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This Paper focuses on multi-criteria decision making techniques (MCDMs), especially analytical networking process (ANP) algorithm to design a model in order to minimize the task scheduling cost during implementation using a queuing model in a cloud environment and also deals with minimization of the waiting time of the task. The simulated results of the algorithm give better outcomes as compared to other existing algorithms by 15 percent.

Purpose: For structure-function research at the transition of aging to age-related macular degeneration, we refined the current consensus optical coherence tomography (OCT) nomenclature and evaluated a novel review software for investigational high-resolution OCT imaging (HR-OCT; <3 µm axial resolution)., Method: Volume electron microscopy, immunolocalizations, histology, and investigational devices informed a refined OCT nomenclature for a custom ImageJ-based review tool to assess retinal band visibility. We examined effects on retinal band visibility of automated real-time averaging (ART) 9 and 100 (11 eyes of 10 healthy young adults), aging (10 young vs 22 healthy aged), and age-related macular degeneration (AMD; 22 healthy aged, 17 early (e)AMD, 15 intermediate (i)AMD). Intrareader reliability was assessed., Results: Bands not included in consensus nomenclature are now visible using HR-OCT: inner plexiform layer (IPL) 1-5, outer plexiform layer (OPL) 1-2, outer segment interdigitation zone 1-2 (OSIZ, including hyporeflective outer segments), and retinal pigment epithelium (RPE) 1-5. Cohen's kappa was 0.54-0.88 for inner and 0.67-0.83 for outer retinal bands in a subset of 10 eyes. IPL-3-5 and OPL-2 visibility benefitted from increased ART. OSIZ-2 and RPE-1,2,3,5 visibility was worse in aged eyes than in young eyes. OSIZ-1-2, RPE-1, and RPE-5 visibility decreased in eAMD and iAMD compared to healthy aged eyes., Conclusions: We reliably identified 28 retinal bands using a novel review tool for HR-OCT. Image averaging improved inner retinal band visibility. Aging and AMD development impacted outer retinal band visibility., Translational Significance: Detailed knowledge of anatomic structures visible on OCT will enhance precision in research, including AI training and structure-function analyses.

Background: Improvements in movement quality (ie, how well an individual moves) facilitate increases in movement quantity, subsequently improving general health and quality of life. Wearable technology offers a convenient, affordable means of measuring and assessing movement quality for the general population, while technology more broadly can provide constructive feedback through various modalities. Considering the perspectives of professionals involved in the development and implementation of technology helps translate user needs into effective strategies for the optimal application of consumer technologies to enhance movement quality., Objective: This study aimed to obtain the opinions of wearable technology experts regarding the use of wearable devices to measure movement quality and provide feedback. A secondary objective was to determine potential strategies for integrating preferred assessment and feedback characteristics into a technology-based movement quality intervention for the general, recreationally active population., Methods: Semistructured interviews were conducted with 12 participants (age: mean 42, SD 9 years; 5 males) between August and September 2022 using a predetermined interview schedule. Participants were categorized based on their professional roles: commercial (n=4) and research and development (R&D; n=8). All participants had experience in the development or application of wearable technology for sports, exercise, and wellness. The verbatim interview transcripts were analyzed using reflexive thematic analysis in QSR NVivo (release 1.7), resulting in the identification of overarching themes and subthemes., Results: Three main themes were generated as follows: (1) "Grab and Go," (2) "Adjust and Adapt," and (3) "Visualize and Feedback." Participants emphasized the importance of convenience to enhance user engagement when using wearables to collect movement data. However, it was suggested that users would tolerate minor inconveniences if the benefits were perceived as valuable. Simple, easily interpretable feedback was recommended to accommodate diverse audiences and aid understanding of their movement quality, while avoiding excessive detail was advised to prevent overload, which could deter users. Adaptability was endorsed to accommodate progressions in user movement quality, and customizable systems were advocated to offer variety, thereby increasing user interest and engagement. The findings indicate that visual feedback representative of the user (ie, an avatar) should be used, supplemented with concise text or audible instructions to form a comprehensive, multimodal feedback system., Conclusions: The study provides insights from wearable technology experts on the use of consumer technologies for enhancing movement quality. The findings recommend the prioritization of user convenience and simplistic, multimodal feedback centered around visualizations, and an adaptable system suitable for a diverse audience. Emphasizing individualized feedback and user-centric design, this study provides valuable findings around the use of wearables and other consumer technologies to enhance movement quality among the general population. These findings, in conjunction with those of future research into user perspectives, should be applied in practical settings to evaluate their effectiveness in enhancing movement quality., (©T Alexander Swain, Melitta A McNarry, Kelly A Mackintosh. Originally published in JMIR Formative Research (https://formative.jmir.org), 13.09.2024.)

Prcis: Diagnosis of glaucoma through telemedicine demonstrates moderate agreement with in-person ophthalmologist (MD) and in-person optometrist (OD) diagnosis, providing evidence that telemedicine is a timely, accurate screening method in settings where an in-person visit may not be feasible., Objective: To compare diagnostic agreement of glaucoma between in-person MD, in-person OD, and a simulated telemedicine program., Patients and Methods: A cross-sectional study of patients with normal optic nerve structural and functional imaging and new patients referred for glaucoma evaluation examined in-person by an MD for glaucoma with a dilated examination and structural and functional optic nerve testing (optical coherence tomography, photos, and visual field); examined in person by an OD with a dilated examination and optic nerve testing; and structural and functional optic nerve testing reviewed separately by 2 ophthalmologists [telemedicine ophthalmologist reviewer 1 (TMD1), telemedicine ophthalmologist reviewer 2 (TMD2)] with masking of prior MD and OD diagnoses. Interrater agreement between each diagnostic method (MD, OD, TMD1, and TMD2) of normal versus disease (open angle glaucoma, normal tension glaucoma, other types of glaucoma, other optic nerve disorders, ocular hypertension, and glaucoma suspect) for each eye was calculated (Cohen unweighted kappa)., Results: A total of 100 patients with a median age of 66 years (interquartile range: 59-72), male (40%) and white (62%) were analyzed. There was moderate agreement between MD and telemedicine [TMD1 kappa 0.49 (95% CI: 0.37-0.61), TMD2 kappa 0.44 (95% CI: 0.32-0.56)] and between MD and OD diagnosis [0.41 (95% CI: 0.28-0.54)] and fair-moderate agreement between OD and telemedicine [TMD1: 0.46 (95% CI: 0.34-0.58), TMD2: 0.61 (95% CI: 0.50-0.72)]., Conclusions: The simulated telemedicine approach had comparable levels of agreement in glaucoma diagnosis with in-person fellowship-trained ophthalmologists, presenting a crucial complementary role in screening and increasing access to care, particularly in rural or underserved settings., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: In AMD, rod-mediated dark adaptation (RMDA) at 5° eccentricity is slower in eyes with subretinal drusenoid deposits (SDDs) than in eyes without. Here we quantified SDD burden using supervised deep learning for comparison to vision and photoreceptor topography., Methods: In persons ≥60 years from the Alabama Study on Early Age-Related Macular Degeneration 2, normal, early AMD, and intermediate AMD eyes were classified by the AREDS nine-step system. A convolutional neural network was trained on 55°-wide near-infrared reflectance images for SDD segmentation. Trained graders annotated ground truth (SDD yes/no). Predicted and true datasets agreed (Dice coefficient, 0.92). Inference was manually proofread using optical coherence tomography. The mean SDD area (mm2) was compared among diagnostic groups (linear regression) and to vision (age-adjusted Spearman correlations). Fundus autofluorescence images were used to mask large vessels in SDD maps., Results: In 428 eyes of 428 persons (normal, 218; early AMD, 120; intermediate AMD, 90), the mean SDD area differed by AMD severity (P < 0.0001): 0.16 ± 0.87 (normal), 2.48 ± 11.23 (early AMD), 11.97 ± 13.33 (intermediate AMD). Greater SDD area was associated with worse RMDA (r = 0.27; P < 0.0001), mesopic (r = -0.13; P = 0.02) and scotopic sensitivity (r = -0.17; P < 0.001). SDD topography peaked at 5° superior, extended beyond the Early Treatment of Diabetic Retinopathy Study grid and optic nerve, then decreased., Conclusions: SDD area is associated with degraded rod-mediated vision. RMDA 5° (superior retina) probes where SDD is maximal, closer to the foveal center than the rod peak at 3 to 6 mm (10.4°-20.8°) superior and the further eccentric peak of rod:cone ratio. Topographic data imply that factors in addition to rod density influence SDD formation.

Purpose: The vulnerability of rod photoreceptors in aging and early and intermediate age-related macular degeneration (AMD) has been well documented. Rod-mediated dark adaptation (RMDA) is a measure of the recovery of light sensitivity in rod photoreceptors following a bright light. Delays in RMDA during early and intermediate AMD have been widely reported. For RMDA's promise as an outcome for trials targeted at early and intermediate AMD to be realized, excellent test-retest reliability, its repeatability, must be established., Methods: Test-retest performance in a commonly used RMDA test based on the rod intercept time metric (RIT) was evaluated in participants with early and intermediate AMD and with normal retinal aging with testing approximately 2 weeks apart. The test target was placed at 5° eccentricity superior to the foveal center, an area with maximal rod loss in aging and AMD. Disease severity was identified by a trained and masked grader of fundus photographs using both the AREDS 9-step and Beckman classification systems. Bland-Altman plots and intra-class correlation coefficients (ICC) evaluated repeatability., Results: The analysis sample consisted of 37 older adults (mean age 76 years, standard deviation 5), with approximately one-third of the sample in each of three groups - normal aging, early AMD, and intermediate AMD. For the total sample, the ICC was 0.98. For individual AMD groups for both AREDS 9-step and Beckman classifications, the ICCs were also very high ranging from 0.82 to 0.99., Conclusion: We demonstrated that RMDA testing using the RIT metric has excellent repeatability when target location is at 5° in studying older adults from normal aging to intermediate AMD, suggesting the reliable use of this functional measure in trials.

Purpose: In aging and early-intermediate age-related macular degeneration (AMD), rod-mediated dark adaptation (RMDA) slows more at 5° superior than at 12°. Using optical coherence tomography angiography (OCTA), we asked whether choriocapillaris flow deficits are related to distance from the fovea., Methods: Persons ≥60 years stratified for AMD via the Age-Related Eye Disease Study's nine-step system underwent RMDA testing. Two adjacent 4.4° × 4.4° choriocapillaris OCTA slabs were centered on the fovea and 12° superior. Flow signal deficits (FD%) in concentric arcs (outer radii in mm, 0.5, 1.5, 2.2, 4.0, and 5.0 superior) were correlated with rod intercept time (RIT) and best-corrected visual acuity (BCVA)., Results: In 366 eyes (170 normal, 111 early AMD, 85 intermediate AMD), FD% was significantly worse with greater AMD severity in all regions (overall P < 0.05) and poorest under the fovea (P < 0.0001). In pairwise comparisons, FD% worsened with greater AMD severity (P < 0.05) at distances <2.2 mm. At greater distances, eyes with intermediate, but not early AMD differed from normal eyes. Foveal FD% was more strongly associated with longer RIT at 5° (r = 0.52) than RIT at 12° (r = 0.39) and BCVA (r = 0.21; all P < 0.0001). Choroidal thickness was weakly associated with longer RIT at 5° and 12° (r = 0.10-0.20, P < 0.05) and not associated with AMD severity., Conclusions: Reduced transport across the choriocapillaris-Bruch's membrane-retinal pigment epithelium complex, which contributes to drusen formation under the macula lutea (and fovea), may also reduce retinoid resupply to rods encircling the high-risk area. FD% has potential as a functionally validated imaging biomarker for AMD emergence.

Introduction: Federally Qualified Health Centers (FQHCs) play a crucial role as safety-net primary health care clinics in the United States, serving medically underserved areas and populations. However, eye services are rarely offered at FQHCs. We examined how telemedicine-generated ocular diagnoses impacted vision-targeted health-related quality of life at FQHCs in rural Alabama. Methods: We focused on patients who are at risk for glaucoma. Both visual function and retinal imaging were assessed. The telemedicine vision screening protocol performed by a remote ophthalmologist evaluated eyes for glaucoma, diabetic retinopathy, cataract, age-related macular degeneration, and a measurement of habitual visual acuity. The National Eye Institute Visual Function Questionnaire-9 (VFQ-9) was administered. Results: Using stepwise regression, the best-fitting model for predicting VFQ-9 scores incorporated visual acuity 20/40 or worse, a diabetic retinopathy diagnosis, and sociodemographic variables (gender, transportation, insurance type/status, and employment status). Conclusion: Vision-targeted, health-related quality of life in our FQHC settings was related to the visual acuity impairment and the diagnosis of diabetic retinopathy but was also influenced by a variety of sociodemographic factors.

Purpose: Research on Alzheimer's disease (AD) and precursor states demonstrates a thinner retinal nerve fiber layer (NFL) compared to age-similar controls. Because AD and age-related macular degeneration (AMD) both impact older adults and share risk factors, we asked if retinal layer thicknesses, including NFL, are associated with cognition in AMD., Methods: Adults ≥ 70 years with normal retinal aging, early AMD, or intermediate AMD per Age-Related Eye Disease Study (AREDS) nine-step grading of color fundus photography were enrolled in a cross-sectional study. Optical coherence tomography (OCT) volumes underwent 11-line segmentation and adjustments by a trained operator. Evaluated thicknesses reflect the vertical organization of retinal neurons and two vascular watersheds: NFL, ganglion cell layer-inner plexiform layer complex (GCL-IPL), inner retina, outer retina (including retinal pigment epithelium-Bruch's membrane), and total retina. Thicknesses were area weighted to achieve mean thickness across the 6-mm-diameter Early Treatment of Diabetic Retinopathy Study (ETDRS) grid. Cognitive status was assessed by the National Institutes of Health Toolbox cognitive battery for fluid and crystallized cognition. Correlations estimated associations between cognition and thicknesses, adjusting for age., Results: Based on 63 subjects (21 per group), thinning of the outer retina was significantly correlated with lower cognition scores (P < 0.05). No other retinal thickness variables were associated with cognition., Conclusions: Only the outer retina (photoreceptors, supporting glia, retinal pigment epithelium, Bruch's membrane) is associated with cognition in aging to intermediate AMD; NFL was not associated with cognition, contrary to AD-associated condition reports. Early and intermediate AMD constitute a retinal disease whose earliest, primary impact is in the outer retina. Our findings hint at a unique impact on the brain from the outer retina in persons with AMD.

Introduction: The aims of the study were to describe baseline quantitative (short-wavelength) autofluorescence (qAF) findings in a large pseudophakic cohort at age-related macular degeneration (AMD)'s beginnings and to assess qAF8 as an outcome measure and evaluate Age-Related Eye Disease Study (AREDS) and Beckman grading systems., Methods: In the ALSTAR2 baseline cohort (NCT04112667), 346 pseudophakic eyes of 188 persons (74.0 ± 5.5 years) were classified as normal (N = 160 by AREDS, 158 by Beckman), early AMD (eAMD) (N = 104, 66), and intermediate AMD (iAMD) (N = 82, 122). Groups were compared via mean qAF intensities in a 6°-8° annulus (qAF8) and maps of differences between observations and the overall mean, divided by standard deviation (Z-score)., Results: qAF8 did not differ significantly among diagnostic groups by either stratification (p = 0.0869 AREDS; p = 0.0569 by Beckman). Notably, 45 eyes considered eAMD by AREDS became iAMD by Beckman. For AREDS-stratified eyes, Z-score maps showed higher centrally located qAF for normal, near the mean in eAMD, and lower values for iAMD. Maps deviated from this pattern for Beckman-stratified eyes., Conclusions: In a large sample of pseudophakic eyes, qAF8 does not differ overall from normal aging to iAMD but also does not capture the earliest AMD activity in the macula lutea. AREDS classification gives results more consistent with a slow decline in histologic autofluorescence than Beckman classification., (© 2024 S. Karger AG, Basel.)

Purpose: Lack of valid end points impedes developing therapeutic strategies for early age-related macular degeneration (AMD). Delayed rod-mediated dark adaptation (RMDA) is the first functional biomarker for incident early AMD. The relationship between RMDA and the status of outer retinal bands on optical coherence tomography (OCT) have not been well defined. This study aims to characterize these relationships in early and intermediate AMD., Methods: Baseline data from 476 participants was assessed including eyes with early AMD (n = 138), intermediate AMD (n = 101), and normal aging (n = 237). Participants underwent volume OCT imaging of the macula and rod intercept time (RIT) was measured. The ellipsoid zone (EZ) and interdigitation zone (IZ) on all OCT B-scans of the volumes were segmented. The area of detectable EZ and IZ, and mean thickness of IZ within the Early Treatment Diabetic Retinopathy Study (ETDRS) grid were computed and associations with RIT were assessed by Spearman's correlation coefficient and age adjusted., Results: Delayed RMDA (longer RIT) was most strongly associated with less preserved IZ area (r = -0.591; P < 0.001), followed by decreased IZ thickness (r = -0.434; P < 0.001), and EZ area (r = -0.334; P < 0.001). This correlation between RIT and IZ integrity was not apparent when considering normal eyes alone within 1.5 mm of the fovea., Conclusions: RMDA is correlated with the status of outer retinal bands in early and intermediate AMD eyes, particularly, the status of the IZ. This correlation is consistent with a previous analysis of only foveal B-scans and is biologically plausible given that retinoid availability, involving transfer at the interface attributed to the IZ, is rate-limiting for RMDA.

Competing Interests: Declaration of interest The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Purpose: To describe baseline results of the Alabama Screening and Intervention for Glaucoma and Eye Health through Telemedicine (AL-SIGHT) for patients at federally qualified health centers (FQHCs). Candidates were persons at risk for glaucoma-associated diseases (GAD) based on age, race/ethnicity, current diagnosis of GAD, family history, and diabetes., Design: Baseline screening visit followed by remote diagnosis and referral for follow-up examinations., Methods: Patients presenting to FQHCs who were at least 18 years of age were enrolled and underwent screening for acuity, autorefraction, intraocular pressure, visual field testing, and fundus imaging. Results were transmitted to an ophthalmologist at University of Alabama at Birmingham for diagnosis who made referrals for follow-up; follow-up attendance was noted. Questionnaires assessed participants' perspectives on screening. Primary outcomes were rates of disease detection, referral for follow-up, follow-up attendance, and participant satisfaction., Results: Of the 500 participants enrolled (mean age 58 years), 45.6% were African American and 51.6% White. Remote diagnostic evaluation of ocular screening by ophthalmologist revealed 30% GAD, 6.8% diabetic retinopathy, 37.6% cataract, 68.4% refractive error, 9.2% other eye conditions. In all, 47.2% of the participants were referred for follow-up examination and for acuity 20/40 or worse or IOP ≥23 mm Hg in one or both eyes. Follow-up examination attendance was 76.7% for those referred. Participants reported being very satisfied with screening (85.8%) and with the convenience of screening in their primary care clinic (92.2%)., Conclusions: The high percentage of patients diagnosed with treatable eye conditions at telemedicine screening suggest these programs in FQHCs can be effective and scalable nationwide. Attendance when referred for follow-up examination was high. Participants welcomed screenings in their communities., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Photoreceptor (PR) outer segments, retinal pigment epithelium apical processes, and inter-PR matrix contribute to the interdigitation zone (IZ) of optical coherence tomography (OCT). We hypothesize that this interface degrades over adulthood, in concert with a delay of rod mediated dark adaptation (RMDA). To explore this idea, we determined IZ discernibility and RMDA in younger and older adults., Methods: For this cross-sectional study, eyes of 20 young (20-30 years) and 40 older (≥60 years) participants with normal maculas according to the AREDS 9-step grading system underwent OCT imaging and RMDA testing at 5° superior to the fovea. Custom FIJI plugins enabled analysis for IZ discernibility at 9 eccentricities in 0.5 mm steps on one single horizontal B-scan through the fovea. Locations with discernible IZ met two criteria: visibility on B-scans and a distinct peak on a longitudinal reflectivity profile. The frequency of sites meeting both criteria was compared between both age groups and correlated with rod intercept time (RIT)., Results: The median number of locations with discernible IZ was significantly higher (foveal, 4 vs. 0, p  = 0.0099; extra-foveal 6 vs. 0, p  < 0.001) in eyes of young (26 ± 3 years) compared to older (73 ± 5 years) participants. For the combined young and older sample, the higher frequency of discernible IZ was correlated with shorter RIT (faster dark adaptation) ( r s  = -0.56, p  < 0.0001). This association was significant within young eyes ( r s  = -0.54; p  = 0.0134) and not within older eyes ( r s  = -0.29, p  = 0.706)., Conclusions: Results suggest that the interface between outer segments and apical processes degrades in normal aging, potentially contributing to delayed rod-mediated dark adaptation. More research is needed to verify an age-related association between IZ discernibility and rod-mediated dark adaptation. If confirmed in a large sample, IZ discernibility might prove to be a valuable biomarker and predictor for visual function in aging.

Purpose: Progress toward treatment and prevention of age-related macular degeneration (AMD) requires imaging end points that relate to vision. We investigated choriocapillaris flow signal deficits (FD%) and visual function in eyes of individuals aged ≥60 years, with and without AMD., Methods: One eye of each participant in the baseline visit of the Alabama Study on Early Age-Related Macular Degeneration 2 (ALSTAR2; NCT04112667) was studied. AMD presence and severity was determined using the Age-Related Eye Disease Study (AREDS) grading system. FD% was quantified using macular spectral domain optical coherence tomography angiography (OCTA) scans. Vision tests included rod-mediated dark adaptation (RMDA), best-corrected visual acuity, and contrast sensitivity (photopic and mesopic), and microperimetric light sensitivity (scotopic, mesopic, and photopic). Presence of subretinal drusenoid deposits (SDD) was determined using multimodal imaging., Results: In 410 study eyes of 410 participants (mean [SD] age = 71.7 years [5.9]), FD% was higher in early AMD (mean [SD] = 54.0% [5.5], N = 122) and intermediate AMD (59.8% [7.4], N = 92), compared to normal (52.1% [5.3], N = 196) eyes. Among visual functions evaluated, RMDA showed the strongest association with FD% (r = 0.35, P < 0.0001), followed by contrast sensitivity (r = -0.22, P < 0.0001). Eyes with SDD had worse FD% (58.3% [7.4], N = 87), compared to eyes without SDD (53.4% [6.0], N = 323, P = < 0.0001)., Conclusions: Choriocapillaris FD% were associated with AMD severity and with impaired vision, especially RMDA. Reduced metabolic transport and exchange across the choriocapillaris-Bruch's membrane retinal pigment epithelium (RPE) complex, a causal factor for high-risk soft drusen formation, also may impair photoreceptor sustenance from the circulation. This includes retinoid resupply, essential to dynamic rod function.

Purpose: Studies on age-related macular degeneration often use rod-mediated dark adaptation (RMDA) to evaluate macular functional health, studying eyes with cataract and pseudophakic eyes within the same sample. We examine a poorly understood issue-whether rod intercept time (RIT), a measure of RMDA, changes after cataract surgery and intraocular lens (IOL) insertion as compared to RIT before cataract surgery. Cataract may serve as a filter reducing photo-bleach magnitude prior to surgery, biasing RMDA interpretation., Methods: A pre-/post-cataract surgery design was used. Persons with nuclear sclerotic and/or cortical cataract per the electronic health record were enrolled. Prior to cataract surgery, visual acuity, RMDA, and the LOCS III classification documenting cataract presence/severity were measured. Thirty days after surgery (mean), visual acuity and RMDA were repeated, followed by fundus photos to document macular health., Results: Twenty-four participants (mean age 72.7 years, standard deviation 5.6) enrolled. All eyes had nuclear sclerotic and nuclear color cataract; 68% had cortical cataract. All IOLs were monofocal with 21 having blue blocking characteristics and 3 had clear IOLs. Most eyes had higher RIT post-surgery (15.6 min, SD 6.7) as compared to pre-surgery (13.7 min, SD 6.4), p  = 0.0006, meaning that RMDA was slower post-surgery. Eyes with moderate cataract (<4 on any LOCS III grade) had RIT that increased on average by 0.7 min; those with more advanced cataract (≥4) had RIT that increased by 3.1 min ( p  = 0.0116). Results were unchanged when clear IOLs were removed from analysis., Conclusion: RMDA was significantly slower (RIT was greater) following cataract surgery, with the greatest impact on RIT in older eyes after surgery for more advanced cataract. These findings suggest that persons with more advanced cataract may bias results when evaluating RMDA using RIT.

Background: Older drivers are a rapidly growing demographic group worldwide; many have visual processing impairments. Little is known about their preferences about vehicle instrument cluster design., Methods: We evaluated the psychometric properties of a questionnaire on "dashboard" design for a population-based sample of 1000 older drivers. Topics included gauges, knobs/switches, and interior lighting; items were statements about their visual design. Response options used a Likert-scale ("Definitely True" to "Definitely False"). Factor and Rasch analyses identified underlying subscales., Results: Driver responses revealed four thematic subscales fitting the Rasch model: cognitive processing, lighting, pattern recognition, and obstructions. Internal consistency of subscales was acceptable (0.70-0.87); all possessed a sufficiently unidimensional structure. Opportunities for improvement were identified (item scope, category ordering, discrimination of respondents' perception levels)., Conclusions: Assessment of motor vehicle dashboard preferences indicated cognitive processing, lighting, pattern recognition, and obstructions are areas relevant to older drivers. Future work will examine the relationship between older drivers' visual function (e.g., contrast sensitivity, visual processing speed) and their design preferences as revealed by the Dashboard Questionnaire, with the aim to optimize instrument cluster displays for older drivers., Competing Interests: Competing interests: The authors declare that they have no competing interests.

Purpose: We evaluate the impact of test target location in assessing rod-mediated dark adaptation (RMDA) along the transition from normal aging to intermediate age-related macular degeneration (AMD). We consider whether RMDA slows because the test locations are near mechanisms leading to or resulting from high-risk extracellular deposits. Soft drusen cluster under the fovea and extend to the inner ring of the ETDRS grid where rods are sparse. Subretinal drusenoid deposits (SDDs) appear first in the outer superior subfield of the ETDRS grid where rod photoreceptors are maximal and spread toward the fovea without covering it., Design: Cross-sectional., Participants: Adults ≥ 60 years with normal older maculas, early AMD, or intermediate AMD as defined by the Age-Related Eye Disease Study (AREDS) 9-step and Beckman grading systems., Methods: In 1 eye per participant, RMDA was assessed at 5° and at 12° in the superior retina. Subretinal drusenoid deposit presence was identified with multi-modal imaging., Main Outcome Measures: Rod intercept time (RIT) as a measure of RMDA rate at 5° and 12°., Results: In 438 eyes of 438 persons, RIT was significantly longer (i.e., RMDA is slower) at 5° than at 12° for each AMD severity group. Differences among groups were bigger at 5° than at 12°. At 5°, SDD presence was associated with longer RIT as compared to SDD absence at early and intermediate AMD but not in normal eyes. At 12°, SDD presence was associated with longer RIT in intermediate AMD only, and not in normal or early AMD eyes. Findings were similar in eyes stratified by AREDS 9-step and Beckman systems., Conclusions: We probed RMDA in relation to current models of deposit-driven AMD progression organized around photoreceptor topography. In eyes with SDD, slowed RMDA occurs at 5° where these deposits typically do not appear until later in AMD. Even in eyes lacking detectable SDD, RMDA at 5° is slower than at 12°. The effect at 5° may be attributed to mechanisms associated with the accumulation of soft drusen and precursors under the macula lutea throughout adulthood. These data will facilitate the design of efficient clinical trials for interventions that aim to delay AMD progression., (© 2023 Published by Elsevier Inc. on behalf of American Academy of Ophthalmology.)

Purpose: Quantification of retinal xanthophyll carotenoids in eyes with and without age-related macular degeneration (AMD) via macular pigment optical volume (MPOV), a metric for xanthophyll abundance from dual wavelength autofluorescence, plus correlations to plasma levels, could clarify the role of lutein (L) and zeaxanthin (Z) in health, AMD progression, and supplementation strategies., Design: Cross-sectional observational study (NCT04112667)., Participants: Adults ≥ 60 years from a comprehensive ophthalmology clinic, with healthy maculas or maculas meeting fundus criteria for early or intermediate AMD., Methods: Macular health and supplement use was assessed by the Age-related Eye Disease Study (AREDS) 9-step scale and self-report, respectively. Macular pigment optical volume was measured from dual wavelength autofluorescence emissions (Spectralis, Heidelberg Engineering). Non-fasting blood draws were assayed for L and Z using high-performance liquid chromatography. Associations among plasma xanthophylls and MPOV were assessed adjusting for age., Main Outcome Measures: Age-related macular degeneration presence and severity, MPOV in fovea-centered regions of radius 2.0° and 9.0°; plasma L and Z (μM/ml)., Results: Of 809 eyes from 434 persons (89% aged 60-79, 61% female), 53.3% eyes were normal, 28.2% early AMD, and 18.5% intermediate AMD. Macular pigment optical volume 2° and 9° were similar in phakic and pseudophakic eyes, which were combined for analysis. Macular pigment optical volume 2° and 9° and plasma L and Z were higher in early AMD than normal and higher still in intermediate AMD ( P  < 0.0001). For all participants, higher plasma L was correlated with higher MPOV 2° (Spearman correlation coefficient [R s ] = 0.49; P < 0.0001). These correlations were significant ( P  < 0.0001) but lower in normal (R s  = 0.37) than early and intermediate AMD (R s  = 0.52 and 0.51, respectively). Results were similar for MPOV 9°. Plasma Z, MPOV 2°, and MPOV 9° followed this same pattern of associations. Associations were not affected by supplement use or smoking status., Conclusions: A moderate positive correlation of MPOV with plasma L and Z comports with regulated xanthophyll bioavailability and a hypothesized role for xanthophyll transfer in soft drusen biology. An assumption that xanthophylls are low in AMD retina underlies supplementation strategies to reduce progression risk, which our data do not support. Whether higher xanthophyll levels in AMD are due to supplement use cannot be determined in this study., (© 2022 Published by Elsevier Inc. on behalf of American Academy of Ophthalmology.)

Purpose: The purpose of this study was to investigate quantitative autofluorescence (qAF8) in patients with and without early or intermediate age-related macular degeneration (AMD); to determine the impact of the aged crystalline lens and posterior capsular opacification (PCO)., Methods: In phakic and pseudophakic eyes ≥60 years, AMD status was determined by the Beckman system. PCO presence and severity was extracted from clinical records. qAF8 was calculated using custom FIJI plugins. Differences in qAF8, stratified by lens status, PCO severity, and AMD status, were analyzed using generalized estimating equations., Results: In 210 eyes of 115 individuals (mean age = 75.7 ± 6.6 years), qAF8 was lower in intermediate AMD compared to early AMD (P = 0.05). qAF8 did not differ between phakic and pseudophakic eyes (P = 0.8909). In phakic (n = 83) and pseudophakic (n = 127) eyes considered separately, qAF8 did not differ by AMD status (P = 0.0936 and 0.3494, respectively). Qualitative review of qAF images in phakic eyes illustrated high variability. In pseudophakic eyes, qAF8 did not differ with PCO present versus absent (54.5% vs. 45.5%). Review of implanted intraocular lenses (IOLs) revealed that 43.9% were blue-filter IOLs., Conclusions: qAF8 was not associated with AMD status, up to intermediate AMD, considering only pseudophakic eyes to avoid noisy images in phakic eyes. In pseudophakic eyes, qAF8 was not affected by PCO. Because blue-filter IOLs may reduce levels of exciting light for qAF8, future studies investigating qAF in eyes with different IOL types are needed., Translational Relevance: To reduce variability in observational studies and clinical trials requiring qAF8, pseudophakic participants without blue-filter IOLs or advanced PCO should be preferentially enrolled.

Purpose: Proper understanding and interaction with the dashboard is an essential aspect of safely operating a motor vehicle. A portion of this task is dependent on vision, yet no published information exists regarding dashboard ergonomics and visual function. This study sought to associate visual functions and person abilities of dashboard ergonomic dimensions relevant to older driver design preferences and attitudes., Methods: In this population-based study of drivers, participants completed functional testing for habitual distance visual acuity, contrast sensitivity, visual field sensitivity, visual processing speed, and spatial ability. A questionnaire assessed attitudes and understanding of dashboard design, with questionnaire items generated from the content of focus groups of older drivers. Dashboard design domains identified in Rasch analysis of questionnaire responses were quantified using person ability measures for the cognitive processing, lighting, obstructions, and pattern recognition domains. Visual functions and person abilities were correlated using Spearman partial correlations, adjusting for age and sex., Results: A total of 997 participants completed functional testing and the dashboard questionnaire. The mean age was 77.4 ± 4.6 years, and the majority were male (55%) and white (81%). The sample had a range of person abilities and visual functions. Contrast and visual field sensitivities were significantly associated with the cognitive processing, lighting, and pattern recognition dashboard design dimensions ( p ≤ 0.0052). For all significant associations, increased visual function was indicative of better person ability. Visual processing speed, as measured by Trails B and UFOV2, was significantly associated with the lighting domain ( p = 0.0008 and p = 0.0007, respectively). The UFOV2 measure was correlated with pattern recognition ( p = 0.0165). Spatial ability was the only visual function associated with the visual obstruction dimension ( p = 0.0347)., Conclusions: Person ability for dashboard design domains are related to visual function in older drivers. Results show person ability for domains increased with improved visual function. Future automotive engineering and design initiatives should consider these associations in improving dashboard designs to increase vehicle utility and accessibility., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Swain, Snyder, McGwin and Owsley.)

Purpose: We hypothesize the first visual dysfunction in transitioning to early and intermediate age-related macular degeneration (AMD) is delayed rod-mediated dark adaptation (RMDA), owing to impaired photoreceptor sustenance from the circulation. This analysis from the Alabama Study on Early Age-related Macular Degeneration 2 provides insight on our framework's validity, comparing RMDA and other visual tests among older normal, early, and intermediate AMD eyes., Methods: AMD disease severity was determined via fundus photos using the Age-Related Eye Disease Study nine-step system. Visual functions evaluated were RMDA 5°, acuity, contrast sensitivity (photopic, mesopic), and light sensitivity for a macular grid (scotopic, mesopic, photopic). Presence versus absence of subretinal drusenoid deposits (SDD) was identified through multimodal imaging., Results: One eye from each of 481 persons (mean age, 72 years) was evaluated. All visual functions were significantly worse with increasing AMD disease severity. Using z-scores to standardize visual function measures across groups, the greatest difference in probability density functions between older normal and intermediate AMD was for RMDA. Early and intermediate AMD eyes with SDD present had longer rod intercept times than eyes with SDD absent. SDD absent eyes also exhibited delayed RMDA and wide probability density functions relative to normal eyes., Conclusions: Among the visual functions evaluated, RMDA best discriminates among normal, early AMD, and intermediate AMD eyes. The Alabama Study on Early Age-related Macular Degeneration 2 will evaluate whether AMD's natural history confirms our hypothesis at the 3-year follow-up., Translational Relevance: Results support a sequence of visual function impairments in aging and AMD, suggesting RMDA as a promising outcome for evaluating interventions in early disease.

Purpose: To assess associations between visual function and on-road driving performance evaluated by a certified driving rehabilitation specialist (CDRS)., Methods: Adults aged 70 and older enrolled and completed assessments of visual acuity, contrast sensitivity, visual processing speed, visual field sensitivity, motion perception and spatial ability. At follow-up, on-road driving performance was evaluated on a 15-mile route. Age-adjusted odds ratios and 95% confidence intervals (95% CIs) were used to associate worse CDRS composite score and CDRS global rating for those with poorer visual function compared to those with better scores and ratings., Results: For the 144 participants who enrolled, completed vision testing and the on-road driving evaluation, the mean age was 79.2 (5.1) and 45.8% were female. The odds of worse CDRS global rating and composite score were significantly associated with moderately and severely impaired visual processing speed under divided attention (all p < 0.05). Those with poorer motion perception were at greater odds of a worse CDRS composite score (OR: 2.67, 95% CI: 1.14-6.26)., Conclusions: The CDRS composite score of on-road driving performance by older adults was associated with slowed visual processing and impaired motion perception, suggesting that older driver performance, as rated by a CDRS, relies on visual skills. The CDRS global rating was also associated with impaired visual processing speed. The literature suggests impairments in these same visual functions elevate crash risk. While the results provide additional evidence suggesting these functional measures are associated with driving, further work is needed to identify and assess visual measures most closely related to driving safety and performance among older adults to better inform interventions, policy and future research., (© 2022 College of Optometrists.)

Purpose: Subretinal drusenoid deposits (SDD) first appear in the rod-rich perifovea and can extend to the cone-rich fovea. To refine the spatial relationship of visual dysfunction with SDD burden, we determined the topography of mesopic and scotopic light sensitivity in participants with non-neovascular AMD with and without SDD., Methods: Thirty-three subjects were classified into three groups: normal (n = 9), AMD-Drusen (with drusen and without SDD; n = 12), and AMD-SDD (predominantly SDD; n = 12). Mesopic and scotopic microperimetry were performed using 68 targets within the Early Treatment Diabetic Retinopathy Study grid, including points at 1.7° from the foveal center (rod:cone ratio, 0.35). Age-adjusted linear regression was used to compare mesopic and scotopic light sensitivities across groups., Results: Across the entire Early Treatment Diabetic Retinopathy Study grid and within individual subfields, the three groups differed significantly for mesopic and scotopic light sensitivities (all P < 0.05). The AMD-SDD group exhibited significantly decreased mesopic and scotopic sensitivity versus both the normal and the AMD-Drusen groups (all P < 0.05), while AMD-Drusen and normal eyes did not significantly differ (all P > 0.05). The lowest relative sensitivities were recorded for scotopic light levels, especially in the central subfield, in the AMD-SDD group., Conclusions: SDD-associated decrements in rod-mediated vision can be detected close to the foveola, and these deficits are proportionately worse than functional loss in the rod-rich perifovea. This finding suggests that factors other than the previously hypothesized direct cytotoxicity to photoreceptors and local transport barrier limitations may negatively impact vision. Larger prospective studies are required to confirm these observations.

Background: This study aimed to evaluate the association between a Certified Driving Rehabilitation Specialist's (CDRS) ratings of on-road driving performance by older drivers and at-fault crash and near-crash involvement using naturalistic driving techniques where crashes and near-crashes are recorded in everyday driving through in-vehicle instrumentation., Methods: This is a cohort study of 144 drivers aged 70 years and over who were recruited due to a recent ophthalmology clinic visit at the University of Alabama at Birmingham. Baseline measurements consisted of demographics, visual status, and other health variables. At-fault crashes and near-crashes over 6 months were identified through instrumentation placed in their personal vehicle that recorded vehicle kinematics and video. After 6 months, a CDRS completed an on-road assessment and provided a composite rating on specific driving behaviors and a global score., Results: Rate ratios examining the association between older drivers with worse CDRS composite scores and rates of at-fault crashes, at-fault near-crashes, and combined at-fault crashes and near-crashes were significantly higher compared to drivers with better scores. Results were similar for the CDRS global score., Conclusions: Motor vehicle administrations use CDRS ratings to make decisions about licensure, and in clinical programs such as those based at rehabilitation clinics use them to make recommendations about fitness to drive and rehabilitation. This study suggests that these decisions and recommendations are valid from a safety standpoint., (© 2021 The American Geriatrics Society.)

Purpose/objectives: Using the periodontal diseases classification published in 2018, this study evaluated the level of agreement among predoctoral and postgraduate students of different education levels and specialties in the diagnosis and treatment planning of periodontal conditions., Methods: Second-year (D2) and fourth-year (D4) dental students, postgraduate orthodontic students (OS), and periodontology students (PS) were presented with an anonymous survey of 10 cases, each with five choices of diagnosis and seven therapeutic approaches. The cases included a patient summary, photographs, radiographs, periodontal charting, and ranged from health to periodontitis. Consensus diagnosis, used as a gold standard, was established between two experienced periodontists. Diagnosis and treatment choices for each case were compared across educational groups using Fisher's exact test. The level of agreement among educational groups was assessed using a multirater kappa coefficient., Results: The survey was completed in 2020 with a 72.4% overall response rate (57-D2, 45-D4, 17-OS, and 12-PS). The overall level of agreement on diagnosis was fair (κ = 0.24, p <.0001) with PS showing the most agreement (κ = 0.55, p <.0001). There were tendencies to prioritize stage over grade and extent in assigning diagnoses and to overdiagnose disease severity and underdiagnose localized periodontitis. Nonsurgical periodontal therapies had the highest overall agreement (κ = 0.63 for scaling/root planing and κ = 0.44 for maintenance, p <.0001). Response distribution per case and per level of education indicated that PS more consistently agreed with the gold standard than any other group., Conclusions: OS, D2, and D4 students demonstrated inferior agreement levels compared to PS, successfully recognized health from disease, suggested appropriate treatment plans, and tended to overdiagnose milder periodontal conditions., (© 2021 American Dental Education Association.)

Background and Objectives: Older drivers are overrepresented in collisions at intersections while making left turns across oncoming traffic. Using naturalistic driving methods, we evaluated the association between vision impairment and their left-turn characteristics., Research Design and Methods: In this prospective, observational study, vision impairment as defined by visual acuity, contrast sensitivity, visual processing speed, visual field sensitivity, and motion perception was assessed in drivers ≥70 years old. Data acquisition systems were installed in their personal vehicles recording video and vehicle kinematics. Driving during everyday life was recorded for 6 months. Data analysts evaluated a temporal data window surrounding randomly selected left turns at 4-way intersections. Left-turn traversals and turning behavior were evaluated in terms of age-adjusted associations with vision impairment., Results: The sample consisted of 151 older drivers. The number of turns studied was 473; 265 turns were rated as unsafe traversals, and 201 as problematic turning behavior. Drivers with slowed visual processing speed and visual field impairment were less likely to exhibit unsafe traversals ( p < .05); those with worse contrast sensitivity, slowed visual processing speed, and visual field impairment were less likely to exhibit problematic turning behavior ( p < .05)., Discussion and Implications: Using naturalistic driving, our study suggests older drivers with vision impairment exhibit better performance in making left turns than those without deficits, which contradicts older driver studies on left turns using driving simulators and on-road driving evaluations. Our findings suggest more cautious and self-regulatory behavior, which are consistent with older visually impaired drivers' commonly expressed concerns about their driving difficulties., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Importance: Government motor vehicle crash reports used in the study of driver safety can be biased and incomplete. Naturalistic driving methods using in-vehicle instrumentation have been developed in recent years to objectively measure crashes and near crashes as they occur on the road using video and vehicle kinematic data., Objective: To examine visual risk factors associated with at-fault crashes and near crashes among older drivers, most of whom have age-related eye conditions associated with vision impairment., Design, Setting, and Participants: This prospective cohort study was conducted at an academic ophthalmology clinic from January 1, 2015, to November 10, 2018, among 154 adults 70 years of age or older who were legally licensed in Alabama and who reported currently driving at least 4 days per week; 137 of 151 participants (90.7%) had an age-related eye condition in at least 1 eye. Drivers participated in a baseline visual function assessment followed by installation of a data acquisition system recording multichannel synchronized video and vehicle kinematics in their personal vehicle. Drivers were instructed to drive for 6 months as they normally would during everyday life. Statistical analysis was performed from June 15 to September 15, 2020., Main Outcomes and Measures: The rate of combined incident at-fault crashes and near crashes, defined by the number of events and the number of miles driven., Results: The sample consisted of 154 drivers (85 men [55.2%]; mean [SD] age, 79.3 [5.1] years). Visual functions associated with crash and near-crash involvement included impaired contrast sensitivity (rate ratio [RR], 2.7; 95% CI, 1.3-5.5), moderate (RR, 2.3; 95% CI, 1.1-4.9) and severe (RR, 5.0; 95% CI, 2.2-11.7) slowing in visual processing speed, and elevated motion perception thresholds for a drifting grating (RR, 1.9; 95% CI, 1.1-3.5). Those with impaired peripheral visual field sensitivity had increased rates of crashes and near crashes (RR, 1.8; 95% CI, 1.0-3.3); however, this finding was not statistically significant (P = .07)., Conclusions and Relevance: With the use of naturalistic driving methods in which crashes and near crashes involving older drivers are objectively measured as they occur on the road, associations have been identified between impaired contrast sensitivity, slowed visual processing speed, and impaired motion perception and an increased rate of a combined total of at-fault crashes and near crashes.

Purpose: To evaluate the relationship between visual function and a five-year history of motor vehicle collision rates in older adults. Motion perception impairment was explored as a risk factor for motor vehicle collisions for the first time in this study., Materials and Methods: Participants were licensed drivers ≥70 years old enrolled in the Alabama VIP Older Driver Study who underwent functional assessments for motion perception, distance visual acuity, contrast sensitivity, visual field sensitivity, and visual processing speed. Participants were recruited based on their being patients in an ophthalmology clinic in the year prior to enrollment or had participated in an earlier driving study. Crash reports were obtained from the Alabama Law Enforcement Agency for the 5 years prior to enrollment and mileage estimated using the Driving Habits Questionnaire. Crude and age-adjusted rate ratios (RRs) and 95 % confidence intervals (95 % CIs) were calculated using Poisson regression., Results: 159 participants enrolled with a mean age of 79 years. The age-adjusted crash rate was higher among those with worse motion perception (RR: 2.7, 95 % CI: 1.4-5.2), severe slowing in visual processing speed (RR: 3.6, 95 % CI: 1.5-8.5), and impaired peripheral visual field sensitivity (RR: 2.4, 95 % CI: 1.3-4.4)., Conclusions: Among a sample of older drivers, crash rates were higher for those with impaired motion perception, severely slowed visual processing speed, and impaired peripheral visual field sensitivity. The association between motion perception and crash risk in older drivers has not been previously reported. Prospective analysis of the Alabama VIP Older Driver Study will examine these risk factors for future collision involvement based on naturalistic driving data., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Wax microsphere bound oxycodone was developed as an abuse-deterrent opioid and maintains a similar pharmacokinetic profile whether administered with or without an intact capsule. We hypothesized that microsphere oxycodone could be utilized for extended release analgesia in patients undergoing radiation (RT) for head-and-neck cancer (HNC) and would not need to be discontinued due to dysphagia or gastrostomy tube dependence., Methods and Materials: We performed a prospective trial that enrolled participants > 18 years with histologically confirmed HNC who were scheduled to receive RT. Analgesia was prescribed in accordance with the WHO pain ladder. Microsphere oxycodone was initiated when total daily opioid dose exceeded 30 mg of morphine sulfate equivalent and was titrated weekly during RT. Pain level and effect on quality of life were assessed using the Brief Pain Inventory. The primary feasibility endpoint was frequency of microsphere oxycodone discontinuation within 3 months of RT for reasons other than pain resolution., Results: Twenty-six eligible patients were enrolled. Microsphere oxycodone was initiated in 16 (61.5%) patients. Six (23.1%) patients utilized a gastrostomy tube to administer microsphere oxycodone during all or part of RT. Microsphere oxycodone was discontinued in 1 (7.6%) patient due to perceived inefficacy. No patients were discontinued due to toxicity or difficulty with administration. Ratings for average pain was 3.1 (± 3.4) at enrollment, 4.0 (± 2.4) at week 6 of RT, and 1.8 (± 2.2) at 3-month follow-up., Conclusions: These results support the feasibility and safety of microsphere oxycodone for extended release analgesia among patients with HNC undergoing RT.

Purpose: Basal laminar deposit (BLamD) is a consistent finding in age-related macular degeneration (AMD). We quantified BLamD thickness, appearance, and topography in eyes of aged donors with and without AMD and evaluated its relationship to other components of the retinal pigment epithelium-basal lamina/Bruch's membrane (RPE-BL-BrM) complex., Methods: Donor eyes (n = 132) were classified as normal (n = 54), early to intermediate AMD (n = 24), geographic atrophy (GA; n = 13), and neovascular AMD (NV; n = 41). In high-resolution histology, we assessed RPE, BLamD, and BrM thicknesses and phenotypes at 3309 predefined locations in the central (foveal and perifovea) and superior (perifoveal) sections. Pre-mortem optical coherence tomography (OCT) imaging of a 90-year-old woman was compared to postmortem histopathology., Results: In non-atrophic areas of AMD eyes, the RPE-BLamD is thick (normal = 13.7 µm, early-intermediate = 16.8 µm, GA = 17.4 µm, NV = 18.7 µm), because the BLamD is thick (normal = 0.3 µm, early-intermediate = 5.5 µm, GA = 4.1 µm, NV = 5.3 µm). RPE layer thickness is similar across these stages. Disease-associated variants of BLamD (thick, late, basal mounds) cluster subfoveally. A thick BLamD is visible on OCT as a hyporeflective split in the RPE-BL-BrM complex. BrM is thin (3.5 µm) in NV (normal = 4.2 µm, early to intermediate = 4.4 µm, and GA = 4.2 µm)., Conclusions: The RPE-BL-BrM complex is thick in AMD, driven by the accumulation and expansion of BLamD rather than expansion of either three-layer BrM, RPE-BL, or RPE. BLamD is clinically appreciable by OCT in some patients as a non-neovascular "split RPE-BL-BrM complex" or "double-layer sign." BLamD may contribute toward the formation and progression of high-risk drusen yet also exhibit protective properties.

Purpose: Hyperreflective foci (HRF) are OCT biomarkers for the progression of nonneovascular age-related macular degeneration (AMD) attributed to anteriorly migrated retinal pigment epithelial cells. We examined associations between rod- and cone-mediated vision and HRF plus smaller hyperreflective specks (HRS); we identified a histologic candidate for HRS., Design: Cross-sectional study and histologic survey., Participants: Patients with healthy maculae (n = 34), early AMD (n = 26), and intermediate AMD (n = 41)., Methods: AMD severity was determined by color fundus photography. In OCT scans, HRF and HRS were counted manually. Vision tests probed cones (best-corrected visual acuity [VA], contrast sensitivity), mixed cones and rods (low-luminance VA, low-luminance deficit, mesopic light sensitivity), or rods (scotopic light sensitivity, rod-mediated dark adaptation [RMDA]). An online AMD histopathologic resource was reviewed., Main Outcome Measures: Vision in eyes assessed for HRF and HRS; histologic candidate for HRS., Results: In 101 eyes of 101 patients, HRF and HRS were identified in 25 and 95 eyes, respectively, with good reliability. Hyperreflective foci were present but sparse in healthy eyes, infrequent in early AMD eyes, and frequent but highly variable among intermediate AMD eyes (mean±standard deviation [SD] number per eye, 0.1 ± 0.2, 0.2 ± 0.5, and 1.9 ± 3.4 for healthy, early AMD, and intermediate AMD eyes, respectively). Hyperreflective specks outnumbered HRF in all groups (mean±SD, 4.5 ± 3.2, 6.3 ± 5.8, and 19.4 ± 22.4, respectively). Delayed RMDA was associated strongly with more HRF and HRS (P < 0.0001). Hyperreflective foci also were associated with worse low-luminance VA (P = 0.0117). Hyperreflective specks were associated with worse contrast sensitivity (P = 0.0278), low-luminance VA (P = 0.0010), low-luminance deficit (P = 0.0031), and mesopic (P = 0.0018) and scotopic (P < 0.0001) sensitivity. By histologic analysis, cone lipofuscin was found in outer retinal layers of 25% of healthy aged eyes., Conclusions: Hyperreflective foci and HRS are markers of cellular activity associated with visual dysfunction, especially delayed RMDA, an AMD risk indicator assessing efficiency of retinoid resupply. Hyperreflective specks may represent lipofuscin translocating inwardly within cones. HRF and HRS may serve as structural end points in clinical trials targeting AMD stages earlier than atrophy expansion. These results should be confirmed in a larger sample., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: This study investigates undiagnosed depression and anxiety related to diabetes in patients with diabetic retinopathy and identifies commonly feared complications that these patients experience., Methods: The 74 consecutive individuals with diabetes were recruited for this investigation from the office of a retina specialist, and data were obtained from the participants through a self-report survey given to the patients before their appointment., Results: The most feared complication reported by patients surveyed was blindness (38.36%). When asked about depression and anxiety related to their diabetes, 20.27% of patients stated they have depression related to their diabetes, whereas 18.92% had anxiety related to their diabetes. Only 17.57% of the patients said they were being treated for their depression and/or anxiety at the time of the survey., Conclusions: This study demonstrates that many patients with diabetic retinopathy have coexisting fears and mental health concerns. Because most retina specialists treat a high number of patients with diabetes, it is crucial to understand the barriers and comorbidities related to this patient population. Retina specialists may play a role in identifying the hidden and underlying fears, depression, and anxieties in patients with diabetes so that these patients can get the necessary help and counseling they need., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Purpose: We assessed the association between the abundance of macular xanthophyll carotenoid pigment using dual-wavelength autofluorescence and multimodal vision testing including rod-mediated dark adaptation (RMDA), a measure of retinoid re-supply, in adults ≥60 years old with and without age-related macular degeneration (AMD)., Methods: AMD severity was determined using the nine-step Age-Related Eye Disease Study grading. Tests probed cones (best-corrected visual acuity, contrast sensitivity), cones and rods (low-luminance visual acuity, low-luminance deficit, mesopic light sensitivity), or rods only (scotopic light sensitivity, RMDA). Signal attenuation by macular pigment optical density (MPOD) was estimated using a ratio of blue and green autofluorescence signal to yield mean MPOD in a 1°-diameter fovea-centered disk, mean MPOD in a 2°-diameter disk centered on a perifoveal RMDA test location, and macular pigment optical volume (MPOV, or integrated MPOD) in a 4°-diameter fovea-centered disk. Age-adjusted associations between vision and imaging measures were determined., Results: In 88 eyes of 88 subjects (age, 74.9 ± 5.8 years) with normal eyes (n = 32), early AMD (n = 23), or intermediate AMD (n = 33), foveal and perifoveal MPOD and MPOV were higher in the AMD eyes than in the normal eyes. At the RMDA test location, higher MPOD was unrelated to AMD severity but was associated with faster RMDA., Conclusions: In older adults with and without AMD, higher macular xanthophyll concentrations are associated with better best-corrected visual acuity and RMDA. Data are consistent with a model of cone resilience and rod vulnerability in aging and AMD and can be further explored in a larger sample study.

Purpose: Type 1 macular neovascularization (MNV) secondary to age-related macular degeneration (AMD) may sustain hypoxic and micronutrient-insufficient outer retinal cells compensatorily. We explored this hypothesis via histologic analysis of an eye with a shallow irregular retinal pigment epithelial elevation (SIRE) on OCT and good vision., Design: Case study and clinicopathologic correlation., Participant: A white woman with untreated nonexudative neovascular AMD and 20/30 visual acuity (left eye) and neovascular AMD (right eye), with 9 years' multimodal imaging before dying at 90 years of age., Methods: The left eye was preserved 6.25 hours after death and prepared for submicrometer epoxy resin sections and transmission electron microscopy aligned to clinical OCT B-scans. Inside and outside the MNV area, layer thicknesses, phenotypes, and vascular density of native choriocapillaris and neovessels were measured. Lengths of choriocapillaries and intervening gaps in the index eye and in early AMD eyes and healthy eyes with similar age (n = 19 each) from the Project MACULA (Maculopathy Unveiled by Laminar Analysis) online histopathologic resource (http://projectmacula.cis.uab.edu/) were measured with custom software (Caps and Gaps)., Main Outcome Measures: Descriptive features, vascular density, histologic and OCT layer thicknesses, and distribution of choriocapillaries and intervening gaps., Results: The SIRE correlated to a type 1 MNV that expanded slowly without evidence of exudation and with numerous choroidal vessels traversing Bruch's membrane defects, some visible on OCT. Tissue layers in and adjacent to the MNV area showed continuous RPE and characteristic AMD deposits. Capillary-like neovessels with fenestrations and caveolae resembling native choriocapillaris lined the retinal pigment epithelium (RPE) with a vascular density comparable with surrounding non-MNV areas. Relative to early AMD and healthy aged eyes, the index eye showed similar capillary lengths but larger gaps between vessels, indicating dropout. Outer nuclear layer thickness was preserved and showed less photoreceptor degeneration over areas of relative choriocapillaris health, including the type 1 MNV., Conclusions: Eyes with nonexudative type 1 MNV in AMD may progress to exudation, yet this stable MNV complex supported outer retinal structure for 9 years. Distinguishing features were numerous connecting vessels, high density of neovessels, continuous RPE, and slow growth. Maintaining beneficial type 1 MNV may be a therapeutic strategy., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background and Objective: Patients with hemorrhagic posterior vitreous detachments (HPVDs) have a high rate of retinal tears and often develop retinal detachments (RDs). This study aims to compare outcomes of 25-gauge pars plana vitrectomy (PPV) for HPVD versus an observational group., Patients and Methods: Retrospective cohort study of 109 consecutive eyes of 105 patients diagnosed with HPVD; 66 eyes underwent PPV and 43 eyes were observed., Results: Twenty-four eyes (36.4%) in the surgical group were found to have tears intraoperatively not seen preoperatively. The median time to vitreous hemorrhage (VH) resolution was significantly shorter for the PPV group, 14 days (interquartile range [IQR]: 7 days to 35 days), compared to those who were observed, 58.5 days (IQR: 30 days to 91 days) (P < .0001). RDs occurred more frequently among observational patients (11.63%) compared to 1.52% of surgical patients (P = .0344)., Conclusion: Twenty-five-gauge PPV for HPVD resulted in less RDs, diagnosis of occult retinal breaks intraoperatively, and shorter time to VH resolution. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e288-e293.]., (Copyright 2019, SLACK Incorporated.)

Background: Angiopoietin-1 (Agpt-1) and Agpt-2 are cytokine regulators of vascular endothelial integrity. Elevated plasma Agpt-2 levels and ratios of Agpt-2:Agpt-1 are associated with adverse outcomes in adult trauma and pediatric sepsis populations. However, the behavior of the angiopoietins after pediatric trauma has not been characterized, and their relationship to endothelial glycocalyx damage, indicated by plasma syndecan-1 (Syn-1) levels, has not been established., Methods: We performed a secondary analysis of prospectively collected data from 52 pediatric trauma patients and 12 control patients at a level one pediatric trauma center from 2013 to 2016. We measured Agpt-1, Agpt-2, and Syn-1 levels from plasma taken upon hospital arrival and 24 h after admission. Angiopoietin levels were compared to controls, and the correlation between Agpt-2 and Syn-1 was assessed., Results: Plasma Agpt-1 and Agpt-2 levels are elevated immediately after pediatric trauma compared with controls. At 24 h, trauma patients demonstrated significantly elevated plasma Agpt-2:Agpt-1 ratios relative to controls due to decline of Agpt-1 levels to near that of controls. Higher 24-h Agpt-2 levels are associated with more hypoperfusion, and elevated 24-h Agpt-2:Agpt-1 ratios are associated with adverse clinical outcomes. Significant positive correlations between Agpt-2 and Syn-1 upon admission and at 24 h after injury were identified., Conclusion: Our findings suggest dysregulation of circulating angiopoietins after pediatric trauma that may be linked to endothelial glycocalyx injury. Larger prospective studies are needed to validate these findings and determine the relationship of Agpt-2 with other markers of endotheliopathy.

Purpose: OCT has revealed many details of retinal disease that were not available with older imaging technologies. In eyes of adults older than 60 years with healthy maculas as determined by color fundus photography (CFP) and a validated grading system, we screened for pathologic features using OCT. We also tested visual function to assess potential impact of the observed pathologic features on patients., Design: Cross-sectional study., Participants: Persons recruited from primary ophthalmology care clinics., Methods: Color fundus photographs were assessed by the 9-step Age-Related Eye Disease Study scale. OCT macular volumes of participants at step 1 on the Age-Related Eye Disease Study scale, considered healthy, were reviewed by a retina specialist masked to other participant characteristics. Participants were tested for 6 different cone- and rod-mediated visual functions., Main Outcome Measures: Percentage of participants with disorders detected on OCT review and visual function measures., Results: In 138 of 984 eyes (14%) considered healthy by CFP, pathologic features were detectable by OCT, with 8.4% having vitreomacular interface disorders. Among the low-prevalence disorders found, 5 eyes (0.5%) showed macular telangiectasia type 2. Relative to eyes lacking detectable chorioretinal pathologic features, eyes with any pathologic features were associated with poorer low-luminance visual acuity and rod-mediated dark adaptation. In eyes with epiretinal membranes, the largest single entity identified (n = 61 [6.2%]), significantly worse visual functions were best-corrected visual acuity (P = 0.0444), low-luminance visual acuity (P = 0.0151), and light sensitivity (central 3° and 9°; P = 0.0035 and P = 0.0097, respectively)., Conclusions: Macular pathologic features with functional visual implications not identified by clinical examination or CFP are detectable with OCT. Vitreomacular interface disorders often are visually significant and treatable conditions that are visible on OCT, but are easily missed on CFP and clinical examination. Another such condition best seen on OCT is macular telangiectasia type 2, an untreatable disorder for which a clinical trial is in progress. OCT has a potential role in primary eye care clinics to screen for retinal pathologic features, especially in eyes with decreased visual acuity and otherwise normal examination results., (Copyright © 2019 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: Lipofuscin and melanolipofuscin organelles in retinal pigment epithelium (RPE) cells are signal sources for clinical fundus autofluorescence (AF). To elucidate the subcellular basis of AF imaging, we identified, characterized, and quantified the frequency of RPE morphology and AF phenotypes in donor eyes with age-related macular degeneration (AMD)., Methods: In 25 RPE-Bruch's membrane flat mounts from 25 eyes, we analyzed 0.4-μm z-stack epifluorescence images of RPE stained with phalloidin for actin cytoskeleton. Using a custom ImageJ plugin, we classified cells selected in a systematic unbiased fashion in six phenotypes representing increasing degrees of pathology. For each cell, area, AF intensity, and number of Voronoi neighbors were compared with phenotype 1 (uniform AF, polygonal morphology) via generalized estimating equations. We also analyzed each cell's neighborhood., Results: In 29,323 cells, compared with phenotype 1, all other phenotypes, in order of increasing pathology, had significantly larger area, reduced AF, and more variable number of neighbors. Neighborhood area and AF showed similar, but subtler, trends. Cells with highly autofluorescent granule aggregates are no more autofluorescent than others and are in fact lower overall in AF. Pre-aggregates were found in phenotype 1. Phenotype 2, which exhibited degranulation despite normal cytoskeleton, was the most numerous nonhealthy phenotype (16.23%)., Conclusions: Despite aggregation of granules that created hyperAF aggregates within cells, overall AF on a per cell basis decreased with increasing severity of dysmorphia (abnormal shape). Data motivate further development of subcellular resolution in clinical fundus AF imaging and inform an ongoing reexamination of the role of lipofuscin in AMD.

Objectives: To test smile dimension variations in adult African American and Caucasian females and males., Setting and Sample Population: The University of Alabama at Birmingham School of Dentistry and Hospital. Three hundred and ninety-four participants were recruited; African American females and males distributed over five age groups: 20-30, 30-40, 40-50, 50-60 and older than 60., Material & Methods: Three-dimensional surface imaging was used to acquire two images of each participant, one at rest and one upon smile. Landmarks were plotted on the lips and linear distances measured to assess the length of the upper and lower lips, mouth width at rest and upon smile, gingival and dental display upon smile., Results: Linear dimensions are larger in males than in females, and in African Americans than in Caucasians, except for the length of the upper lip that does not differ between male African American and Caucasian males, in any given age group. Gingival display and dental display decrease with age in all groups., Conclusion: Norms should reflect race, age and sex in order to optimize treatment goals., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Purpose: To determine the level of adherence to the American Academy of Ophthalmology preferred practice pattern (PPP) guidelines for quality primary open-angle glaucoma (POAG) and POAG suspect (POAGS) care among retail-based optometrists., Methods: Patients with a diagnosis of POAG or POAGS who participated in a telemedicine pilot project were included. Patients' charts were evaluated for 15 elements of PPP guidelines for glaucoma care. Results were further stratified by number of follow-up visits and diagnosis., Results: Of 360 identified patients, 10 elements were documented in over 98%. Documentation of the remaining 5 components was as follows: dilated fundus examination 91.1%, central corneal thickness (CCT) 88.6%, visual field 78.9%, gonioscopy 47.5%, and target intraocular pressure (IOP) 15.6%. in total, 32.8% of patients were seen once, whereas the remaining 67.2% had multiple visits. In patients with multiple visits, providers were more likely to document systemic history (100.0% vs. 97.5%; P=0.0346), review of systems (100.0% vs. 97.5%; P=0.0346), gonioscopy (60.0% vs. 22.0%; P<0.001), CCT (94.2% vs. 77.1%; P<0.001), visual field (97.5% vs. 40.7%; P<0.001), and target IOP (22.4% vs. 1.7%; P<0.001) compared with single visit patients. In stratifying results by diagnosis, POAG patients more often received visual field testing (92.7% vs. 68.9%; P<0.001) and had an established target IOP (35.1% vs. 1.4%; P<0.001) compared with POAGS patients., Conclusions: Compliance with PPP guidelines for glaucoma care was very high for most elements but lower for performing dilated fundus examination, CCT, visual field, gonioscopy, and target IOP. This study highlights deficiencies in care likely to hamper the detection of glaucoma progression.

The broadly expressed transcriptional coregulator LDB1 is essential for β-cell development and glucose homeostasis. However, it is unclear whether LDB1 has metabolic roles beyond the β-cell, especially under metabolic stress. Global Ldb1 deletion results in early embryonic lethality; thus, we used global heterozygous Ldb1+/- and inducible β-cell-specific Ldb1-deficient (Ldb1Δβ-cell) mice. We assessed glucose and insulin tolerance, body composition, feeding, and energy expenditure during high-fat diet exposure. Brown adipose tissue (BAT) biology was evaluated by thermogenic gene expression and LDB1 chromatin immunoprecipitation analysis. We found that partial loss of Ldb1 does not impair the maintenance of glucose homeostasis; rather, we observed improved insulin sensitivity in these mice. Partial loss of Ldb1 also uncovered defects in energy expenditure in lean and diet-induced obese (DIO) mice. This decreased energy expenditure during DIO was associated with significantly altered BAT gene expression, specifically Cidea, Elovl3, Cox7a1, and Dio2. Remarkably, the observed changes in energy balance during DIO were absent in Ldb1Δβ-cell mice, despite a similar reduction in plasma insulin, suggesting a role for LDB1 in BAT. Indeed, LDB1 is expressed in brown adipocytes and occupies a regulatory domain of Elovl3, a gene crucial to normal BAT function. We conclude that LDB1 regulates energy homeostasis, in part through transcriptional modulation of critical regulators in BAT function., (Copyright © 2017 Endocrine Society.)

Purpose To determine if computed tomographic (CT) metrics of bone mineral density and muscle mass can improve the prediction of noncancer death in men with localized prostate cancer. Materials and Methods Institutional review board approval was obtained, with waiver of informed consent. All patients who underwent radiation therapy for localized prostate cancer between 2001 and 2012 with height, weight, and past medical history documented and who underwent CT that included the L4-5 vertebral interspace were included. On a single axial CT section obtained at the mid-L5 level, the mean CT attenuation of the trabecular bone of the L5 vertebral body (L5 HU ) was measured. The height-normalized psoas cross-sectional area (Psoas L4-5 ) was measured on a single CT section obtained at the L4-5 vertebral interface. Multivariable Cox proportional hazards models were used to assess effects on noncancer death. By using parameter estimates from an adjusted model, a prognostic index for prediction of noncancer death was generated and compared with age-adjusted Charlson Comorbidity Index (CCI) by using the Harrell c statistic. Results Six hundred fifty-three men met the inclusion criteria. Prostate cancer risk grouping, androgen deprivation, race, age-adjusted CCI, L5 HU , and Psoas L4-5 were included in a multivariable model. Age-adjusted CCI (hazard ratio [HR] = 1.36, P < .001), L5 HU (HR = 2.88 for L5 HU < 105 HU, HR = 1.42 for 105 HU ≤ L5 HU ≤ 150 HU, P < .001), Psoas L4-5 (HR = 1.95 for Psoas L4-5 < 7.5 cm 2 /m 2 , P = .003), and race (HR = 1.68 for African American race, HR = 1.77 for other nonwhite race, P = .019) were independent predictors of noncancer death. The prognostic index yielded a c value of 0.747 for the prediction of noncancer death versus 0.718 for age-adjusted CCI alone. Conclusion L5 HU and Psoas L4-5 , which are surrogates for bone mineral density and muscle mass, respectively, were independent predictors of noncancer death. The prognostic index that incorporated these measures with the CCI was associated with improved accuracy for prediction of noncancer death. © RSNA, 2016 Online supplemental material is available for this article.

Objective: Previous studies have reported that children are at risk of severe injuries from exposure to laundry detergent pods. For the first time, this study sought to compare demographic and exposure characteristics and risk among children exposed to pod and non-pod laundry detergents presenting to emergency departments (EDs)., Methods: Data from the National Electronic Injury Surveillance System (NEISS) from 2012-2014 were used. All observations with injuries involving laundry detergent (NEISS code 0949) were included in this study. The χ 2 test was used for bivariate analysis and logistic regression was used to determine the OR and 95% CI of hospitalisation for pod related versus non-pod laundry detergent exposures., Results: From 2012-2014, there were an estimated 26 062 non-pod and 9814 pod laundry detergent related exposures among those aged 18 years and younger. For pod detergent, children aged 0-5 years had the most injuries. Poisoning (71.3%) was the most common diagnosis for pod detergent while contact dermatitis (72.2%) was most common for non-pod detergent. Hospitalisation occurred in 12.5% of pod detergent cases and just 3.0% of non-pod cases. Compared with non-pod detergent, those exposed to pod detergent were 4 times as likely to be hospitalised (OR 4.02; 95% CI 1.96 to 8.24)., Conclusions: A greater effort should be made to appropriately educate the public about the dangers of laundry detergents, specifically pods, so a safe home environment can be established. While new regulations such as childproof containers, opaque packaging, and less appealing and colourful pods could reduce the number of pod related ED visits for children, caregivers should store detergents, along with other chemicals, in a secure location where children cannot easily access them., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Hair removal practices have changed in frequency and location on the body. Previous research on hair removal injuries has focused on a specific body region, age, or gender., Objective: This study sought to take a broader perspective of hair removal-associated injuries in the United States which sought treatment at emergency departments., Methods: Data from the National Electronic Injury Surveillance System (NEISS) from 1991 to 2014 were used to identify hair removal-related injuries. Incidence rates were determined for the overall population and stratified by gender and age category using US Census Bureau population estimates., Results: From 1991 to 2014, there were an estimated 292 053 hair removal-associated injuries in the United States. The overall incidence rate was highest in 2013 (9/100 000). Those aged 65+ had the highest incidence from 1991 to 2010 with those aged 19-34 having the highest rate starting in 2011. When stratified by body region injured, males had highest injury rates to the face and females had highest rates to the lower limbs. Starting in 2010, those aged 19-34 had higher incidence particularly for pubic and trunk regions., Conclusion: The incidence of hair removal-associated injuries seen by emergency departments increased nearly ninefold between 1991 and 2013. Due to the increased incidence among 19- to 34-year-olds, caution should be taken particularly for this age group when undergoing depilatory practices. Overall, individuals should practice safe and acceptable usage of hair removal products to reduce the risk of injury., (© 2016 Wiley Periodicals, Inc.)

Background: Yoga has become more popular among people in the United States and has been touted by both yoga participants as well as some physicians and researchers for its health benefits. While the health benefits have been studied, the frequency of injury among yoga participants has not been well documented., Purpose: Injury incidence, rates, and types associated with yoga in the United States have not been quantified. This study estimates US yoga-associated injury incidence and characterizes injury type over a 13-year period., Study Design: Descriptive epidemiology study., Methods: Data from the National Electronic Injury Surveillance System (NEISS) from 2001 to 2014 were used to estimate the incidence and type of yoga-associated injuries. The number and age distribution of yoga participants was estimated using data from National Health Statistics Reports. These national population estimates were applied to the NEISS data to determine injury rates overall and stratified according to age categories., Results: There were 29,590 yoga-related injuries seen in hospital emergency departments from 2001 to 2014. The trunk (46.6%) was the most frequent region injured, and sprain/strain (45.0%) accounted for the majority of diagnoses. The injury rate increased overall from 2001 to 2014, and it was greatest for those aged 65 years and older (57.9/100,000) compared with those aged 18 to 44 years (11.9/100,000) and 45 to 64 years (17.7/100,000) in 2014., Conclusion: Participants aged 65 years and older have a greater rate of injury from practicing yoga when compared with other age groups. Most injuries sustained were to the trunk and involved a sprain/strain. While there are many health benefits to practicing yoga, participants and those wishing to become participants should confer with a physician prior to engaging in physical activity and practice only under the guidance of certified instructors., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.