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1.
Models of care in tele-ophthalmology: A scoping review.
Caffery, LJ, Taylor, M, Gole, G, Smith, AC
Journal of telemedicine and telecare. 2019;(2):106-122
Abstract
The objective of this review was to identify and describe telehealth models of care for ophthalmic services. We conducted a scoping review of the literature to identify how ophthalmic care can be delivered by telehealth. We searched the PubMed database to identify relevant articles which were screened based on pre-defined inclusion criteria. For included articles, data were extracted, categorised and analysed. Synthesis of findings was performed narratively. The scoping review included 78 articles describing 62 discrete tele-ophthalmic models of care. Tele-ophthalmic models of care can be used for consultative service, screening, triage and remote supervision. The majority of services were for general eye care and triage ( n = 17; 26%) or emergency services ( n = 8; 12%). The most common conditions for disease-specific models of care were diabetic retinopathy ( n = 14; 21%), and glaucoma ( n = 8; 12%). Most models of care involved local clinicians capturing images and transmitting them to an ophthalmologist for assessment. This scoping review demonstrated tele-ophthalmology to be feasible for consultation, screening, triage and remote supervision applications across a broad range of ophthalmic conditions. A large number of models of care have been identified and described in this review. Considerable collaboration between patient-end clinicians and substantial infrastructure is typically required for tele-ophthalmology.
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Systematic review of nutrition screening and assessment in inflammatory bowel disease.
Li, S, Ney, M, Eslamparast, T, Vandermeer, B, Ismond, KP, Kroeker, K, Halloran, B, Raman, M, Tandon, P
World journal of gastroenterology. 2019;(28):3823-3837
Abstract
BACKGROUND Malnutrition is prevalent in inflammatory bowel disease (IBD). Multiple nutrition screening (NST) and assessment tools (NAT) have been developed for general populations, but the evidence in patients with IBD remains unclear. AIM: To systematically review the prevalence of abnormalities on NSTs and NATs, whether NSTs are associated with NATs, and whether they predict clinical outcomes in patients with IBD. METHODS Comprehensive searches performed in Medline, CINAHL Plus and PubMed. Included: English language studies correlating NSTs with NATs or NSTs/NATs with clinical outcomes in IBD. Excluded: Review articles/case studies; use of body mass index/laboratory values as sole NST/NAT; age < 16. RESULTS Of 16 studies and 1618 patients were included, 72% Crohn's disease and 28% ulcerative colitis. Four NSTs (the Malnutrition Universal Screening Tool, Malnutrition Inflammation Risk Tool (MIRT), Saskatchewan Inflammatory Bowel Disease Nutrition Risk Tool (SaskIBD-NRT) and Nutrition Risk Screening 2002 (NRS-2002) were significantly associated with nutritional assessment measures of sarcopenia and the Subjective Global Assessment (SGA). Three NSTs (MIRT, NRS-2002 and Nutritional Risk Index) were associated with clinical outcomes including hospitalizations, need for surgery, disease flares, and length of stay (LOS). Sarcopenia was the most commonly evaluated NAT associated with outcomes including the need for surgery and post-operative complications. The SGA was not associated with clinical outcomes aside from LOS. CONCLUSION There is limited evidence correlating NSTs, NATs and clinical outcomes in IBD. Although studies support the association of NSTs/NATs with relevant outcomes, the heterogeneity calls for further studies before an optimal tool can be recommended. The NRS-2002, measures of sarcopenia and developments of novel NSTs/NATs, such as the MIRT, represent key, clinically-relevant areas for future exploration.
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A prospective RCT comparing combined chromoendoscopy with water exchange (CWE) vs water exchange (WE) vs air insufflation (AI) in adenoma detection in screening colonoscopy.
Leung, JW, Yen, AW, Jia, H, Opada, C, Melnik, A, Atkins, J, Feller, C, Wilson, MD, Leung, FW
United European gastroenterology journal. 2019;(4):477-487
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Abstract
BACKGROUND A low adenoma detection rate (ADR) increases risks of interval cancers (ICs). Proximal colon flat polyps, e.g. serrated lesions (SLs), are difficult to find. Missed proximal colon flat lesions likely contribute to IC. AIMS We compared chromoendoscopy with water exchange (CWE), water exchange (WE) and air insufflation (AI) in detecting adenomas in screening colonoscopy. METHODS After split-dose preparation, 480 veterans were randomized to AI, WE and CWE. RESULTS Primary outcome of proximal ADR (55.6% vs 53.4% vs 52.2%, respectively) were similar in all groups. Adenoma per colonoscopy (APC) and adenoma per positive colonoscopy (APPC) were comparable. Detection rate of proximal colon SLs was significantly higher for CWE and WE than AI (26.3%, 23.6% and 11.3%, respectively, p = 0.002). Limitations: single operator; SLs only surrogate markers of but not IC. CONCLUSIONS When an endoscopist achieves high-quality AI examinations with overall ADR twice (61.6%) the recommended standard (30%), use of WE and CWE does not produce further improvement in proximal or overall ADR. Comparable APC and APPC confirm equivalent withdrawal inspection techniques. WE alone is sufficient to significantly improve detection of proximal SLs. The impact of increased detection of proximal SLs by WE on prevention of IC deserves to be studied. This study is registered at ClinicalTrial.gov (NCT#01607255).
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Single-Field Non-Mydriatic Fundus Photography for Diabetic Retinopathy Screening: A Systematic Review and Meta-Analysis.
Hu, J, Chen, R, Lu, Y, Dou, X, Ye, B, Cai, Z, Pu, Z, Mou, L
Ophthalmic research. 2019;(2):61-67
Abstract
PURPOSE Single-field non-mydriatic fundus photography (NMFP) has been used to detect diabetic retinopathy (DR) in many studies; however, its value in a general clinical setting has not been established. Here we performed a meta-analysis to evaluate its diagnostic effectiveness. METHOD We systematically searched PubMed, EMBASE, and Cochrane databases for candidate studies published through May 19, 2018. A random-effect model was used to calculate the diagnostic indicators including the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), area under the curve (AUC), and 95% confidence intervals. RESULTS Ten prospective studies were ultimately included. The pooled sensitivity, specificity, PLR, NLR, and DOR were 0.68, 0.94, 11.2, 0.34 and 33, respectively. The AUC was 0.88. Subgroup analysis showed that single-field NMFP had a respective sensitivity and specificity of 0.73 and 0.91 when compared to standard 7-field mydriatic stereoscopic photography (7SF), and 0.54 and 0.98 when compared to slit-lamp biomicroscopy as reference standard. CONCLUSIONS Single-field NMFP is inadequate to detect DR. Additionally, it showed higher sensitivity and lower specificity when 7SF was used as reference standard, as compared to slit-lamp biomicroscopy, suggesting that different reference standards used in DR screening might have affected the diagnostic results.
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Obstructive sleep apnoea syndrome in patients living with diabetes: Which patients should be screened?
Borel, AL, Tamisier, R, Böhme, P, Priou, P, Avignon, A, Benhamou, PY, Hanaire, H, Pépin, JL, Kessler, L, Valensi, P, et al
Diabetes & metabolism. 2019;(2):91-101
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Abstract
AIM: Because type 2 diabetes (T2D) is related to obesity, it is often associated with obstructive sleep apnoea syndrome (OSAS), although OSAS is also frequently diagnosed in patients with type 1 diabetes (T1D) and may promote gestational diabetes. Thus, this systematic review of the scientific evidence aimed to evaluate the epidemiological association between OSAS and all forms of diabetes, the current understanding of the pathophysiological mechanisms behind these associations, the expected benefits and limitations of OSAS treatment in patients with diabetes and, finally, to propose which patients require screening for OSAS. METHODS A panel comprising French expert endocrinologists and pneumologists was convened. Two of these experts made a search of the relevant literature for each subpart of the present report; all panel experts then critically reviewed the entire report separately as well as collectively. RESULTS There is little evidence to support the notion that OSAS treatment improves glycated haemoglobin, although it may improve nighttime blood glucose control and insulin sensitivity. However, there is robust evidence that OSAS treatment lowers 24-h blood pressure. CONCLUSION The high prevalence of OSAS in patients with T1D and T2D justifies screening for the syndrome, which should be based on clinical symptoms, as the benefits of OSAS treatment are mainly improvement of symptoms related to sleep apnoea. There are also several clinical situations wherein screening for OSAS seems justified in patients with diabetes even when they have no symptoms, particularly to optimalize control of blood pressure in cases of resistant hypertension and microvascular complications.
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Bone Health Optimization: Beyond Own the Bone: AOA Critical Issues.
Anderson, PA, Jeray, KJ, Lane, JM, Binkley, NC
The Journal of bone and joint surgery. American volume. 2019;(15):1413-1419
Abstract
Worldwide, osteoporosis management is in crisis because of inadequate delivery of care, competing guidelines, and confusing recommendations. Additionally, patients are not readily accepting the diagnosis of poor bone health and often are noncompliant with treatment recommendations. Secondary fracture prevention, through a program such as Own the Bone, has improved the diagnosis and medical management after a fragility fracture. In patients who undergo elective orthopaedic procedures, osteoporosis is common and adversely affects outcomes. Bone health optimization is the process of bone status assessment, identification and correction of metabolic deficits, and initiation of treatment, when appropriate, for skeletal structural deficits. The principles of bone health optimization are similar to those of secondary fracture prevention and can be initiated by all orthopaedic surgeons. Patients who are ≥50 years of age should be assessed for osteoporosis risk and, if they are in a high-risk group, bone density should be measured. All patients should be counseled to consume adequate vitamin D and calcium and to discontinue use of any toxins (e.g., tobacco products and excessive alcohol consumption). Patients who meet the criteria for pharmaceutical therapy for osteoporosis should consider delaying surgery for a minimum of 3 months, if feasible, and begin medication treatment. Orthopaedic surgeons need to assume a greater role in the care of bone health for our patients.
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Accuracy of Detection and Grading of Diabetic Retinopathy and Diabetic Macular Edema Using Teleretinal Screening.
Date, RC, Shen, KL, Shah, BM, Sigalos-Rivera, MA, Chu, YI, Weng, CY
Ophthalmology. Retina. 2019;(4):343-349
Abstract
PURPOSE To determine the accuracy of a county teleretinal screening program of detecting referable diabetic retinopathy (DR) and treatable diabetic macular edema (DME), as well as to evaluate patient compliance with clinic follow-up after referral from teleretinal screening. DESIGN Retrospective observational study. PARTICIPANTS Patients in the Harris Health System (HHS, Houston, TX) older than 18 years of age who underwent teleretinal screening between July 2014 and July 2016. METHODS Teleretinal imaging (TRI) consisting of single-field 45-degree nonmydriatic color fundus photography with referral thresholds of severe nonproliferative DR, proliferative DR, and significant DME. Teleretinal imaging results for all referred subjects were obtained and cross-referenced with dilated fundus examination findings with regard to DR severity and the presence of DME. Follow-up status was also noted. Subjects underwent OCT if deemed necessary by the examining specialist. Agreement between TRI and dilated fundus examination (DFE) findings was determined by calculating the Cohen κ coefficient. MAIN OUTCOME MEASURES The primary outcome measure is agreement between TRI results and DFE findings with regard to DR severity and the presence of DME. The secondary outcome measure is compliance with follow-up. RESULTS Of 1767 patients who were screened and referred for clinical examination, 935 (52.9%) attended their clinic appointment. Overall agreement between DFE and TRI was moderate (weighted κ 0.45) in terms of DR severity. There was agreement within one DR severity level in 86.2% of patients. The positive predictive value for detecting referable disease was 71.3%. Of patients referred for DME, 30.4% were deemed to have treatable DME. CONCLUSIONS The HHS teleretinal screening program demonstrates a high level of accuracy in the detection and classification of referable DR, but a lesser degree of accuracy in the detection of treatable DME. Only slightly more than half of participants were compliant with follow-up after a TRI referral. This large-scale study provides insight into the utility of teleretinal screening in a county health care system.
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New approach for detection of LDL-hypercholesterolemia in the pediatric population: The Fr1dolin-Trial in Lower Saxony, Germany.
Kordonouri, O, Lange, K, Boettcher, I, Christoph, J, Marquardt, E, Tombois, C, Galuschka, L, Stiller, D, Mueller, I, Roloff, F, et al
Atherosclerosis. 2019;:85-91
Abstract
BACKGROUND AND AIMS Lipid disorders are often detected very late, particularly in affected young children. We evaluated the feasibility of a screening for LDL-hypercholesterolemia (highLDL) among toddlers and preschoolers. METHODS Population-based screening has been offered to all children (2-6 years) living in the State of Lower Saxony, Germany, with capillary blood sampling for detection of elevated LDL-cholesterol (LDL-C ≥ 135 mg/dL). Positive results were confirmed by a second measurement. Follow-up in specialized centers, including disease specific counselling and extended diagnostics, as well as evaluation of psychological distress of the parents, is carried out longitudinally. RESULTS Up to March 2018, 5656 children have participated in the screening program. 5069/5656 children have completed the screening for highLDL (52.0% boys; median age: 4.0 years [Interquartile range, IQR 3.0-5.1]; mother age: 35 years [IQR 31-38]; father's age: 37 years; [IQR 33-42]). HighLDL was identified in 112 children (2.2%; 40.2% boys; LDL-C 157.6 ± 29.5 mg/dL, mean ± SD). In the total cohort, parents stated in 40.9% of the cases a positive family history for hyperlipidemia and in 29.9% a premature cardiovascular event. Children with highLDL had more often both risk factors in their family history; however, in 37% of them none of these factors were reported. CONCLUSIONS The first results of the screening program showed its feasibility and revealed high prevalence of highLDL in the general population. Furthermore, a large proportion of families of affected children were not aware about their lipid disorders.
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Screening coronary angiography in patients with long-standing diabetes mellitus undergoing kidney transplant evaluation.
Puttarajappa, CM, Tevar, AD, Hariharan, S, Silver, SJ, Soman, P, Hendrick, S, Mour, G, Wu, CM
Clinical transplantation. 2019;(4):e13501
Abstract
BACKGROUND The utility of coronary angiography in patients with diabetes mellitus undergoing kidney transplant evaluation is unclear. Predictors of critical angiography lesions in these patients will aid in appropriate use of angiography. METHODS Single-center study of 80 patients with ≥15 years of diabetes mellitus who underwent a screening coronary angiography despite a negative cardiac stress test. Risk factors for needing coronary intervention (CI) (percutaneous or bypass grafting) were analyzed. RESULTS Eighteen patients (23%) had a ≥70% occlusion in one or more major coronary vessel(s), with right coronary artery being the most commonly involved (71%). Fifteen patients (19%) underwent coronary intervention: ten percutaneously and five with bypass surgery. Risk factors for needing CI were not being on statin (OR 3.54, P = 0.047) and history of stroke or peripheral vascular disease (PVD; OR 3.5, P = 0.034). A model that included statin use, stroke/PVD history, and glycosylated hemoglobin had a receiver operating characteristic curve area under the curve of 0.8 to predict CI. CONCLUSION Despite a negative stress test, the prevalence of critical coronary lesions was high among kidney transplant candidates with long-standing diabetes. Risk factors for needing coronary intervention were absence of statin use and a history of stroke or peripheral vascular disease.
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Deep Learning-Based Algorithms in Screening of Diabetic Retinopathy: A Systematic Review of Diagnostic Performance.
Nielsen, KB, Lautrup, ML, Andersen, JKH, Savarimuthu, TR, Grauslund, J
Ophthalmology. Retina. 2019;(4):294-304
Abstract
TOPIC Diagnostic performance of deep learning-based algorithms in screening patients with diabetes for diabetic retinopathy (DR). The algorithms were compared with the current gold standard of classification by human specialists. CLINICAL RELEVANCE Because DR is a common cause of visual impairment, screening is indicated to avoid irreversible vision loss. Automated DR classification using deep learning may be a suitable new screening tool that could improve diagnostic performance and reduce manpower. METHODS For this systematic review, we aimed to identify studies that incorporated the use of deep learning in classifying full-scale DR in retinal fundus images of patients with diabetes. The studies had to provide a DR grading scale, a human grader as a reference standard, and a deep learning performance score. A systematic search on April 5, 2018, through MEDLINE and Embase yielded 304 publications. To identify potentially missed publications, the reference lists of the final included studies were manually screened, yielding no additional publications. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used for risk of bias and applicability assessment. RESULTS By using objective selection, we included 11 diagnostic accuracy studies that validated the performance of their deep learning method using a new group of patients or retrospective datasets. Eight studies reported sensitivity and specificity of 80.28% to 100.0% and 84.0% to 99.0%, respectively. Two studies report accuracies of 78.7% and 81.0%. One study provides an area under the receiver operating curve of 0.955. In addition to diagnostic performance, one study also reported on patient satisfaction, showing that 78% of patients preferred an automated deep learning model over manual human grading. CONCLUSIONS Advantages of implementing deep learning-based algorithms in DR screening include reduction in manpower, cost of screening, and issues relating to intragrader and intergrader variability. However, limitations that may hinder such an implementation particularly revolve around ethical concerns regarding lack of trust in the diagnostic accuracy of computers. Considering both strengths and limitations, as well as the high performance of deep learning-based algorithms, automated DR classification using deep learning could be feasible in a real-world screening scenario.