Outcomes and Revenue Generation of a Community-based Screening at a Center in the United States: The SToP Glaucoma Program.

PRCIS: Of 611 individuals seen at referral clinic visits following community screenings, 76% were diagnosed with ≤1 eye condition needing treatment, generating a total of $213,110 in collections for the institution over 2.5 years. PURPOSE: The purpose of this study was to examine the outcomes and revenue generation of community-based eye screenings. MATERIALS AND METHODS: Individuals aged 50 years and above screened at community sites in Baltimore, MD, with abnormal ophthalmic findings were referred for one free-of-charge definitive eye examination at the Wilmer Eye Institute. Diagnoses, treatment, and billing information were abstracted from electronic medical records of patients subsequently seen at Wilmer from January 1, 2016, to July 31, 2018. RESULTS: A total of 611 individuals attended 3696 encounters at Wilmer during this time period. Most patients were female (60.3%) and African American (83.7%). At the screening event, 82.9% reported difficulty seeing when not wearing corrective eyewear, although only 49.8% reported having visited an eye doctor within the last 2 years. The majority (60.2%) reported having Medicare/Medicaid coverage, and 8.1% reported being uninsured. At the definitive eye examination after the screening, 75.5% of patients were diagnosed with ≥1 eye condition, most commonly cataract (30.3%), suspicion of glaucoma (24.9%), manifest glaucoma (11.9%), diabetic retinopathy (5.4%), and ocular hypertension (2.6%). Overall, 430 (70.4%) individuals required treatment including surgery (n=106), intravitreal injections (n=14), laser procedures (n=9), and medications (n=48). A total of $213,110 was collected for visits and procedures after the initial referral visit during the study period. CONCLUSIONS: A large community-based vision screening program in Baltimore was able to identify ocular conditions requiring treatment in underserved older adults and connect them to eyecare. Our findings also highlight that this model simultaneously generates new revenue streams for the institution organizing the community screenings.

Providing vouchers and value information for already free eye exams increases uptake among a low-income minority population: A randomized trial.

We study whether vouchers without and with value information encourage attendance of already free follow-up appointments among low-income minority individuals referred for evaluation of possible eye disease. Between May 2017 and September 2018, 821 individuals referred from 114 screening events across Baltimore City were offered (1) standard referral for a free follow-up appointment and prescription glasses, (2) a paper voucher described as redeemable for free follow-up and prescription glasses, or (3) an otherwise identical paper voucher which also indicated the monetary value of the appointment ($250). Under all three conditions, all referred individuals received the same patient education, counseling, and appointment reminders. We find that vouchers without and with value information increase follow-up by 12.5 and 20.3 percentage points, respectively, corresponding to a 36% and 58% increase compared to the standard referral for free follow-up (i.e., without a voucher). We conclude that using vouchers is a promising, low-cost approach to increase uptake of already free health services, particularly when the vouchers also provide value information.

Lessons Learned From 2 Large Community-based Glaucoma Screening Studies.

Community-based screening programs have had limited success in preventing vision loss from glaucoma due to overall low prevalence of glaucoma, screening limitations, and barriers to follow-up appointments. This editorial highlights lessons learned from 2 large prospective trials: the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study and the Screening To Prevent Glaucoma Study. While some lessons are specific to ophthalmology, many lessons are applicable to screening for asymptomatic diseases in underserved, vulnerable communities.

Knowledge of patient emotional health status: impact on clinical care in glaucoma and retinal services.

OBJECTIVE: Knowledge of a patient's emotional health status and using patient-centred communication may be key to providing early intervention and referral to appropriate treatment/support services for ophthalmology patients. This study aims to determine if and how ophthalmologists use anxiety and depression scores to determine clinical care of patients with chronic eye disease. METHODS AND ANALYSIS: This cross-sectional study included 10 ophthalmologists and a convenience sample of 100 of their patients (>18 years). The Patient Health Questionnaire (PHQ-9) for depression and the Generalised Anxiety Disorder (GAD-7) tool were administered to patients. Scores from these instruments were provided to ophthalmologists just prior to the clinic visit. After the visit, ophthalmologists were given a questionnaire to assess self-reported change in clinical practice and whether knowledge of scores impacted their communication style, treatment plan and follow-up protocol. RESULTS: Of these patients (mean age=63), 27% reported mild-moderate anxiety or depression as their worst score, while 2% reported suicidal thoughts; 20% reported neither anxiety nor depression. Ophthalmologists' response to patients with mild or worse anxiety or depression was to change clinical approach (28%) and communication style (31%), both metrics increasing with severity of symptoms (Fisher's exact p<0.05). None reported changing their choice of treatment or modifying follow-up protocols; referral to social work/psychiatry services was 60%, 3.7% and 0% for patients with moderately severe or worse, mild-to-moderate, or minimal scores, respectively. CONCLUSION: Providing ophthalmologists with knowledge of the emotional health of their patients may change the clinical approach and referral pattern.

New obstacles and widening gaps: A qualitative study of the effects of the COVID-19 pandemic on U.S. adults with disabilities.

BACKGROUND: Prior research has demonstrated that the needs of the disability community have not been met during public health emergencies. The COVID-19 pandemic has exacerbated existing inequities for many populations including people with disabilities, and data is needed to develop inclusive public health response policies. OBJECTIVE: To identify how COVID-19 has uniquely impacted the lives of adults with disabilities. METHODS: 38 participants were recruited through disability advocacy groups and social media. Semi-structured virtual focus groups were conducted with adults (≥18 years) who self-identified as having a disability. Focus groups were conducted for each of six disability sub-groups: vision, hearing, mobility and physical, mental health, cognitive, intellectual, and developmental, and chronic illness. Using inductive coding, major themes were identified and compared across the disability sub-groups. RESULTS: Three major themes and thirteen sub-themes were identified from the focus groups. The three major themes comprised: new problems created by the pandemic, obstacles in daily life that were exacerbated by the pandemic, and broader changes to accessibility and disability identity. Sub-themes such as difficulty with COVID-19 testing and regular medical care were reported by participants of all disability sub-groups, while other sub-themes like direct care needs and medical rationing were reported by participants from a subset of the disability sub-groups. CONCLUSIONS: These results indicate how the COVID-19 pandemic unequally impacts disabled people. The participants indicated that to fully address their needs, disability perspectives must be included in the public health pandemic response. As new research shows that COVID-19 can cause long-term disability, the urgency to ensure the disability community is part of public health policies will increase.

Evaluation of a Portable Wavefront Aberrometer for Community Screening Refraction in the Elderly.

SIGNIFICANCE: The SVOne may prove useful to quickly and easily assess refractive correction needs in community screenings and low-resource settings, but not all subjects were testable with the device. PURPOSE: This study aimed to compare the SVOne handheld, smartphone-based wavefront aberrometer with a tabletop autorefractor in identifying refractive errors in elderly subjects. METHODS: Participants 50 years or older at community eye screenings with visual acuity worse than 20/40 in either eye underwent autorefraction followed by two SVOne trials. Power vectors of right eye data were analyzed. RESULTS: Of 84 subjects who underwent autorefraction, 67 (79.8%) were successfully autorefracted with the SVOne, of whom 82.1% (55/67) had a successful repeat reading. Mean M (spherical equivalent) values from tabletop and handheld autorefraction were -0.21 D (95% confidence interval [CI], -0.71 to +0.29 D) and -0.29 D (95% CI, -0.79 to +0.21 D), respectively (P > .05). Mean astigmatism values from tabletop and handheld devices were +1.06 D (95% CI, 0.87 to 1.26 D) and +1.21 D (95% CI, 0.99 to 1.43 D), respectively (P > .05). Intraclass correlation coefficients between devices were 0.95 (95% CI, 0.93 to 0.97) for M, 0.78 (95% CI, 0.66 to 0.86) for J0, and 0.45 (95% CI, 0.24 to 0.63) for J45 (P < .05 for all). Excellent test-retest correlation between SVOne measurements was noted for M (Pearson correlation [r] = 0.96; P < .05), but a weaker correlation was noted for J0 and J45 (r = 0.67 and r = 0.63 [P < .05 for both], respectively). CONCLUSIONS: The SVOne provided strong agreement for M, with the majority of readings within ±1.00 D of each other, when compared with the tabletop autorefractor. A weaker but still good correlation was noted for astigmatism. Similar findings were noted when assessing repeatability.

Evaluation of Tablet-Based Tests of Visual Acuity and Contrast Sensitivity in Older Adults.

Purpose: Recent innovations in mobile technology for the measurement of vision present a valuable opportunity to measure visual function in non-clinical settings, such as in the home and in field-based surveys. This study evaluated agreement between a tablet-based measurement of distance and near acuity and contrast sensitivity as compared to gold-standard clinical tests.Methods: Participants aged ≥55 years recruited from a tertiary eye clinic underwent testing with three tablet-based and corresponding gold-standard clinical measures (ETDRS distance acuity, Pelli-Robson contrast sensitivity, and MNRead near acuity). Correlation and agreement between tablet-based and clinical tests were assessed.Results: A total of 82 participants with a mean age of 69.1 (SD = 7.6) years, and majority female (67.1%) and white (64.6%), were enrolled in this study. The mean (SD) difference between the tests (gold-standard - tablet) was -0.04 (0.08) logMAR for distance acuity, -0.11 (0.13) log units for contrast sensitivity, and -0.09 (0.12) logMAR for near acuity. 95% limits of agreement for distance acuity (-0.21, 0.12 logMAR), near acuity (-0.34, 0.14 logMAR), and contrast sensitivity (-0.36, 0.14 logCS) were also determined. The correlation between tablet-based and gold-standard tests was strongest for distance acuity (r = 0.78), followed by contrast sensitivity (r = 0.75), and near acuity (r = 0.67). The agreement between the standard and tablet-based methods did not appear to be dependent on the level of vision.Conclusions: This study demonstrates the agreement of tablet-based and gold-standard tests of visual function in older adults. These findings have important implications for future population vision health surveillance and research.

Human Radiation Dosimetry for Orally and Intravenously Administered 18F-FDG.

Intravenous access is difficult in some patients referred for 18F-FDG PET imaging. Extravasation at the injection site and accumulation in central catheters can lead to limited tumor 18F-FDG uptake, erroneous quantitation, and significant image artifacts. In this study, we compared the human biodistribution and dosimetry for 18F-FDG after oral and intravenous administrations sequentially in the same subjects to ascertain the dosimetry and potential suitability of orally administered 18F-FDG as an alternative to intravenous administration. We also compared our detailed intravenous 18F-FDG dosimetry with older dosimetry data. Methods: Nine healthy volunteers (6 male and 3 female; aged 19-32 y) underwent PET/CT imaging after oral and intravenous administration of 18F-FDG. Identical preparation and imaging protocols (except administration route) were used for oral and intravenous studies. During each imaging session, 9 whole-body PET scans were obtained at 5, 10, 20, 30, 40, 50, 60, 120, and 240 min after 18F-FDG administration (370 ± 16 MBq). Source organ contours drawn using CT were overlaid onto registered PET images to extract time-activity curves. Time-integrated activity coefficients derived from time-activity curves were given as input to OLINDA/EXM for dose calculations. Results: Blood uptake after orally administered 18F-FDG peaked at 45-50 min after ingestion. The oral-to-intravenous ratios of 18F-FDG uptake for major organs at 45 min were 1.07 ± 0.24 for blood, 0.94 ± 0.39 for heart wall, 0.47 ± 0.12 for brain, 1.25 ± 0.18 for liver, and 0.84 ± 0.24 for kidneys. The highest organ-absorbed doses (µGy/MBq) after oral 18F-FDG administration were observed for urinary bladder (75.9 ± 17.2), stomach (48.4 ± 14.3), and brain (29.4 ± 5.1), and the effective dose was significantly higher (20%) than after intravenous administration (P = 0.002). Conclusion:18F-FDG has excellent bioavailability after oral administration, but peak organ activities occur later than after intravenous injection. These data suggest PET at 2 h after oral 18F-FDG administration should yield images that are comparable in biodistribution to conventional clinical images acquired 1 h after injection. Oral 18F-FDG is a palatable alternative to intravenous 18F-FDG when venous access is problematic.

Repeatability of brown adipose tissue measurements on FDG PET/CT following a simple cooling procedure for BAT activation.

Brown Adipose Tissue (BAT) is present in a significant number of adult humans and can be activated by exposure to cold. Measurement of active BAT presence, activity, and volume are desirable for determining the efficacy of potential treatments intended to activate BAT. The repeatability of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) measurements of BAT presence, activity, and volume under controlled conditions has not been extensively studied. Eleven female volunteers underwent double baseline FDG PET imaging performed following a simple, regional cold intervention intended to activate brown fat. The cold intervention involved the lightly-clothed participants intermittently placing their feet on a block of ice while sitting in a cooled room. A repeat study was performed under the same conditions within a target of two weeks. FDG scans were obtained and maximum standardized uptake value adjusted for lean body mass (SULmax), CT Hounsfield units (HU), BAT metabolic volume (BMV), and total BAT glycolysis (TBG) were determined according to the Brown Adipose Reporting Criteria in Imaging STudies (BARCIST) 1.0. A Lin's concordance correlation (CCC) of 0.80 was found for BMV between test and retest imaging. Intersession BAT SULmax was significantly correlated (r = 0.54; p < 0.05). The session #1 mean SULmax of 4.92 ± 4.49 g/mL was not significantly different from that of session #2 with a mean SULmax of 7.19 ± 7.34 g/mL (p = 0.16). BAT SULmax was highly correlated with BMV in test and retest studies (r ≥ 0.96, p < 0.001). Using a simplified ice-block cooling method, BAT was activated in the majority (9/11) of a group of young, lean female participants. Quantitative assessments of BAT SUL and BMV were not substantially different between test and retest imaging, but individual BMV could vary considerably. Intrasession BMV and SULmax were strongly correlated. The variability in estimates of BAT activity and volume on test-retest with FDG should inform sample size choice in studies quantifying BAT physiology and support the dynamic metabolic characteristics of this tissue. A more sophisticated cooling method potentially may reduce variations in test-retest BAT studies.

Dual sensory impairment: The association between glaucomatous vision loss and hearing impairment and function.

BACKGROUND: Hearing impairment, vision impairment, and dual impairment (both hearing and vision impairment), have been independently associated with functional and cognitive decline. In prior studies of dual impairment, vision impairment is generally not defined or defined by visual acuity alone. Glaucoma is a leading cause of blindness and does not affect visual acuity until late in the disease; instead, visual field loss is used to measure vision impairment from glaucoma. OBJECTIVE: To examine the effect of glaucomatous visual field loss and hearing impairment on function. DESIGN: Cross-sectional. SETTING: Hospital-based clinic in Baltimore, Maryland. SUBJECTS: 220 adults, ≥55 years presenting to the glaucoma clinic. METHODS: Vision impairment was defined as mean deviation on visual field testing worse than -5 decibels in the better eye, and hearing impairment was defined as pure tone average worse than 25 decibels on threshold audiometry testing in the better ear. Standardized questionnaires were used to assess functional status. RESULTS: Five participants were excluded for incomplete testing, leaving 32 with vision impairment only, 63 with hearing impairment only, 42 with dual impairment, and 78 controls with no hearing impairment or vision impairment. Participants with dual impairment were more likely to be older and non-White. Dual impairment was associated with significantly more severe driving limitation and more difficulty with communication compared to those without sensory impairment when adjusted for age, race, gender and number of comorbidities. CONCLUSION: Older individuals with glaucoma and hearing loss seem to have generally poorer functioning than those with single sensory loss. Health professionals should consider visual field loss as a type of vision impairment when managing patients with dual impairment.

Measurement of Brown Adipose Tissue Activity Using Microwave Radiometry and 18F-FDG PET/CT.

The aim of this study was to evaluate the operating characteristics of a microwave radiometry system in the noninvasive assessment of activated and nonactivated brown adipose tissue (BAT) and normal-tissue temperatures, reflecting metabolic activity in healthy human subjects. The radiometry data were compared with 18F-FDG PET/CT images in the same subjects. Methods: Microwave radiometry and 18F-FDG PET/CT were sequentially performed on 19 participants who underwent a cold intervention to maximize BAT activation. The cold intervention involved the participants' intermittently placing their feet on an ice block while sitting in a cool room. Participants exhibiting BAT activity qualitatively on PET/CT were scanned again with both modalities after undergoing a BAT minimization protocol (exposure to a warm room and a 20-mg dose of propranolol). Radiometry was performed every 5 min for 2 h before PET/CT imaging during both the warm and the cold interventions. A grid of 15-20 points was drawn on the participant's upper body (data were collected at each point), and a photograph was taken for comparison with PET/CT images. Results: PET/CT identified increased signal consistent with BAT activity in 11 of 19 participants. In 10 of 11 participants with active BAT, radiometry measurements collected during the cold study were modestly, but significantly, higher on points located over areas of active BAT on PET/CT than on points not exhibiting BAT activity (P < 0.01). This difference lessened during the warm studies: 7 of 11 participants showed radiometry measurements that did not differ significantly between the same set of points. The mean radiometry result collected during BAT maximization was 33.2°C ± 1.5°C at points designated as active and 32.7°C ± 1.3°C at points designated as inactive (P < 0.01). Conclusion: Passive microwave radiometry was shown to be feasible and, with substantial improvements, has the potential to noninvasively detect active brown adipose tissue without a radiotracer injection.

Improving Follow-up and Reducing Barriers for Eye Screenings in Communities: The SToP Glaucoma Study.

PURPOSE: To evaluate factors associated with attendance to follow-up ophthalmic care, and to assess the impact of strategies to improve follow-up. DESIGN: Cross-sectional study. METHODS: This is an ongoing study to develop an eye screening paradigm, focusing on African Americans ≥50 years of age at multiple urban community sites in Baltimore, Maryland. Several strategies were employed aiming to increase follow-up attendance rates. Multivariable logistic regression was used to evaluate the associations between demographic, medical, and ocular factors with follow-up rate. RESULTS: The total number of referred patients presenting for a free eye examination (attendance rate) during the first phase, during the second phase, and overall was 686 (55.0%), 199 (63.8%), and 885 (57.0%), respectively. In fully adjusted models, the odds ratio (95% confidence intervals) for attending the follow-up visit was 1.82 (1.19, 2.79) for screening in second phase vs first phase, 0.62 (0.39, 0.99) for screening sites that were 3 to <5 miles vs <1 mile from the hospital, 1.70 (1.12, 2.59) in patients with body mass index ≥ 30 vs < 25 kg/m2, 2.03 (1.28, 3.21) in patients with presenting visual acuity < 20/40 vs ≥ 20/40, and 2.32 (1.24, 4.34) for patients with an abnormal vs normal macula. CONCLUSIONS: Obesity, short distance between screening sites and hospital, poor presenting visual acuity in the better eye, and an abnormal macula on fundus photography were associated with increased follow-up rate. Implementation of a combination of strategies effectively increased the follow-up rate. Wider adoption of these strategies in other screening programs has the potential to reduce the burden of visual impairment.

Optimizing Glaucoma Screening in High-Risk Population: Design and 1-Year Findings of the Screening to Prevent (SToP) Glaucoma Study.

PURPOSE: To develop, implement, and evaluate a replicable community-based screening intervention designed to improve glaucoma and other eye disease detection and follow-up care in high-risk populations in the United States. We present the design of the study and describe the findings of the first year of the program. DESIGN: Prospective study to evaluate screening and follow-up. METHODS: This is an ongoing study to develop an eye screening program using trained personnel to identify individuals with ophthalmic needs, focusing on African Americans ≥50 years of age at multiple inner-city community sites in Baltimore, Maryland. The screening examination uses a sequential referral approach and assesses presenting visual acuity (VA), best-corrected VA, digital fundus imaging, visual field testing, and measurement of intraocular pressure. RESULTS: We screened 901 individuals between January 2015 and October 2015. Subjects were mostly African Americans (94.9%) with a mean (standard deviation) age of 64.3 (9.9) years. Among them, 356 (39.5%) participants were referred for a definitive eye examination and 107 (11.9%) only needed prescription glasses. The most common reasons for referral were ungradable fundus image (39.3% of those referred), best-corrected VA < 20/40 (14.6%), and ungradable autorefraction (11.8%). Among people referred for definitive examination, 153 (43%) people attended their scheduled examination. The most common diagnoses at the definitive examination were glaucoma and cataract (51% and 40%, respectively). CONCLUSIONS: A large proportion of individuals screened required ophthalmic services, particularly those who were older and less well educated. To reach and encourage these individuals to attend screenings and follow-up examinations, programs could develop innovative strategies and approaches.

A comparison of FLT to FDG PET/CT in the early assessment of chemotherapy response in stages IB-IIIA resectable NSCLC.

BACKGROUND: The aim of this study was to compare the percentage change in 18F-fluorothymidine (FLT) standard uptake value (SUV) between baseline and after one cycle of chemotherapy in patients categorized by RECIST 1.1 computed tomography (CT) as responders or non-responders after two cycles of therapy. Change in 18F-fluorodeoxyglucose (FDG) uptake was also compared between these time points. Nine patients with newly diagnosed, operable, non-small cell lung cancer (NSCLC) were imaged with FDG positron emission tomography/CT (PET), FLT PET/CT, and CT at baseline, following one cycle of neoadjuvant therapy (75 mg/m2 docetaxel + 75 mg/m2 cisplatin), and again after the second cycle of therapy. All patients had a biopsy prior to enrollment and underwent surgical resection within 4 weeks of post-cycle 2 imaging. RESULTS: Between baseline and post-cycle 1, non-responders had mean SULmax (maximum standard uptake value adjusted for lean body mass) increases of 7.0 and 3.4% for FDG and FLT, respectively. Responders had mean decreases of 44.8 and 32.0% in FDG and FLT SULmax, respectively, between baseline and post-cycle 1 imaging. On post-cycle 1 imaging, primary tumor FDG SUL values were significantly lower in responders than in non-responders (P = 0.016). Primary tumor FLT SUL values did not differ significantly between these groups. Using the change from baseline to post-cycle 1, receiver-operating characteristic (ROC) analysis showed an area under the curve (AUC) of 0.94 for FDG and 0.78 for FLT in predicting anatomic tumor response after the second cycle of therapy. CONCLUSIONS: Fractional decrease in FDG SULmax from baseline to post-cycle 1 imaging was significantly different between anatomic responders and non-responders, while percentage changes in FLT SULmax were not significantly different between these groups over the same period of time.