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      Accuracy and Feasibility of an Android-Based Digital Assessment Tool for Post Stroke Visual Disorders—The StrokeVision App

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          Abstract

          Background

          Visual impairment affects up to 70% of stroke survivors. We designed an app (StrokeVision) to facilitate screening for common post stroke visual issues (acuity, visual fields, and visual inattention). We sought to describe the test time, feasibility, acceptability, and accuracy of our app-based digital visual assessments against (a) current methods used for bedside screening and (b) gold standard measures.

          Methods

          Patients were prospectively recruited from acute stroke settings. Index tests were app-based assessments of fields and inattention performed by a trained researcher. We compared against usual clinical screening practice of visual fields to confrontation, including inattention assessment (simultaneous stimuli). We also compared app to gold standard assessments of formal kinetic perimetry (Goldman or Octopus Visual Field Assessment); and pencil and paper-based tests of inattention (Albert’s, Star Cancelation, and Line Bisection). Results of inattention and field tests were adjudicated by a specialist Neuro-ophthalmologist. All assessors were masked to each other’s results. Participants and assessors graded acceptability using a bespoke scale that ranged from 0 (completely unacceptable) to 10 (perfect acceptability).

          Results

          Of 48 stroke survivors recruited, the complete battery of index and reference tests for fields was successfully completed in 45. Similar acceptability scores were observed for app-based [assessor median score 10 (IQR: 9–10); patient 9 (IQR: 8–10)] and traditional bedside testing [assessor 10 (IQR: 9–10); patient 10 (IQR: 9–10)]. Median test time was longer for app-based testing [combined time to completion of all digital tests 420 s (IQR: 390–588)] when compared with conventional bedside testing [70 s, (IQR: 40–70)], but shorter than gold standard testing [1,260 s, (IQR: 1005–1,620)]. Compared with gold standard assessments, usual screening practice demonstrated 79% sensitivity and 82% specificity for detection of a stroke-related field defect. This compares with 79% sensitivity and 88% specificity for StrokeVision digital assessment.

          Conclusion

          StrokeVision shows promise as a screening tool for visual complications in the acute phase of stroke. The app is at least as good as usual screening and offers other functionality that may make it attractive for use in acute stroke.

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          Most cited references12

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          Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke.

          The lack of agreement regarding assessment methods is responsible for the variability in the reported rate of occurrence of spatial neglect after stroke. The aim of this study was to assess the sensitivity of different tests of neglect after right hemisphere stroke. Two hundred and six subacute right hemisphere stroke patients were given a test battery including a preliminary assessment of anosognosia and of visual extinction, a clinical assessment of gaze orientation and of personal neglect, and paper and pencil tests of spatial neglect in the peripersonal space. Patients were compared with a previously reported control group. A subgroup of patients (n=69) received a behavioural assessment of neglect in daily life situations. The most sensitive paper and pencil measure was the starting point in the cancellation task. The whole battery was more sensitive than any single test alone. About 85% of patients presented some degree of neglect on at least one measure. An important finding was that behavioural assessment of neglect in daily life was more sensitive than any other single measure of neglect. Behavioural neglect was considered as moderate to severe in 36% of cases. A factorial analysis revealed that paper and pencil tests were related to two underlying factors. Dissociations were found between extrapersonal neglect, personal neglect, anosognosia, and extinction. Anatomical analyses showed that neglect was more common and severe when the posterior association cortex was damaged. The automatic rightward orientation bias is the most sensitive clinical measure of neglect. Behavioural assessment is more sensitive than any single paper and pencil test. The results also support the assumption that neglect is a heterogeneous disorder.
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            The incidence of neglect phenomena and related disorders in patients with an acute right or left hemisphere stroke.

            We studied 171 consecutive patients with an acute hemispheric stroke (69 right hemisphere, 102 left), at 2-3 days post-stroke. A standardized test battery, previously validated in patients with acute stroke, was used to detect a wide variety of neglect phenomena and related disorders. Visual neglect was found in 82% of assessable right hemisphere patients and 65% of left hemisphere patients. Hemi-inattention was found in 70% of right and 49% of left hemisphere strokes. Tactile extinction was found in 65% of right and 35% of left hemisphere patients; allaesthesia in 57% (right), and 11% (left); visual extinction in 23% (right) 2% (left). Anosognosia was found in 28% (right), and 5% (left); anosodiaphoria in 27% (right), and 2% (left); non-belonging in 36% (right) and 29% (left). Visual neglect occurred more commonly in left hemisphere stroke than previously reported. Although neglect phenomena and related disorders were associated with right hemisphere damage, it is possible that language difficulties obscured their presence in some patients with a left hemisphere stroke.
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              Use of 3×2 tables with an intention to diagnose approach to assess clinical performance of diagnostic tests: meta-analytical evaluation of coronary CT angiography studies

              Objective To determine whether a 3×2 table, using an intention to diagnose approach, is better than the “classic” 2×2 table at handling transparent reporting and non-evaluable results, when assessing the accuracy of a diagnostic test. Design Based on a systematic search for diagnostic accuracy studies of coronary computed tomography (CT) angiography, full texts of relevant studies were evaluated to determine whether they could calculate an alternative 3×2 table. To quantify an overall effect, we pooled diagnostic accuracy values according to a meta-analytical approach. Data sources Medline (via PubMed), Embase (via Ovid), and ISI Web of Science electronic databases. Eligibility criteria Prospective English or German language studies comparing coronary CT with conventional coronary angiography in all patients and providing sufficient data for a patient level analysis. Results 120 studies (10 287 patients) were eligible. Studies varied greatly in their approaches to handling non-evaluable findings. We found 26 studies (including 2298 patients) that allowed us to calculate both 2×2 tables and 3×2 tables. Using a bivariate random effects model, we compared the 2×2 table with the 3×2 table, and found significant differences for pooled sensitivity (98.2 (95% confidence interval 96.7 to 99.1) v 92.7 (88.5 to 95.3)), area under the curve (0.99 (0.98 to 1.00) v 0.93 (0.91 to 0.95)), positive likelihood ratio (9.1 (6.2 to 13.3) v 4.4 (3.3 to 6.0)), and negative likelihood ratio (0.02 (0.01 to 0.04) v 0.09 (0.06 to 0.15); (P<0.05)). Conclusion Parameters for diagnostic performance significantly decrease if non-evaluable results are included by a 3×2 table for analysis (intention to diagnose approach). This approach provides a more realistic picture of the clinical potential of diagnostic tests.
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                Author and article information

                Contributors
                URI : https://frontiersin.org/people/u/96626
                Journal
                Front Neurol
                Front Neurol
                Front. Neurol.
                Frontiers in Neurology
                Frontiers Media S.A.
                1664-2295
                28 March 2018
                2018
                : 9
                : 146
                Affiliations
                [1] 1Institute of Cardiovascular and Medical Sciences, University of Glasgow , Glasgow, United Kingdom
                [2] 2Glasgow Centre for Ophthalmic Clinical Research, Gartnavel General Hospital , Glasgow, United Kingdom
                [3] 3Medical Devices Unit, NHS Greater Glasgow and Clyde , Glasgow, United Kingdom
                [4] 4Glasgow Stroke Services, NHS Greater Glasgow and Clyde , Glasgow, United Kingdom
                Author notes

                Edited by: Valerie Moyra Pomeroy, University of East Anglia, United Kingdom

                Reviewed by: David J. Seiffge, University Hospital of Basel and University of Basel, Switzerland; Nishant K. Mishra, Tulane University, United States

                *Correspondence: Terence J. Quinn, terry.quinn@ 123456glasgow.ac.uk

                Specialty section: This article was submitted to Stroke, a section of the journal Frontiers in Neurology

                Article
                10.3389/fneur.2018.00146
                5882791
                29643830
                29e721fd-3b4e-469d-99d0-107cbf758207
                Copyright © 2018 Quinn, Livingstone, Weir, Shaw, Breckenridge, McAlpine and Tarbert.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 19 January 2018
                : 27 February 2018
                Page count
                Figures: 3, Tables: 3, Equations: 0, References: 19, Pages: 8, Words: 6491
                Categories
                Neuroscience
                Clinical Trial

                Neurology
                apps,assessment,hemianopia,information technology,stroke,sensitivity,specificity,visual neglect
                Neurology
                apps, assessment, hemianopia, information technology, stroke, sensitivity, specificity, visual neglect

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