 Next up we have, and I butcher your name every time, Daniel Agraws, close enough, yeah. So he's here from Nebraska, so he's a friend of Russell Swan, so he's a friend of ours, but he's also going to be talking about pediatrics as well, and screening, and then yours is... Thank you very much. Well, good morning everyone. As Rhys said, my name is Daniel, visiting fourth year from Nebraska. I know Brent made the comment, and I'll make the comment as well. I talked a little bit to Russell before I came here, and he definitely said hello, which everybody's doing well, so. Today's presentation I just wanted to talk about. Obviously community outreach isn't anything new here at the Moran. In fact, it's one of the reasons why I wanted to take the opportunity to do a rotation here. Today I'll be presenting a talk, just kind of talking about what's going on back home in Omaha, about an organization specifically designed with the intention of community outreach. Building Healthy Futures isn't just a title of my talk. It's a nonprofit back home that aims to improve the health of the Omaha community. It's underserved children and youth through thoughtful collaboration and advocacy. It works with public schools in Omaha and four major health care systems in Douglas County to provide health care. Services implemented by this organization up to this point include school-based health centers, the Child Oral Health Collaborative, and the Child Vision Collaborative. As far as just kind of some quick hits as to the students served by Building Healthy Futures back home, 60% of children are enrolled in Medicaid or state children's health insurance programs. In addition, school service by Building Healthy Futures have an average free and reduced lunch rate of 90.5%. In addition, the average English language learner rate in these schools is about 30.9%. I will be more specifically talking today about the Child Vision Collaborative and just kind of talking a little bit about what that is. I'll first start just by reading off their aim, which is the following. To create a coordinated system for vision care that includes education, screening, diagnosing treatment for underserved children in our city's most impoverished communities by maximizing resources through cross-sector and interdisciplinary partnerships. This is a collaborative form in February of 2015. Just a quick timeline of just since it's been formed in July of 2015, the Child Vision Collaborative teamed up with one site, an international organization aimed at increasing access to vision care to organize a school-based vision program. In between from August to December of 2015, a vision screening protocol was developed. In addition, just a couple pilot schools were identified just to conduct a pilot screening. And finally, this past spring, a pilot vision screening was conducted to identify the best practices for screening a large population of students. Eight sites were selected. They included six elementary, one middle and one high school. Overall, about 5,000 students, 4,994, received vision screening in February of 2016, and over 120 volunteers contributed their time and effort to this project. As I'm sure everybody knows in this room, vision is very important in our daily lives. I just want to touch a couple points how it pertains to learning in children in the school age. 80% of learning is dependent on a child's vision. 75% of a typical school day involves visual activities. In addition, one in four children have undiagnosed eye problems that appear with learning and can lead to academic and or behavioral problems. For example, maybe a child could be misdiagnosed with ADHD, but really their manager is just a visual problem where they can't focus or can't see the images. In addition, children frequently do not report symptoms because they think everyone sees the same way they do. So I'm going to talk a little bit next about the vision screening protocol and what it entailed. So they just did a very comprehensive vision screening with the aim of trying to find the best and most efficient methods to identify a large population of students. They incorporated the use of a spot vision screener manufactured by a wall of talent. It's a very cool device, hold it about three feet away from the student, takes about two seconds, takes a photo, makes some noise to attract the child's attention. And in that process, it measures pupillary diameter, ocular alignment, estimated by an ocular refraction, and it kind of recommends our values within normal limits or does it recommend referral. In addition, traditional cell and eye chart visual acuity was measured with referral with a visual acuity of 20 over 40 or worse. In addition, near vision testing, the stereopsis fly testing, when we put on those full 3D glasses and kind of test their depth perception. In addition, color testing, and if just parents had a general vision concern, anything they kind of thought maybe was off with their child's vision, that also prompted recommended referral. Should a student have a recommended referral, comprehensive eye exams, along with providing free frames and glasses performed by the one-site vision van and four private vision clinics in the MWAP community was available. So, talking a little bit about the results, as I mentioned previous, about 5,000 students were screened. 1,669 or 33% of these students were recommended for referral. At the end of this kind of initial pilot screening, the students actually receiving formal eye exams was 500 or 30% of students for referral was recommended. This was in large part, the resources were available to screen all the students recommended for referral. But there was a consent form process, which I will talk down the line, where it was a very good learning point on this initial pilot screening. For the students who were examined, 340 students received consent from their parents to be part of this study. And these are the results we'll be talking about here shortly. As you can see, just kind of on the first graph on the left, initially the prime goal was to say of these 340 students that were recommended for referral, how were these patients or how were these students identified? The first bar just kind of shows which patients were identified just solely by vision screener, which was 68%. Those strictly identified by visual acuity was 61%. Using a combination of visual screening and visual acuity, identified 89% of the students recommended for referral. In addition, about 10% for 36 students out of the 340 were identified by testing not visual acuity or visual screening. Could be the color testing, stereopsis, or just general referral by the parents. Kind of looking a step further of these 340 students who were examined, how many of them kind of received glasses or who needed to correct the lenses. That would kind of bring us to the pie chart on the right, which in green shows the percentage of students who did receive corrective lenses, which we were happy to see was a large amount, 80%. And as you can see with the grade, 20% did not receive corrective lenses. The next question that the collaborative owner now was of these patients who did receive corrective lenses, how effective were the tools they were using to identify these patients? Let's bring this next to the next point here about the graphs where we kind of broke down the data to students that received corrective lenses versus those that did not. As we can see here, the patients who were detected by vision screening in those that received glasses was approximately 73%. And those that were detected by visual acuity was 61.62%. When we put in combination the use of the visual acuity testing and vision screener, we identified around 90% of these students who did receive corrective lenses. When we kind of do the same analysis in those that did not receive glasses, we see similar trends just with detection by vision screening alone. By vision screener alone, we note that 49.2% of these patients were identified for referral. For those patients identified by visual acuity, it was about 63%. When we put both of these methods in combination, we found it to be 85%. So overall, obviously, each tool picks up some, but it misses a couple. And just kind of the conclusions that were generally drawn out from this project was that the combined use of the vision screener and visual acuity testing identified 89% of the referred students who were examined. Visual acuity and vision screening have similar rates independently at 61% and 68% respectively, but it was known that they worked much better in unison. In addition, as I mentioned previous, stereo and color testing identified 36 or 10.58% of students not otherwise identified by visual acuity or vision screening. And as I mentioned right at the start, obviously only 500 students were examined out of the 1600s. So obviously what happened in that process, one of the biggest takeaway lessons from this pilot screening was the model used for obtaining consent. As far as the vision, initial vision screening, that was done with no consent provided at all sites for the schools. But if they were recommended for referral, it was used in school-based nursing system to send consent forms with the children back to their parents to gain approval. And it was noted that we definitely need to improve that method. As obviously only about 300 or 500 students or 30% actually received formal eye exams. The resources were there and it's just one area of improvement that we definitely see for the future. As far as just kind of, this is just being a pilot screening, the goal of the child vision collaborative is in around two years' time to screen over 50,000 students in the Omaha area community. So I would also just kind of like to acknowledge all the organizations and people that are involved in this building for the future without their time and efforts. This would not be possible. Specifically UNMC, the Cholson Institute back home with my mentor, Dr. Donny Soft, pediatric ophthalmologist and Dr. Shane Havens, back home a specialist, back home. The Lancelot International Midwest Eye Care, just Cholson's Hospital Medical Center, which kind of got me involved with this project. And additionally just the people back home who without their efforts would not be possible, specifically Kathy Austin, Dr. Donny Soft, Dr. Mike Filmire who I'm sure many of you may know here for a Utah graduate or fellow in the past. So I also put some pictures of just what I've done with Utah, but I'll also take any questions that you guys might have. So thank you. So what do you think the breakdown was in that 1600 kids that, you know, you only got 500. Was it that the consents didn't get actually home with the kid or they just weren't followed up if they didn't come back? Yeah, so obviously there was just kind of pretty much a couple of days when they were available to do the formal eye exams. And they needed to have those consents back in due time to be examined at that time. If they didn't have those forms back in time, they weren't available to be examined. So more than anything we would kind of think about maybe extending the period between how long we give of giving the consent forms to the students and actually doing the formal eye exams. But a good number also didn't. Yeah. So if there's any questions, just want to briefly talk about what I've been doing here in Utah to occupy my time outside of the clinic. It's just me in the middle hiking up to work in the big cottonwood canyon. I had the opportunity to visit Red Butte Garden to see a Casey Moser Eves concert. Got to go to the BYU Utah game, which is pretty awesome. I think that rivalry, it was a good game to be a part of a great atmosphere. I also hiked up with a classmate who was here for an ortho rotation to Ensign Peak, or Ensign Point. Kind of got to see the sun rising in one weekend. So thank you very much for your time and I appreciate the opportunity.