IMPORTANCE Retinal telescreening for evaluation of diabetic retinopathy (DR) in the primary care setting may be useful in reaching rural and underserved patients.OBJECTIVES To evaluate telemedicine retinal screenings for patients with type 1 or 2 diabetes and identify factors for ophthalmology referral in the North Carolina Diabetic Retinopathy Telemedicine Network. DESIGN, SETTING, AND PARTICIPANTSA preimplementation and postimplementation evaluation was conducted from January 6, 2014, to November 1, 2015, at 5 primary care clinics serving rural and underserved populations in North Carolina among 1787 adult patients with type 1 or 2 diabetes who received primary care at the clinics and obtained retinal telescreening to determine the presence and severity of DR. A total of 1661 patients with complete data were included in the statistical analysis.INTERVENTION Nonmydriatic fundus photography with remote interpretation by an expert. MAIN OUTCOMES AND MEASURESNumber of patients recruited, level of detected DR, change in rates of screening, rate of ophthalmology referral, percentage of completed referrals, and patient characteristics associated with varying levels of DR. RESULTSOf the 1661 patients (1041 women and 620 men; mean [SD] age, 55.4 [12.7] years), 1323 patients (79.7%) had no DR, 183 patients (11.0%) had DR without a need for an ophthalmology referral, and 155 patients (9.3%) had DR with a need for an ophthalmology referral. The mean rate of screening for DR before implementation of the program was 25.6% (1512 of 5905), which increased to 40.4% (1884 of 4664) after implementation. A total of 93 referred patients (60.0%) completed an ophthalmology referral visit within the study period. Older patients (odds ratio [OR], 1.28; 95% CI, 1.11-1.48) and African American patients (OR, 1.84; 95% CI, 1.24-2.73) or other racial/ethnic minorities (OR, 2.19; 95% CI, 1.16-4.11) had greater odds of requiring an ophthalmology referral compared with white and/or younger patients. Patients with higher hemoglobin A 1c levels (OR, 1.19 per unit change; 95% CI, 1.13-1.25 per unit change) and longer duration of diabetes (OR, 1.76 per decade; 95% CI, 1.53-2.02 per decade) had greater odds of DR requiring an ophthalmology referral. History of stroke (OR, 1.65; 95% CI, 1.10-2.48) and kidney disease (OR, 1.59; 95% CI, 1.10-2.31) were strongly associated with DR and ophthalmology referral. CONCLUSIONS AND RELEVANCEWhen implemented in the primary care setting, retinal telescreening increased the rate of evaluation for DR for patients in rural and underserved settings. This strategy may also increase access to care for minorities and patients with DR requiring treatment.

BACKGROUND: Risk factors for cardiovascular disease, the leading cause of death, have been documented in children as young as 3 years of age. Maternal environment (eg, exercise) influences fetal development and long-term health. Thus, the development of the fetal cardiovascular system during pregnancy is likely a preliminary indicator of cardiac health at birth and a proxy for the future risk of cardiovascular disease throughout life. OBJECTIVE: The purpose of this study was to assess the effects of supervised prenatal aerobic exercise at recommended levels on fetal cardiac function and outflow in the third trimester of pregnancy. We hypothesized that fetuses of aerobically trained women compared with fetuses of nonexercising women would exhibit increased cardiac function and greater cardiac output. STUDY DESIGN: Secondary data analyses of a 20-week, randomized controlled exercise intervention trial in pregnant women between 2015 and 2018 in Eastern North Carolina were performed. Eligibility criteria included pregnant women <16 weeks gestation, singleton pregnancy, aged 18e40 years, body mass index of 18.5e34.99 kg/m 2 , physician clearance letter for exercise participation, reliable transportation, and method of communication. Exclusion criteria included the presence of chronic conditions (eg, type 1 or 2 diabetes mellitus), current medications known to adversely affect fetal growth (eg, antidepressants), alcohol, smoking, or illicit drug use. The patient cohort consisted of 133 eligible pregnant women who were assigned randomly to either an aerobic exercise (n¼66) group that participated in 150 minutes of supervised, moderate-intensity (40-59% VO 2peak ; 12e14 on Borg Rating of Perceived Exertion) aerobic exercise per week or a nonexercising group (n¼61) that consisted of 150 minutes per week of light (<40% VO 2peak ) stretching and relaxation breathing techniques. Between 34 and 36 weeks gestation, a fetal echocardiogram was performed to assess fetal cardiac function, which included fetal heart rate, right-and left-ventricular stroke volume, stroke volume index, cardiac output, cardiac output index, and cardiac outflow that included pulmonary and aortic valve diameters, peak flow velocity, and peak flow velocity-time integral. Fetal activity state (quiet vs active) during the echocardiogram and maternal aerobic capacity served as covariates. Intention-to-treat and per-protocol (participants who attended !80% of exercise sessions) analysis of covariance regression models were performed. RESULTS: Of the 127 randomly assigned participants, 66 and 50 participants were included in the intention-to-treat and per-protocol analyses, respectively. Prenatal aerobic exercise significantly increased fetal right-ventricular cardiac measures of right ventricular stroke volume (P¼.001) and stroke index via velocity-time integral (P¼.003), right ventricular cardiac output (P¼.002), cardiac index via velocity-time integral (P¼.006), pulmonary artery diameter (P¼.02), and pulmonary valve velocity-time integral (P¼.03). Only in ...

IMPORTANCE Minimal information exists on the use of geographic information systems mapping for visualizing access barriers to eye care for patients with diabetes.OBJECTIVE To use geographic information systems mapping techniques to visualize (1) the locations of patients participating in the North Carolina Diabetic Retinopathy Telemedicine Network, (2) the locations of primary care clinicians and ophthalmologists across the state, and (3) the travel times associated with traveling to the 5 primary care clinics in our study.

Objective: To evaluate the association of sex and pregnancy status with rates of naloxone administration during opioid overdose-related emergency department (ED) visits using the Nationwide Emergency Department Sample (NEDS).Methods: A retrospective cohort study was conducted using NEDS 2016 and 2017 datasets. Eligible records included men and women, 15-49 years of age, with an opioid overdose-related ED visit; records for women were stratified by pregnancy status (ICD-10 O codes). A multivariable logistic regression model was used to assess the primary outcome of naloxone administration (CPT code: J2310). Secondary outcomes included subsequent admission and mortality. A subgroup analysis compared pregnant women who did versus did not receive naloxone.Results: Records from 443,714 men, 304,364 non-pregnant women, and 25,056 pregnant women were included. Non-pregnant women had lower odds for naloxone administration (1.70% vs 2.10%; aOR: 0.86(0.83-0.89)) and mortality (2.21% vs 2.99%; aOR: 0.71(0.69-0.73)) but higher odds of subsequent admission (30.22% vs 27.18%; aOR: 1.04(1.03-1.06)) compared with men. Pregnant women had lower odds for naloxone administration (0..27% vs 1.70%; aOR: 0.16(0.13-0.21)) and mortality (0.41% vs 2.21%; aOR: 0.28(0.23-0.35)) but higher odds of subsequent admission (40.50% vs 30.22%; aOR: 2.04(2.00-2.10)) compared with non-pregnant women. Pregnant women who received naloxone had higher odds of mortality (14% vs 0.39%; aOR: 6.30(2.11-18.78)) compared with pregnant women who did not receive naloxone. Pregnant

Background: Neonatal abstinence syndrome is an array of signs and symptoms experienced by a newborn due to abrupt discontinuation of intrauterine exposure to certain drugs, primarily opioids. In the United States, the incidence of neonatal abstinence syndrome has tripled over the past decade. The current standard of care for drug testing includes the analysis of infant urine and meconium. Sample collection is associated with several limitations, including diaper media interferences, limited sample amount, sample heterogeneity, and the need for professional staff for collection. Umbilical cord tissue has emerged as a convenient sample matrix for testing owing to its universal availability. The purpose of this study was to examine umbilical cords using an untargeted metabolomics approach to determine the detected drugs and validate an analytical method to confirm and quantify the identified drugs. Methods: A metabolomics analysis was performed with 21 umbilical cords to screen for drugs and drug metabolites by liquid chromatography–mass spectrometry. Drugs were identified using the National Institute of Standards and Technology database, and an analytical method was developed and validated using secondary liquid chromatography–mass spectrometry instrument for positive confirmation and quantitative analysis. Results: Twenty-one random umbilical cords from women were tested: 4 were positive for cocaine and the primary and secondary metabolites; one was positive for methadone, the primary metabolite; 3 were positive for cotinine, the metabolite of nicotine; and 5 were positive for acetyl norfentanyl. Conclusions: Our research is a prospective method development study using untargeted and targeted approaches to characterize steady-state drug metabolite levels in the umbilical cord matrix at the time of delivery. By characterizing drug type and concentration, this methodology can be used to develop a reliable complementary testing method for meconium toxicology screens.

PurposeTo determine if there are systematic differences in cup-to-disc ratio (CDR) grading using fundus biomicroscopy compared to stereoscopic disc photograph reading.MethodsThe vertical cup-to-disc ratio (VCDR) and horizontal cup-to-disc ratio (HCDR) of 2200 eyes (testing set) were graded by glaucoma subspecialists through fundus biomicroscopy and by a reading center using stereoscopic disc photos. For validation, the glaucoma experts also estimated VCDR and HCDR using stereoscopic disc photos in a subset of 505 eyes that they had assessed biomicroscopically. Agreement between grading methods was assessed with Bland-Altman plots.ResultsIn both sets, photo reading tended to yield small CDRs marginally larger, but read large CDRs marginally smaller than fundus biomicroscopy. The mean differences in VCDR and HCDR were 0.006±0.18 and 0.05±0.18 (testing set), and -0.053±0.23 and -0.028±0.21 (validation set), respectively. The limits of agreement were ~0.4, which is twice as large as the cutoff of clinically significant CDR difference between methods. CDR estimates differed by 0.2 or more in 33.8-48.7% between methods.ConclusionsThe differences in CDR estimates between fundus biomicroscopy and stereoscopic optic disc photo reading showed a wide variation, and reached clinically significance threshold in a large proportion of patients, suggesting a poor agreement. Thus, glaucoma should be monitored by comparing baseline and subsequent CDR estimates using the same method rather than comparing photographs to fundus biomicroscopy.

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