Remote Screening And Self-Monitoring For Vision Loss Diseases Based On Smartphone Applications

Remote Healthcare Monitoring System (RHMS) represents remote observing of patient’s well-being and providing therapeutic services. Sensors play an essential part in RHMs. They measure the physical parameters and give continuous information to health organizations, doctors. The presence of Smartphones and other portable devices have allowed us to utilize remote healthcare monitoring system for an assortment of structures. Also, Wireless Sensor Network (WSN) advances considered as one of the critical research factor healthcare application for enhancing the standard of living. In this dissertation, I have presented three tiers operating in the remote healthcare monitoring system; the Body Area Network (BAN), the PAN Coordinator and the Back- Medical End System (BMEsys). The three tiers focused on several patients PAN coordinators include the Wireless Sensor Network. The Wireless Sensor Network can be used at the fixed tale-monitor location and periodic measurements. The Personal Digital Assistant (PDA) can be used in patients own home or community setting with continuous measurements and smartphones can be utilized anywhere with full range parameters, and I have provided a meaningful utilization comparison between Wireless Sensor Network, PDA and smartphone in Remote Healthcare Monitoring System (HRMs) architecture design. Evaluate the approaches of the healthcare monitoring system architecture and investigate the use of advanced technologies enabling the patient vital signs and diagnostic medical team in real-time. This dissertation demonstrates that how a Smartphone can be used for medical treatment in the field of Ophthalmology and discussed how a Smartphone and its technology could be used to diagnose loss of eye vision. Most recent smartphones have been equipped with a featured camera with high megapixels and advanced sensors which can be used to record fundus photographs through a slit lamp or record videos from an operating microscope and display images from optical coherence tomography systems and other high-tech devices. The ophthalmologists can share these images and analyze with their colleagues utilizing media sharing applications and make the optimal diagnostic and therapeutic results to diagnose the low vision of patients. At present, three widely used pocket-sized adapters can improve the magnification and lighting of the camera, which enables the smartphones to capture high-quality images of the eye. These are Portable Eye Examination Kit (PEEK), EyeGo, and D-Eye. Peek Adapter consists of a smartphone application and retina adapter which can be clipped onto the device and synchronized with the peek application for sharing and analyzing the images. This adapter can be used by anyone and anywhere in the world to examine eyes. EyeGo is an adapter intended to allow ophthalmologists and healthcare specialists to capture high-quality images of the eye using an ophthalmic lens. D-Eye Adapter is one of the extensively used adapters which yield excellent results. It consists of a portable eye and retinal system that fits onto a smartphone creating a retinal camera for evaluation and screening of the eye. It uses LED lights as a light source and requires no extra power, making it an ideal solution for portable diagnostics. The medical field has widely accepted these adaptors with the smartphones for diagnosing low vision and eye-related infections. In this dissertation, I also provide a meaningful utilization comparison between the smartphone adapters: D-Eye, EyeGo and Portable Eye Examination Kit (PEEK). In this dissertation, I have developed a new App (Remote Healthcare-Monitoring Mobile App) to help patients who have low vision and who are suffering from the diseases which may cause a vision loss. This app is capable of a process, evaluate, interact and store health data which is continuously measured by (Personal Health Monitors). This App can exchange the information directly to the Smartphone users (patients) and the doctor who allows more security and privacy. The idea of the App consists of the following: A Smartphone Application, a Data Collection Center, and Professionals in Ophthalmology. The patient should be registered in the system, for example, (Retina Michigan Center or Glaucoma Michigan Center). After registration, the patient is instructed on how to take photos of his/her eyes correctly, and then use the Smartphone application. The patient takes photos of his/her eyes and sends them to the data collection center, the specialists get access to these data and help in the treatment according to the analysis. Finally, I completed the development of the Mobile app (including the Skype and Viber links), which can help in exchanging the information between the patient and the doctor

The Empirical Evidence for the Telemedicine Intervention in Diabetes Management

Objective: The research presented here assesses the scientific evidence for the telemedicine intervention in the management of diabetes (telediabetes), gestational diabetes, and diabetic retinopathy. The impetus derives from the confluence of high prevalence of these diseases, increasing incidence, and rising costs, while telemedicine promises to ameliorate, if not prevent, type 2 diabetes and its complications. Materials and Methods: A purposeful review of the literature identified relevant publications from January 2005 to December 2013. These were culled to retain only credible research articles for detailed review and analysis. The search yielded approximately 17,000 articles with no date constraints. Of these, 770 appeared to be research articles within our time frame. A review of the abstracts yielded 73 articles that met the criteria for inclusion in the final analysis. Evidence is organized by research findings regarding feasibility/acceptance, intermediate outcomes (e.g., use of service, and screening compliance), and health outcomes (control of glycemic level, lipids, body weight, and physical activity.) Results: Definitions of telediabetes varied from study to study vis-à-vis diabetes subtype, setting, technology, staffing, duration, frequency, and target population. Outcome measures also varied. Despite these vagaries, sufficient evidence was obtained from a wide variety of research studies, consistently pointing to positive effects of telemonitoring and telescreening in terms of glycemic control, reduced body weight, and increased physical exercise. The major contributions point to telemedicine's potential for changing behaviors important to diabetes control and prevention, especially type 2 and gestational diabetes. Similarly, screening and monitoring for retinopathy can detect symptoms early that may be controlled or treated. Conclusions: Overall, there is strong and consistent evidence of improved glycemic control among persons with type 2 and gestational diabetes as well as effective screening and monitoring of diabetic retinopathy.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140288/1/tmj.2015.0029.pd

Management of neovascular age-related macular degeneration with ranibizumab: Long-term outcomes and second eye outcomes

Background: Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents are the established standard of care for neovascular age related macular degeneration (nAMD), however there are currently limited data on long-term outcomes of this therapy. Ranibizumab is one such anti-VEGF agent administered to treat nAMD. Patients diagnosed with nAMD undergo regular clinic based follow-up as part of their treatment, often on a monthly basis. Assessment during these appointments includes optical coherence tomography (OCT) scans, which can contribute to the detection of nAMD in the second eye. There is limited data on the symptomatic status, clinical presentation and outcomes of second eye nAMD whilst undergoing regular assessment for the first treatment eye under these conditions. Aims: The first aim of this thesis is to evaluate the long-term (5-year) outcomes of intravitreal ranibizumab (an anti-VEGF agent) in treating nAMD by examining a cohort within a real life clinic setting. The second aim is to compare the clinical presentation and treatment outcomes between the first and second treated eyes in patients that developed nAMD in both eyes, whilst under regular review for unilateral nAMD. Methods: A total of 208 patients (208 eyes) were included in a retrospective case series assessing the 5-year outcomes of nAMD treated with ranibizumab, entitled the long-term ranibizumab study (LTRS) (Chapter 3). Intervention was an individualised treatment model after three initial monthly loading doses. Visual acuity (VA), central macular thickness (CMT), qualitative OCT features, and adverse events (AE) were determined for each visit. Snellen VA was converted to Early Treatment Diabetic Retinopathy Study (ETDRS) letters for analysis. To assess outcomes of second eyes diagnosed with nAMD, a retrospective case series entitled second-eye ranibizumab study (SERS) forms the second part of this thesis (Chapter 4). Forty-five consecutive patients fulfilled the inclusion criteria of commencing treatment with ranibizumab in the first eye for nAMD between July 2007 and March 2011,and subsequently developing nAMD in the second eye with at least 12-months of follow-up in each eye. Treatment was administered under the same conditions as the LTRS. Snellen VA was measured, and OCT examination of both eyes at each visit assessed the presence of intra-retinal fluid (IRF) and sub-retinal fluid (SRF). Patient reported symptoms were recorded at every clinic visit. Paired t-tests were used to assess changes in VA and CMT over the study duration of the LTRS and SERS and two sample t- tests were used to evaluate VA differences between groups. Changes in VA compared to baseline were classified into the three categories: stable VA (loss or gain of ≤15 letters), improved VA (gain of >15 letters), or worse VA (loss of >15 letters). Linear regression was used to assess the effects of age, gender, number of injections, previous treatment, medical history, medications, and baseline VA on both VA and CMT changes. Chi-square test or Fisher’s exact test were used to measure proportions of patients with visual stability and OCT fluid free status at 12-months in the SERS. Results: In the LTRS, mean VA improved by 1.9 letters after 1 year (p=0.020) and decreased by 2.4 letters over 5-years of the treatment (p=0.040). At the end of year 5, 11.1% (23/208) of patients improved VA by more than 15 letters and 68.8% (143/208) of patients had stable VA, while 20.2% (42/208) patients lost more than 15 letters. Patients with VA less than 35 letters (approximate Snellen VA 6/60) at baseline showed significant VA improvement after 5-years of treatment (mean increase 11.5 letters, p=0.01), whilst those that were between 70 and 85 letters (approximate Snellen VA 6/12 to 6/6) at baseline showed a mean decrease (-12.9 letters, p=76 letters, or Snellen VA approximately 6/9)) showed greater stability of vision at 12-months vs. first treated eyes (p=0.05). There was no significant difference in mean VA change between first and second treated eyes. The proportion of OCT - fluid free eyes was higher amongst second treated eyes compared with first treated eyes at 12-months (70% vs. 40%, p=0.02). Intra-retinal fluid (IRF) was seen in 54% of second treated eyes at baseline compared with 84% in first treated eyes (p=0.01). Symptoms were absent in 54% of second treated eyes at baseline. The most common symptoms were “blurred vision” (28% of all patients) and metamorphopsia (11% of all patients). Conclusions: The visual gains achieved were not as significant as clinical trials, likely reflecting the differences in inclusion criteria of patients, and less rigorous follow-up and treatment. Intravitreal ranibizumab was effective in maintaining vision in patients with nAMD and reducing macula thickness over 5-years using an individualised treatment regime in a real-world setting.. Ranibizumab is a safe drug to use over 5-years in a real-world clinical setting. In patients undergoing treatment for nAMD in the first eye, OCT screening of the second eye at each visit may be necessary to detect second eye nAMD in this at-risk population. A large proportion of patients are asymptomatic at diagnosis of second eye disease, and a significant proportion of patients were detected to have treatable subfoveal nAMD with OCT alone. Second eye disease detected and treated by such a protocol showed a lower rate of IRF at baseline, suggesting early detection had occurred. Second eyes showed a higher rate of fluid free status at 12-months compared to the first treated eye, suggesting that early detection and treatment led to improved anatomical outcomes, potentially explaining superior VA outcomes. Patients commencing treatment in their second eye with good VA had better visual outcomes compared to those with worse VA

Clinical implications of persistent beta cell function in long duration type 1 diabetes

Type 1 diabetes was thought to be a disease of absolute insulin deficiency. However, recent evidence has shown that most people with Type 1 diabetes have persistent endogenous insulin production, even those with long disease duration. Close to diagnosis preserved beta cell function is associated with reduced HbA1c, hypoglycaemia and complication rates. However, very little is known about the clinical impact of persistent endogenous insulin in long duration diabetes. This thesis aims to assess the clinical impact of preserved beta cell function in long duration type 1 diabetes. During this analysis we identified the potential for glucagon to be used as a biomarker of hypoglycaemic risk. Intensive treatment is an integral part of diabetes management and is key to reducing the risk of both development and progression of microvascular complications. However, treatment induced hypoglycaemia poses a significant barrier to intensive treatment. Currently, prediction of those most at risk of hypoglycaemia is based on clinical information, such as diabetes duration, with no biomarkers used to assess hypoglycaemic risk. As such, this finding prompted an additional aim: to investigate the relationship between meal stimulated glucagon and hypoglycaemia in long duration type 1 diabetes. In Chapter 1 I review current evidence on the role and importance of persistent beta cell function in type 1 diabetes. In Chapter 2 I outline the methods of the TIGI Study, which provided the data for this project. In Chapter 3 I demonstrate that preserved beta cell function is associated with significantly reduced reported hypoglycaemia in long duration type 1 diabetes. In Chapter 4 I show that higher meal stimulated glucagon is associated with reduced hypoglycaemia rate in long duration type 1 diabetes, independent of HbA1c, C-peptide and disease duration. Chapter 5 discusses the findings of Chapters 3 and 4 and highlights areas for future research

Health System Analysis of Diabetes and Diabetic Retinopathy Services in Nigeria – The Case of Akwa Ibom State

This research project, undertaken for a MPH dissertation investigated and analysed the situation of diabetes and diabetic retinopathy services and management systems in four (4) government hospitals in Akwa Ibom State Nigeria using the World Health Organisation (WHO) Tool for the Assessment of Diabetic Retinopathy and Diabetes Management Systems (TADDS). Part A is the research protocol, which explains the background and the key components of this research study. This is a cross sectional descriptive case study involving primary data collection. We conducted the case study using the WHO TADDS to survey health personnel involved in the management of diabetes mellitus (DM) and diabetic retinopathy (DR) in four (4) government hospitals in Akwa Ibom State. Concurrently, semi-structured interviews were conducted with key informants to investigate and analyse the situation of DM and DR services in Akwa Ibom State in Nigeria. Part B is a structured literature review of published articles, online reports, and summaries related to DR. It covers the review of scientific evidence (clinical overview) about the aetiology and prevention of DR and the known risk factors; the review of epidemiological evidence on DM and DR globally and in sub-Saharan Africa (SSA); and the review of the evidence on effectiveness and cost-effectiveness of public health and health system interventions for the prevention and management of DR. Part C is the journal-ready manuscript. In this part, the format of the journal Ophthalmic Epidemiology was used to present the research project and its main findings. Part D contains all the relevant appendices used during the research project

Psychiatric Case Record

Bipolar Disorder-Mania: Patient was apparently normal one-month back, Then all of a sudden he developed sleep disturbances –mainly difficult in initiation of sleep. He also started abusing his family members for unwanted things. Subsequently, he started talking excessively and irritable. Sometimes he sings film songs and dances. He used to say that God Supreme exists in himself and so he has all the powers of Almighty. With that superior power he says that he can solve all the problems in this world. He also says that he has invented herbs to keep people young. For the past one week, he talks excessively without having an hour of sleep & wanders here and there & found excessively smoking. He becomes excessively spiritual and goes to near by villages for offering prayers to God. He takes only a little food everyday and he is very much keen in personal cleanliness. Paranoid Schizophrenia: She was apparently normal 8 months back, then she developed sleep disturbances in the form of difficult in falling asleep. She was found talking & smiling to herself at night & day with mirror gazing. She started saying that her neighbour & relatives are planning to kill herself by poisoning. In this context she had frequent quarrels with them and she refused to take food prepared by her mother in law. She left the home at night without informing any one and started wandering in the road side near her home. She was complaining that she hears voices as if her neighbour & relatives were talking about her among themselves She was not doing house hold activities for past 6 months and she was not taking care of her child. Her personal hygiene was very much deteriorated slowly as she used to take bath & brush, only if she was asked to do so. She started abusing & assaulting the strangers and family members. Generalised Anxiety Disorder: Six months back he was apparently normal. He is working as a system analyst in a private bank . He had once, made a mistake in his bank work for which he was given charges by his employer, followed this event he becomes very tense and afraid whenever his boss called him. He is very cautious that he should not commit any mistakes. Even though he is not doing so, he fears that he may commit some mistake in his work. At that moment he develops palpitation, giddiness, breathlessness, excessive sweating over palms and soles. Slowly these symptoms present through out the day even when he was not in his office, and he could not control his fearfulness. For the past 6 months he didn’t sleep well. His sleep is disturbed by bad dreams. Recurrent Depressive Disorder: Patient was apparently alright 2 months back. Then she developed sleep disturbances particularly early morning awakening, she use to wake up by 3.00 am and use to brood about herself and started crying. She was not doing her domestic work as before, as she felt excess tiredness and use to take frequent rests. She developed poor communication. She had lost her interest in pleasurable activities and was not interested in watching TV, and attending family gatherings. She stayed aloof most of the time & calm, quiet and withdrawn. She was expressing her helplessness and hopelessness about the future. She started to have decline in maintaining self care. 15 days back, she frequently expressed suicidal ideas and she had attempted suicide by hanging herself and was rescued by neighbours. 5 days back, she started talking in an irrelevant manner. She was smiling to self. She was assaulting her family members. She was suspicious that her neighbour had done black magic on her and also saying that people are talking about her. She reported hearing the voice of her neighbour scolding and threatening her. Organic Brain Syndrome – Dementia: Ten months back he was apparently alright. Then his relatives noticed himself frequently misplaces things inside his home. Then he started behaving aggressively. He was beating his wife without reason. He was roaming here and there, running out of home and wandering aimlessly. He was not able to come back home when he goes out. He was brought back to home by his relatives. Slowly he developed fearfulness and tremulousness while he was staying alone. He also started saying that his family members & neighbours were talking about himself, in this context he would make frequent quarrels with them. He also started hearing voices of known male voices abusing himself in third person. He sleeps for few hour only. He is passing urine and motion inside the house. He is asking about his brother and mother-in-law who were expired long back. He behaves abnormally such as pouring water in the plate while eating. And his relatives found the symptoms were worsened by evening. All these symptoms started insidiously, increased in severity through time and attained the present state. No history of loss of appetite / crying spells / suicidal tendencies / convulsions / fever / head injury

Clinical Studies into the Causes of Idiopathic Macular Telangiectasia Type 2: Sleep Apnoea and Macular Telangiectasia: The SAMTel Project

Purpose: To assess the prevalence of Obstructive Sleep Apnoea (OSA) in a population with Macular Telangiectasia Type 2 (MacTel) and how OSA impacts on MacTel progression. Methods: In this case-control study participants completed a questionnaire which incorporated the Berlin Questionnaire (BQ) and questions regarding anthropometric data and medical history. A subset was sequentially selected to undertake overnight sleep analysis using the ResMed ApneaLink™. Using data acquired from the Busselton Population and Medical Research Foundation participants were case-matched based on age, sex and body mass index (BMI) along with, where possible, the presence of hypertension and diabetes. Results: There were 57 (30 ApneaLink) MacTel and 183 controls, respectively. There was no difference in self-reported sleep disordered breathing outcomes between the cohorts using the BQ (p=0.95). Analysis of key indices from ApneaLink recordings found that those with an Apnoea – Hypopnoea Index (AHI) and Oxygen Desaturation Index (ODI) > 5 episodes per hour had a more advanced stage of MacTel (AHI p = 0.05, ODI p = 0.03). 2 year MacTel disease progression rates were unremarkable. Conclusion: Patients with MacTel have a high prevalence of OSA which appears to result in a more advanced form of the disease

Clinical Studies into the Causes of Idiopathic Macular Telangiectasia Type 2: Sleep Apnoea and Macular Telangiectasia: The SAMTel Project

Purpose: To assess the prevalence of Obstructive Sleep Apnoea (OSA) in a population with Macular Telangiectasia Type 2 (MacTel) and how OSA impacts on MacTel progression. Methods: In this case-control study participants completed a questionnaire which incorporated the Berlin Questionnaire (BQ) and questions regarding anthropometric data and medical history. A subset was sequentially selected to undertake overnight sleep analysis using the ResMed ApneaLink™. Using data acquired from the Busselton Population and Medical Research Foundation participants were case-matched based on age, sex and body mass index (BMI) along with, where possible, the presence of hypertension and diabetes. Results: There were 57 (30 ApneaLink) MacTel and 183 controls, respectively. There was no difference in self-reported sleep disordered breathing outcomes between the cohorts using the BQ (p=0.95). Analysis of key indices from ApneaLink recordings found that those with an Apnoea – Hypopnoea Index (AHI) and Oxygen Desaturation Index (ODI) > 5 episodes per hour had a more advanced stage of MacTel (AHI p = 0.05, ODI p = 0.03). 2 year MacTel disease progression rates were unremarkable. Conclusion: Patients with MacTel have a high prevalence of OSA which appears to result in a more advanced form of the disease

Retinal vessel traits and their association with diabetic retinopathy and cognitive decline in a population with type 2 diabetes

Background People with diabetes are at an increased risk of developing vascular disease, which is the leading cause of morbidity and mortality in this population. The retina is one of the few places in the body that offers noninvasive visualisation of the vascular system and thus provides a rich platform to evaluate local and systemic vascular disease. Recent advancements in retinal image analysis tools allow us to evaluate the retinal microvasculature in a more efficient and unbiased way compared to manual methods. Local retinal changes may provide insight into vascular disease prior to overt pathological changes. Aim The aim of this thesis was to explore and evaluate retinal vessel traits in relation to various manifestations of vascular disease, specifically diabetic retinopathy and cognitive decline, using prospectively collected data. In addition to undertaking this research, this PhD project also aimed to contribute to the collection of primary data from in ongoing longitudinal cohort in order to provide data not only for this project, but for many other future and ongoing projects. Methods Edinburgh Type 2 Diabetes Study is a cohort of 1,066 adults aged 60-75 years with type 2 diabetes living in the Lothian region of Scotland. Data were collected through research clinics as well as record linkage. Diabetic retinopathy status was obtained from the national screening programme and to evaluate cognitive decline, dementia diagnosis was obtained from a combination of medical records, death records and self-report. Cognitive decline was also evaluated using cognitive status derived from a battery of cognitive tests administered at baseline and then again after 10 years. Retinal images were analysed using VAMPIRE software for central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), arteriolar and venular tortuosity, fractal dimension and density. Results A total of 83 participants (11.6%) developed retinopathy over 10 years. After controlling for a wide number of cardiometabolic, diabetic and vascular risk factors, there was evidence of an association between increased venular tortuosity and incident retinopathy (odds ratio (OR) 1.51, 95% confidence interval (CI) 1.15 to 1.98, p = 0.003), as well as decreased standardised fractal dimension and incident retinopathy (OR 0.75, 0.58 to 0.96, p = 0.025). Of the total 1066, 106 (9.9%) were determined to have a dementia diagnosis after 10 years of follow-up. Cognitive decline, as measured by cognitive testing after 10 years, controlling for baseline cognitive status, was measured in the 581 returning participants. There were no independent associations between the retinal vessel traits and cognitive decline, using either dementia or the general intelligence factor, after controlling for various covariates. There was, however, evidence of age-related decreases in fractal dimension and density over the course of the study. Conclusions This thesis has provided evidence from the ET2DS that venular tortuosity and fractal dimension are independently associated with diabetic retinopathy. The independent associations were modest and need to be contextualised within the heterogeneity that exists within the supporting literature as well as replicated in other studies, but they provide exciting support for the use of the retinal vessel traits in future risk prediction modelling for diabetic retinopathy. There was no evidence of an association between the reported retinal vessel traits and cognitive decline. Novel findings regarding age-related decreases in fractal dimension and density are important as more information is coming to light regarding the vessel traits and their associations with vascular disease