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PubMed1987

Predicting diabetic retinopathy.

The purpose of this study was to determine the occurrence and severity of diabetic retinopathy and to clarify its association with the duration of diabetes and several other factors in an outpatient diabetic population. The material consisted of 328 diabetics, mainly (77%) C-peptide negative, type 1 diabetics. The mean age of the patients was 45 years, and the mean duration of diabetes was 15 years. Retinal changes were assessed by ophthalmoscopy and widefield fundus photography. All retinopathy was confirmed in 59% and proliferative retinopathy (PR) in 20% of the patients. The frequency of diabetic retinopathy was 15% in patients with diabetes for less than five years but 100% in those with diabetes for 30 or more years. In type 1 diabetics PR was seen only after 10 or more years' duration but, after 20 years' duration it was seen in half of the patients with type 1 and in one-third of the patients with type 2 diabetes. The patients with diabetic nephropathy often had PR. In type 1 diabetics with onset of the disease less than 30 years peripheral sensory neuropathy, coronary disease, hypertension and leg-vessel disease were also often associated with PR. Because one reason for visual handicapping in diabetes is the delay of the diagnosing of vision-threatening lesions screening for treatable retinopathy should be intensive after 10 years' duration and in poorly-controlled diabetics even earlier.

Adolescent↗
PubMed2003

Use of an electronic medical record improves the quality of urban pediatric primary care.

OBJECTIVE: To evaluate the quality of pediatric primary care, including preventive services, before and after the introduction of an electronic medical record (EMR) developed for use in an urban pediatric primary care center. METHODS: A pre-postintervention analysis was used in the study. The intervention was a pediatric EMR. Routine health care maintenance visits for children <5 years old were reviewed, and documentation during preintervention (paper-based, 1998) and postintervention visits (computer-based, 2000) was compared. RESULTS: A total of 235 paper-based visits and 986 computer-based visits met study criteria. Twelve clinicians (all attendings or nurse practitioners) contributed an average of 19.4 paper-based visits (range: 5-39) and 7 of these clinicians contributed an average of 141 computer-based visits each (range: 61-213). Computer-based clinicians were significantly more likely to address a variety of routine health care maintenance topics including: diet (relative risk [RR]: 1.09), sleep (RR: 1.46), at least 1 psychosocial issue (RR: 1.42), smoking in the home (RR: 15.68), lead risk assessment (RR: 106.54), exposure to domestic or community violence (RR: 35.19), guns in the home (RR: 58.11), behavioral or social developmental milestones (RR: 2.49), infant sleep position (RR: 9.29), breastfeeding (RR: 1.99), poison control (RR: 3.82), and child safety (RR: 1.29). Trends toward improved lead exposure, vision, and hearing screening were seen; however, differences were not significant. Users of the system reported that its use had improved the overall quality of care delivered, was well-accepted by families, and improved guidance quality; however, 5 of 7 users reported that eye-to-eye contact with patients was reduced, and 4 of 7 reported that use of the system increased the duration of visits (mean: 9.3 minutes longer). All users recommended continued use of the system. CONCLUSION: Use of the EMR in this study was associated with improved quality of care. This experience suggests that EMRs can be successfully used in busy urban pediatric primary care centers and, as recommended by the Institute of Medicine, must play a central role in the redesign of the US health care system.

Appointments and Schedules↗
PubMed2005

A process for developing community consensus regarding the diagnosis and management of attention-deficit/hyperactivity disorder.

There remain large discrepancies between pediatricians' practice patterns and the American Academy of Pediatrics (AAP) guidelines for the assessment and treatment of children with attention-deficit/hyperactivity disorder (ADHD). Several studies raise additional concerns about access to ADHD treatment for girls, blacks, and poorer individuals. Barriers may occur at multiple levels, including identification and referral by school personnel, parents' help-seeking behavior, diagnosis by the medical provider, treatment decisions, and acceptance of treatment. Such findings confirm the importance of establishing appropriate mechanisms to ensure that children of both genders and all socioeconomic, racial, and ethnic groups receive appropriate assessment and treatment. Publication of the AAP ADHD toolkit provides resources to assist with implementing the ADHD guidelines in clinical practice. These resources address a number of the barriers to office implementation, including unfamiliarity with Diagnostic and Statistical Manual of Mental Disorders criteria, difficulty identifying comorbidities, and inadequate knowledge of effective coding practices. Also crucial to the success of improved processes within clinical practice is community collaboration in care, particularly collaboration with the educational system. Such collaboration addresses other barriers to good care, such as pressures from parents and schools to prescribe stimulants, cultural biases that may prevent schools from assessing children for ADHD or may prevent families from seeking health care, and inconsistencies in recognition and referral among schools in the same system. Collaboration may also create efficiencies in collection of data and school-physician communications, thereby decreasing physicians' non-face-to-face (and thus nonreimbursable) elements of care. This article describes a process used in Guilford County, North Carolina, to develop a consensus among health care providers, educators, and child advocates regarding the assessment and treatment of children with symptoms of ADHD. The outcome, ie, a community protocol followed by school personnel and community physicians for >10 years, ensures communication and collaboration between educators and physicians in the assessment and treatment of children with symptoms of ADHD. This protocol has the potential to increase practice efficiency, improve practice standards for children with ADHD, and enhance identification of children in schools. Perhaps most importantly, the community process through which the protocol was developed and implemented has an educational component that increases the knowledge of school personnel about ADHD and its treatment, increasing the likelihood that referrals will be appropriate and increasing the likelihood that children will benefit from coordination of interventions among school personnel, physicians, and parents. The protocol reflects a consensus of school personnel and community health care providers regarding the following: (1) ideal ADHD assessment and management principles; (2) a common entry point (a team) at schools for children needing assessment because of inattention and classroom behavior problems, whether the problems present first to a medical provider, the behavioral health system, or the school; (3) a protocol followed by the school system, recognizing the schools' resource limitations but meeting the needs of community health care providers for classroom observations, psychoeducational testing, parent and teacher behavior rating scales, and functional assessment; (4) a packet of information about each child who is determined to need medical assessment; (5) a contact person or team at each physician's office to receive the packet from the school and direct it to the appropriate clinician; (6) an assessment process that investigates comorbidities and applies appropriate diagnostic criteria; (7) evidence-based interventions; (8) processes for follow-up monitoring of children after establishment of a treatment plan; (9) roles for central participants (school personnel, physicians, school nurses, and mental health professionals) in assessment, management, and follow-up monitoring of children with attention problems; (10) forms for collecting and exchanging information at every step; (11) processes and key contacts for flow of communication at every step; and (12) a plan for educating school and health care professionals about the new processes. A replication of the community process, initiated in Forsyth County, North Carolina, in 2001, offers insights into the role of the AAP ADHD guidelines in facilitating development of a community consensus protocol. This replication also draws attention to identification and referral barriers at the school level. The following recommendations, drawn from the 2 community processes, describe a role for physicians in the collaborative community care of children with symptoms of ADHD. (1) Achieve consensus with the school system regarding the role of school personnel in collecting data for children with learning and behavior problems; components to consider include (a) vision and hearing screening, (b) school/academic histories, (c) classroom observation by a counselor, (d) parent and teacher behavior rating scales (eg, Vanderbilt, Conner, or Achenbach scales), (e) consideration of speech/language evaluation, (f) screening intelligence testing, (g) screening achievement testing, (h) full intelligence and achievement testing if discrepancies are apparent in abbreviated tests, and (i) trials of classroom interventions. (2) Use pediatric office visits to identify children with academic or behavior problems and symptoms of inattention (history or questionnaire). (3) Refer identified children to the contact person at each child's school, requesting information in accordance with community consensus. (4) Designate a contact person to receive school materials for the practice. (5) Review the packet from the school and incorporate school data into the clinical assessment. (6) Reinforce with the parents and the school the need for multimodal intervention, including academic and study strategies for the classroom and home, in-depth psychologic testing of children whose discrepancies between cognitive level and achievement suggest learning or language disabilities and the need for an individualized educational plan (special education), consideration of the "other health impaired" designation as an alternate route to an individualized educational plan or 504 plan (classroom accommodations), behavior-modification techniques for targeted behavior problems, and medication trials, as indicated. (7) Refer the patient to a mental health professional if the assessment suggests coexisting conditions. (8) Use communication forms to share diagnostic and medication information, recommended interventions, and follow-up plans with the school and the family. (9) Receive requested teacher and parent follow-up reports and make adjustments in therapy as indicated by the child's functioning in targeted areas. (10) Maintain communication with the school and the parents, especially at times of transition (eg, beginning and end of the school year, change of schools, times of family stress, times of change in management, adolescence, and entry into college or the workforce).

Adolescent↗
PubMed1985

Medical examination of school entrants: later school problems and absenteeism of attenders and non-attenders.

Children who were scheduled for medical examination before entering school were followed in school one or two years later. Non-attenders had a two-fold risk of repeating grades, special class placement, referral for speech/language problems, teacher-reported learning or behavior problems, failure of vision or hearing screening, and transfer between schools. Absenteeism was also significantly more common. Children not brought in for preventive health care are at greater risk than others for difficulties in school.

Absenteeism↗
PubMed1982

Fingertip textural perception of normal children.

The current study investigated the influence of masking upon children's fingertip textural perception. While a screen occluded their vision 52 6- to 10-yr.-old subjects palpated a pair of equivalent paper-covered sandpaper blocks and judged whether the blocks felt rougher when palpated with or without intermediate paper covering their fingertips. Pressure exerted by the subjects was recorded. It was concluded that children's judgment is independent of pressure exerted; r = .04. Masking in children, unlike adults, was related to sandpaper grit, for the children judged the paper condition tougher primarily when the coarser sandpaper was used. Possible explanations are presented.

Child↗
PubMedDate not supplied

Second Generation Binocular Polaroid Test.

BACKGROUND: The aim of the study was to introduce a new test to detect small areas of suppression in the binocular visual field and to lower the minimum age at which a suppression test could be identified correctly. Two tests were compared: the Binocular Polaroid Test (poltest), introduced in clinical practice a few years ago and used in screening programs for vision impairment; and the Second Generation Binocular Polaroid Test (polstar), more recently designed to have simpler answers than the poltest. METHODS: One hundred and eighty-two children were examined consecutively. To assess the validity of the two tests, sensitivity, specificity, predictive value, and phi coefficient were calculated. The applicability of the two tests and the speed of the responses was assessed by means of the test of probability of binomial distribution. RESULTS: The polstar has appeared to be simpler and easier in younger patients (age range 20 to 36 months, P = 0.078), and has shown 100% of specificity with a sensitivity of 84% for the polstar 1 and of 100% for the polstar 2. CONCLUSION: The results appear to demonstrate that the poltest has been improved, and that the polstar may be considered an interesting investigation device for early detection of monocular visual impairment.

Child↗
PubMed2001

Evaluation and treatment of ADHD.

Symptoms of attention-deficit/hyperactivity disorder (ADHD) are present in as many as 9 percent of school-age children. ADHD-specific questionnaires can help determine whether children meet diagnostic criteria for the disorder. The recommended evaluation also includes documenting the type and severity of ADHD symptoms, verifying the presence of normal vision and hearing, screening for comorbid psychologic conditions, reviewing the child's developmental history and school performance, and applying objective measures of cognitive function. The stimulants methylphenidate and dextroamphetamine remain the pharmacologic agents of first choice for the management of ADHD. These agents are equally effective in improving the core symptoms of the disorder, but individual children may respond better to one stimulant medication than to another. Achievement of maximal benefit may require titration of the initial dosage and dosing before breakfast, before lunch and in the afternoon. The family physician should tailor the treatment plan to meet the unique needs of the child and family. Psychosocial, behavioral and educational strategies that enhance specific behaviors may improve educational and social functioning in the child with ADHD.

Attention Deficit Disorder with Hyperactivity↗
PubMed2002

[Percutaneous tracheotomy: personal contributions to the technique].

We developed within our service of intensive care a hybrid procedure combining the advantages of the techniques of Caglia and Fantoni. Ventilation downstream from the site of dilatation, thanks to a longer tracheal tube of small diameter, ensures an optimal spirometry and reduces to a minimum the time of apnea. It decreases the risks of per-operational subcutaneous emphysema. A system of camera video assembled on a flexible fibroscope allows a direct vision on television screen. The operator can, constantly, visualise his gesture in one glance, in real time. Such an approach increases the security and the effectiveness of the method. The procedure remains nevertheless simple and does not require a thorough experience in percutaneous dilatational tracheotomy.

Emphysema↗
PubMed1985

Effects of aniseikonia, anisometropia, accommodation, retinal illuminance, and pupil size on stereopsis.

The sensitivity of clinical measures of stereoacuity in the detection of interocular differences in retinal images was examined in 50 adults with normal binocularity. Interocular differences in retinal image size (aniseikonia), clarity (anisometropia) and brightness, as well as differences in absolute and relative pupil size (anisocoria) were created in small steps over a large range to determine their effect on threshold levels of stereopsis. Their effect on stereoacuity was measured in both contour (Titmus test) and random dot (Randot test) stereograms. Stereoacuity measured by both types of stereograms decreased in a curvilinear manner for aniseikonic and anisometropic test conditions. Monocular blur caused a more rapid decrease in stereoacuity than induced aniseikonia. Stereoacuity measured by the contour stereogram decreased about 1.8 times faster than that measured by the random dot stereogram during induced aniseikonia and anisometropia. This differential sensitivity suggests that the Titmus test would detect small interocular differences in retinal images more effectively than the Randot test in clinical screening procedures for vision abnormalities. However, both tests can miss clinically significant amounts of aniseikonia and anisometropia, and fail to differentiate the cause of reduced stereopsis. Interocular differences in retinal image brightness and pupil size within a normal physiologic range did not reduce stereopsis to clinically unacceptable levels.

Accommodation, Ocular↗
PubMed1994

[Establishment of a primary eye care network and creation of a cataract-free zone in Shunyi County of Beijing].

Based on the epidemiological survey of eye diseases in 1985, a primary eye care network was established in Shunyi County of Beijing in 1987. Cataract surgery was the primary measure for the prevention of blindness, with the aim of creating a cataract-free zone in the county. The activities included (1) establishment of a County Guiding Committee for the prevention of blindness; (2) establishment of a 3-levelled primary eye care network and a referral and monitor system; (3) training of 7 ophthalmologists, 449 eye care workers and 6 optometrists; (4) extensive publicity of knowledge for the prevention of blindness; (5) screening of low vision and blindness in which 815 cataract blind patients were identified; and (6) conducting benefit ophthalmic counselling services. Up to December, 1991, 667 cataract operations were performed, representing 81.84% of the total cataract blind, to meet the qualifications of a cataract-free zone. 90.64% of the blind were restored sight and 59.16% of the blind were able to resume work. Operative infection occurred in none and 97.42% of the operations had no complication.

Aged↗
PubMed1993

Total error assessment of five methods for cholesterol screening.

We report the accuracy, imprecision, total analytical errors, and patient misclassification errors for cholesterol measured from capillary whole blood, venous whole blood, and venous plasma samples by five devices used in public cholesterol screening environments: Reflotron, Vision, Ektachem DT-60, QuickRead, and Liposcan. None of the methods met the National Cholesterol Education Program (NCEP) performance recommendations of 3% CV with 3% bias. The Vision and Reflotron methods used with venous samples gave individual results with total errors consistent with a combined CV and bias in the 4-5% range; capillary blood samples had total errors > 5% (combined CV and bias criteria). The DT-60 performance was near the 5% total error criterion for capillary samples and was > 5% for venous samples. Misclassification of individuals into desirable or referral groups for venous samples was as great as 5.1% for the DT-60, 5.7% for the Vision, and 7.1% for the Reflotron. Misclassifications for capillary blood samples were as great as 6.7%, 18.3%, and 14.1% for DT-60, Vision, and Reflotron, respectively. The QuickRead and Liposcan results were substantially poorer than those obtained by the other methods.

Adult↗
PubMed2006

Glaucoma screening: current trends, economic issues, technology, and challenges.

PURPOSE OF REVIEW: Glaucoma is one of the leading causes of irreversible blindness worldwide. Early glaucoma detection and treatment are currently the only known methods for preventing blindness and low vision resulting from this frequently asymptomatic disease. RECENT FINDINGS: New technologies for detecting early glaucomatous damage are important in diagnosing optic nerve disease, not only in community screening settings but also in clinics. Imaging of the optic nerve head and macula and retinal nerve fiber layer analysis can provide quick, automated, and quantitative measurements in agreement with clinical estimates of optic disc structure and visual function. In the area of perimetry, frequency-doubling technology is a promising and feasible mass-screening method with reasonable sensitivity for detecting visual field loss. Central corneal thickness has emerged as a new risk factor for the development and progression of glaucoma, thereby complicating the role of tonometry and measurement of intraocular pressure as screening parameters for glaucoma. Along with technological advances, strides are also being made with public policy and legislative efforts to bring glaucoma onto the national and global health care agenda. These initiatives incorporate vision-screening goals into national disease prevention programs emphasizing the need for early glaucoma detection and treatment. SUMMARY: Glaucoma awareness needs to be increased through better education, and compliance with follow-up care needs to be improved to decrease the economic and social costs from glaucoma. In addition, screening models need to be developed that will be effective in developing countries where the risk of blindness from glaucoma is highest.

Biomedical Technology↗
PubMed2003

Eye examination in infants, children, and young adults by pediatricians: organizational principles to guide and define the child health care system and/or improve the health of all children.

Early detection and prompt treatment of ocular disorders in children is important to avoid lifelong visual impairment. Examination of the eyes should be performed beginning in the newborn period and at all well-child visits. Newborns should be examined for ocular structural abnormalities, such as cataract, corneal opacity, and ptosis, which are known to result in visual problems. Vision assessment beginning at birth has been endorsed by the American Academy of Pediatrics, the American Association of Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. All children who are found to have an ocular abnormality or who fail vision assessment should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.

Academies and Institutes↗
PubMedDate not supplied

Eye screening in the elderly.

Poor vision is considered to be a common unreported illness in the elderly population. To determine its prevalence we carried out an eye screen on 150 randomly selected co-operative elderly subjects attending St James's Hospital. A database [mean age 78.2 years (range 65 to 97)], medical history, mini-mental test score [mean score 9.1 (range 2 to 10)], mobility assessment and history of eye problems was gathered. A visual test of both eyes together (standard N6 and N8), inspection of the eyes, tonometry (Perkin's handheld tonometer) and fundoscopy were performed on each subject and the need and reason for referral to an optician or an ophthalmologist was documented. Results show that 64% of subjects could read N6 or N8. Tonometry revealed no subject with raised intraocular pressure, including 4 subjects who were currently on treatment for glaucoma. Fundoscopy showed that 57.3% of subjects had some evidence of cataracts, 16.6% moderate and 3% severe. The retina appeared normal in 58.6% of subjects, 20.6% of the population had hypertensive changes, 4.6% had diabetic changes, 3% had optic atrophy, 1.3% had macular degeneration and a further 10% could not be clearly visualised due to cataracts. 90% of subjects wore glasses and the average duration since the glasses were last changed was 3.7 years (range 2 weeks to 20 years). No glasses examined were in need of cleaning or repair. 36% of subjects could not read N8 (28 of these had forgotten their glasses and were advised to visit their optician if they could not read newsprint). 7.3% of subjects were referred to an optician for new glasses, 1.3% were referred to an ophthalmologist for newly diagnosed cataracts and 6.6% were regular attenders to an ophthalmologist. We conclude that the rate of new referrals for the occurrence of correctable undetected visual acuity deficit was lower than expected at 8.6% of subjects screened.

Aged↗
PubMed2001

Ophthalmology. Screening and treatment of age-related and pathologic vision changes.

In the older adult, deterioration of normal vision is caused by age-related physiologic and pathologic changes. Vision impairment undermines quality of life by reducing independence, mobility, and the enjoyment that goes with seeing clearly. The most common causes of vision impairment are age-related macular degeneration (AMD), glaucoma, cataract, and diabetic retinopathy. Key to successful management of vision impairment is early detection of signs and symptoms, patient education regarding preventive strategies, and swift medical or surgical intervention for established or emerging conditions. Vision rehabilitation is an important management option.

Age Factors↗
PubMed1997

Evaluation of a new ultraviolet-emitting rare-earth film-screen combination.

The performance of a 400 speed class DuPont Ultra Vision Rapid (UVR) film-screen combination has been evaluated and compared with that of DuPont Quanta Fast Detail screens with Cronex 10L film (QFD-200 speed class). The speed was calculated from the constructed characteristic curves (H&D) at different energies. Image quality was derived objectively using the Leeds test object TOR (CDR). An anthropomorphic phantom was then employed to determine image quality subjectively by means of radiologist appraisal. Lumbar spine and chest radiography of patients were performed to evaluate the potential for dose reduction in clinical conditions by measuring skin entrance doses with thermoluminescent dosimeters (TLDs). UVR provided better resolution (9 lp mm-1 as opposed to 8 lp mm-1) and contrast response than QFD. UVR has accommodated a wider exposure latitude than might be expected with conventional 400 speed class film-screen combinations. Use of UVR resulted in better image quality than use of QFD over a wide range of exposure factors. The use of UVR can result in a dose reduction of 50% with no loss in image quality.

Evaluation Studies as Topic↗
PubMed1976

The "Pooh Corner" vision study.

Two groups of children were screened by selected optometrical tests. Infants between the ages of 3 and 24 months and kindergarten children aged from 2 to 5 years were tested. The results indicated that meaningful data can be obtained from both groups and that the tests revealed visuosensory and visuomotor defects, correction of which at an early stage is not only desirable but, in most cases, essential.

Age Factors↗