Agnieshka Baumritter

Predictors for the development of referral-warranted retinopathy of prematurity in the telemedicine approaches to evaluating acute-phase retinopathy of prematurity (e-ROP) study.

IMPORTANCE Detection of treatment-requiring retinopathy of prematurity (ROP) involves serial eye examinations. An ROP prediction model using predictive factors could identify high-risk infants and reduce required eye examinations. OBJECTIVE To determine predictive factors for the development of referral-warranted (RW) ROP. DESIGN, SETTING, AND PARTICIPANTS This multicenter observational cohort study included secondary analysis of data from the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity Study. Infants included in the study had a birth weight (BW) of less than 1251 g. EXPOSURES Serial ROP examinations of premature infants who had 2 or more ROP examinations. MAIN OUTCOMES AND MEASURES Incidence of RW-ROP (defined as the presence of plus disease, zone I ROP, or ROP stage 3 or greater in either eye) and associations with predictive factors. RESULTS Among 979 infants without RW-ROP at first study-related eye examination (median postmenstrual age, 33 weeks; range, 29-40 weeks) who underwent at least 2 eye examinations, 149 (15.2%) developed RW-ROP. In a multivariate model, significant predictors for RW-ROP were male sex (odds ratio [OR], 1.80; 95% CI, 1.13-2.86 vs female), nonblack race (OR, 2.76; 95% CI, 1.50-5.08 for white vs black race and OR, 4.81; 95% CI, 2.19-10.6 for other vs black race), low BW (OR, 5.16; 95% CI, 1.12-7.20 for ≤500 g vs >1100 g), younger gestational age (OR, 9.79; 95% CI, 3.49-27.5 for ≤24 weeks vs ≥28 weeks), number of quadrants with preplus disease (OR, 7.12; 95% CI, 2.53-20.1 for 1-2 quadrants and OR, 18.4; 95% CI, 4.28-79.4 for 3-4 quadrants vs no preplus disease), stage 2 ROP (OR, 4.13; 95% CI, 2.13-8.00 vs no ROP), the presence of retinal hemorrhage (OR, 4.36; 95% CI, 1.57-12.1 vs absence), the need for respiratory support (OR, 4.99; 95% CI, 1.89-13.2 for the need for controlled mechanical ventilator; OR, 11.0; 95% CI, 2.26-53.8 for the need for high-frequency oscillatory ventilation vs no respiratory support), and slow weight gain (OR, 2.44; 95% CI, 1.22-4.89 for weight gain ≤12 g/d vs >18 g/d). These characteristics predicted the development of RW-ROP significantly better than BW and gestational age (area under receiver operating characteristic curve, 0.88 vs 0.78; P < .001). CONCLUSIONS AND RELEVANCE When controlling for very low BW and prematurity, the presence of preplus disease, stage 2 ROP, retinal hemorrhage, and the need for ventilation at time of first study-related eye examination were strong independent predictors for RW-ROP. These predictors may help identify infants in need of timely eye examinations.

The Efficacy of Motivational Interviewing Versus Brief Advice for Adolescent Smoking Behavior Change

OBJECTIVE: In this study we sought to evaluate the efficacy of motivational interviewing (MI) compared with structured brief advice (SBA) for adolescent smoking behavior change. METHODS: Participants (N = 355) were randomly assigned to 5 sessions of either MI or SBA. The primary outcomes were attempts to reduce and to quit smoking, smoking reduction, and cotinine-validated 7-day point-prevalence smoking abstinence at the end of treatment (week 12) and the 24-week follow-up. RESULTS: White adolescents were ∼80% less likely to attempt to cut back (odds ratio [OR]: 0.21; confidence interval [CI]: 0.08–0.53) and >80% less likely to attempt to quit smoking compared with black adolescents (OR: 0.17 [CI: 0.06–0.46]). Adolescents who were at least planning to cut back or quit smoking at baseline were almost 3 times more likely to attempt to cut back (OR: 2.87 [CI: 1.26–6.52]) and to attempt to quit smoking (OR: 3.13 [CI: 1.19–8.26]). Adolescents who received MI were ∼60% less likely than adolescents who received SBA to try to quit smoking (OR: 0.41 [CI: 0.17–0.97]). However, adolescents who received MI showed a greater reduction in cigarettes smoked per day than adolescents who received SBA (5.3 vs 3.3 fewer cigarettes per day). There were no statistically significant differences between MI and SBA in smoking abstinence (5.7% vs 5.6%, respectively). CONCLUSIONS: The effects of MI on adolescent smoking behavior change are modest, and MI may best fit within a multicomponent smoking cessation treatment approach in which behavior change skills can support and promote smoking behavior change decisions.

A Comparison of Strategies for Retinopathy of Prematurity Detection

BACKGROUND AND OBJECTIVES: Delayed detection of type 1 retinopathy of prematurity (ROP) can lead to permanent visual impairment. Providing ROP examinations is challenging because of the limited ophthalmology workforce. This study compares digital imaging–based ROP detection strategies versus serial ROP examinations. METHODS: We conducted an individual-level microsimulation studyof a hypothetical cohort of 650 infants with gestational age from 23 to 30 weeks. Infants were evaluated by using strategies based on indirect ophthalmoscopy or digital imaging beginning at 32 weeks’ postmenstrual age (PMA) and continuing to discharge, transfer, or 40 weeks’ PMA. ROP status and the accuracy of digital imaging were based on the e-ROP (Telemedicine Approaches to Evaluating Acute-Phase ROP) study, which enrolled high-risk infants. RESULTS: Within the hypothetical NICU, the strategy of ROP examinations identified an average of 45.8 cases of type 1 ROP by discharge, transfer, or 40 weeks’ PMA, and another 1.9 cases were included in the group of infants recommended to have later follow-up. Digital imaging with an ROP examination at discharge identified all 47.7 cases of type 1 ROP. On average, the ROP examination–only strategy required 1745.7 ROP examinations, whereas digital imaging with a discharge examination required 1065.5 ROP examinations and 1786.2 digital imaging sessions. CONCLUSIONS: Although digital imaging decreased the number of ROP examinations per infant, there was an increase in the total number of interventions (ie, ROP examinations and imaging sessions). Providing an ROP examination at the time of NICU discharge can significantly reduce the number of infants who require follow-up.

Participant- and study-related characteristics predicting treatment completion and study retention in an adolescent smoking cessation trial.

PURPOSE To determine which factors predict smoking cessation treatment completion and retention among adolescents. METHODS In a multisite, randomized, controlled trial, the efficacy of motivational interviewing was compared with structured brief advice for smoking cessation and reduction in adolescents (n = 355) aged 14-18 years (55% female, 45% black, 12% Hispanic). Treatment spanned 12 weeks, with follow-up assessments at 24 weeks. Treatment completion was defined as completion of all five counseling sessions. Study retention was defined as completing the 24-week assessment. Participant and study variables served as predictors of treatment completion and retention. RESULTS In all, 79% of participants completed all five counseling sessions and the same percent completed the 24-week assessment. Black race, precontemplation stage to cut back, and shorter length of time between the baseline assessment and the first counseling session were significantly associated with treatment completion. For every 7.5-day delay in starting treatment after the baseline visit, there was a 50% decrease in the odds of completing all five treatment sessions. Retention at 24 weeks was predicted by black race, younger age, greater maternal education, expectations of graduating college, and structured brief advice intervention. CONCLUSIONS High rates of treatment completion and study retention can be achieved in a multisession, behavioral intervention for adolescent smoking cessation. Findings suggest that treatment should begin soon after the intake session to maximize treatment completion. Enhanced efforts to retain older adolescents and youth with lower academic goals and lower family income will be important in future studies.

Impact of number and quality of retinal images in a telemedicine screening program for ROP: results from the e-ROP study

BACKGROUND Telemedicine for the detection of retinopathy of prematurity (ROP) is becoming increasingly common; however, obtaining the required multiple retinal images from an infant can be challenging. This secondary analysis from the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) study evaluated the detection of referral-warranted ROP (RW-ROP) by trained readers when a full set of 5 retinal images could not be obtained. METHODS A total of 7,905 image sets from 1,257 infants in the study were evaluated. Retinal location of images and image quality were recorded. Sensitivity and specificity of RW-ROP detection by trained readers were calculated by comparing findings in incomplete image sets to the findings on standard eye examination. RESULTS The majority of image sets contained all 5 retinal images (92.8%). The disk center view was the image most likely to be present and to be of acceptable image quality (96.8%). The nasal retina was the most difficult to obtain with acceptable image quality (83.4%). Sensitivity of detection of RW-ROP was 82.1% when 5 retinal images of acceptable quality were submitted for grading, 67.2% when 4 acceptable images were submitted, and 66.7% for 3 or fewer acceptable images (P = 0.02), with corresponding specificity of 82.2%, 89.0%, and 81.7% respectively (P < 0.0001). When images of any quality were evaluated, sensitivity was not increased (P = 0.74). CONCLUSIONS The likelihood of detecting RW-ROP by telemedicine screening is decreased when a full set of retinal images is not obtained.

Retinopathy of prematurity risk prediction for infants with birth weight less than 1251 grams.

OBJECTIVE To predict retinopathy of prematurity (ROP) exam findings among infants with birth weight <1251 g from 32-40 weeks postmenstrual age (PMA). STUDY DESIGN Secondary analysis of 3714 eye exams from 1239 infants. RESULTS The likelihood of developing type 1 ROP by 40 weeks PMA varied by gestational age (GA) (P < .001), from 33% for ≤25 weeks, 10% for 26 or 27 weeks, 4% for 28 or 29 weeks, and none for ≥30 weeks. By 40 weeks PMA, 51% with GA ≤27 weeks still needed subsequent exams. Previous exam findings, GA, and PMA were predictive of the development of type 1 ROP (area under the curve, 0.78) or mature retina (area under the curve, 0.85). CONCLUSIONS This analysis provides the opportunity for development of an ROP approach to estimate resource needs in the neonatal intensive care unit and to facilitate communication with families when planning discharge or transfer.

A Tiered Approach to Retinopathy of Prematurity Screening (TARP) Using a Weight Gain Predictive Model and a Telemedicine System

Importance The Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) Study telemedicine system of remote fundus image grading and The Children’s Hospital of Philadelphia Retinopathy of Prematurity (CHOP-ROP) postnatal weight gain predictive model are 2 approaches for improving ROP screening efficiency. Current screening has low specificity for severe ROP. Objective To describe a tiered approach to ROP screening (TARP) for identifying children who develop severe ROP using telemedicine and a predictive model synergistically. Design, Setting, and Participants This investigation was a post hoc analysis of a cohort in the e-ROP Study (a multicenter prospective telemedicine study) and the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study (a multicenter retrospective cohort study). The setting was neonatal intensive care units at The Children’s Hospital of Philadelphia and the Hospital of the University of Pennsylvania. Participants in the e-ROP Study were premature infants with a birth weight less than 1251 g and a known ROP outcome enrolled between May 25, 2011, and October 31, 2013. The G-ROP Study enrolled all infants undergoing ROP examinations with a known ROP outcome who were born between January 1, 2006, and December 31, 2011. Main Outcomes and Measures The mean outcomes were the sensitivity for type 1 ROP, reductions in infants requiring imaging or examinations, numbers of imaging sessions and examinations, and total clinical encounters (imaging sessions and examinations combined). The following 4 screening approaches were evaluated: ROUTINE (only diagnostic examinations by an ophthalmologist), CHOP-ROP (birth weight and gestational age, with weekly weight gain initiating examinations when the risk cut point is surpassed), e-ROP IMAGING (trained reader grading of type 1 or 2 ROP initiates diagnostic examinations), and TARP (CHOP-ROP alarm initiates imaging, and imaging finding of severe ROP initiates diagnostic examinations). Results A total of 242 infants were included in the study, with a median birth weight of 858 g (range, 690-1035 g). The median gestational age was 27 weeks (range, 25-29 weeks). Fifty-one percent (124 of 242) were female, and 49% (118 of 242) were male. The race/ethnicity was 27.3% (66 of 242) white, 56.2% (136 of 242) black, 2.1% (5 of 242) Native American, 1.7% (4 of 242) Asian, and 12.8% (31 of 242) other. The sensitivity for detecting type 1 ROP (32 infants) was 100% (95% CI, 89.3%-100%) with each approach. With ROUTINE, 242 infants had 877 examinations; with CHOP-ROP, 184 infants had 730 examinations; with e-ROP IMAGING, 242 infants had 532 imaging sessions, and 94 infants had 345 examinations (877 patient encounters); and with TARP, 182 infants had 412 imaging sessions, and 87 infants had 322 examinations (734 patient encounters). Conclusions and Relevance The tiered approach to ROP screening was associated with a reduced number of examinations and imaging sessions compared with the other approaches. Applying a postnatal growth model and telemedicine system in a tiered approach may reduce the number of clinical ROP interventions more than either approach alone.

Detection of Potentially Severe Retinopathy of Prematurity by Remote Image Grading

Importance Telemedicine in retinopathy of prematurity (ROP) has the potential for delivering timely care to premature infants at risk for serious ROP. Objective To describe the characteristics of eyes at risk for ROP to provide insights into what types of ROP are most easily detected early by image grading. Design, Setting, and Participants Secondary analysis of eyes with referral-warranted (RW) ROP (stage 3 ROP, zone I ROP, plus disease) on diagnostic examination from the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) study was conducted from May 1, 2011, to October 31, 2013, in 1257 premature infants with birth weights less than 1251 g in 13 neonatal units in North America. Data analysis was performed between February 1, 2016, and June 5, 2017. Interventions Serial imaging sessions with concurrent diagnostic examinations for ROP. Main Outcomes and Measures Time of detecting RW-ROP on image evaluation compared with clinical examination. Results In the e-ROP study, 246 infants (492 eyes) were included in the analysis; 138 (56.1%) were male. A total of 447 eyes had RW-ROP on diagnostic examination. Image grading in 123 infants (mean [SD] gestational age, 24.8 [1.4] weeks) detected RW-ROP earlier than diagnostic examination (early) in 191 (42.7%) eyes by about 15 days and detected RW-ROP in 123 infants (mean [SD] gestational age, 24.6 [1.5] weeks) at the same time (same) in 200 (44.7%) eyes. Most of the early eyes (153 [80.1%]) interpreted as being RW-ROP positive on imaging evaluation agreed with examination findings when the examination subsequently documented RW-ROP. At the sessions in which RW-ROP was first found by examination, stage 3 or more in 123 infants (mean [SD] gestational age, 24.8 [1.4] weeks) ROP was noted earlier on image evaluation in 151 of 191 early eyes (79.1%) and in 172 of 200 of same eyes (86.0%) (P = .08); the presence of zone I ROP was detected in 57 of 191 (29.8%) early eyes vs 64 of 200 (32.0%) same eyes (P = .90); and plus disease was noted in 30 of 191 (15.7%) early eyes and 45 of 200 (22.5%) same eyes (P = .08). Conclusions and Relevance In both early and same eyes, zone I and/or stage 3 ROP determined a significant proportion of RW-ROP; plus disease played a relatively minor role. In most early RW-ROP eyes, the findings were consistent with clinical examination and/or image grading at the next session. Because ROP telemedicine is used more widely, development of standard approaches and protocols is essential.

Intereye Agreement of Retinopathy of Prematurity from Image Evaluation in the Telemedicine Approaches to Evaluating of Acute-Phase ROP (e-ROP) Study

PURPOSE To determine the symmetry on retinal image grading of fellow eyes for retinopathy of prematurity (ROP) features (stage, zone and plus disease) and severity, to provide the basis for the within subject comparison for ROP trials. DESIGN Secondary analyses of data from the Telemedicine Approaches to Evaluating of Acute-Phase ROP (e-ROP) Study. SUBJECTS Infants with birth weight less than 1251g. METHODS Infants underwent serial retinal imaging sessions in both eyes by certified imagers starting at 32-weeks postmenstrual age (PMA). Two trained non-physician readers graded each eye independently for ROP features in a 5 retinal-image set from each session. Discrepancies were adjudicated by a reading center supervisor. Readers were masked to all eye examination results, previous gradings of both eyes, current grading of the fellow eye, and demographic data. MAIN OUTCOME MEASURES The inter-eye agreement assessed using percent exact agreement and weighted kappa (Kw ) for stage, zone, plus, referral-warranted ROP (RW-ROP, defined as presence of stage 3 or above, plus disease, or zone I ROP), and severity of ROP. RESULTS Among 3918 image sessions in 1235 infants, the percent agreement (Kw ) between paired eyes was 75.3% (0.65) for stage of ROP, 82.3% (0.68) for zone of ROP, 78.7% (0.51) for plus disease, 84.7% (0.56) for RW-ROP, and 72.7% (0.63) for severity of ROP. Similar inter-eye agreements were found when considering ROP features at the first image session, at the last image session, at any image session. Based on image evaluations from all sessions, 412 (33.4%) infants had ROP stage 3 or above, 148 (12.0%) had zone I ROP, 70 (5.7%) had plus disease, and 419 (33.9%) had RW-ROP in one or both eyes; symmetrical findings were present in 71.4% for ROP stage 3 or above, 56.8% for zone I ROP, 50.0% for plus disease, and 73.7% for RW-ROP. CONCLUSIONS Masked image evaluations by trained readers showed good inter-eye agreement in ROP characteristics, consistent with the high inter-eye agreement in ROP from clinical examinations by ophthalmologists in other studies. These data confirm that acute ROP is typically symmetrical and supports within subject comparison in ROP trials.