Reliability of retinal imaging screening in retinopathy of prematurity

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Navarro-Blanco, J. Peralta-Calvo, N. Pastora-Salvador, L. Álvarez-Rementería, E. Chamorro, C. Sánchez-Ramos" "autores" => array:6 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Navarro-Blanco" "email" => array:1 [ 0 => "carolinanavarroblanco@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Peralta-Calvo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Pastora-Salvador" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Álvarez-Rementería" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "E." 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"apellidos" => "Sánchez-Ramos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Grupo de Neuro-Computación y Neuro-Robótica, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Oftalmología, Clínica Rementería, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Oftalmología Infantil, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fiabilidad en el cribado de la retinopatía del prematuro mediante el análisis de retinografías" ] ] "textoCompleto" => "IntroductionDespite advances in retinopathy of prematurity (ROP), this disorder is one of the main potentially avoidable causes of childhood blindness.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> ROP is a vasoproliferative retinopathy, characterised by the presence of an immature and partially vascularised retina, affecting low birth-weight preterm infants. The spectrum of possible results for patients with ROP ranges from mild cases, where the sequelae are minimal and do not affect vision, to more aggressive, bilateral cases, with total and irreversible blindness.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Prompt intervention is critical to maximise the chance of a favourable outcome<a class="elsevierStyleCrossRef" href="#bib0015">3</a>; without treatment, at least 50% of eyes with severe ROP will suffer serious and permanent visual loss.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Recent studies show that in the last 20 years the number of children requiring monitoring has risen constantly.<a class="elsevierStyleCrossRefs" href="#bib0005">1,4–7</a> Advances in neonatal care enable very low weight newborns to survive; low weight and gestational age are associated with a higher incidence of severe ROP.<a class="elsevierStyleCrossRefs" href="#bib0020">4,8–10</a> The incidence of the disorder in developed countries varies compared to developing countries,<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a> partly due to greater use of assisted conception, increasing maternal age, possible genetic aetiologies and other socioeconomic issues.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Prevalence in Spain, during the last decade and the beginning of the present one,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> was similar to that of other developed countries in the European Community and the United States.<a class="elsevierStyleCrossRefs" href="#bib0035">7,14</a> Currently, according to the available data from the Instituto Nacional de Estadística (INE: National Statistics Institute), the number of newborns whose weight was less than 1500g in Spain in 2011 was 4178, of whom 682 were in the Autonomous Community of Madrid.The current method of diagnosis, binocular indirect ophthalmoscopy (BIO), has serious limitations.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> The examiner's interpretations are transcribed onto ophthalmological examination sheets, where the interpretation is assumed to be correct and cannot be revised.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Another worrying factor is the shortage of trained ophthalmologists capable of performing examinations for diagnosis of ROP.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6,10</a> As a result, a large number of untrained ophthalmologists are carrying out screening and treatment of ROP.<a class="elsevierStyleCrossRefs" href="#bib0050">10,16,17</a> Several studies show that inexperienced ophthalmologists are less skilled than trained ophthalmologists at identifying clinically significant ROP by analysing digital images.<a class="elsevierStyleCrossRefs" href="#bib0050">10,17,18</a> Because of the shortage of trained ophthalmologists, long delays can occur in screening; another alternative is for the infants to be transferred, with the considerable cost this entails and the potential risk to which the premature baby is subjected.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Telemedicine makes it possible to capture images and send them for subsequent interpretation by a remote expert,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> thereby solving many of the limitations in diagnosis of ROP performed by means of the “gold standard”. By using wide-angle cameras, telemedicine has demonstrated high precision and reliability in the diagnosis of ROP,<a class="elsevierStyleCrossRefs" href="#bib0030">6,19–26</a> and may be more cost-effective than the current method of diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0030">6,27</a>The main objectives of this study are:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•To assess the reliability of diagnosis of ROP through ocular fundus images obtained with a RetCam 3 mobile retinal camera (Clarity Medical Systems Inc.) via telemedicine.</li><li class="elsevierStyleListItem" id="lsti0010">•To explore the variability in diagnosis of ROP according to the training profile of the evaluator.</li></ul>Materials and methodsThis study followed the principles of the Helsinki Declaration and was approved by the Ethics Committee of the Hospital Clínico San Carlos and the Hospital Universitario La Paz in Madrid. All the parents of the preterm infants at risk of ROP who participated in the study signed an informed consent document.PatientsDigital images were taken of children at risk of ROP admitted to the neonatal intensive care unit (NICU) of the Hospital Universitario La Paz in Madrid. The screening criterion applied was that laid down in the NICU protocol, which includes all infants with a gestational age of less than 31 weeks (≤30+6), those of less than 34 weeks (31–33) with unstable clinical course or a weight of less than 1250g. Thirty retinal photographs were captured (15 right eyes and 15 left eyes) of 9 preterm infants between January 2012 and April 2012. A total of 24 preterm infants were examined, but only the cases with ROP were included in the study. Excluded from the study were the preterm infants who, in the neonatologist's opinion, had an unstable clinical evolution and those whose retinopathy had previously been treated by laser. In three low birth-weight preterm infant the initial examination could not be performed owing to the poor quality of the images obtained, two of them because of corneal oedema and one because of insufficient pupillary dilation.Schedule of careThe first ocular fundus examination is carried out at the age of 4 weeks for newborns with a gestational age at birth of 27 weeks or more. For newborns with a gestational age of less than 27 weeks, the first examination is performed at the postmenstrual age of 31 weeks. Depending on the results found in the ocular fundus exploration by BIO, the scheduling of the follow-up examinations will adhere to the guidelines published by the Academy of Paediatrics, the American Association for Paediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> The check-ups are continued until (a) the retina is fully vascularised; (b) the vessels reach zone III without previous ROP in zone I or II (a confirmatory examination would be indicated in very low-weight infants) or (c) absence of “pre-threshold” disease by 45 weeks post-conceptional age (zone I: any stage with plus, stage 3 without plus; zone II: stage 2 “plus” or stage 3).Examination techniquesPupillary dilation is necessary to perform an ophthalmological examination. Mydriasis is achieved by instillation of one drop of cyclopentolate 0.25% and one drop of phenylephrine 1% 1h before the examination, repeated after 10min. The presence or absence of ROP, its location, its extent and plus disease were documented according to the criteria established in the International Classification of ROP.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> During the ophthalmological examination a nurse immobilises the premature infant and monitors his or her vital signs; if there is any sudden alteration in the low birth-weight preterm infant cardiorespiratory indicators the examination is interrupted until the infant stabilises. To avoid retinal phototoxicity, ambient lighting is kept to a minimum and the lowest light intensity that allows a reliable examination is used in the ophthalmoscope.Indirect ophthalmoscopic examination (the “gold standard”) was performed by a paediatric ROP-expert ophthalmologist. The eyelids are kept open with special blepharostats for premature infants. Viewing of the peripheral retina is carried out using scleral indentation and a 28-D lens. Immediately after the BIO examination, the same ophthalmologist and a technician specialising in capture of digital images (Certificate of Completion. Training Module Series: RetCam Practice, Ocular Anatomy and Imaging ROP Presented by Clarity Medical Systems Inc., Pleasanton, CA) captured the images of each eye using the RetCam 3 wide-angle camera (Clarity Medical Systems, Pleasanton, CA, USA) equipped with a special 130° lens for premature infants. In the methodology employed the ophthalmologist holds the camera while the technician controls the lighting and focus. A minimum of 3 photos per eye was captured (posterior pole, nasal retina and temporal retina); a group of images of the same eye in the same session was called a “set”.Reading and coding of digital imagesThe retinal photographs obtained were sent to the storage centre, where they were coded. A total of 30 sets were interpreted independently by 3 masked groups: group A, comprising 8 ophthalmologists (3 anterior pole surgeons, 3 retinologists, and 2 general ophthalmologists); group B, composed of 5 vision experts from the Universidad Complutense in Madrid (graduates with official master's degrees in optics, optometry and vision) and group C, consisting of 2 ophthalmologist experts in diagnosis and treatment of ROP. Groups A and B were informed about the diagnosis of ROP by means of a 4-page guide compiled by the authors. All those surveyed were asked about the diagnosis of ROP; each set of photos was classified by ROP, stage, zone, plus, referral to paediatric ophthalmologist (type 1+type 2) and observations. The interpretation of the retinal photographs was based on the criteria laid down in the study Early Treatment for Retinopathy of Prematurity (ETROP).<a class="elsevierStyleCrossRef" href="#bib0150">30</a> The images transmitted were coded at the storage centre and classified using a system of 4 levels, as in the study by Myung et al.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">(1)Type 1 ROP: zone I, any stage with plus disease or stage 3 without plus disease; zone II, stages 2 or 3 with plus disease.</li><li class="elsevierStyleListItem" id="lsti0020">(2)Type 2 ROP: zone I, stages 1 or 2 without plus disease; zone II, stage 3 without plus disease.</li><li class="elsevierStyleListItem" id="lsti0025">(3)Moderate ROP: defined as ROP less severe than type 2.</li><li class="elsevierStyleListItem" id="lsti0030">(4)No ROP.</li></ul>No time limit was set for interpreting the images. The diagnosis and recommendations for control examinations were returned by email to the storage centre.Analysis of dataThe validity of the new diagnosis system was determined by comparing the results obtained by the three groups, and the diagnosis performed using BIO by a paediatric ophthalmologist specialising in ROP was taken as a reference. The results obtained with BIO and RetCam for each set were collected in separate columns using statistical software (Microsoft Excel 2010, Redmond, WA, USA). The calculations for the statistical analysis were performed with SAS 9.2 software. Sensitivity, specificity, Kappa index and percent success rate of each group were calculated for detection of type 1 ROP and referral (type 1+type 2 ROP). We used ANOVA and Duncan's test to compare the results between groups.ResultsA total of 30 sets of images were analysed by 15 observers (8 ophthalmologists, 5 vision experts and 2 paediatric ophthalmologists specialising in ROP). According to the diagnosis with BIO performed by the reference observer (the “gold standard”), 47% of the digital images showed type 1 ROP, 3% type 2 ROP, and 50% moderate ROP.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows sensitivity, specificity, Kappa index and percent agreement in the diagnosis of type 1 ROP and type 1+type 2 (referral) by group C, comprising two ophthalmologists expert in the diagnosis of ROP.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> show sensitivity, specificity, Kappa index and percent agreement in the diagnosis of type 1 ROP and type 1+type 2 (referral) by three groups of specialists compared with the reference diagnosis performed by a paediatric ROP-expert ophthalmologist. Sensitivity, Kappa index and percent success rate were statistically significant in group C for diagnosis of type 1 ROP. In the diagnosis of type 1+type 2 ROP the Kappa index and percent success rate were statistically significant, producing higher values in group C. No statistically significant differences were found between groups A and B in the diagnosis of type 1 ROP and type 1+type 2 ROP.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionThe results of this study confirm, firstly, the efficacy of the RetCam 3 wide-angle camera through images obtained by trained staff. In addition, the study demonstrates the viability of telemedicine for the diagnosis of type 1 ROP and type 1+type 2 ROP (referral) when performed by paediatric ROP-expert ophthalmologists.The viability of telemedicine in the assessment of low birth-weight preterm infant is a point of great interest given the gradually increasing number of children at risk of ROP<a class="elsevierStyleCrossRefs" href="#bib0020">4,8</a> in developed countries. Digital images offer an innovative strategy for detecting infants with severe ROP,<a class="elsevierStyleCrossRefs" href="#bib0155">31,32</a> and several studies show excellent sensitivity and specificity in the diagnosis of ROP.<a class="elsevierStyleCrossRefs" href="#bib0025">5,18–20,24,25,33–36</a> In most research studies an ophthalmologist<a class="elsevierStyleCrossRefs" href="#bib0025">5,19,26,32,33,36–38</a> or a nurse<a class="elsevierStyleCrossRefs" href="#bib0085">17,21,22,25,34,35,39,40</a> carried out the test, although occasionally an ophthalmological photographer<a class="elsevierStyleCrossRefs" href="#bib0090">18,20,23</a> obtained the images. Our conclusions coincide with the results published by Skalet et al.,<a class="elsevierStyleCrossRef" href="#bib0200">40</a> in which two trained nurses captured the images with the NIDEK NM200-D camera and subsequently sent them to five ROP experts. The conclusions of Skalet et al. show that images obtained by trained staff and sent to specialists can be useful for identifying infants who require evaluation by a ROP-expert ophthalmologist.In 2008 Kemper et al.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> showed that there was a high proportion of untrained ophthalmologists carrying out screening and treatment of ROP. Moreover, Paul Chan et al.,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> in 2010, assessed the reliability of inexperienced ophthalmologists in the diagnosis of ROP; they demonstrated a clinically significant underestimation of ROP, which raises important questions about the quality of ROP screening performed by non-expert ophthalmologists. We therefore agree with the suggestion of Wong et al.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> that an ophthalmologists’ training should include a minimum number of ROP examinations and treatments.The results of this research are similar to those obtained in the study by Myung et al.,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> which shows a sensitivity of approximately 50% in the detection of type 1 and type 2 ROP by paediatric ophthalmologists inexperienced in ROP; it is equivalent, in this study, to the sensitivity in referral (type 1+type 2) of groups A and B, consisting of non-ROP experts. The results also coincide for type 1 ROP, where low sensitivity and high specificity were obtained in groups A and B. Unlike the study by Myung et al.,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> in which the diagnosis made by a paediatric retina expert using digital images is taken as a reference, the “gold standard” used here is the diagnosis obtained using indirect ophthalmoscopy performed by an expert in ROP, following the recommendations of the Section on Ophthalmology of the American Academy of Pediatrics, the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>The advantages of telemedicine have already been described by several authors. It has been shown to be reliable for the diagnosis of ROP and to save costs compared with the conventional method of diagnosis,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> but this is not enough; the opinion of the parents must be taken into account. The research of Lee<a class="elsevierStyleCrossRef" href="#bib0030">6</a> concludes that parents have a positive impression of ROP diagnosis by telemedicine, but express a preference for face-to-face contact. The current benefits of new technologies are indisputable, but it should not be forgotten that information must be as widely available as possible, both to patients and to those accompanying them.In our review of the literature we found few studies that evaluated the training of ophthalmologists who carry out the examination, assessment and treatment of ROP.<a class="elsevierStyleCrossRefs" href="#bib0050">10,16–18</a> As has been shown, differences in the diagnosis of ROP lead to different outcomes of the disease, and therefore future research should propose a minimum number of examinations for untrained ophthalmologists. We also wish to highlight the potential risk involved in untrained staff carrying out the diagnosis and treatment of ROP. This study found no significant differences in the results between ophthalmologists (group A) and vision experts (group B). Future projects could analyse the role of opticians and optometrists for screening of ROP, which would save the cost of transferring the premature infant and avoid having specialists perform the test.We recognise that one of the limitations of this study is the number of premature infants examined and the small number of experts performing the diagnosis of ROP. In this phase, only retinal photographs of premature infants with some stage of retinopathy were captured. This was done to avoid the stress for the infant caused by the additional test with the RetCam. Future research could be conducted, as in the study by Skarlet et al.,<a class="elsevierStyleCrossRef" href="#bib0200">40</a> with several experts on premature infants, comparing them with a series of ophthalmologists without experience of ROP. As in previous studies, the principal limitations were the assessment of zone III and the quality of the images;<a class="elsevierStyleCrossRef" href="#bib0085">17</a> in particular, serious difficulties were encountered in the examination of patients with CPAP both by BIO and by RetCam; the view of the retina is slightly better with digital images.In conclusion, use of the RetCam 3 mobile retinal camera by ophthalmologist experts in ROP has proved to be reliable for diagnosis.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres369695" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec348855" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres369696" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec348856" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Schedule of care" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Examination techniques" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Reading and coding of digital images" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Analysis of data" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-07-08" "fechaAceptado" => "2013-10-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec348855" "palabras" => array:5 [ 0 => "Retinopathy of prematurity" 1 => "Preterm infants" 2 => "Retinal image" 3 => "Diagnostic imaging" 4 => "Telemedicine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec348856" "palabras" => array:5 [ 0 => "Retinopatía del prematuro" 1 => "Recién nacido pretérmino" 2 => "Imagen retina" 3 => "Diagnóstico imagen" 4 => "Telemedicina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionThe retinopathy of prematurity (ROP) is a potentially avoidable cause of blindness in children. The advances in neonatal care make the survival of extremely premature infants, who show a greater incidence of the disease, possible. The aim of the study is to evaluate the reliability of ROP screening using retinography imaging with the RetCam 3 wide-angle camera and also to study the variability of ROP diagnosis depending on the evaluator. Materials and methodsThe indirect ophthalmoscopy exam was performed by a paediatric ROP-expert ophthalmologist. The same ophthalmologist and a technician specialised in digital image capture took retinal images using the RetCam 3 wide-angle camera. A total of 30 image sets were analysed by 3 masked groups: group A (8 ophthalmologists), group B (5 experts in vision), and group C (2 ROP-expert ophthalmologists). ResultsAccording to the diagnosis using indirect ophthalmoscopy, the sensitivity (26–93), Kappa (0.24–0.80), and the percentage agreement were statistically significant in group C for the diagnosis of ROP type 1. In the diagnosis of ROP type 1+type 2, Kappa (0.17–0.33) and the percentage agreement (58–90) were statistically significant, with higher values in group C. ConclusionThe diagnosis, carried out by ROP-expert ophthalmologists, using the wide-angle camera RetCam 3 has proven to be a reliable method." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa retinopatía del prematuro (ROP) es una de las principales causas de ceguera infantil potencialmente evitable. Los avances en los cuidados neonatales consiguen la supervivencia de niños de bajo peso extremo asociado con una mayor incidencia de la enfermedad. El objetivo de este estudio es evaluar la fiabilidad en el diagnóstico de la ROP a través de retinografías obtenidas con la cámara de campo amplio RetCam 3 y estudiar la variabilidad en el diagnóstico de ROP en función del evaluador. Material y métodosEl examen con oftalmoscopio indirecto fue realizado por un oftalmólogo pediátrico experto en ROP. Las imágenes retinianas fueron obtenidas por el mismo oftalmólogo y un técnico especializado en la captura de imágenes digitales. Un total de 30sets de imágenes fueron analizados por 3 grupos enmascarados: grupo A (8 oftalmólogos), grupoB (5 expertos en visión) y grupo C (2 oftalmólogos expertos en ROP). ResultadosAcorde con el diagnóstico mediante oftalmoscopia indirecta, la sensibilidad (26-93), el índice Kappa (0,24-0,80) y el porcentaje de aciertos fueron estadísticamente significativos en el grupoC para el diagnóstico de ROP tipo1. En el diagnóstico de ROP tipo1+tipo2 el índice Kappa (0,17-0,33) y el porcentaje de aciertos (58-90) fueron estadísticamente significativos, obteniendo valores superiores en el grupo C. ConclusionesEl diagnóstico realizado por oftalmólogos expertos en ROP con el retinógrafo móvil RetCam 3 ha demostrado ser un método fiable." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Navarro-Blanco C, Peralta-Calvo J, Pastora-Salvador N, Álvarez-Rementería L, Chamorro E, Sánchez-Ramos C. Fiabilidad en el cribado de la retinopatía del prematuro mediante el análisis de retinografías. An Pediatr (Barc). 2014;81:149–154." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sensitivity (%) (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Specificity (%) (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Kappa (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CD (%) (maximum–minimum) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.80 (0.14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88 (95–81) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type 1+type 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.80 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 (95–85) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556684.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Sensitivity, specificity, Kappa index and percent agreement for diagnosis of type 1 ROP and type 1+type 2 ROP (referral) in group C (ROP-expert ophthalmologist)." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "CD, correct diagnoses." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sensitivity (%) (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Specificity (%) (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Kappa (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CD (%) (maximum–minimum) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.24 (0.20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 (68–40) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.29 (0.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56 (65–47) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.80 (0.14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88 (95–81) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Value of p \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0114<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6944 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0046<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0053<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556686.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Group C different from the other groups." ] ] ] "descripcion" => array:1 [ "en" => "Sensitivity, specificity, Kappa index and percent agreement for diagnosis of type 1 ROP by 3 groups of specialists compared with the reference diagnosis performed by a paediatric ROP-expert ophthalmologist." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "CD, correct diagnoses." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type 1+type 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sensitivity (%) (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Specificity (%) (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Kappa (standard error) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CD (%) (maximum–minimum) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.33 (0.23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66 (78–55) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.17 (0.07) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 (61–55) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.80 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 (95–85) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Value of p \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1358 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1101 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0048<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0045<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556685.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Group C different from the other groups." ] ] ] "descripcion" => array:1 [ "en" => "Sensitivity, specificity, Kappa index and percent agreement for diagnosis of type 1+type 2 ROP (referral) by 3 groups of specialists compared with the reference diagnosis performed by a paediatric ROP-expert ophthalmologist." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => 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"vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008100000003/v1_201409120835/S2341287914000647/v1_201409120835/en/main.assets" "Apartado" => array:4 [ "identificador" => "26005" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008100000003/v1_201409120835/S2341287914000647/v1_201409120835/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287914000647?idApp=UINPBA00005H"]

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Reliability of retinal imaging screening in retinopathy of prematurity

Fiabilidad en el cribado de la retinopatía del prematuro mediante el análisis de retinografías

C. Navarro-Blancoa,b,

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carolinanavarroblanco@hotmail.com

Corresponding author.

, J. Peralta-Calvoc, N. Pastora-Salvadorc, L. Álvarez-Rementeríab, E. Chamorroa, C. Sánchez-Ramosa

a Grupo de Neuro-Computación y Neuro-Robótica, Universidad Complutense de Madrid, Madrid, Spain

b Departamento de Oftalmología, Clínica Rementería, Madrid, Spain

c Departamento de Oftalmología Infantil, Hospital Universitario La Paz, Madrid, Spain

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without treatment&#44; at least 50&#37; of eyes with severe ROP will suffer serious and permanent visual loss&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent studies show that in the last 20 years the number of children requiring monitoring has risen constantly&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#8211;7</span></a> Advances in neonatal care enable very low weight newborns to survive&#59; low weight and gestational age are associated with a higher incidence of severe ROP&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8&#8211;10</span></a> The incidence of the disorder in developed countries varies compared to developing countries&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> partly due to greater use of assisted conception&#44; increasing maternal age&#44; possible genetic aetiologies and other socioeconomic issues&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Prevalence in Spain&#44; during the last decade and the beginning of the present one&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> was similar to that of other developed countries in the European Community and the United States&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;14</span></a> Currently&#44; according to the available data from the Instituto Nacional de Estad&#237;stica &#40;INE&#58; National Statistics Institute&#41;&#44; the number of newborns whose weight was less than 1500<span class="elsevierStyleHsp" style=""></span>g in Spain in 2011 was 4178&#44; of whom 682 were in the Autonomous Community of Madrid&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The current method of diagnosis&#44; binocular indirect ophthalmoscopy &#40;BIO&#41;&#44; has serious limitations&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The examiner&#39;s interpretations are transcribed onto ophthalmological examination sheets&#44; where the interpretation is assumed to be correct and cannot be revised&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Another worrying factor is the shortage of trained ophthalmologists capable of performing examinations for diagnosis of ROP&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;10</span></a> As a result&#44; a large number of untrained ophthalmologists are carrying out screening and treatment of ROP&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;16&#44;17</span></a> Several studies show that inexperienced ophthalmologists are less skilled than trained ophthalmologists at identifying clinically significant ROP by analysing digital images&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;17&#44;18</span></a> Because of the shortage of trained ophthalmologists&#44; long delays can occur in screening&#59; another alternative is for the infants to be transferred&#44; with the considerable cost this entails and the potential risk to which the premature baby is subjected&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Telemedicine makes it possible to capture images and send them for subsequent interpretation by a remote expert&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> thereby solving many of the limitations in diagnosis of ROP performed by means of the &#8220;gold standard&#8221;&#46; By using wide-angle cameras&#44; telemedicine has demonstrated high precision and reliability in the diagnosis of ROP&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;19&#8211;26</span></a> and may be more cost-effective than the current method of diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;27</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The main objectives of this study are&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">To assess the reliability of diagnosis of ROP through ocular fundus images obtained with a RetCam 3 mobile retinal camera &#40;Clarity Medical Systems Inc&#46;&#41; via telemedicine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">To explore the variability in diagnosis of ROP according to the training profile of the evaluator&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study followed the principles of the Helsinki Declaration and was approved by the Ethics Committee of the Hospital Cl&#237;nico San Carlos and the Hospital Universitario La Paz in Madrid&#46; All the parents of the preterm infants at risk of ROP who participated in the study signed an informed consent document&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0045" class="elsevierStylePara elsevierViewall">Digital images were taken of children at risk of ROP admitted to the neonatal intensive care unit &#40;NICU&#41; of the Hospital Universitario La Paz in Madrid&#46; The screening criterion applied was that laid down in the NICU protocol&#44; which includes all infants with a gestational age of less than 31 weeks &#40;&#8804;30<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>6&#41;&#44; those of less than 34 weeks &#40;31&#8211;33&#41; with unstable clinical course or a weight of less than 1250<span class="elsevierStyleHsp" style=""></span>g&#46; Thirty retinal photographs were captured &#40;15 right eyes and 15 left eyes&#41; of 9 preterm infants between January 2012 and April 2012&#46; A total of 24 preterm infants were examined&#44; but only the cases with ROP were included in the study&#46; Excluded from the study were the preterm infants who&#44; in the neonatologist&#39;s opinion&#44; had an unstable clinical evolution and those whose retinopathy had previously been treated by laser&#46; In three low birth-weight preterm infant the initial examination could not be performed owing to the poor quality of the images obtained&#44; two of them because of corneal oedema and one because of insufficient pupillary dilation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Schedule of care</span><p id="par0050" class="elsevierStylePara elsevierViewall">The first ocular fundus examination is carried out at the age of 4 weeks for newborns with a gestational age at birth of 27 weeks or more&#46; For newborns with a gestational age of less than 27 weeks&#44; the first examination is performed at the postmenstrual age of 31 weeks&#46; Depending on the results found in the ocular fundus exploration by BIO&#44; the scheduling of the follow-up examinations will adhere to the guidelines published by the Academy of Paediatrics&#44; the American Association for Paediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> The check-ups are continued until &#40;a&#41; the retina is fully vascularised&#59; &#40;b&#41; the vessels reach zone III without previous ROP in zone I or II &#40;a confirmatory examination would be indicated in very low-weight infants&#41; or &#40;c&#41; absence of &#8220;pre-threshold&#8221; disease by 45 weeks post-conceptional age &#40;zone I&#58; any stage with plus&#44; stage 3 without plus&#59; zone II&#58; stage 2 &#8220;plus&#8221; or stage 3&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Examination techniques</span><p id="par0055" class="elsevierStylePara elsevierViewall">Pupillary dilation is necessary to perform an ophthalmological examination&#46; Mydriasis is achieved by instillation of one drop of cyclopentolate 0&#46;25&#37; and one drop of phenylephrine 1&#37; 1<span class="elsevierStyleHsp" style=""></span>h before the examination&#44; repeated after 10<span class="elsevierStyleHsp" style=""></span>min&#46; The presence or absence of ROP&#44; its location&#44; its extent and plus disease were documented according to the criteria established in the International Classification of ROP&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> During the ophthalmological examination a nurse immobilises the premature infant and monitors his or her vital signs&#59; if there is any sudden alteration in the low birth-weight preterm infant cardiorespiratory indicators the examination is interrupted until the infant stabilises&#46; To avoid retinal phototoxicity&#44; ambient lighting is kept to a minimum and the lowest light intensity that allows a reliable examination is used in the ophthalmoscope&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Indirect ophthalmoscopic examination &#40;the &#8220;gold standard&#8221;&#41; was performed by a paediatric ROP-expert ophthalmologist&#46; The eyelids are kept open with special blepharostats for premature infants&#46; Viewing of the peripheral retina is carried out using scleral indentation and a 28-D lens&#46; Immediately after the BIO examination&#44; the same ophthalmologist and a technician specialising in capture of digital images &#40;Certificate of Completion&#46; Training Module Series&#58; RetCam Practice&#44; Ocular Anatomy and Imaging ROP Presented by Clarity Medical Systems Inc&#46;&#44; Pleasanton&#44; CA&#41; captured the images of each eye using the RetCam 3 wide-angle camera &#40;Clarity Medical Systems&#44; Pleasanton&#44; CA&#44; USA&#41; equipped with a special 130&#176; lens for premature infants&#46; In the methodology employed the ophthalmologist holds the camera while the technician controls the lighting and focus&#46; A minimum of 3 photos per eye was captured &#40;posterior pole&#44; nasal retina and temporal retina&#41;&#59; a group of images of the same eye in the same session was called a &#8220;set&#8221;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Reading and coding of digital images</span><p id="par0065" class="elsevierStylePara elsevierViewall">The retinal photographs obtained were sent to the storage centre&#44; where they were coded&#46; A total of 30 sets were interpreted independently by 3 masked groups&#58; group A&#44; comprising 8 ophthalmologists &#40;3 anterior pole surgeons&#44; 3 retinologists&#44; and 2 general ophthalmologists&#41;&#59; group B&#44; composed of 5 vision experts from the Universidad Complutense in Madrid &#40;graduates with official master&#39;s degrees in optics&#44; optometry and vision&#41; and group C&#44; consisting of 2 ophthalmologist experts in diagnosis and treatment of ROP&#46; Groups A and B were informed about the diagnosis of ROP by means of a 4-page guide compiled by the authors&#46; All those surveyed were asked about the diagnosis of ROP&#59; each set of photos was classified by ROP&#44; stage&#44; zone&#44; plus&#44; referral to paediatric ophthalmologist &#40;type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2&#41; and observations&#46; The interpretation of the retinal photographs was based on the criteria laid down in the study <span class="elsevierStyleItalic">Early Treatment for Retinopathy of Prematurity</span> &#40;ETROP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> The images transmitted were coded at the storage centre and classified using a system of 4 levels&#44; as in the study by Myung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Type 1 ROP&#58;</span> zone I&#44; any stage with plus disease or stage 3 without plus disease&#59; zone II&#44; stages 2 or 3 with plus disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Type 2 ROP&#58;</span> zone I&#44; stages 1 or 2 without plus disease&#59; zone II&#44; stage 3 without plus disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;3&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Moderate ROP&#58;</span> defined as ROP less severe than type 2&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;4&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">No ROP</span>&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">No time limit was set for interpreting the images&#46; The diagnosis and recommendations for control examinations were returned by email to the storage centre&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Analysis of data</span><p id="par0095" class="elsevierStylePara elsevierViewall">The validity of the new diagnosis system was determined by comparing the results obtained by the three groups&#44; and the diagnosis performed using BIO by a paediatric ophthalmologist specialising in ROP was taken as a reference&#46; The results obtained with BIO and RetCam for each set were collected in separate columns using statistical software &#40;Microsoft Excel 2010&#44; Redmond&#44; WA&#44; USA&#41;&#46; The calculations for the statistical analysis were performed with SAS 9&#46;2 software&#46; Sensitivity&#44; specificity&#44; Kappa index and percent success rate of each group were calculated for detection of type 1 ROP and referral &#40;type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2 ROP&#41;&#46; We used ANOVA and Duncan&#39;s test to compare the results between groups&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">A total of 30 sets of images were analysed by 15 observers &#40;8 ophthalmologists&#44; 5 vision experts and 2 paediatric ophthalmologists specialising in ROP&#41;&#46; According to the diagnosis with BIO performed by the reference observer &#40;the &#8220;gold standard&#8221;&#41;&#44; 47&#37; of the digital images showed type 1 ROP&#44; 3&#37; type 2 ROP&#44; and 50&#37; moderate ROP&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows sensitivity&#44; specificity&#44; Kappa index and percent agreement in the diagnosis of type 1 ROP and type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2 &#40;referral&#41; by group C&#44; comprising two ophthalmologists expert in the diagnosis of ROP&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> show sensitivity&#44; specificity&#44; Kappa index and percent agreement in the diagnosis of type 1 ROP and type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2 &#40;referral&#41; by three groups of specialists compared with the reference diagnosis performed by a paediatric ROP-expert ophthalmologist&#46; Sensitivity&#44; Kappa index and percent success rate were statistically significant in group C for diagnosis of type 1 ROP&#46; In the diagnosis of type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2 ROP the Kappa index and percent success rate were statistically significant&#44; producing higher values in group C&#46; No statistically significant differences were found between groups A and B in the diagnosis of type 1 ROP and type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2 ROP&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The results of this study confirm&#44; firstly&#44; the efficacy of the RetCam 3 wide-angle camera through images obtained by trained staff&#46; In addition&#44; the study demonstrates the viability of telemedicine for the diagnosis of type 1 ROP and type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2 ROP &#40;referral&#41; when performed by paediatric ROP-expert ophthalmologists&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The viability of telemedicine in the assessment of low birth-weight preterm infant is a point of great interest given the gradually increasing number of children at risk of ROP<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8</span></a> in developed countries&#46; Digital images offer an innovative strategy for detecting infants with severe ROP&#44;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32</span></a> and several studies show excellent sensitivity and specificity in the diagnosis of ROP&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;18&#8211;20&#44;24&#44;25&#44;33&#8211;36</span></a> In most research studies an ophthalmologist<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;19&#44;26&#44;32&#44;33&#44;36&#8211;38</span></a> or a nurse<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;21&#44;22&#44;25&#44;34&#44;35&#44;39&#44;40</span></a> carried out the test&#44; although occasionally an ophthalmological photographer<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;20&#44;23</span></a> obtained the images&#46; Our conclusions coincide with the results published by Skalet et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> in which two trained nurses captured the images with the NIDEK NM200-D camera and subsequently sent them to five ROP experts&#46; The conclusions of Skalet et al&#46; show that images obtained by trained staff and sent to specialists can be useful for identifying infants who require evaluation by a ROP-expert ophthalmologist&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In 2008 Kemper et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> showed that there was a high proportion of untrained ophthalmologists carrying out screening and treatment of ROP&#46; Moreover&#44; Paul Chan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> in 2010&#44; assessed the reliability of inexperienced ophthalmologists in the diagnosis of ROP&#59; they demonstrated a clinically significant underestimation of ROP&#44; which raises important questions about the quality of ROP screening performed by non-expert ophthalmologists&#46; We therefore agree with the suggestion of Wong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> that an ophthalmologists&#8217; training should include a minimum number of ROP examinations and treatments&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The results of this research are similar to those obtained in the study by Myung et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> which shows a sensitivity of approximately 50&#37; in the detection of type 1 and type 2 ROP by paediatric ophthalmologists inexperienced in ROP&#59; it is equivalent&#44; in this study&#44; to the sensitivity in referral &#40;type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2&#41; of groups A and B&#44; consisting of non-ROP experts&#46; The results also coincide for type 1 ROP&#44; where low sensitivity and high specificity were obtained in groups A and B&#46; Unlike the study by Myung et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> in which the diagnosis made by a paediatric retina expert using digital images is taken as a reference&#44; the &#8220;gold standard&#8221; used here is the diagnosis obtained using indirect ophthalmoscopy performed by an expert in ROP&#44; following the recommendations of the Section on Ophthalmology of the American Academy of Pediatrics&#44; the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The advantages of telemedicine have already been described by several authors&#46; It has been shown to be reliable for the diagnosis of ROP and to save costs compared with the conventional method of diagnosis&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> but this is not enough&#59; the opinion of the parents must be taken into account&#46; The research of Lee<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> concludes that parents have a positive impression of ROP diagnosis by telemedicine&#44; but express a preference for face-to-face contact&#46; The current benefits of new technologies are indisputable&#44; but it should not be forgotten that information must be as widely available as possible&#44; both to patients and to those accompanying them&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In our review of the literature we found few studies that evaluated the training of ophthalmologists who carry out the examination&#44; assessment and treatment of ROP&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;16&#8211;18</span></a> As has been shown&#44; differences in the diagnosis of ROP lead to different outcomes of the disease&#44; and therefore future research should propose a minimum number of examinations for untrained ophthalmologists&#46; We also wish to highlight the potential risk involved in untrained staff carrying out the diagnosis and treatment of ROP&#46; This study found no significant differences in the results between ophthalmologists &#40;group A&#41; and vision experts &#40;group B&#41;&#46; Future projects could analyse the role of opticians and optometrists for screening of ROP&#44; which would save the cost of transferring the premature infant and avoid having specialists perform the test&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">We recognise that one of the limitations of this study is the number of premature infants examined and the small number of experts performing the diagnosis of ROP&#46; In this phase&#44; only retinal photographs of premature infants with some stage of retinopathy were captured&#46; This was done to avoid the stress for the infant caused by the additional test with the RetCam&#46; Future research could be conducted&#44; as in the study by Skarlet et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> with several experts on premature infants&#44; comparing them with a series of ophthalmologists without experience of ROP&#46; As in previous studies&#44; the principal limitations were the assessment of zone III and the quality of the images&#59;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> in particular&#44; serious difficulties were encountered in the examination of patients with CPAP both by BIO and by RetCam&#59; the view of the retina is slightly better with digital images&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion&#44; use of the RetCam 3 mobile retinal camera by ophthalmologist experts in ROP has proved to be reliable for diagnosis&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The retinopathy of prematurity &#40;ROP&#41; is a potentially avoidable cause of blindness in children&#46; The advances in neonatal care make the survival of extremely premature infants&#44; who show a greater incidence of the disease&#44; possible&#46; The aim of the study is to evaluate the reliability of ROP screening using retinography imaging with the RetCam 3 wide-angle camera and also to study the variability of ROP diagnosis depending on the evaluator&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The indirect ophthalmoscopy exam was performed by a paediatric ROP-expert ophthalmologist&#46; The same ophthalmologist and a technician specialised in digital image capture took retinal images using the RetCam 3 wide-angle camera&#46; A total of 30 image sets were analysed by 3 masked groups&#58; group A &#40;8 ophthalmologists&#41;&#44; group B &#40;5 experts in vision&#41;&#44; and group C &#40;2 ROP-expert ophthalmologists&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">According to the diagnosis using indirect ophthalmoscopy&#44; the sensitivity &#40;26&#8211;93&#41;&#44; Kappa &#40;0&#46;24&#8211;0&#46;80&#41;&#44; and the percentage agreement were statistically significant in group C for the diagnosis of ROP type 1&#46; In the diagnosis of ROP type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2&#44; Kappa &#40;0&#46;17&#8211;0&#46;33&#41; and the percentage agreement &#40;58&#8211;90&#41; were statistically significant&#44; with higher values in group C&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The diagnosis&#44; carried out by ROP-expert ophthalmologists&#44; using the wide-angle camera RetCam 3 has proven to be a reliable method&#46;</p>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La retinopat&#237;a del prematuro &#40;ROP&#41; es una de las principales causas de ceguera infantil potencialmente evitable&#46; Los avances en los cuidados neonatales consiguen la supervivencia de ni&#241;os de bajo peso extremo asociado con una mayor incidencia de la enfermedad&#46; El objetivo de este estudio es evaluar la fiabilidad en el diagn&#243;stico de la ROP a trav&#233;s de retinograf&#237;as obtenidas con la c&#225;mara de campo amplio RetCam 3 y estudiar la variabilidad en el diagn&#243;stico de ROP en funci&#243;n del evaluador&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El examen con oftalmoscopio indirecto fue realizado por un oftalm&#243;logo pedi&#225;trico experto en ROP&#46; Las im&#225;genes retinianas fueron obtenidas por el mismo oftalm&#243;logo y un t&#233;cnico especializado en la captura de im&#225;genes digitales&#46; Un total de 30<span class="elsevierStyleHsp" style=""></span>sets de im&#225;genes fueron analizados por 3 grupos enmascarados&#58; grupo A &#40;8 oftalm&#243;logos&#41;&#44; grupo<span class="elsevierStyleHsp" style=""></span>B &#40;5 expertos en visi&#243;n&#41; y grupo <span class="elsevierStyleSmallCaps">C</span> &#40;2 oftalm&#243;logos expertos en ROP&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Acorde con el diagn&#243;stico mediante oftalmoscopia indirecta&#44; la sensibilidad &#40;26-93&#41;&#44; el &#237;ndice Kappa &#40;0&#44;24-0&#44;80&#41; y el porcentaje de aciertos fueron estad&#237;sticamente significativos en el grupo<span class="elsevierStyleHsp" style=""></span>C para el diagn&#243;stico de ROP tipo<span class="elsevierStyleHsp" style=""></span>1&#46; En el diagn&#243;stico de ROP tipo<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>tipo<span class="elsevierStyleHsp" style=""></span>2 el &#237;ndice Kappa &#40;0&#44;17-0&#44;33&#41; y el porcentaje de aciertos &#40;58-90&#41; fueron estad&#237;sticamente significativos&#44; obteniendo valores superiores en el grupo C&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico realizado por oftalm&#243;logos expertos en ROP con el retin&#243;grafo m&#243;vil RetCam 3 ha demostrado ser un m&#233;todo fiable&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Navarro-Blanco C&#44; Peralta-Calvo J&#44; Pastora-Salvador N&#44; &#193;lvarez-Rementer&#237;a L&#44; Chamorro E&#44; S&#225;nchez-Ramos C&#46; Fiabilidad en el cribado de la retinopat&#237;a del prematuro mediante el an&#225;lisis de retinograf&#237;as&#46; An Pediatr &#40;Barc&#41;&#46; 2014&#59;81&#58;149&#8211;154&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
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        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sensitivity &#40;&#37;&#41; &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Specificity &#40;&#37;&#41; &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Kappa &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">CD &#40;&#37;&#41; &#40;maximum&#8211;minimum&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;80 &#40;0&#46;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">88 &#40;95&#8211;81&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">90 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;80 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90 &#40;95&#8211;85&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
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        "etiqueta" => "Table 2"
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        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sensitivity &#40;&#37;&#41; &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Specificity &#40;&#37;&#41; &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Kappa &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Group A&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;24 &#40;0&#46;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57 &#40;68&#8211;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Group B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;29 &#40;0&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56 &#40;65&#8211;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Group C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;80 &#40;0&#46;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88 &#40;95&#8211;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Value of <span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0114<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6944&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0046<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0053<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              ]
              "imagenFichero" => array:1 [
                0 => "xTab556686.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Group C different from the other groups&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Sensitivity&#44; specificity&#44; Kappa index and percent agreement for diagnosis of type 1 ROP by 3 groups of specialists compared with the reference diagnosis performed by a paediatric ROP-expert ophthalmologist&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CD&#44; correct diagnoses&#46;</p>"
          "tablatextoimagen" => array:1 [
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>type 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Sensitivity &#40;&#37;&#41; &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Specificity &#40;&#37;&#41; &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Kappa &#40;standard error&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">CD &#40;&#37;&#41; &#40;maximum&#8211;minimum&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Group A&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                      "titulo" => "Characteristics of infants with severe retinopathy of prematurity in countries with low&#44; moderate&#44; and high levels of development&#58; implications for screening programs"
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                        0 => array:2 [
                          "etal" => true
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                            4 => "R&#46; Semiglia"
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                          "autores" => array:4 [
                            0 => "I&#46; Casteels"
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                          "etal" => true
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2013.10.011

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Year/Month	Html	Pdf	Total

2024 November	7	8	15
2024 October	44	42	86
2024 September	50	27	77
2024 August	55	46	101
2024 July	35	30	65
2024 June	44	25	69
2024 May	42	34	76
2024 April	45	31	76
2024 March	32	22	54
2024 February	26	25	51
2024 January	38	31	69
2023 December	27	23	50
2023 November	37	16	53
2023 October	34	28	62
2023 September	35	28	63
2023 August	31	15	46
2023 July	36	29	65
2023 June	35	28	63
2023 May	36	19	55
2023 April	31	19	50
2023 March	39	22	61
2023 February	42	20	62
2023 January	45	17	62
2022 December	61	36	97
2022 November	49	36	85
2022 October	37	37	74
2022 September	24	34	58
2022 August	34	47	81
2022 July	21	36	57
2022 June	39	42	81
2022 May	31	44	75
2022 April	38	28	66
2022 March	44	46	90
2022 February	45	28	73
2022 January	35	34	69
2021 December	31	39	70
2021 November	28	48	76
2021 October	42	73	115
2021 September	23	53	76
2021 August	25	43	68
2021 July	17	53	70
2021 June	29	34	63
2021 May	27	34	61
2021 April	83	42	125
2021 March	31	26	57
2021 February	23	12	35
2021 January	23	26	49
2020 December	39	32	71
2020 November	33	29	62
2020 October	23	16	39
2020 September	25	15	40
2020 August	19	6	25
2020 July	17	16	33
2020 June	23	12	35
2020 May	45	24	69
2020 April	39	17	56
2020 March	32	22	54
2020 February	24	21	45
2020 January	26	17	43
2019 December	62	17	79
2019 November	23	14	37
2019 October	55	14	69
2019 September	37	19	56
2019 August	65	22	87
2019 July	26	56	82
2019 June	28	41	69
2019 May	81	30	111
2019 April	72	21	93
2019 March	30	17	47
2019 February	41	26	67
2019 January	33	19	52
2018 December	35	23	58
2018 November	47	36	83
2018 October	53	16	69
2018 September	39	9	48
2018 August	7	0	7
2018 July	15	0	15
2018 June	15	0	15
2018 May	58	0	58
2018 April	27	0	27
2018 March	23	0	23
2018 February	20	0	20
2018 January	33	0	33
2017 December	35	0	35
2017 November	28	0	28
2017 October	27	0	27
2017 September	25	0	25
2017 August	27	0	27
2017 July	11	0	11
2017 June	48	15	63
2017 May	14	8	22
2017 April	17	7	24
2017 March	18	11	29
2017 February	9	8	17
2017 January	15	4	19
2016 December	31	21	52
2016 November	34	8	42
2016 October	42	8	50
2016 September	47	18	65
2016 August	37	15	52
2016 July	22	12	34

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