Low Vision Rehabilitation Service Utilization Before and After Implementation of a Clinical Decision Support System in Ophthalmology.

Importance: Electronic clinical decision support systems apply clinical guidelines in real time and offer a new approach to improve referral and utilization of low vision rehabilitation (LVR) care. Objective: To characterize patients and factors associated with LVR service utilization with and without the use of an electronic health record (EHR) clinical decision support system (CDSS) alert. Design, Setting, and Participants: Quality improvement study using EHR data to compare patients who did and did not utilize LVR service after referral between November 6, 2017, and October 5, 2019, (primary) and to assess overall service utilization rate from September 1, 2016, to April 2, 2021, regardless of referral status (secondary). Participants in the primary analysis were patients at a large ophthalmology department in an academic medical center in the US who received an LVR referral recommendation from their ophthalmologist according to the CDSS alert. The secondary analysis included patients with best documented visual acuity (BDVA) worse than 20/40 before, during, and after the CDSS implementation. Data were analyzed from August 2021 to April 2022. Exposures: Number and locations of referral recommendations for LVR service according to the CDSS alert in the primary analysis; active CDSS implementation in the secondary analysis. Main Outcomes and Measures: LVR service utilization rate was defined as the number of patients who accessed service among those who were referred (primary) and among those with BDVA worse than 20/40 (secondary). EHR data on patient demographics (age, sex, race, ethnicity) and ophthalmology encounter characteristics (numbers of referral recommendations, encounter location, and BDVA) were extracted. Results: Of the 429 patients (median [IQR] age, 71 [53 to 83] years; 233 female [54%]) who received a CDSS-based referral recommendation, 184 (42.9%) utilized LVR service. Compared with nonusers of LVR, users were more likely to have received at least 2 referral recommendations (12.5% vs 6.1%; χ21 = 5.29; P = .02) and at an ophthalmology location with onsite LVR service (87.5% vs 78.0%; χ21 = 6.50; P = .01). Onsite LVR service (odds ratio, 2.06; 95% CI, 1.18-3.61) persisted as the only statistically significant factor after adjusting for patient demographics and other referral characteristics. Among patients whose BDVA was worse than 20/40 before, during, and after the CDSS implementation regardless of referral status, the LVR service utilization rate was 6.1%, 13.8%, and 7.5%, respectively. Conclusions and Relevance: In this quality improvement study, ophthalmologist referral recommendations and onsite LVR services at the location where patients receive other ophthalmic care were significantly associated with service utilization. Ophthalmology CDSSs are promising tools to apply clinical guidelines in real time to improve connection to care.

Approaching rehabilitation in patients with advanced glaucoma.

Vision loss from advanced glaucoma is currently irreversible and impairs functional visual ability to effectively perform everyday tasks in a number of distinct functional domains. Vision rehabilitation strategies have been demonstrated to be effective in low vision populations and should be utilized in persons with advanced glaucoma to reduce disability and improve quality of life. Initial challenges to rehabilitation include an incomplete understanding of vision rehabilitation by the physician and patient, motivation to integrate rehabilitation into the plan of care, and availability of suitable providers to deliver this care. Physicians, working with well-trained vision rehabilitation providers can maximize function in important visual domains customized to the patient based on their needs, specific complaints, severity/pattern of visual damage, and comorbidities. Potential rehabilitative strategies to be considered for reading impairment include spectacle correction, visual assistive equipment, and sensory substitution, while potential strategies to facilitate driving in those deemed safe to do so include refractive correction, lens design, building confidence, restriction of driving to safer conditions, and avoiding situations where cognitive load is high. Mobility is frequently disrupted in advanced glaucoma, and can be addressed through careful distance refraction, behavior modification, home modification, mobility aids, walking assistance (i.e., sighted guide techniques), and smartphone/wearable technologies. Visual motor complaints are best addressed through optimization of lighting/contrast, sensory substitution, IADL training, and education. Special rehabilitative concerns may arise in children, where plans must be coordinated with schools, and working adults, where patients should be aware of their rights to accommodations to facilitate specific job tasks.

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

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

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

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

The NEI VFQ-25C: Calibrating Items in the National Eye Institute Visual Function Questionnaire-25 to Enable Comparison of Outcome Measures.

Purpose: To improve the usefulness of the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) by enabling estimation of measures on an invariant scale and comparisons between patients and across studies. Methods: Datasets of baseline NEI VFQ-25 responses from nine studies (seven retina randomized trials, n = 2770; two low vision studies, n = 572) were combined. The method of successive dichotomizations was applied to patient ratings of the main NEI VFQ-25 and six supplemental items to estimate Rasch model parameters using the R package 'msd.' Calibrated item measures and rating category thresholds were estimated for the NEI VFQ-25, as well as for two domain-specific versions: the NEI VFQ-VF that includes only visual function items and the NEI VFQ-SE that includes only socioemotional items. Results: Calibrated item measures were estimated from study participants (n = 3342) ranging in age from 19 to 103 years, with mean (SD) age of 69.3 (11) years and a mean logMAR visual acuity of 0.30 (Snellen 20/40). Item measure estimates had high precision (standard error range, 0.026-0.085 logit), but person measure estimates had lower precision (standard error range, 0.108-0.499 logit). Items were well targeted to most persons, but not to those with higher levels of function. Conclusions: Calibrated item measures and rating category thresholds enable researchers and clinicians to estimate visual, socioemotional, and combined measures on an invariant scale using the NEI VFQ-25. Translational Relevance: Applying NEI VFQ 25C calibrated item measures (software provided) to the NEI VFQ-25, users can estimate overall, visual, and socioemotional function measures for individual patients.

Calibration of the Activity Inventory Item Bank: A Patient-Reported Outcome Measurement Instrument for Low Vision Rehabilitation.

Purpose: To provide calibrated item measures and rating category thresholds for the Activity Inventory (AI), an adaptive visual function questionnaire, from difficulty ratings obtained from a large sample of new low vision patients at pre-rehabilitation baseline. Methods: Baseline AI (510 items) rating scale data from five previous low vision rehabilitation outcome studies (n = 3623) were combined, and the method of successive dichotomizations was used to estimate calibrated item measures and rating category thresholds. Infit statistics were analyzed to evaluate the fit of the data to the model. Factor analysis was applied to person measures estimated from different subsets of items (e.g., functional domains such as reading, mobility) to evaluate differential person functioning. Results: Estimated item measures were well targeted to the low vision patient population. The distribution of infit statistics confirmed the validity of the estimated measures and the two-factor structure previously observed for the AI. Conclusions: Our calibrated item measures and rating category thresholds enable researchers to estimate changes in visual ability from low vision rehabilitation on the same scale, facilitating comparisons between studies. Translational Relevance: The work described in this paper provides calibrated item measures and rating category thresholds for a visual function questionnaire to measure patient-centered outcomes in low vision clinical research. The calibrated AI also can be used as a patient outcome measure and quality assurance tool in clinical practice.

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

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

Association of Visual Acuity Improvement With Uncorrected Refractive Error in Patients New to Low Vision Clinics.

Importance: There is substantial socioeconomic and individual burden from uncorrected refractive error (URE) and chronic ocular disease. Understanding the association of visual acuity (VA) reduction with URE and the adults most likely to benefit from refraction may help support clinical decision-making in ophthalmologic care and maximize patient outcomes. Objectives: To assess the magnitude of VA improvement associated with URE among adults under ophthalmic care who obtain low vision rehabilitation (LVR) services and identify the characteristics of the patients who are most likely to experience improvement. Design, Setting, and Participants: This retrospective case series assessed patients 20 years or older who were new to the LVR clinics from August 1, 2013, to December 31, 2015, and who had habitual VA between 20/40 and counting fingers (not including) and underwent refraction. Data analysis was performed from April 4, 2018, to December 20, 2019. Exposures: Patient demographics and clinical data, including habitual and refraction VA, refraction, and disease diagnosis. Habitual VA was categorized as mild (VA worse than 20/40 and at least 20/60), moderate (VA worse than 20/60 and better than 20/200), severe (VA 20/200 or worse and better than 20/500), and profound (VA 20/500 or worse) vision impairment (VI). Main Outcomes and Measures: At least 2-line VA improvement and any VA improvement (≥1-line) by refraction. Results: Among the 2923 patients new to LVR clinics, 1773 (mean [SD] age, 70 [18.2] years; 1069 [60.3%] female) were included in these analyses. The mean habitual VA was 20/100 (mean [SD], 0.67 [0.36] logMAR). At least 2-line improvement was observed in 493 patients (27.8%), and any VA improvement was seen in 1023 patients (57.7%). At least 2-line improvement was observed in 54 patients (34.8%) with corneal disorders and was more likely seen among patients aged 40 to <65 years compared with those aged 20 to <40 years (odds ratio [OR], 1.57; 95% CI, 1.02-2.41), African American patients compared with white patients (OR, 1.41; 95% CI, 1.08-1.85), or patients with moderate VI compared with mild VI (OR, 1.36; 95% CI, 1.07-1.72). Conclusions and Relevance: The findings suggest that URE is prevalent among patients with ocular disease and accessing LVR and that refractive evaluation should be considered for patients with ocular disease and reduced VA, especially working-age adults aged 40 to <65 years, African American patients, and those with moderate VI.

Low Vision Care - Out of Site. Out of Mind.

PURPOSE: To estimate the number of patients accessing eye care with low vision (LV) at a large multi-site ophthalmology institute who utilize low vision rehabilitation (LVR) services and compare their characteristics to individuals who do not utilize LVR services. METHODS: This is an electronic health record-based retrospective chart analysis. Patients with LV were identified as having at least one encounter in 2014 where the best visual acuity (VA) in the better-seeing eye was worse than 20/40. Utilization of LVR services across 9 clinic locations was evaluated. Logistic regression analyses were used to examine patient characteristics associated with service utilization. RESULTS: Of the 7,752 LV patients, 1,585 (20%) utilized LVR services over the 17-month period. Those utilizing LVR were more likely to have VA between 20/60 and 20/200 or between 20/200 and 20/500 than non-users (P < .001). The highest LVR utilization rates were in patients evaluated in retina (23%), glaucoma (22%), and neuro-ophthalmology (18%) subspecialties. Patients seen at clinic locations with onsite LVR services available were more likely to utilize services (odds ratio [OR] ranged from 2.69 [95% confidence interval, 95% CI: 1.63-4.44] to 4.94 [95% CI: 2.12-11.48] across location categories), as were patients who had evidence of fluctuations in VA measurements (OR = 3.33, 95% CI: 2.89-3.84). CONCLUSIONS: Patients are more likely to utilize services when VA is moderately to severely impaired, VA fluctuations are present, or when LVR services are provided at the same location where other ophthalmic services are obtained. These estimates are important for developing interventions aimed at improving LVR utilization.

Host Kairomones Influence Searching Behavior of Trissolcus japonicus (Hymenoptera: Scelionidae), a Parasitoid of Halyomorpha halys (Heteroptera: Pentatomidae).

The brown marmorated stink bug, Halyomorpha halys (Stål), is a highly polyphagous species native to Asia that has become a serious invasive agricultural and nuisance pest across North America and Europe. Classical biological control host range evaluations have revealed egg parasitoid Trissolcus japonicus (Ashmead) to be the primary candidate biocontrol agent for field release against H. halys. However, these evaluations only provide us with the physiological host range of T. japonicus. Other Trissolcus species have demonstrated that contact kairomones from different host species elicit varied responses in the parasitoids' host foraging behaviors. To assess T. japonicus response to host kairomones, mated naive females were exposed to leaf surfaces contaminated with adult kairomones from its preferred host, H. halys, or from a native nontarget host, Podisus maculiventris (Say) (Heteroptera: Pentatomidae). Red maple, apple, and soybean were used as plant substrate treatments. The wasp's residence time on the leaf surface, linear walking velocity, and angular walking velocity were observed and measured using Noldus EthoVision XT tracking software. Within each leaf treatment, T. japonicus displayed stronger behavioral responses on leaves contaminated with contact kairomones from H. halys. The parasitoid resided on H. halys contaminated leaves for approximately twice as a long as it did on P. maculiventris contaminated leaves. Further, both species' kairomones elicited significant decreases in parasitoid walking velocity on all tested substrate types. Overall, our study suggests that kairomone-based behavioral studies can be used to further evaluate the host specificity of T. japonicus and can be an invaluable supplement to classical biocontrol host range testing regimes.

Leveraging Electronic Health Records to Identify and Characterize Patients with Low Vision.

PURPOSE: To use electronic health record (EHR) data to estimate the prevalence and characteristics of low-vision (LV) patients. METHODS: EHR data were obtained for all patients at the nine clinical locations of the Wilmer Eye Institute in 2014. LV status at each visit was defined as visual acuity (VA) worse than 20/40 in the better-seeing eye. Prevalence and incidence estimates were determined over a 12-month period. Demographic and clinical data were used to compare the characteristics of patients with and without LV. Logistic regression analyses were used to determine prevalence and incidence estimates adjusted for age, sex, race, and ethnicity. RESULTS: A total of 100,755 patients were included in the analysis. There were 7752 (7.7%) prevalent and 1962 (2.1%) incident cases of LV. Among patients with LV, 55% had VA between 20/40 and 20/60. Outside of LV clinics, retina and glaucoma clinics had the highest prevalence (18% and 14%, respectively) and incidence (5% and 4%, respectively) of LV. The urban hospital center had twice the prevalence of LV than suburban clinics (11.5% vs. 5.6%). The odds of prevalent LV was greatest among patients 80 years and older (odds ratio = 6.18; 95% confidence interval: 5.62-6.80) as compared to those 20-39 years old. CONCLUSIONS: EHR can be used to estimate the prevalence and describe the characteristics of patients with LV seeking ophthalmic care. The highest prevalence rates of LV are observed in the urban setting and among patients obtaining retina and glaucoma care.

The Effect of a Head-mounted Low Vision Device on Visual Function.

SIGNIFICANCE: Head-mounted low vision devices have received considerable attention in recent years owing to rapidly developing technology, facilitating ease of use and functionality. Systematic clinical evaluations of such devices remain rare but are needed to steer future device development. PURPOSE: The purpose of this study was to investigate, in a multicenter prospective trial, the short- and medium-term effects of a head-worn vision enhancement device (eSight Eyewear). METHODS: Participants aged 13 to 75 years with stable vision (distance acuity, 20/60 to 20/400; visual field diameter >20°) were recruited across six sites. Data were collected at baseline (no device), at fitting (with device), and after 3 months of everyday use. Outcome measures were visual ability measured by the Veterans Affairs Low Vision Visual Functioning Questionnaire 48, distance acuity (Early Treatment Diabetic Retinopathy Study), reading performance (MNREAD chart), contrast sensitivity (MARS chart), face recognition, and a modified version of the Melbourne Low Vision Activities of Daily Living (ADL) Index. RESULTS: Among the 51 participants, eSight introduction immediately improved distance acuity (0.74 ± 0.28 logMAR), contrast sensitivity (0.57 ± 0.53 log units), and critical print size (0.52 ± 0.43 logMAR), all P < .001, without any further change after 3 months; reading acuity improved at fitting (0.56 ± 0.35 logMAR) and by one additional line after 3 months, whereas reading speed only slightly increased across all three time points. The Melbourne ADL score and face recognition improved at fitting (P < .01) with trends toward further improvement at 3 months. After 3 months of use, Veterans Affairs Low Vision Visual Functioning Questionnaire 48 person measures (in logits) improved: overall, 0.84, P < .001; reading, 2.75, P < .001; mobility, 0.04, not statistically significant; visual information, 1.08, P < .001; and visual motor, 0.48, P = .02. CONCLUSIONS: eSight introduction yields immediate improvements in visual ability, with face recognition and ADLs showing a tentative benefit of further use. Overall, visual ability, reading, and visual information showed greatest benefit with device use. Further studies need to examine benefits of practice and training and possible differential effects of underlying pathology or baseline vision.

Calibrating the Impact of Vision Impairment (IVI): Creation of a Sample-Independent Visual Function Measure for Patient-Centered Outcomes Research.

PURPOSE: Provide item calibrations estimated for the Impact of Vision Impairment (IVI) questionnaire by pooling data from several studies of people with vision impairment (VI) representing a variety of countries and causes of VI. METHODS: Eight data sets from six principal investigators representing responses to IVI items from 2867 VI patients were pooled for analysis. Eligible patients were 18 years or older and from Australia, India, and the United States. Rasch analysis, using the Andrich Rating Scale Model (Winsteps version 3.65), was performed on preintervention IVI responses to estimate item and person measures, reliability coefficients, and response category thresholds. Differential item functioning (DIF) analysis and analysis of variance (ANOVA) were used to examine the effects different data sets and covariates on item estimates. RESULTS: Patient age range was 18 to 103 years (median 62 years); 55% were male. Visual acuity ranged from 20/20 to no light perception and primary diagnosis was macular degeneration in 29% of patients. Item measure estimates showed good separation reliability (R 2 = 0.99). DIF magnitude did not preclude use of all IVI-28 data. ANOVA showed VA (P < 0.001) and gender (P < 0.002) were predictors of visual ability. CONCLUSIONS: Analysis from pooled data support the provision of calibrated IVI item measures for researchers and clinicians to use, thus better enabling direct comparisons of patients with VI. TRANSLATIONAL RELEVANCE: Validity testing of the IVI show that we can combine disparate data sets of patient responses to calibrate item measures and response category thresholds, and provide to others for use in comparing patients across clinical trials and on an individual basis.

Influence of Temperature on the Reproductive and Developmental Biology of Ontsira mellipes (Hymenoptera: Braconidae): Implications for Biological Control of the Asian Longhorned Beetle (Coleoptera: Cerambycidae).

Ontsira mellipes Ashmead (Hymenoptera: Braconidae) is a North American parasitoid species that develops on the invasive pest, Anoplophora glabripennis (Moltschulsky) (Coleoptera: Cerambycidae), under laboratory conditions and is currently being considered as a potential new-association biocontrol agent. To develop mass-rearing protocols and field-release strategies for this parasitoid, information on its reproductive biology in relation to temperature is needed. We determined the effect of temperature (10, 15, 20, 25, and 30 °C) on development, survivorship, and sex ratio, and its effect on the longevity, fecundity, and host attack rates (parasitism) of adults. Developmental time for parasitoid eggs to pupae decreased from 26.7 d to 6.1 d as temperature increased from 10 °C to 30 °C. While no pupae eclosed as adults at 10 °C, time of adult emergence from pupae decreased from 39.7 d to 12.2 d as temperature increased from 15 °C to 30 °C. Based on estimated lower development temperature threshold (11.1 °C), the degree-days required for one generation was estimated at 342.9. When female parasitoids were provided with host larvae, parasitism occurred at all temperatures and was maximized at 25 °C. Additionally, increasing temperatures significantly reduced the preoviposition period and longevity of female O. mellipes. In addition, combining these results with temperature data from areas in the United States currently infested with A. glabripennis, we estimated that O. mellipes can complete 1.2-3.7 generations per year. Findings from this study may be considered for the future development of effective mass rearing and augmentative release strategies of O. mellipes for biological control of A. glabripennis.

Survivorship of Z-Pheromone Race European Corn Borer (Lepidoptera: Crambidae) on a Range of Host Plants Varying in Defensive Chemistry.

The European corn borer, Ostrinia nubilalis (Hübner), was introduced in North America in the early 1900s and became a major pest of corn. After its introduction, it was found on > 200 other plant hosts, but corn remained its primary host. Early life history studies indicated that European corn borer had the potential of a wide host range. For nearly 80 yr before the introduction of Bt corn, the European corn borer was a major pest of corn in North America. This study investigated the growth and survivorship of the Z-pheromone race European corn borer on a range of hosts that vary in defensive chemistries and historic degree of infestation to better understand the current host plant range of Z-pheromone race of O. nubilalis. The plants tested include sweet corn, cry1F Bt field corn, non-Bt corn, cucumber, tomato, and green bean. Experiments were conducted in the growth chamber, greenhouse, and field to determine survival under different conditions. In most cases, results supported the expected outcome, with significantly higher survival on non-Bt corn hosts than the other hosts tested. Neonate larvae fed exclusively on leaves of green bean exhibited intermediate survival, whereas third-instars fed on only leaves of cucumber survived intermediately. Larvae on Bt corn and tomato had comparable low survival rates, overall suggesting that the defensive features of tomato are about as effective as Cry1F Bt corn. Non-Bt corn was found to be the most suitable host plant, overall for European corn borer among those tested.

Multivariable Regression Model of the EuroQol 5-Dimension Questionnaire in Patients Seeking Outpatient Low Vision Rehabilitation.

PURPOSE: To understand the source of between-person variance in baseline health utilities estimated from EuroQol 5-dimension questionnaire (EQ-5D) responses of a representative sample of the US low vision outpatient population prior to rehabilitation. METHODS: A prospective, observational study of 779 new low vision patients at 28 clinic centers in the US. The EQ-5D, Activity Inventory (AI), Telephone Interview for Cognitive Status (TICS), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical functioning component, and Geriatric Depression Scale (GDS) were administered by telephone interview prior to rehabilitation. EQ-5D responses were transformed into health utilities, which served as the dependent variable in all analyses. Data were then analyzed to determine how much overall visual ability, functional domains of visual ability, and comorbidities (e.g. physical functioning, depression, cognition) independently contribute to the EQ-5D-based health utility index. RESULTS: Multivariable regression analyses showed that the GDS and SF-36 physical account for nearly 40% of the variance observed in health utilities estimated from EQ-5D responses of low vision patients. Age was also a significant predictor of health utilities, but accounted for very little variance. None of the other variables were significant predictors. CONCLUSIONS: Health utilities of low vision patients estimated from the EQ-5D primarily are associated with comorbid factors that are not likely to be responsive to low vision rehabilitation, thereby rendering the EQ-5D an unsuitable outcome measure for this population. However, because the EQ-5D is responsive to comorbid states, it could be a useful tool for evaluating the impact of comorbidities on low vision patient quality of life.

Life History, Reproductive Biology, and Larval Development of Ontsira mellipes (Hymenoptera: Braconidae), a Newly Associated Parasitoid of the Invasive Asian Longhorned Beetle (Coleoptera: Cerambycidae).

The invasive Asian longhorned beetle, Anoplophora glabripennis (Motschulsky), is a destructive xylophagous forest pest species originating from Asia. Several endemic North American hymenopteran (Braconidae) species in the mid-Atlantic region were capable of attacking and reproducing on A. glabripennis larvae in laboratory bioassays. Ontsira mellipes Ashmead (Hymenoptera: Braconidae) has been continually reared on A. glabripennis larvae at USDA-ARS BIIRU since 2010, and has been identified as a potential new-association biocontrol agent. Two experiments were conducted to investigate parasitism, paralysis, reproductive biology, larval development, and longevity of adult O. mellipes In the first experiment, pairs of adult parasitoids were given single A. glabripennis larvae every 2 d (along with honey and water) over their lifetimes, while in the second experiment individual parasitoids were observed daily from egg to adult, and adults were subsequently starved. Adults in the first experiment parasitized ∼21% of beetle larvae presented to them throughout their life, and paralysis of larvae occurred 1-2 d after oviposition. More than half of the individual pairs parasitized A. glabripennis larvae, with each female producing around 26 offspring throughout her life. In the second experiment, median development time of O. mellipes from egg to adult was about 3 wk, with five larval instars. Adult O. mellipes that were provided with host larvae, honey, and water lived 9 d longer than host-deprived and starved adults. These findings indicate that mass-rearing procedures for O. mellipes may be developed using the new association host for development of effective biocontrol programs against A. glabripennis.

Effect of Parasitoid: Host Ratio and Group Size on Fitness of Spathius galinae (Hymenoptera: Braconidae): Implications for Mass-Rearing.

Producing insect natural enemies in laboratories or insectaries for biological pest control is often expensive, and developing cost-effective rearing techniques is a goal of many biological control programs. Spathius galinae Belokobylskij and Strazenac (Hymenoptera: Braconidae), a newly described ectoparasitoid of emerald ash borer, Agrilus planipennis Fairmaire (Coleoptera: Buprestidae), is currently being evaluated for environmental introduction in the United States to provide biological control of this invasive pest. To improve mass-rearing outcomes for S. galinae, we investigated the effects of parasitoid: host ratio and parasitoid and host group size (density) on parasitoid fitness. Our results showed that when 1 emerald ash borer larva was exposed to 1, 2, 4, or 8 female parasitoids, parasitism rate was positively associated with increasing parasitoid: host ratio, while brood size, sex ratio, and fitness estimates of progeny were not affected. When a constant 1:1 parasitoid: host ratio was used, but group size varied from 1 female parasitoid and 1 host, 5 parasitoids and 5 hosts, 10 of each, and 20 of each in same size rearing cages, parasitism rates were highest when at least 5 females were exposed to 5 host larvae. Moreover, the number of progeny produced per female parasitoid was greatest when group size was 10 parasitoids and 10 hosts. These findings demonstrate that S. galinae may be reared most efficiently in moderately high-density groups (10 parasitoids and hosts) and with a 1:1 parasitoid: host ratio.

Effects of Brown Marmorated Stink Bug (Hemiptera: Pentatomidae) Feeding Injury on Sweet Corn Yield and Quality.

The brown marmorated stink bug, Halyomorpha halys (Stål), is an Asian species that now dominates the stink bug complex in many cultivated crops throughout the mid-Atlantic United States. Sweet corn (Zea mays L.) is a preferred host of H. halys, and the bug can cause kernel injury on developing ears. Currently, there is limited information available on which plant growth stages are most sensitive to H. halys feeding or density of bugs required to cause yield and quality reductions on processing and fresh market sweet corn ears. In 2011 and 2012, sweet corn ears were infested at three different corn growth stages: silking (R1), blister (R2), and milk (R3) at densities of zero, one, three, and five H. halys adults per ear for 7 d. At harvest, four yield measurements were assessed and ears were inspected for quality reductions. The greatest yield loss from H. halys occurred when infestations were initiated during early stages of ear development, and the greatest quality reductions (damaged kernels) occurred during later stages of ear development. A density of one H. halys per ear resulted in levels of kernel damage great enough to cause significant quality reductions. This study highlights the ability of H. halys to cause substantial economic losses in both fresh market and processing sweet corn in a relatively short period of time at low population densities. Therefore, infestations by this insect in sweet corn must be considered when making pest management decisions in regions where it has become established.

Equating Visual Function Scales to Facilitate Reporting of Medicare Functional G-Code Severity/Complexity Modifiers for Low-Vision Patients.

OBJECTIVE: To present a method of estimating and equating scales across functional assessment instruments that appropriately represents changes in a patient's functional ability and can be meaningfully mapped to changes in Medicare G-code severity modifiers. DESIGN: Previously published measures of patients' overall visual ability, estimated from low-vision patient responses to 7 different visual function rating scale questionnaires, are equated and mapped onto Medicare G-code severity modifiers. SETTING: Outpatient low-vision rehabilitation clinics. PARTICIPANTS: The analyses presented in this article were performed on raw or summarized low-vision patient ratings of visual function questionnaire (VFQ) items obtained from previously published research studies. INTERVENTIONS: Previously published visual ability measures from Rasch analysis of low-vision patient ratings of items in different VFQs (National Eye Institute Visual Functioning Questionnaire, Index of Visual Functioning, Activities of Daily Vision Scale, Visual Activities Questionnaire) were equated with the Activity Inventory (AI) scale. The 39 items in the Self-Report Assessment of Functional Visual Performance (SRAFVP) and the 48 items in the Veterans Affairs Low Vision Visual Functioning Questionnaire (VA LV VFQ) were paired with similar items in the AI in order to equate the scales. MAIN OUTCOME MEASURES: Tests using different observation methods and indicators cannot be directly compared on the same scale. All test results would have to be transformed to measures of the same functional ability variable on a common scale as described here, before a single measure could be estimated from the multiple measures. RESULTS: Bivariate regression analysis was performed to linearly transform the SRAFVP and VA LV VFQ item measures to the AI item measure scale. The nonlinear relationship between person measures of visual ability on a logit scale and item response raw scores was approximated with a logistic function, and the 2 regression coefficients were estimated for each of the 7 VFQs. These coefficients can be used with the logistic function to estimate functional ability on the same interval scale for each VFQ and for transforming raw VFQ responses to Medicare's G-code severity modifier categories. CONCLUSIONS: The principle of using equated interval scales allows for comparison across measurement instruments of low-vision functional status and outcomes, but can be applied to any area of rehabilitation.