cohort study. PARTICIPANTS: Fifty-eight ophthalmology residents and fellows from a training program in Mexico consented to participate. Twenty-nine of 58 trainees (50%) were randomized to the educational intervention (pretest, ROP tutorial, ROP educational chapters, and posttest), and 29 of 58 trainees (50%) were randomized to a control group (pretest and posttest only). METHODS: A secure web-based educational system was created using clinical cases (20 pretest, 20 posttest, and 25 training chapter-based) developed from a repository of over 2500 unique image sets of ROP. For each image set used, a reference standard ROP diagnosis was established by combining the clinical diagnosis by indirect ophthalmoscope examination and image-based diagnosis by multiple experts. Trainees were presented with image-based clinical cases of ROP during a pretest, posttest, and training chapters. MAIN OUTCOME MEASURES: The accuracy of ROP diagnosis (e.g., plus disease, zone, stage, category) was determined using sensitivity and specificity calculations from the pretest and posttest results of the educational intervention group versus control group. The unweighted kappa statistic was used to analyze the intragrader agreement for ROP diagnosis by the ophthalmologists-in-training during the pretest and posttest for both groups. RESULTS: Trainees completing the tele-education system had statistically significant improvements (P < 0.01) in the accuracy of ROP diagnosis for plus disease, zone, stage, category, and aggressive posterior ROP (AP-ROP). Compared with the control group, trainees who completed the ROP tele-education system performed better on the posttest for accurately diagnosing plus disease (67% vs. 48%; P = 0.04) and the presence of ROP (96% vs. 91%; P < 0.01). The specificity for diagnosing AP-ROP (94% vs. 78%; P < 0.01), type 2 ROP or worse (92% vs. 84%; P = 0.04), and ROP requiring treatment (89% vs. 79%; P < 0.01) was better for the trainees completing the tele-education system compared with the control group. Intragrader agreement improved for identification of plus disease, zone, stage, and category of ROP after completion of the educational intervention. CONCLUSIONS: A tele-education system for ROP education was effective in improving the diagnostic accuracy of ROP by ophthalmologists-in-training in Mexico. This system has the potential to increase competency in ROP diagnosis and management for ophthalmologists-in-training from middle-income nations.

Purpose:To describe a series of retinal arterial occlusions in healthy children.Methods:Chart review from multiple US and international institutions.Results:Five episodes affecting otherwise health...