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Background Morbidity and Mortality (M&M) conferences are widespread but vary in goals and methodology. Some focus on clinical enigmas while an increasing number utilize quality improvement (QI) tools to effect systems change. Little is known about the current state of US Neurology M&Ms. Methods We surveyed 56 US academic neurology departments regarding their M&Ms to understand the use of QI tools and assess variability. Additionally, we reviewed the evolution of M&Ms in our department. Results The survey was completed by 44 (80%) departments; 68% reported quarterly frequency with 61% discussing 1–2 safety events per conference. The number of written guidelines or protocols resulting from M&Ms in 2 years varied from 0 (14% of departments), 1–2 (45%), to >5 (5%). Institutional culture regarding quality and safety and conference timing were cited by 71% as important in improving participation. In our own department, the M&M format changed in 2014 based on a sentinel patient event combined with improving safety culture across the hospital: neurology M&Ms transformed into thematic quarterly conferences utilizing QI tools. Attendance increased 3-fold, and in 7 years, we have generated 26 guidelines or pathways with corresponding decision-support tools, among other improvement efforts, resulting in specific systems changes. Based on survey results and our experience, suggested M&M “best practices” include the use of just culture, peer review protection, safety event analysis with QI methodology, trainee involvement, and logistical optimization. Conclusion Structured M&Ms incorporating suggested QI-informed “best practices” can be highly effective in driving system change within neurology.

Background In older adults, vision impairment (VI) is associated with worse cognitive function. However, the relationship between midlife vision and future cognitive function remains unknown. Methods The Study of Women’s Health Across the Nation, Michigan site, is a longitudinal cohort of midlife women aged 42–52 years at baseline. Presenting Titmus visual acuity (VA) in the better-seeing eye was assessed at baseline and categorized as no or mild VI (VA ≥20/60), or moderate or worse VI (VA Results About 394 women aged 42–52 at baseline with a maximum follow-up of 20 years were included in this analysis. After covariate adjustment, moderate or worse VI was associated with lower EMBTi (β = −0.56, p = .012), EBMTd (β = −0.60, p = .009), and DSB (β = −0.84, p = .04). While we detected significant associations between VI and levels of cognitive function scores, rates of cognitive decline as individuals aged did not vary by VI status. Conclusion Moderate or worse VI, assessed during midlife, was associated with lower scores on measures of cognitive function over a 15-year period during which women transitioned from midlife to older adulthood.

Purpose The purpose of this study was to evaluate the ability to screen for glaucoma using a Food Drug Administration (FDA) Class II diagnostic digital fundus photography system used for diabetic retinopathy screening (DRS). Methods All research participants underwent a comprehensive eye examination as well as non-mydriatic 45°single photograph retinal imaging centered on the macula. Optic nerve images within the 45° non-mydriatic and non-stereo DRS image were evaluated by two methods: 1) grading by three glaucoma specialists, and 2) a computer-aided automated segmentation system to determine the vertical cup-to-disc ratio (VCDR). Using VCDR from clinical assessment as gold standard, VCDR results from two methods were compared to that from clinical assessment. Inter-grader agreement was assessed by computing intraclass correlation coefficient (ICC). In addition, sensitivity and specificity were calculated. Results Among 245 fundus photos, 166 images met quality specifications for analysis. Fifty images were not processed by the automated system due to the poor quality of the optic disc, and 29 images did not include the optic nerve head due to the patient movement during the photo acquisition. The ICC value for the VCDR between the gold standard clinical exam and the automated system was 0.41, indicating fair agreement. The ICC value between the three ophthalmologists and the gold standard was 0.51, 0.56, and 0.69, respectively, indicating fair to moderate agreement. Discussion Assessing the VCDR on non-mydriatic and non-stereo DRS fundus photographs by either the computer-aided automated segmentation system or by glaucoma specialists showed similar fair to moderate agreement. In summary, optic nerve assessment for glaucoma from these 45° non-mydriatic and non-stereo DRS images is not yet suitable for tele-glaucoma screening.

This article examines three key tours of the Stratford Festival from 1967 to 1986. In 1967, the Festival undertook its first and only cross-Canada tour in celebration of the Centennial. In 1973, the Festival staged its most direct production of cultural diplomacy with a Department of External Affairs sponsored tour of Europe. The Festival also went on a substantial tour of the United States in the winter of 1985/1986 with support from External Affairs. During these moments when the company left Stratford to perform elsewhere, the theatre brought with it a performance not only of Shakespeare but also of purported Canadian culture, and was motivated by not only by a cultural agenda but also a commercial one. Drawing on archival records of the Festival’s tours and attempts to gain state funding, this article charts the Festival’s turn away from domestic national touring to international touring and the calculations, done by both the theatre and the state, of the value involved in prioritizing touring outside of Canada over touring the nation. Ultimately, touring Canada was expensive, and was not seen as giving the same return on investment in terms of nationalist prestige, cultural diplomacy, and the attraction of tourists. I argue that through a claim to Canadian national culture, the Stratford Festival attempted to secure state support, with commercial interests for the Festival and town of Stratford at stake., Cet article examine trois tournées majeures effectuées par le Festival de Stratford entre 1967 et 1986. En 1967, le Festival avait entrepris sa première et unique tournée canadienne dans le cadre des célébrations du Centenaire. En 1973, il avait mis en scène sa production la plus directe de diplomatie culturelle en effectuant une tournée en Europe parrainée par le ministère des Affaires étrangères. Le Festival effectua également une importante tournée aux États-Unis durant l’hiver 1985-1986 avec le soutien des Affaires étrangères. Durant ces moments où la compagnie quittait Stratford pour se produire ailleurs, elle emportait avec elle non seulement Shakespeare, mais aussi ce qui était censé être la culture canadienne, et son programme n’avait pas seulement des motivations culturelles, mais aussi commerciales. À partir des documents d’archives des tournées du Festival et des tentatives d’obtenir un financement de l’État, cet article cartographie le trajet du Festival et son éloignement des tournées nationales au profit des tournées internationales, ainsi que les calculs, que faisaient tant le théâtre que l’État, pour évaluer la rentabilité des tournées à l’extérieur du Canada et celles à l’intérieur du pays. En fin de compte, les tournées canadiennes s’avéraient onéreuses et ne paraissaient pas offrir le même retour sur investissement pour ce qui était du prestige national, de la diplomatie culturelle et de l’attrait touristique. J’avance que, tout en se prévalant de la culture canadienne, le Festival de Stratford s’efforçait de s’assurer le soutien de l’État dans le but de valoriser ses intérêts commerciaux ainsi que la ville de Stratford.

SIGNIFICANCE This study increases foundational knowledge about the dynamic relationships between intraocular pressure (IOP), blood pressure (BP), and mean ocular perfusion pressure (MOPP) in the setting of steep Trendelenburg positioning and may inform medical decision making for patients in which this positioning is planned. PURPOSE The purpose of this study was to explore the demographic and clinical factors related to IOP, MOPP, and BP change during Trendelenburg positioning in a large sample of subjects. METHODS A single-cohort interventional study was conducted at the American Academy of Optometry 2017 annual meeting. Baseline demographic data were collected by a secure survey tool. IOP and BP were then measured while seated and again after 1 and 2 minutes in a steep Trendelenburg position. Raw and percentage differences for each variable were compared between time points, and regression analyses demonstrated factors related to change in IOP, BP, and MOPP during steep Trendelenburg positioning. RESULTS Median IOP increased from 16.3 mmHg (13.3 to 18.3 mmHg) at baseline to 25.0 mmHg (21.7 to 28.7 mmHg) at 1 minute after assuming the Trendelenburg position. More than 95% of individual eyes exhibited an IOP increase of at least 10%, and 45% had an IOP increase of 10 mmHg or greater. Correspondingly, MOPP fell from 50.3 mmHg (43.4 to 55.4 mmHg) at baseline to 36.3 mmHg (31.9 to 43.3 mmHg). Mean ocular perfusion pressure decreased by at least 10 in 90% of eyes. In multivariate regression analysis, factors independently related to percentage IOP increase were increasing weight, less myopic refractive error, lower baseline pulse, and lower baseline IOP (total r = 0.31, P < .001). Conversely, weight was the only variable independently related to percent MOPP change, and this relationship was weak (r = 0.05, P = .008). CONCLUSIONS Our results confirm that steep Trendelenburg positioning causes an increase in IOP and a decrease in MOPP in almost all eyes. Considering the identified causative factors will inform clinical education and provide foundational knowledge for future investigations.

Resilience may help people living with HIV (PLWH) overcome adversities to disease management. This study identifies multilevel resilience resources among African American/Black (AA/B) PLWH and examines whether resilience resources differ by demographics and neighborhood risk environments. We recruited participants and conducted concept mapping at two clinics in the southeastern United States. Concept Mapping incorporates qualitative and quantitative methods to represent participant-generated concepts via two-dimensional maps. Eligible participants had to attend ≥75% of their scheduled clinic appointments and did not have ≥2 consecutive detectable HIV-1 viral load measurements in the past two years. Of the 85 AA/B PLWH who were invited, forty-eight participated. Twelve resilience resource clusters emerged - five individual, two interpersonal, two organizational/policy and three neighborhood level clusters. There were strong correlations in cluster ratings for demographic and neighborhood risk environment comparison groups (r ≥ 0.89). These findings could inform development of theories, measures and interventions for AA/B PLWH.

Importance During the coronavirus disease 2019 (COVID-19) pandemic, eye care professionals caring for patients with sight-threatening diseases, such as glaucoma, have had to determine whether some patient appointments could safely get postponed, weighing the risk that the patient’s glaucoma could worsen during the interim vs the morbidity risk of acquiring COVID-19 while seeking ophthalmic care. They also need to prioritize appointment rescheduling during the ramp-up phase (when pandemic-associated service reductions are eased). Objective To describe a flexible and scalable scoring algorithm for patients with glaucoma that considers glaucoma severity and progression risk vs the presence of high-risk features for morbidity from COVID-19, using information from a large data repository. Design, Setting, and Participants In this cross-sectional study, patients with upcoming clinic appointments for glaucoma from March 16, 2020, to April 16, 2020, at an academic institution enrolled in the Sight Outcomes Research Collaborative (SOURCE) Ophthalmology Electronic Health Record Data Repository were identified. A risk stratification tool was developed that calculated a glaucoma severity and progression risk score and a COVID-19 morbidity risk score. These scores were summed to determine a total score for each patient. Main Outcomes and Measures Total scores and percentages of clinic appointments recommended for rescheduling. Results Among the 1034 patients with upcoming clinic appointments for glaucoma, the mean (SD) age was 66.7 (14.6) years. There were 575 women (55.6%), 733 White individuals (71%), and 160 Black individuals (15.5%). The mean (SD) glaucoma severity and progression risk score was 4.0 (14.4) points, the mean (SD) COVID-19 morbidity risk score was 27.2 (16.1) points, and the mean (SD) total score was 31.2 (21.4) points. During pandemic-associated reductions in services, using total score thresholds of 0, 25, and 50 points would identify 970 appointments (93.8%), 668 appointments (64.6%), and 275 appointments (26.6%), respectively, for postponement and rescheduling. The algorithm-generated total scores also helped prioritize appointment rescheduling during the ramp-up phase. Conclusions and Relevance A tool that considers the risk of underlying ophthalmic disease progression from delayed care receipt and the morbidity risk from COVID-19 exposure was developed and implemented, facilitating the triage of upcoming ophthalmic appointments. Comparable approaches for other ophthalmic and nonophthalmic care during the COVID-19 pandemic and similar crises may be created using this methodology.

There are few data on mid-life sensory health and its contribution to health and disability outcomes. The Study of Women’s Health Across the Nation—Michigan site (N=252 women, mean age=66.0 years) collected comprehensive data regarding ocular health to estimate the burden and correlates of vision impairment (VI) and unmet need for vision correction in this population. The prevalence of VI based on presenting and best-corrected visual acuity was 11.1% (95% CI 7.5,15.7) and 2.8% (95% CI 1.1,5.6), respectively. Thus, 75.0% of presenting VI was correctable, yet only 29.0% of women wore an appropriate eyeglass prescription. Black women and those with greater financial strain or less education were more likely to have presenting VI, but there were no differences in best-corrected VI. This presentation will include a discussion of the contributions of SWAN to the study of sensory aging, as well as methodological considerations for research from a mid-life aging cohort. Part of a symposium sponsored by Sensory Health Interest Group.

In this analysis of data from the Study of Women Across the Nation (SWAN), a longitudinal cohort study of mid-life women, we sought to describe the relationship between vision impairment (VI) during mid-life and future CF during the mid- to later-life transition period. Presenting visual acuity was assessed at baseline, between 1996-2000, using a Titmus occupational screener. “Mild” and “moderate to severe” VI were respectively categorized as visual acuity

Patients with CKD suffer from food aversion, anorexia, and malnutrition. Although olfaction has a significant role in determining food flavor, our understanding of olfactory impairment and of the olfaction-nutrition axis in patients with kidney disease is limited. We quantified odor identification, odor threshold, and subjective odor perception in a cohort (n=161) comprising 36 participants with CKD, 100 participants with ESRD, and 25 controls. We investigated olfaction-nutrition associations in these participants and examined a novel intervention to improve olfaction in ESRD. The mean odor identification score was lower in patients with CKD (75.6%±13.1%; P=0.02) and ESRD (66.8%±15.1%; P

Physicians and other licensed health professionals are involved in force-feeding prisoners on hunger strike at the US Naval Base at Guantanamo Bay (GTMO), Cuba, the detention center established to hold individuals captured and suspected of being terrorists in the wake of September 11, 2001. The force-feeding of competent hunger strikers violates medical ethics and constitutes medical complicity in torture. Given the failure of civilian and military law to end the practice, the medical profession must exert policy and regulatory pressure to bring the policy and operations of the US Department of Defense into compliance with established ethical standards. Physicians, other health professionals, and organized medicine must appeal to civilian state oversight bodies and federal regulators of medical science to revoke the licenses of health professionals who have committed prisoner abuses at GTMO.DoughertySM, LeaningJ, GreenoughPG, BurkleFMJr. Hunger strikers: ethical and legal dimensions of medical complicity in torture at Guantanamo Bay. Prehosp Disaster Med. 2013;28(6):1-9.

This article examines international, regional and national sources of law with respect to the rights of children and considers how a strict age of majority affects adolescents' access to health care. Using Rwanda as a case study, this article outlines how a high age of majority, combined with mandatory parental consent, creates barriers for Rwandan adolescents to prevent human immunodeficiency virus (HIV) transmission, learn their status and receive treatment for the disease. It further examines the relevant legal and policy framework of the Rwandan Government in order to suggest successful methods to gauge a child's maturity level for Rwanda and other countries. The article argues for the improvement of adolescents' level of participation in making health decisions, and thereby also increasing their access to HIV/acquired immune deficiency syndrome (AIDS) services.

Background. B-cell infiltrates are common in rejected kidney allografts, yet their composition is still unclear. The aim of our study was to characterize the clonal composition of B-cell infiltrates of rejected human kidney grafts. Methods. We used a molecular approach to characterize the partial B-cell repertoires of 5 failed human kidney grafts with detectable B-cell infiltrates. A comparison between the intragraft and blood repertoire was also conducted for 1 case. Results. Redundant sequences were observed in both blood and graft, although the level of clonal amplification was significantly higher for the graft. Somatic hypermutations (SHMs) were also more frequent in sequences found in the graft compared to the blood. The rate of nonsilent mutations was significantly higher in complementarity determining regions (CDRs) compared to framework regions in blood sequences as well as in graft sequences found at low frequency. In contrast, this preferential distribution was lost in sequences found at high frequency in the graft, suggesting a lack of affinity maturation in situ. Lastly, follicular dendritic cells were undetectable in CD20 + infiltrates in all samples examined. Conclusions. We provide here evidence that B-cell clones expand and undergo SHMs in situ. However, the even distribution of nonsilent SHM in high-frequency graft sequences together with the absence of follicular dendritic cells do not support the view that infiltrating B cells are part of functional germinal centers.

Dry eye disease is multifactorial in aetiology and complex in pathophysiology that makes its diagnosis clinically challenging. Although there are numerous tools for assessment of dry eye disease, no single test is sufficient for the diagnosis. Typically a combination of subjective symptoms and objective tests are used. The aim of this article is to review the available tests, including traditional tools and emerging technologies. This review includes a description of the test methodology, type of data collected, diagnostic reliability of data, benefits and limitations of each test, expected outcomes and tips for practical application.

Under international, regional, and domestic law, adolescents are entitled to measures ensuring the highest attainable standard of health. For HIV/AIDS, this is essential as adolescents lack many social and economic protections and are disproportionately vulnerable to the effects of the disease. In many countries, legal protections do not always ensure access to health care for adolescents, including for HIV/AIDS prevention, treatment, and care. Using Rwanda as an example, this article identifies gaps, policy barriers, and inconsistencies in legal protection that can create age-related barriers to HIV/AIDS services and care. One of the most pressing challenges is defining an age of majority for access to prevention measures, such as condoms, testing and treatment, and social support. Occasionally drawing on examples of existing and proposed laws in other African countries, Rwanda and other countries may strengthen their commitment to adolescents' rights and eliminate barriers to prevention, family planning, testing and disclosure, treatment, and support. Among the improvements, Rwanda and other countries must align its age of consent with the actual behavior of adolescents and ensure privacy to adolescents regarding family planning, HIV testing, disclosure, care, and treatment.

Earlier studies suggest that an inverse relationship exists between diabetes mellitus and exfoliation syndrome (ES). We evaluated the relationship between diabetes mellitus and ES while controlling for important covariates. In addition, we investigated whether glucose control, as measured by glycosylated hemoglobin (HbA1c) levels, differed between the subset of diabetic patients with and without ES.This retrospective case-control study included outpatients seen in Veterans Affairs Boston Healthcare System eye clinics. Exfoliation cases (n=328) and controls (n=328) were drawn from the same clinic and matched for age. For all participants, we ascertained diabetes status, sex, race, body mass index, and glaucoma status. Among patients with diabetes mellitus, we collected the 5 most recent HbA1c levels and type of diabetes control.Diabetes mellitus was present in 96 (29.2%) cases and in 114 (34.8%) controls. In multivariate analysis, no statistically significant relationship between diabetes mellitus and ES (OR=0.77; 95% CI, 0.55-1.07) was identified. When glaucoma status was added as a covariate, the results were essentially unchanged (OR=0.81, 95% CI, 0.57-1.14). Adjusted mean HbA1c levels were similar in diabetic patients with (6.85%; 95% CI, 6.66-7.04) and without (7.05%; 95% CI, 6.87-7.22) ES (P=0.14).In this predominately white male population, we did not observe a statistically significant relationship between diabetes mellitus and ES. In addition, HbA1c levels did not vary among diabetic patient based on exfoliation status.

Background A cranial nerve (CN) III palsy can be caused by a life-threatening aneurysm, typically of the posterior communicating artery. The “rule of the pupil” states the majority (96%) of such cases will present with abnormal pupil findings caused by compression of the fibers, located superficially along CN III. Careful examination of the size and reactivity of the pupils is critical. Case Report This case describes the complex management of a 79-year-old man with sudden-onset ptosis and diplopia consistent with a superior division CN III palsy. The pupils were normal, but because of the incomplete nature of the palsy the “rule of the pupil” could not be applied, and an aneurysm remained a threat. After urgent testing, microvascular infarct was deemed the cause. However, the palsy failed to resolve after 3 months. Further investigation found myasthenia gravis as the final diagnosis. Conclusions Several important points are outlined regarding CN III palsies. First, lack of pupil involvement in an incomplete palsy is not equivalent to pupil sparing in a complete palsy. Second, after initial diagnosis, if subsequent findings are no longer consistent, further investigation is warranted. Lastly, myasthenia gravis should be considered as a differential in apparent palsy cases.

Background There currently is a need for a non-invasive measure of renal fibrosis. We aim to explore whether shear wave elastography (SWE)-derived estimates of tissue stiffness may serve as a non-invasive biomarker that can distinguish normal and abnormal renal parenchymal tissue. Methods Participants with CKD (by estimated GFR) and healthy volunteers underwent SWE. Renal elasticity was estimated as Young’s modulus (YM) in kilopascals (kPa). Univariate Wilcoxon rank-sum tests were used. Results Twenty-five participants with CKD (median GFR 38 mL/min; quartile 1, quartile 3 28, 42) and 20 healthy controls without CKD underwent SWE performed by a single radiologist. CKD was associated with increased median YM (9.40 [5.55, 22.35] vs. 4.40 [3.68, 5.70] kPa; p = 0.002) and higher median intra-subject inter-measurement estimated YM’s variability (4.27 [2.89, 9.90] vs. 1.51 [1.21, 2.05] kPa; p