Dr McCullough is a lecturer in Optometry at Ulster University. She is currently working on the Northern Ireland Childhood Errors of Refraction (NICER) Study which is investigating the epidemiology and risk factors for myopia and other refractive errors in children and young adults in the UK. She also has an interest in binocular vision and orthoptics providing lectures to undergraduate students and continuous education training to qualified optometrists.
Background: We applied the National Screening Committee vision screening protocol [pass criterion monocular acuity ≤ 0.2 LogMAR in both eyes(BE)] to children four to five years old to investigate the visual profile of children who passed/failed. Previous studies have only evaluated those failing. The aim was to derive false positive and negative values, specificity/sensitivity of the vision screening protocol for detecting significant visual defects (strabismus and/or significant refractive error) and the utility of a 'plus blur test' in identifying hyperopia.
Methods: Participants included 294 children (5.2 ± 0.4 yrs). In addition to the vision screening protocol (monocular acuity–3 m crowded Keeler LogMAR letters), acuities were recorded through +2.50D and +4.00D lenses and ocular alignment and cycloplegic refractive error were assessed. Using acuity measures, participants were classed as passing/failing the screening protocol. Each participant was also classed as having a strabismus and/or significant refractive error (hyperopia ≥ +4.00DS; myopia ≤ –0.50DS; astigmatism ≤ –1.50DC; anisometropia ≥ +1.50DS) or no significant visual defects.
Results: Of the 284 children who completed all tests, 27.8% failed to achieve 0.2 LogMAR in BE. The acuity pass/fail criterion had a sensitivity of 70.4% and specificity of 82.2% for detecting strabismus and/or significant refractive error. Of those who failed, 51.9% (n = 41/79) had no strabismus and/or significant refractive error (false positives). Of those who passed, 7.8% (n = 16/205) had visual defects (false negatives). The 'plus blur tests' improved sensitivity in detecting significant refractive error (+2.50D & +4.00D 90.7%) but significantly reduced specificity (+2.50D = 65.2%; +4.00D = 60.9%).
Conclusions: School-entry vision screening is reasonably sensitive and specific for detecting strabismus and/or significant refractive error. Most children with visions poorer than 0.2 LogMAR need refractive intervention, and the majority of the remainder are likely false positives for significant visual defects. One in 13 children who pass have either strabismus and/or significant refractive error (7.8%). The inclusion of a 'plus blur test' was not a useful addition to the vision screening protocol.
School-entry vision screening aims to detect children with reduced vision. The most common deficits causing reduced vision in children of this age are uncorrected refractive error and strabismus, which can lead to amblyopia if left undetected. Early treatment with glasses or occlusion/penalisation therapy can effectively improve vision; however, if left undetected and untreated, reduced vision can have long-term implications for the child's education, potential occupation and future vision loss (Chua & Mitchell 2004; Rahi et al. 2002).
The United Kingdom (UK) National Screening Committee (NSC) recommends that all children can be to are screened for reduced vision at school entry (aged four to five years) (UKNSC 2013). The recommendation is for an orthoptic-led service delivered by health professionals, such as a school nurse, orthoptist, health care assistant or specifically trained vision screeners.
Visual acuity is assessed using the Keeler crowded LogMAR test, and children are referred to specialist services for further assessment if they do not achieve 0.2 LogMAR in both eyes. The guidance states that 'amblyopia is the most likely condition to be detected' by school vision screening but also suggests that 'refractive error and strabismus would be detected' (UKNSC 2013); however, there are few published studies evaluating how well the NSC recommended school vision screening protocol identifies these problems. Neither is it clear from the available literature how many children with significant visual issues pass the recommended screening protocol.
The National Screening Committee have outlined a list of criteria to appraise the viability, effectiveness and appropriateness of screening programmes in the UK (Public Health England 2015). These criteria describe the importance of 'a plan for managing and monitoring the screening programme and an agreed set of quality assessment standards'; however, there is currently no guidance on what metrics should be used to gauge quality.
Previous studies have described the visual features and treatment needs of children who 'fail' vision screening protocols; without exception, they report that the single largest group referred from screening are those with significant uncorrected refractive error without amblyopia or strabismus (Beardsell et al. 1989; Donaldson et al. 2002; Edwards et al. 1989; Fathy & Elton 1993; Jutley et al. 2012; Karas et al. 1999; Kohler & Stigmar 1973; Newman et al. 1996; Williamson et al. 1995). Previous reports also note relatively high proportions of 'false positive' referral ranging from 13.3% (O'Colmain et al. 2016) to 43% (Donaldson et al. 2002). However, none of these studies profiled the outcomes derived from the basic NSC-recommended protocol consisting solely of monocular measures of LogMAR crowded acuity at 3 m.
With the recent publication by Public Health England of new child vision screening materials and guidance (Public Health England 2017a), it is timely to investigate the visual profile of children passing and failing the recommended school vision screening protocol. This information can be used to ensure that the diagnostic pathway implemented, and competency frameworks developed to support the pathway, are evidence based and optimise prompt, appropriate treatment. Such an approach is required to meet the NSC screening appraisal criteria that 'there should be an agreed policy on the further diagnostic investigation with a positive test result' and that 'all other options for managing the condition should be considered … to ensure that no more cost effective intervention could be introduced' (Public Health England 2015).
Given the high number of children reported as failing vision screening with uncorrected refractive error (Bruce et al. 2018), a secondary aim of the present study was to determine whether incorporating an additional assessment of visual acuity with the child looking through a plus (convex) lens may help improve the detection of hyperopia (Bodack et al. 2010; Bosse et al. 1992; Laatikainen & Erkkila 1980; Thomson & Evans 1999; Williams et al. 2005). Viewing through a plus lens should blur the distance vision of those children who are not hyperopic but have little or no impact on children who are hyperopic.
Recent work by the Vision in Preschoolers Hyperopia in Preschoolers (VIP HIP) group has shown that significant levels of uncorrected hyperopia (≥+4.00D in the most hyperopic meridian) are linked to poorer literacy and educational attainment in early school-aged children (Kulp et al. 2016), in addition to the deleterious effect hyperopia has on visual performance at near (Ciner et al. 2016). While school vision screening protocols are designed to detect reduced-distance vision, with the primary aim of identifying potential amblyopes, the inclusion of a plus lens test has been suggested as a useful measure to aid the discovery of children whose visual function, educational attainment and engagement may also be challenged by uncorrected hyperopia. Whilst the use of a plus lens test has been discussed for some time, there is currently a paucity of robust evidence to support the incorporation of such a test into school vision screening protocols and to quantify the most appropriate lens and visual acuity cut-off to employ.
the visual profile of those who fail the vision screening protocol.
Additionally, visual acuity was assessed through positive lenses to determine whether the inclusion of a 'plus blur test' alongside the current school vision screening protocol would improve the detection of school-entry children with significant uncorrected hyperopic refractive error. An evaluation of the utility of school vision screening will also be assessed with regards to whether children regularly attend for eye examinations or whether parents/guardians had concerns about their children's vision or eyes.
Fourteen primary schools were approached and agreed to facilitate the study, including seven rural and seven urban. All schools were of mixed gender, were non-selective in academic ability and drew children from a range of socioeconomic backgrounds. Written informed consent was obtained from the parents/guardians of the participants, and verbal assent was given by the participant on the day data collection took place. Data collection took place on school premises during school time. The study was approved by Ulster University Research Ethics Committee (Project number REC/12/0200), and the conduct of the study adhered to the tenets of the Declaration of Helsinki.
Each child underwent the recommended UK NSC school vision screening protocol of monocular visual acuity assessment using a computerised Keeler crowded LogMAR acuity chart at 3m (UKNSC 2013). The computerised version of the chart was used to standardise background luminance at different testing locations. Other computerised test charts (e.g., Kay pictures) have been shown to be a valid alternative to paper-based test charts in a paediatric population (Shah et al. 2012). The procedure for visual acuity assessment followed the guidelines on the Keeler crowded LogMAR test provided by Public Health England (Public Health England 2018). The screening procedure was used to determine the correct level at which to commence acuity testing. The child then attempted to identify all letters on the initial line, with the examiner proceeding to smaller or larger lines as necessary. At least two letters needed to be correctly identified before decreasing the letter size. All letters were tested on a line where errors occurred; by-letter scoring was applied with each letter equal to 0.025 LogMAR and the final result documented. Acuity was tested to threshold level. Children responded either by naming or matching the letters. The right eye was tested first, followed by the left eye, with the non-tested eye occluded with children's occlusion glasses. Care was taken to ensure children were not peeking around the occlusion lens. Children who habitually wore spectacles completed all tests unaided. The visual acuity test was carried out by authors SJM or KJS, qualified optometrists with considerable experience of visual acuity testing in children in both research and clinical settings. Acuity measurement was performed prior to all other measures.
Monocular acuity measures were used to identify children who failed the vision screening protocol as set out by the UK National Screening Committee (monocular acuity worse than 0.20 LogMAR in one or both eyes).
An assessment of ocular alignment at distance and near using the cover/uncover test unaided. The child was directed to fixate on detail within a picture at 3 m and on the Lang Cube at 33 cm.
Refractive error was assessed using distance autorefraction (Shin-Nippon NVision-K-5001, Shin-Nippon, Tokyo, Japan) at least 30 minutes after the instillation of one drop of 0.5% proxymetacaine hydrochloride followed by one drop of 1% cyclopentolate hydrochloride. The presence of dilated pupils that were nonresponsive to light was used to confirm that cycloplegia had been achieved; where this was not the case, a second drop of 1% cyclopentolate hydrochloride was instilled. No less than five readings were taken from which the representative value as determined by the instrument was used for further analysis. The representative value is widely used as an output value for this instrument and has been shown to be comparable to other methods of averaging refractive error (Tang et al. 2014). Spherical equivalent refractive error (SER) was calculated using sphere + (cylinder/2).
The VIP-HIP Study (Kulp et al. 2016; Ciner et al. 2016) report the greatest deficits of visual function and literacy among children who had ≥4.00D of hyperopia. The Royal College of Ophthalmologists (RCOphth 2012) also suggest that children with hyperopic refractive errors of less than +4.00D do not require glasses. Our cut-off criteria for significant hyperopia have encompassed these publications and guidelines and should be interpreted accordingly; variations in the level of significant refractive error will alter the sensitivity/specificity and false positive/negative results derived.
Monocular distance acuities were also measured using the Keeler crowded LogMAR computerised acuity chart at 3m with the child wearing glasses with a plus lens (either +2.50DS or +4.00DS) in front of one eye and an occlusion lens in front of the other eye. All children had their vision assessed with both the +2.50DS and the +4.00DS lens for both eyes. The time taken to deliver the 'plus blur test' was recorded using a stopwatch.
All statistical analyses were carried out using Stata Intercooled 13.0 (StataCorp, Texas, USA). Sensitivity and specificity values were calculated for the ability of the UK NSC school vision screening protocol to detect strabismus and/or significant refractive error. The visual profile of the children who passed or failed the school vision screening protocol was also determined. Receiver Operating Characteristic (ROC) curves were examined to ascertain the best cut-off point (taken as the point closest to the top left-hand corner of the ROC curve) of visual acuity with the '+2.50D and +4.00D blur tests' to detect significant hyperopia. These visual acuity cut-offs were used in addition to the current school vision screening to determine whether the combination of the tests improved the detection of those children with significant hyperopia, as well as strabismus and/or other significant refractive errors. Chi-squared analysis was used to assess agreement between the pass/fail classifications assigned to participants by the current study group compared with that of the school nurse's assessment. Mann-Whitney tests were used to assess differences in age between children who passed or failed the vision screening protocol.
A total of 294 typically developing children in their first year of formal education in Northern Ireland (Kindergarten equivalent) were recruited, with a participation rate of 36%. The median age of participants was 5.23 years (range 4.0 to 5.9 years), with a gender mix of 45% male and 55% female. The majority of participants were white (n = 278, 95%) consistent with the demographics of the Northern Irish population (NISRA 2011).
All participants (n = 294, 100%) were compliant with the measurement of monocular distance visual acuities. Complete acuity and diagnostic data were available for 284 participants (96.6%) (Table 1). Eighteen participants were unable to complete monocular distance visual acuities with the '+2.50DS and +4.00DS blur tests' (data available for n = 276, 93.9% of those recruited).
Visual assessment results. Those classified with astigmatism are those children not already classified with myopia or hyperopia. Those classified with strabismus are also re-classified in the Significant Refractive Error section.
Table 2 shows the sensitivity and specificity of the UK NSC vision screening protocol for detecting strabismus and/or significant refractive error.
Sensitivity and specificity of the UK NSC vision screening protocol (vision assessment using the Keeler crowded LogMAR acuity chart) at detecting children with strabismus and/or significant refractive error. EE = either eye.
The majority of children who passed the vision screening protocol (n = 189/205, 92.2%) were found in the diagnostic assessment to have no potentially amblyogenic risk factors. Sixteen children had strabismus and/or significant refractive error and were found to pass the screening protocol (n = 16/205, 7.8%); the majority of these had significant uncorrected refractive errors (n = 15/16), predominantly hyperopia (n = 13/16) (most ametropic eye, median +4.50DS, range +4.00DS to +8.00D). One child had significant anisometropia with significant astigmatism and a visual acuity difference between their eyes of 0.10 LogMAR (RE 0.05 LogMAR, LE 0.15 LogMAR). Two children passing the screening protocol had manifest strabismus, one with alternating exotropia and one with a left distance exotropia.
What is the visual profile of those who fail the vision screening protocol?
Of the 79 children whose visual acuity was worse than 0.2 LogMAR in either eye, strabismus and/or significant refractive error were present in 38 children (48.1%) and were likely to explain the reduced acuity measure. The majority of these children had significant uncorrected refractive error only (n = 31/38, 81.6%). Seven children (8.9%) whose acuity was poorer than 0.2 LogMAR had strabismus, and six of these children had a significant co-existing refractive error. The visual profile of 51.9% of participants (n = 41/79) who had a visual acuity of worse than 0.2 LogMAR did not indicate any need for clinical intervention and demonstrated no significant visual issues to explain the poor acuity measure. The median sphere and cylinder for both eyes was 2.25D (range 0.25 to 3.75D) and –0.50DC (range 0.00 to –1.25DC), respectively. The median visual acuity of these children was 0.25 LogMAR for both eyes, which equates to approximately two letters poorer than the criteria required to pass the acuity test. The median age for these children was 5.1 years (IQR 4.2 to 5.8 years) compared to 5.3 years (IQR 4.3 to 5.8 years) for those children who passed the screening protocol and did not indicate a need for clinical intervention; this difference was statistically significant (Mann-Whitney analysis, z = 2.27, p = 0.02). Overall, children who failed the school vision screening protocol were statistically significantly younger (median = 5.1 years, IQR 4.8 to 5.4 years) than those who passed (median = 5.3 years, IQR 5.0 to 5.8 years) (Mann-Whitney analysis z = 2.18, p = 0.03).
Parent questionnaire data were available from 279 participants. Of these participants, 89 parents reported taking their child for an eye examination within the last year (31.9%).
A number of significant visual defects were previously undiagnosed (n = 29/53, 54.7%), with the majority of these being significant uncorrected refractive error alone (n = 26/29, 89.7%) (Figure 1A) (data were missing from one parent questionnaire where the child had a significant refractive error; therefore, we cannot comment whether it was diagnosed or not). Most of the parents/guardians of these children had no concerns about their child's vision/eyes (n = 26/29, 89.7%), and most (n = 28/29, 96.6%) had not taken them for an eye examination within the last year. Details of the visual defects (significant refractive error and/or strabismus) that were diagnosed and undiagnosed before the child attended the vision study are presented in Figure 1A and 1B. The diagnosed visual defects in Figure 1B are calculated from the details provided in the parent questionnaire on whether the child currently wore spectacles or if the child had strabismus.
Frequency of undiagnosed visual defects (A). Frequency of diagnosed visual defects (B).
One hundred and four parents/guardians (37%) responded to the request for information about their child's performance in the school vision screening carried out by the school nurse/vision screener during the first year of formal education. This may have occurred prior to or after their participation in the present study. Three (n = 3/104, 2.9%) parents/guardians reported their child 'did not take part', and five (n = 5/104, 4.8%) reported their child was 'not offered to take part' in school vision screening. Twenty (n = 20/104, 19.2%) parents/guardians reported they were 'unsure of the result' of their child's school vision screening. A comparison of the child's school vision screening result according to parental report to the results of the vision assessment carried out within the present study is outlined in Table 3 for the remaining 77 participants. There was significant agreement between the outcomes of the two vision assessments for 90.9% of the children (Chi-squared = 44.2, p < 0.0001).
Comparison of the outcomes from school vision screening by the school nurse (according to parental report) and the results of the visual acuity test in the present study, n = 77.
Receiver Operator Characteristic (ROC) curves were generated to explore the best visual acuity cut-off point for the detection of significant hyperopia using +2.50D and +4.00D lenses for the right and left eyes (Figures 2A, 2B, 3A and 3B, respectively).
ROC Curves: Use of '+2.50D blur test' to detect significant hyperopia (≥+4.00D). The boxes highlight the best visual acuity cut-off points that relate to the right (sensitivity 69.7%, specificity 81.63%) (A) and left eyes (sensitivity 70.00%, 83.87%) (B).
ROC Curves: Use of '+4.00D blur test' to detect significant hyperopia (≥+4.00D). The boxes highlight the best visual acuity cut-off points that relate to the right (sensitivity 72.73%, specificity 73.66%) (A) and left eyes (sensitivity 66.67%, 90.65%) (B).
Visual acuity >0.2 LogMAR in either eye or visual acuity with '+2.50D blur test' of ≤0.638 LogMAR in either eye.
Visual acuity >0.2 LogMAR in either eye or visual acuity through '+4.00D blur test' of ≤1.021 LogMAR in either eye.
Table 4 shows the sensitivity and specificity using failure criteria 1.) and 2.) and the current vision screening protocol for comparison.
Sensitivity and specificity of failure criteria 1.) and 2.) and the current screening protocol at detecting children with strabismus and/or significant refractive error.
Using the additional '+2.50D blur test' or the '+4.00D blur test' identified a further 11 participants with strabismus and/or significant refractive error who were not detected by the UK NSC school vision screening protocol. However, 39 additional false positive results were generated with the '+2.50D blur test' and an additional 49 with the '+4.00D blur test'.
It took, on average, an additional 93 seconds (range 40–199 secs) to measure visual acuities of both eyes with the '+2.50D blur test' and an additional 80 seconds (37–222 secs) with the '+4.00D blur test'.
While previous studies have reported the visual profiles of children failing the UK NSC recommended school vision screening protocol (e.g., O'Colmain et al. 2016; Bruce et al. 2018), the present study also reports, for the first time, the profile of those who pass the screening protocol. These data allow estimation of the vision screening protocol's false negative value and sensitivity and specificity in identifying treatable amblyogenic risk factors, such as strabismus and/or significant refractive error. The majority of children who passed the UK NSC vision screening protocol, achieving 0.2 LogMAR or better in both eyes, in the present study (92.2%) were not found, on further examination, to have either strabismus and/or significant refractive error. However, 7.8% who passed the acuity test did have one of these significant visual defects. Although these children are unlikely to need amblyopia treatment as their level of vision falls within normal limits for their age, identification and correction of these visual issues would be of benefit to the child for future visual and educational development. These figures suggest the UK NSC vision screening protocol has moderately good sensitivity (70.4%) and specificity (82.2%) for detecting strabismus and/or significant refractive error. To the authors' knowledge, these figures have not previously been available for the current UK NSC school vision screening protocol.
Children who were deemed false negatives, having passed the vision screening protocol, had significant refractive errors ranging from +4.00D to +8.00D (n = 15/16), significant astigmatism and anisometropia (n = 1/16), and strabismus (n = 2/16). The false negative figure derived (7.8%) is determined by the criteria chosen to indicate significant refractive error. The criteria chosen in the present study are conservative, in line with prescribing guidance from the Royal College of Ophthalmologists. If less conservative criteria are applied (e.g., Bruce et al. 2018), false negative rates will increase (and correspondingly false positives will decrease).
While it is not possible to directly compare sensitivity and specificity across vision screening protocols with different criteria for inclusion of significant refractive error, our figures compare favourably with outcomes reported by the Vision in Preschoolers (VIP) Study using crowded LogMAR acuity charts to detect refractive error (≥5.00D hyperopia, ≥2.50 astigmatism, myopia ≤ –6.00D, severe anisometropia = interocular difference >2D hyperopia, >3D astigmatism, or >6D myopia) and strabismus among children aged 3–5 years in the United States (US). The crowded LEA symbols chart administered by school nurses in the US showed a 49% sensitivity when specificity was set to 90% (Vision in Preschoolers Study Group 2005), and the crowded HOTV acuity chart showed 54% sensitivity and 89% specificity when administered by eye care professionals (Schmidt et al. 2004). The lower sensitivity found in the VIP study compared to the current study is likely due to the higher categories set for significant refractive error.
Amongst participants in the present study, almost 55% (n = 29/53) of those who were found to have a visual defect at age 4–5 years were undiagnosed (10.2% of the study group), and 55% of these (n = 16/29) would have been identified by the standard NSC school vision screening protocol. Recent coverage in the optometric media (Association of Optometrists 2017) has reported that one in five school-aged children have an undiagnosed vision problem within the UK. Our results suggest this figure is closer to one in ten among children of school-entry age. However, we acknowledge that, with increasing age, the number of children with myopia will increase and potentially inflate this figure (O'Donoghue et al. 2010; Breslin et al. 2013; McCullough et al. 2016).
Within our study group, just over 30% of children had undergone an eye examination within the last year. This figure is higher than that reported by Guggenheim and Farbrother (2005), who reported that only 7% of children under the age of five years living in the North of England had visited their optometrist for an eye examination within the last year. However, the fact that 70% of the children within our study had not had an eye examination within the last year highlights the importance of continuing universal coverage of vision screening at school entry. It is also important to make parents/guardians of children who pass school vision screening aware that screening, by its nature, cannot detect all vision problems (7.8% of those who passed had significant visual issues). Following the recent consultation on school vision screening, Public Health England recommend that post-screening information letters given to parents/guardians of children who pass should identify the limitations of school entry vision screening and highlight the availability and importance of ongoing eye care through childhood (Public Health England 2017b).
The percentage of children failing to achieve acuities of 0.2 LogMAR or better in both eyes was 27.8% within the present study. Published failure rates for school vision screening protocols in the UK (2015/16) range from 4–24%, with an average of 12% (Carlton et al. 2017); the failure rate of the present study is at the high end of this range. The age profile of children participating in screening programmes is likely to influence the failure rate. Those children who failed the vision screening protocol in the absence of potentially amblyogenic risk factors were significantly younger than those children who passed. The median vision measurement achieved for both eyes for these children was 0.25 LogMAR, two letters worse than the pass criterion. This highlights that younger children are more likely to fail vision screening even when age appropriate vision tests are used with matching cards available.
All children within the present study were able to complete the crowded LogMAR letter test, which is considered to be the most sensitive for screening for amblyopia (Simmers et al. 1997). Acuity measurement undertaken by eye care clinicians, rather than school nurses, may have inflated our failure rate. The Vision in Preschoolers Study (Vision in Preschoolers Group 2009) report an increased failure rate when experienced clinicians carry out the vision assessment compared to lay screeners. The higher failure rate could have inflated the number of false positive results presented; however, in the main, our pass/fail classification of participants is in agreement with that conducted by the school nurse screener.
Significant refractive error alone was found to be the predominant cause for a child to have reduced vision under the current screening protocol (39.2%, n = 31/79). Seven children who failed (8.9%) were found to have strabismus, and all but one of these children had significant uncorrected refractive error. More than half of the children who failed the vision assessment within the current study had no significant visual issues to explain reduced visual acuities (51.9%). Donaldson et al. (2002) reported on a secondary vision screening service that triaged children who failed school vision screening using a joint optometric/orthoptic assessment. They report similar figures; 43% of the children failing initial screening were found to be 'visually normal' and were discharged without treatment, and 41% of children required refractive correction as the only treatment. Only 16% of children required onward referral to the Hospital Eye Service. Donaldson et al.'s findings and those of the present study are echoed by other published data [5–13]. A recent paper by Bruce et al. (2018) report a false positive rate of 7% for their study population of children based in Bradford, UK, which is low in contrast to the results of the present study. However, almost 40% (n = 953) of the children who failed the vision assessment did not attend for their follow-up visit to determine whether a visual defect was present or not. Bruce et al.'s threshold for significant hyperopia is also considerably lower (≥+2.00D SER) than that used within the present study. A higher level of hyperopia (≥+4.00D sphere) was chosen in the present study to reflect prescribing guidance from the Royal College of Ophthalmologists and to mediate against inflation of false negatives; in turn, this may have increased the number of false positives. Lowering the criteria for significant hyperopia to ≥+2.00D SER would result in a false positive result of 29.1% (n = 23/79), which still remains significantly greater than that reported by Bruce et al. In the context of quality improvement frameworks for healthcare (e.g., The Health Foundation 2013), such data should be utilised to develop service delivery models that prioritise the assessment and treatment of refractive error for children who fail vision screening diagnostic pathways such that children's visual needs are identified and met in a timely and efficient fashion.
The addition of the '+2.50D and +4.00D blur tests' improved the sensitivity of the screening protocol for the detection of significant refractive error and strabismus; however, the specificity was significantly reduced with both 'plus blur tests'. A substantial number of false positives would be generated if added to the current vision screening protocol recommendations. Additionally, administration of each 'plus blur test' added an average of 80–90 seconds to the assessment duration for each child. The extra time taken to administer the test, together with the poor specificity values achieved, suggest that the 'plus blur tests' may not be a useful addition to the recommended school entry vision screening protocol.
The study presents data from a large number of typically developing children who underwent the recommended UK NSC school vision screening protocol. We have assessed for the first time the presence of visual defects among those children who pass the school vision screening protocol and have identified the percentage of false negatives generated. The study conducted a diagnostic assessment on all the participants to establish refractive error under cycloplegia and oculomotor status. However, we did not assess the integrity of the fundus; therefore, some children may have been incorrectly identified as a false positive where a fundal abnormality may have been the cause of reduced visual acuity. Given the extremely rare nature of such deficits, we expect this omission to have had minimal impact on our findings (Pollack & Brodie 1998).
The results of our judgement on whether the child's visual performance should pass or fail the vision screening test was comparable to that carried out by the school vision screening service in our area, with the majority of the results in agreement (90%). However, we had access to limited data on the screening outcome as only 37% of parents/guardians responded to our request to share the outcome of their child's school vision screening.
The UK NSC school vision screening protocol has moderately good sensitivity and specificity for the detection of strabismus and/or significant refractive error, and inclusion of plus blur lenses doesn't add significant value. More than half of the children who failed the vision screening protocol had no apparent visual defect and were regarded as false positives. Younger children were more likely to contribute to this figure. Significant refractive error was the primary cause of reduced visual acuity.
One in 13 children who passed the school vision screening protocol had a significant visual defect (false negative 7.8%). In line with Public Health England's updated vision screening recommendations, our data support the need for clear advice for parents/guardians regarding the limitations of vision screening and, in the UK context, making them aware of the availability of the free NHS eye examination, particularly where concerns about their child's vision or eyes exist.
The authors thank the College of Optometrists (London, UK) for their financial support of the study. We are grateful to the children, schools and parents for their participation. The authors would like to thank Dr Lesley Doyle, Dr Stephanie Kearney and Dr Lisa O'Donoghue for their help with data collection. We would like to thank Professor David Thomson for providing the computerised crowded Keeler LogMAR chart.
Association of Optometrists. 2017. Many children will return to school without the right prescription; New campaign reminds parents to book a sight test. Available at: https://www.aop.org.uk/about-aop/media-centre/press releases/2017/08/31/wolverhampton-toddler-loves-her-new-glasses [Last accessed October 2017].
Beardsell, R. 1989. Orthoptic visual screening at 3 1/2 years by Huntington Health Authority. Br Orthopt J, 46: 7–13.
Bosse, JC, Mallet, JM and Santoro, J. 1992. Preliminary report of the Colorado School Vision Screening Interdisciplinary Task Force. Journal of Behavioural Optometry, 3: 151–3.
Carlton, J, Griffiths, H and Mazzone, P. 2017. BIOS Screening Audit report 2015–15. Available at: https://figshare.com/articles/BIOS_Screening_Audit_report_2015-2016/5532910 [Last accessed January 31, 2019].
Edwards, R, Whitelaw, A and Abbott, A. 1989. Orthoptists as pre-school screeners: A 2-year study. Br Orthopt J, 46: 14–19.
Jutley, G, Ho, D, Gohil, B, Khan, S and Dhir, L. 2012. Paediatric Ophthalmology Referrals: Causes of reduced vision in children and how accurate are the referrals from Family Practitioners? Invest Ophthalmol Vis Sci, 53: 6772.
NISRA. 2011. Northern Ireland Statistics and Research Agency. Availabe at: http://www.nisra.gov.uk/Census/key_stats_bulletin_2011.pdf [Last accessed June 2, 2017].
Public Health England. 2015. Criteria for appraising the viability, effectiveness and appropriateness of a screening programme. Available at: https://www.gov.uk/government/publications/evidence-review-criteria-national-screening-programmes/criteria-for-appraising-the-viability-effectiveness-and-appropriateness-of-a-screening-programme [Last accessed Octobert 2017].
Public Health England. 2017a. Child vision screening resources. Available at: https://www.gov.uk/government/consultations/child-vision-screening-resources [Last accessed October 2017].
Public Health England. 2017b. Guidance Child Vision Screening. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/653434/vision_screening_parent_leaflet.pdf [Last accessed November 2017].
Public Health England. 2018. Guidance, Screening Competencies. Available at: https://www.gov.uk/government/publications/child-vision-screening/screening-competencies [Last accessed October 2018].
Royal College of Ophthalmologists. 2012. Guidelines for the Management of Strabismus in Children. Available at: https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-SCI-250-Guidelines-for-Management-of-Strabismus-in-Childhood-2012.pdf [Last accessed February 2019].
The Health Foundation. 2013. Available at: http://www.health.org.uk/sites/health/files/QualityImprovementMadeSimple.pdf [Last accessed November 2017].
UKNSC. 2013. UK National Screening Committee Recommendation on Vision Defects Screening in Children. Avaiable at: http://legacy.screening.nhs.uk/vision-child [Last accessed January 31, 2019].


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Browse profiles of Member members here at Teachers Date that are tagged with Ugly. Dating other singles that have similar interests is an ideal way to come up with ideas to do once you are dating. Signup for a Totally Free Account to Date Tonight!
I love cats and jean shorts!!!
I'm layback but love to have fun indoors or outdoors. Spending time with my kids. I love my job,i'm assistant teacher. Cuddling up to a good movie.


I have just been introduced to CityVille. Can't stop. Won't stop.
What are some others you're fond of?!
I remember playing Zombie Assault all last year in school. I was never that good, but my golly it was fun!
I hate when I can't pull myself away from a game...especially something that's online. That generally means anything I'm doing on the computer is pushed aside.
Mine would be the bloon monkey game on tg :/ im sort of addicted ha.
I used to be an avid Runescape player (who wasn't?). Sometimes I go through phases where I play again for a few weeks/a few months at a time and then I quit again.


An iconic exploration of the film industry, this Oscar winner is set in the epicenter of the dream factory amidst budding fascination with Hollywood scandals and portrays a duplicitous tale of murder, deception, and fading glory. An aging silent film star played by Gloria Swanson seeks a comeback while finding herself at Tinseltown's complicated intersection of gender and age.
KinoNoir is presented on the second Monday of the month through July by Kinonik and SPACE with support from the Maine Humanities Council.


Get acquainted with the writings of every Human Resource books writers whenever possible.
This is what every Human Resource Manager and HR specialist need to do so in order to update their knowledge.
These HR expert writers have continued to recommend the use of strategies in human resource management.
Let us see what some of these writers had stated.
reliance upon a set of 'levers' or drivers to shape the employment relationship.
A rigorous selection is intended to identify people with the attitudes and skills that high performance organizations require.
Yet another writer, J. M. Ivancevich in his book "Human Resource Management (2001)" states that "performance management practices generate profitability gains, share price increases, higher company survival rates, increased sales and lower labour turnover."
These refer to the positive impacts of effective performance management on the financial performance of organizations.
R. S. Randall Schuler, Galante and Susan Jackson stated that organizations can improve their environment for success by making choices about HR planning, staffing appraisal, compensation, training and development and labour relations that are "consistent with and support the corporate strategy."
"If organizations can reduce the rates and severity of occupational accidents, diseases and stress and improve the quality of the working life of their employees, they will be more effective."
J. J. Black, H. B. Gregersen, M. E. Mendenhall and L. K. Stroh wrote about international assignments which has reference to global human resource management.
"International assignments are the single most powerful means for developing future global leaders."
A survey has shown that pre-departure knowledge and orientation on the culture, history, geography, politics and economics of the country of destination was "significantly and positively related to work success, interaction and general adjustments (of Japanese expatriated in the US).
Global management skills are now in great demand due to the internationalization of business operations.
However, not all human resource books writers paint a rosy picture of human resource management.
This suggests manipulation of people in order to achieve certain objectives.
Keep up-to-date on any new HR book.
In this way, you will not miss anything important that can help in finding better ways of managing your human resource. Ensure you are aware of current books churned out by Human Resource books writers.


But how did you manage to DL the model? I don't see any options!
Several meshes have been reworked, the new block engine with AO enhancement looks great, no more overlaping meshes.
Very, very cool, my friend!
I'm still working on some features. Hopefully I'll finish them and be ready for sync'ing by the end of Sunday.
And the amazing Hot Rod version.
Yes, it's been a long long way indeed, practically as long as we know each other.
And while we're at it, please start thinking about deprecating FFP altogether when we have our OR v3.0 out that will have frame buffer objects to render and post-process to. It isn't going to be this time but rather shortly indeed.
No way will FFP be able to compete with, or even stand near by, the new v3.0. It will be kinda a disgrace to have it in there, though ALL of the models you ever laid your hands on will remain great pieces of 3D art.
The two models have been released into the car collection.
I'm still at work with OR.


text:
Home > Miss Hammurabi > Miss Hammurabi Recap Episode 3
V May 29, 2018 Recaps
Miss Hammurabi Recap Episode 3
Women's rights in the workplace and inappropriate behavior by superiors is the lead case today. The men on the team need a little lesson in how woman are treated just by going outside the house; it is a lesson that the ladies of the traditional market are very happy to teach.
MUSIC: Miss Hammurabi Music List.
CHARACTER CHART: Shorthand Character Chart
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KDRAMA MISS HAMMURABI RECAP EPISODE 3
OPENING, COURT SCENE
A man talks passionately about his case. the man says they cannot fire that person. BR is very sarcastic in his mind and says this ex-politician lawyer is half air and the other half sound. Someone sent a sexual harassment KaTalk to a college intern. The judge asks to look at the messages. he starts to read the KaTalk. It says things like, "You look nice from the front but from the back, you drive me crazy."
SS asks if this is for the college interns benefit? The lawyer says women need to look good to be proud of themselves.
The next evidence is a picture of the man's chest with the nipples with hearts on them. the crowd can't even look at it. The lawyer says he works for an entertainment company that deals with these kinds of jokes a lot. He didn't mean it as sexual harassment. He shouldn't get fired, you know. Our society is too harsh for men.
BR grumbles in his brain that sitting through that is the harshest.
At lunch. COR wonders how a person like that can become a senator. BR says people like people like him. We are a free country. COR thinks this lawyer had a scandal where he felt up female reporters. SS tells her not to think about the lawyer, only the case. That lawyer is not 100% wrong. Isn't it a joke using that popular song.
COR asks about his chest. What about that? BR says you don't always have to have sexual feelings for sexual harassment. SS says he knows this, but they need enough proof to fire him. Some people just haven't caught up with the changing society. COR wants to know if they have to forgive him and understand him until he catches up with society? She mocks the situation by covering her chest and saying Ajusshi, it is not your fault, do you think you will catch up with society?
SS is angry and hits his table. He says they have to think about the family members. If the father is fired, then the family suffers, it is not that easy.
Back to the case. A female witness says their boss is a funny guy…..with old-fashioned jokes. Another person says he doesn't have cruel intentions…..he is popular.
SS asks the plaintiff why he sent those things. The plaintiff stands up and says he is sorry, he thought young people accepted his jokes well but he just went too far. Until now he thought he was a funny person, but now he is really embarrassed. His family is not guilty and his daughter is in college. the two others are high school students. If he gets fired then it means they will all die.
Afterward, BR says this is a huge problem. At first, he thought their chief was too humanistic, but after the afternoon trial, he is confused. COR asks him if he wants a serial drinking person to drive a truck because their family is important? BR thinks there should be another solution like cutting his salary. But firing is a death sentence.
COR says, yeah, head of the family is the most important thing. But that disappeared under the law, why are you still talking about it? Br says it isn't about the law, he is just thinking about their living situation. All the witnesses said it was just a joke, he is just a funny guy, right?
COR thinks the defendant should be thought about too. This is big trouble, she feels it very seriously. If she is too particular then she won't be a good judge. She stares at BR.
But then BW comes in with his hand up and speaks a mile a minute about an Asian actress that wants to travel with him (his usual nonsense). Then he tells them that he will give them a decision. BW looks at the facts of the case and jumps when he sees the picture of the naked body.
He literally jumps back several feet. Then he sits and says there are a lot of attractive people outside. Why does he do that?
DY comes in at that time and gives documents to BR. BW keeps talking and says for a man like him when he sees an attractive woman he does not do those creepy things because his reason is controlling him. Those types of guys who only follow male instinct are unable to be understood.
DY says the distance between his reason and his animal instinct is only ten centimeters. He says, huh? She repeats herself and then takes down her hair and pulls up her skirt to 10 centimeters, opens her shirt to 10 centimeters, and turns her waist to show of its 10 centimeters. BW melts. DY tells him he is very normal and then leaves.
BW stutters and says that her skirt was much shorter than 10 centimeters! COR tells him his eyes never looked so big. BR tells him his eyes went too far. You should be careful, that can be sexual harassment. COR tells them that she will buy dinner for them, would they like to join her? BE asks if it will be a nice place?
Cut to them walking through the ajumma market. All the women take photos of them and talk about their butts, they would like to grab it. You should have a big thingy, tiny ones are spicier! COR gives all the ajummas a thumbs up.
The men go to sit. The ajummas tell them that they shouldn't wear such tight clothing. Men shouldn't dress like that. I see your nipples, you should wear under clothing. Why are you dressed like that? You are handsome young guys. Hey, if Jun Ji Hyun or Song Hye-kyo said those compliments then it would be a compliment to you. The men are so uncomfortable.
Halmoni shows up which makes the men stand. She asks them to treat her granddaughter well.
The men cut to the bathroom to pee. They think this is a strange place. An ajumma shows up behind them and tries to get a look at their little wee wee's. Then she tells BW, fighting! BW is all like, why are you telling me, fighting? hey? BR tells him fighting as well, lol.
The men go to sit back at the spot. COR tells them that she is sorry she took them to a really scary place, but do you at least see how women feel? As men, you don't think anything will happen even though they talk about you, but as women, we also have that fear. BR thinks for a moment and says that sexual humiliation is a little different than uncomfortableness between a management and intern. It is a difference in power.
BW asks if this is all about that guy with the hairy chest? Why did he do that? Does he want to tell people that he is a man? COR says, he just does it because he has the power to do it. It doesn't matter if the other person likes them or not. Ajumma's yell, how is this so difficult! You don't have to know the reason, just cut them! She chops a piece of soondae which looks like she is cutting off a penis.
COR and BR talk about the case. He says he only knew this type of case with his brain. COR tells him that when she was in college, she worked at a café part-time. he said she is rich, why did she do that? COR asks him if she has to have a reason for it? She continues with her story…
We see an image of COR playing the piano at a café. One of the men comes up to her, he looks a little tipsy. he tells her that his college friend is a Julliard professor, he can support her. Do you want me to give you a ride? It is dangerous at night. COR immediately knew they were bad guys.
She leaves but goes to the elevator and one of the men is in the elevator, he is drunk as well. He tells her that he said he would give her a call several times doesn't she trust him? If you trust me then give me your phone number. She writes her phone number down but it is a fake one that doesn't ring. She is able to run out of the elevator.
BR thinks she was their kids' age. COR tells him that these men are good fathers and socially acknowledged. She tells him that a lot of things should not be known too early in life. BR agrees. But he wants to ask her more about this just in case he missed something. He knows it is important. His job is to see if there is enough evidence, even though this sounds like an excuse. COR says it isn't an excuse, she knows that is their job.
They work until just after midnight. COR tells BR that she will continue reviewing it all at home. He will stay and finish some other things up.
She walks out and it starts to feel creepy. The lights turn off momentarily. COR clenches her hands as she tries to go into the elevator. But she can't press the elevator doors because she remembers the elevator scene that she described to BR. But this new image looks a little different from the one she described?
BR shows up and presses the elevator which makes COR feel more relaxed. While in the elevator she notices that he is sweating, did he run? He says he didn't run. But we see a flashback where he actually did run to catch up with her. He is still wearing his work rubber cap on his finger. COR tells him thank you, just because…~.
BW comes into the office and asks them if this is the pervert case with the chest hair? COR says yes it is. BW tells them a secret that he doesn't usually tell rookies. He actually majored in electronic engineering. His grades were low, but he is developing AI projects so they hired him as a judge. BR tells him that he learned how to lie from con men.
BW tells him that it was working! My clerk really believes it. then he grumbles about how jokes can't live there, it is too cold. he leaves and COR smiles as she mentions that she laughs because of him. BR mentions that DW lives in the building with his own folding couch. he also had a tent in the lab when he was in college.
The witness from the company side talks on the witness stand. It looks like the case spread because her boyfriend put this case in SNS, that is why the company fired the plaintiff, right? She says yes. He says those are all his questions.
BR – Nonsense, they fired that guy and that is the only question? Do they want to win the case?
The other man goes up to the witness and aggressively yells in her face. he tells her to look in his face, the life of one head of the family depends on this case. SS tells the man that this is not an American law drama, just go to your seat and ask the question, we have good microphones.
The man goes back and asks his question. The plaintiff told the witness that she should be as strong as a man if she wants to still be in this company right? That means that he was joking to make you strong. In this advertising industry, you have to meet a lot of people and drink and stuff. Did he teach you that you should be ready to take on sexual jokes and things? That is why he sent you those text messages.
She says no, he sent her things every night.
The lawyer wants to know if she has it as evidence.
She says she erased everything because it was so scary.
The lawyer yells at her but SS tells him that he is not interrogating a criminal! Be nice to the witness! The man laughs cheerfully and says it is because he was so sad to the plaintiffs family. he is done with his questions.
The plaintiff apologizes to the witness profusely.
Another witness goes up. It is another woman witness. The witness says this man has good ability and contributed to the growth of their company a lot. She works under the plaintiff as the assistant manager. He makes a lot of sexual jokes, he makes these jokes with her as well but she lets it pass. As a woman, she knows she has to make a compromise to survive in a man dominated company. From when she was a young employee she was told not to go too far as a female. Now young people make a big deal about small things and it destroys their company cohesiveness.
The lawyer says he heard that a lot of people in the company think that firing him was too much. She says that she is not in that position but they should recognize that the company has its own difficulties.
the plaintiff turns to the crowd. In the crowd, it looks like everyone supports him. But it also looks like BW is blowing him kisses?
The company side has no questions for this witness. the judges are stunned and the woman in the back tries to wipe her tears.
The next witness comes up. She is also a woman. She says that people thought this person was too sensitive. She didn't' adjust herself well. The lawyers say that no one else thinks the company is strange, right? Only the part-timer? SS says she is not a part-timer, she is an intern. he says that is right, the intern didn't adjust to the company.
The woman yells, NO, in the back and tries not to cry.
The lawyer says she is sensitive like that all the time, she can't adjust. The witness says that is true, but she looks stunned.
COR has a flashback to her teacher touching her uncomfortably on her shoulder and back. He tells her she will grow up nicely as a woman.
The woman keeps crying in the back of the courtroom, the other women turn and see her, they look concerned for her.
Another woman goes up as a witness. She says everything is the same as her statement. The defendant doesn't ask her any questions. Everyone is against the woman in the back.
BR – No questions for the defendant? It ends there?
SS tells them that if both sides don't have any questions then they will end there. But there will be another trial. they all leave.
SS tells his other judges that he likes baseball, but sometimes the game looks fixed. He doesn't like those games. Do they do that to have a better seed in the next season? Or is it gambling related? I want to review that game again when that moment happens. He also has another set of eyes looking at him that will hit him if he quits.
He looks at COR. he tells her that people should know that she is into the case, but she should maintain her facial expression well. COR agrees.
BW goes into the office and asks if this is a fixed case? he is loud and incredulous. Is the case closed? COR says their chief isn't that kind of chief. She smiles at BW. But then DY comes in and stands behind BW. She asks him if he can excuse her for a moment. he says yes and steps aside. But he can't help but look her up and down like a meathead. She looks at him and he starts to talk about nonsense. But he realizes it and shuts himself up.
BR and COR talk about why the company did this. They fired someone, so was it just for show? Who has the most power in advertisement? Sulhyun (a girl group?)? The company?
DY speaks up and says she is sorry to talk while judges are talking, but cosmetics advertisements on TV right now are from the defendants' company. SO they should care about female customers. Me too is an issue on SNS as well. Can you search sexual harassment in the advertising industry? Maybe the interns' boyfriend posted something in the beginning.
COR says, yes, yes, that is what happened in the beginning, that is why they fired him even though they didn't want to. So now they are making it like it didn't' happen and are purposefully not doing anything in the trial. That is their plan. They are bad.
COR asks DY how she knows those things. DY says it was just a little search because the company side defendant was nonsense. I don't care about other people's business, but ~. She takes her things and leaves. BW is in love.
Cut to BR and COR talking to SS about it. SS says it makes sense but it will be difficult to prove. For them, an agreement between the two parties is the most difficult thing.
BR – Why don't we just call the female employees and ask them. All the evidence should be submitted by both sides. If they need something then they can also collect evidence.
SS asks them if they want to call witnesses again and again? it is scary for regular citizens. COR says, of course, it is scary for them, but what if a witness and the lawyers all work together to cover up the sexual harassment guy. What about the feeling of the victim? When you suspect that the game is fixed, do you want them to play it again?
They think they should call the 4th witness, the one that was looking back over and over again. Let's play the game again, but we have to play it thoroughly, if something goes wrong then I will kill you both.
SS'S FAMILY HOUSE
SS's daughter runs around and eats at the table. he has two daughters. She says their math teacher came to their classroom while they were changing clothes. But maybe it was a mistake. That grandfather teacher is also very friendly, he asks students with huge chests if their shoulders are okay. SS tells them that all those people should be fired.
The trial is called to order again for the 4th witness that is called to the stand again. SS asks her if she is close to the defendant since they are the same age. She says not particularly. They ask her if she noticed anything? The woman says not particularly. Was there a difference in how the manager treated her and the other employees? She says she isn't sure.
COR tells her that she will show her the text messages. It pops up on the TV. But the woman says she can't look at the screen, can you turn it off. COR asks her to read it to them. The woman doesn't understand how she can read those things. So COR reads her statement that those texts were regular jokes. She wants her to read the text messages lightly.
The woman is quiet.
BR tells her she was an intern a couple years ago at the same age, so the victim should have a lot more comfort with her. Did anyone have lunch with the victim among regular employees? Yes, she does. BR asks how many times, not just one or two times right? She says yes. So BR tells her that she is the closest person to the victim, he will rephrase his question, just in case the victim as an intern is going through a difficult time at work but no regular employees cared about her, who do you think will cause the most harm? She says she doesn't' know. Who do you think is the one she can trust and the one who won't ignore her at work? She says she doesn't' know.
COR asks the witness that she remembers that she cannot like in court, she will be punished. If you change what you said before court ends, then you won't get punished. People can make mistakes, if you correct your mistake then we grant permission for that. If it is not too late. Human relationships are the same.
But the lawyer objects to this and points to the young victim. He says she disrupted the team. People like her do anything to get the job. This case happened because the plaintiffs rival asked her to do it. Don't you think you won't be part of these things as a regular employee right? I heard other teams think the first team is just like family and they were envious.
Witness – Family like? Lawyer, do you have a good relationship with your family? My family all fights each other.
Lawyer – You didn't feel harassed about the jokes he made did you? Your assistant manager also said the same thing
Witness – She wants to be the first female executive so she is just winning and winning and she touches male employees butts all the time.
You signed a petition for the plaintiff, why are you so hostile?
Witness – I signed it, also I was on my managers' side in the internal investigation. But you shouldn't' go too far. You told me that I need to be a good witness otherwise I will be fired if the manager is fired. You told me we have to make her a psychopath because she is just an intern so the regulars don't have to care about her. I am ashamed, even though it is shameful, I tried to do it. that is how I got this job anyway. But on the weekend I was watching a movie and I heard this line, 'we don't have money, but we have our pride. We shouldn't' live embarrassingly like this.' I couldn't finish the movie because I was crying so much. Judge, can you see this?
She gives the judge her phone.
Witness – Two years ago I was an intern and these are the text messages that the plaintiff sent me. I tried to go to a big company so I endure it. All the female interns were treated like this. This manager is careful to the regular employees, but he is not that way to the interns. When we go to norebang he wants to dance with us and touch our butts. Now I want to sue him for sexual harassment.
The lawyer stands up in anger and says this is a problem with women. Their emotions are too much.
Another woman stands up and says she will file a complaint also. I think it is the accusers' wife? She addresses their lawyer.
Wife – Lawyer, when you touch someone's body forcefully, that is forced sexual harassment. You told me that I have good connections and you are the only one that can help us. You told me that my daughter will finish college. You told me that. You also called me to a Japanese restaurant and gave me a lot of alcohol and told me I was too pretty for my husband. Because I am pretty, you took this case. You touched me on my shoulder and held my hand. You touched my breast as if pretending that you spilled alcohol. I endure it to protect my husband's job. Why are you asking for my daughter's phone number?
Mother and daughter cry and hug each other.
The lawyer gets punched by the husband and falls on the floor, the police try to separate them. But the judge basically says to let them fight.
The witness hugs the victim and they tearfully cry.
It is an emotional smorgasbord in that courtroom.
Later on, SS says yes to something as he meets with BR and COR
SS tells the court that someone getting fired is a death sentence to the family. But the victim of harassment is also big. using your power destroys people's heart and pride and makes their life hell. I cannot put that person at work with the victim. It is hard to measure the pain of the accuser, but your pain is canceled because of your position. Whatever the measurement, firing was the right decision. We decline the plaintiffs' case.
So it looks like the plaintiff lost and they still have to pay all the fees.
Much later on. COR asks BR if he would like to have a part-time job with her? An Employer at the market picked you.
SS AT HOME
SS gets home, perhaps drunk? He came home either too late or too early, not sure. He is happy to be home though and tiptoes inside so as not to alert anyone to his presence. He sneaks to his room and asks his wife if she is sleeping?
He opens the door and sneaks inside. She is sleeping, but then she says, are you junk mail? Why do you go out and come back with the morning newspaper? SS says he wants to die.
The next morning, he sits on the couch and hides as he reads his paper. he thinks that is the dead spot on his house. But his daughters come in and asks if he came home while drinking! SS says there is no dead spot in that house.
Appa sits on the couch and talks to his wife. An ajusshi has prostate cancer on TV. They talk about how the head of the family doesn't' have a right to get sick. So if you die and leave us then I will kill you. SS says he understands, he won't die until they pay off their mortgage. She tells him to live forever. He mutters that she is living with the man that has the most secure job in Korea. His wife says her heart pumps at all the responsibility of raising their daughters. SS lets her know that he can always open his own practice.
The wife sarcastically says that he will be a great lawyer, his temper will yell at all the judges. You were on the news twice already. Just stick to your job until you retire like a clam sticking to a rock. He says he will stick to it.
His wife does not want him to be nice to thugs as a lawyer, he has too big of a temper for that. You don't even have friends that are judges. Poor SS just wants to eat an apple, so he asks if he can. She lets him.
Cut to BR and COR taking a lot of photos in traditional clothing for one of the ajumma's clothing stores. The ajumma is so thankful and says they look so good. She gives them other clothing to wear and walk around in. They walk around in traditional newly married couples clothing. Everyone in the market jokes with them about how great they look together.
The ajumma tells them that her business was declining, but COR grabbed all the foreign customers by wearing hanboks, thank you COR. I still ask a judge to do this type of part-time job. COR is the one that feeds all of them because no one would visit this small market. Maybe they can even charge an entrance fee with this handsome young man.
BR says he is happy to help. they are thankful because they don't want the traditional market to disappear.
Later on, BR and COR walk around.
VO – Don't you think this is a date? (to himself)
COR says she wanted to have a little bit of private time with him, the part-time job was just an excuse. She is old-fashioned, she doesn't just hang out with colleagues outside of work things.
They sit on a bench. She asks him what kind of things she would like to talk to him about. First, she says that she is sorry. When chief told her to keep her distance from the case, it awakened her, she failed to keep her distance. Do you remember the piano teacher I told you about in our book club? He says he remembers it. She tells him that she never forgot how he touched a young students body. She thought she was okay now, but it is still difficult for her. When she was a student, when she had a little shoulder touch with men in the hallway, it made her jump.
BR – Maybe you had a hard time in this case? But on the first day on the subway, how did you…
Because I wasn't alone, I had other people around that would help me and wouldn't' ignore it. Someone like you, judge. That is why. I work hard to be that kind of person. Someone who is helpful, someone no one would ignore, a cool person.
Later on, three ladies talk about how cool the court was. A huge crowd of drunk Busan baseball team loving men are in the bar too. The women look like DD and her friends. One of her friends says it is so cool, her courthouse caught the bad sexual harasser. DD says that case showed how scary the law is! The judge opened his eyes and said that the plaintiffs firing is right! So cool! The law really protects us and I protect the law! They all cheer.
Later, the lieutenant leaves and is approached by a thug. But then another guy shows up. And another guy. So it is three guys against her. She looks scared. But then the drunk Busan baseball loving guys stumble out of the bar so she runs up, grabs two of them by the arms, and walks out with them until she gets to the street. At the street, she turns around and looks to see if those other guys are following her.
A song singing "It's alright….it's all over….it's all over…." plays
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May 30, 2018 / 10:43 am
So you guys decided to cover this one too! I don't know how you are managing this. amazing job as always.
I really look forward to some plot movements, unless its supposed to be one case each week (which am fine with). But i do think our female protagonist is more suited as a lawyer than judge.
May 30, 2018 / 1:42 pm
I don't know how we do it either! We'll try to keep up with it because this show looks really cute! It might get tough for when the other two shows premier (Are You Human Too and Secretary Kim). But we will try and make it work for all the people that watch raw and are dying to know what happens. 🙂
It feels like a one case a week show with emotional growth for everything on a case by case basis. Is this 12 or 16 episodes? They might run out of cases in the closing weeks.

redpajama_set_name: RedPajamaCommonCrawl


Klingberg Family Centers is pleased to welcome a registered therapy dog to our staff. Winston works with his handler, Lauren Pedersen, LMFT, in our school-based clinics. Winston's superpower is helping people relax, and twice a week he puts that superpower to good use at a total of four New Britain elementary schools.
Spending some time with a friendly dog can be just what children need to calm down during a stressful day. Winston helps students relax so that their stress does not continue to build up until it is unmanageable and debilitating. Winston spends time with staff, too. Reducing stress for teachers and other school staff helps everyone, as it results in improved relationships with students.
Winston loves his new job, and we love having him!


You can factory reset a Roku through its on-screen settings or perform a hardware reset on the device.
Performing a factory reset on a Roku gets you a fresh start for a device that's not working quite right or one you're looking to sell or return to the store.
Resetting removes all apps and personalization, and unlinks the device from your Roku account.
Your channel list, however, is stored in the cloud on your Roku account.
There are two ways to reset a Roku. Here are your options.
Electronic devices are great when they work as intended. But sometimes they act up and refuse to do much of anything very well. This is one of the times when a factory reset could be necessary. Another time might be when you plan to return the device to the store for whatever reason.
Before you begin resetting a Roku device, you must understand that resetting the device will erase any personalization, remove all downloaded channel apps, and unlink the device from your Roku account.
Your device will be set back to its original state (fresh from the factory). You won't have to make a list of installed apps since they're stored in your Roku account, but you will need to login to each one after the device has been reset.
There are two ways to perform a factory reset on a Roku. You can navigate through the onscreen settings menu to the reset option or use a hardware reset by pressing the reset button or reset pinhole at the back of the device. Below are instructions for each method.
Choose "Advanced system settings" from the "System" tab of the device's settings.
Use the Home button on your Roku remote to jump to the home screen.
Navigate to the settings menu by scrolling up or down until you find it.
Press "Ok" on your Roku remote to select the settings menu.
Choose "System" from the available menu items.
Select "Factory reset" from the available menu items.
When prompted, choose "Factory reset everything" and follow the reset wizard's onscreen instructions.
The author's Roku Express device has a pinhole reset, while newer models have a reset button.
Every Roku device comes with a hardware reset option. Newer devices will have a hardware reset button, while older devices will have a pinhole for resetting.
Locate the reset option on the outside of your Roku device.
Press and hold the button for 20 seconds. If your device has a pinhole reset, you'll need to use a paperclip to press and hold the button.
Most Roku devices have an indicator light that will blink rapidly once the reset is complete.
Log back onto your "Network" in settings.
After your device has been reset, it should boot up to the home screen. If you're not selling the device or returning it, but instead looking to use the device again, you'll need to reconnect to your home network. Once you're connected, login to your Roku account on your computer or from your mobile device to relink it to your account.
Your Roku channels will begin downloading after the device has been added to your Roku account. Now you're ready to spend some quality time logging into all your channel apps!


While an independent schooling is the most expensive option The Independent Schools Council of Australia (ISCA) advises that the expense can be misrepresented by companies selling financial products.
ISCA says that fee estimates used in the marketing material of school fee financing products do not reflect the fees of the majority of independent schools.
ISCA's school fee information is derived from data on fees collected from all Australian Independent schools in 2017 (the most recent year for which accurate data is available).
ASG last year stated that their school fee estimates have been derived from a 2017 survey of their parent members, plus CPI adjusted data from similar surveys conducted in 2013 and 2015, which asked parents to estimate various costs that they paid for their children's schooling. They state these are a guide only and do not guarantee that they will represent actual costs.


Very light, healthy, low cal, low carb chicken salad. With every bite, you will know this is an original cajun alternative to an old favorite American dish.
Boil chicken breasts in crab and shrimp boil with garlic, salt and pepper, as you would crawfish. Go light on the spices, or your chicken breasts may be too overwhelming. You dont want it to over power the spices you will add once you are making the chicken salad. Or you can slow cooked a turkey breast in a crock pot with the same ingredients. (This is what a prefer) Once the chicken breasts or slow cooked turley breast is cooked, allow to cool. Then ground the cooked meat in a bowl with a fork until it falls apart. Add celery, onion, and carrots (to taste) that have been grated. Add mustard, sweet relish, mayo. I also add zatarans, greek spices, garlic powder, salt and pepper. Chill for an hour and serve on warm homemade bread or use on a cool summer green bed of romaine.


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Flexible Bronchoscopy: Overview, Study Guide, and Practice Questions
by Respiratory Therapy Zone | Therapeutic Procedures
Flexible Bronchoscopy is a procedure that offers multiple important uses in the medical field. Respiratory Therapists play a pivotal role in assisting with this procedure.
This study guide was created to make the learning process easier for you to develop an understanding of this topic. It contains practice questions for your benefit as well. So if you're ready, let get started.
What is Flexible Bronchoscopy?
A bronchoscopy is a procedure where a flexible tube, known as a bronchoscope, is inserted into the airways of the lungs. It contains a camera and light source which allows the physician to view the airways.
This process can be used for both diagnostic and therapeutic purposes. However, a flexible bronchoscope is more maneuverable which makes it better for diagnostic purposes. A rigid bronchoscope, on the other hand, is typically used for surgical procedures and thus for therapeutic purposes.
A Respiratory Therapist is usually present to assist with the procedure and ensure that all tools and equipment are present and functioning properly. They also help monitor and keep the patient in stable condition.
Flexible Bronchoscopy Practice Questions:
1. Flexible Bronchoscopy has been used for what?
It has been used for most diagnostic and therapeutic indications in patients with pulmonary diseases.
2. What is the goal of sedation during a bronchoscopy?
It is used to improve the patient's comfort during the procedure.
3. The continuous monitoring of what is important during the procedure?
The monitoring of oxygenation and hemodynamic stability.
4. What are the most commonly used diagnostic procedures in Flexible Bronchoscopy?
BAL, biopsy, and TBNA.
5. BAL obtains samples from what?
The alveoli.
6. Needle aspiration has a role in sampling mediastinal lymph nodes to diagnose what?
Lung cancer, sarcoidosis, and some infectious processes.
7. Biopsy has value in the diagnosis of what?
Infiltrative pulmonary diseases.
8. What has been used along with flexible bronchoscopy as treatments?
Various thermal ablation techniques.
9. When using thermal ablation techniques, what is the most important point to keep in mind?
You should ensure a low FiO2 environment before the use of any thermal ablative therapy.
10. Airway stenting has been used to maintain airway patency when?
After dilation of any obstructed major airways. It is important to recognize the difference between silicone and metallic stents.
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11. What is Bronchial thermoplasty?
It is a novel bronchoscopic technique for patients with steroid-dependent asthma.
12. What is being studied in the management of patients with severe emphysema as a minimally invasive lung volume reduction therapy?
Endobronchial valves and coil placement.
13. Who plays a vital role in assisting before, during, and after bronchoscopy?
The Respiratory Therapist.
14. What does a Respiratory Therapist do in regards to helping with a bronchoscopy procedure?
There are many aspects to this role, but they include ensuring appropriate documentation (e.g., physician's order), preparing the patient and the equipment, patient monitoring, and responding to adverse events.
15. What are the special considerations that the Respiratory Therapist and other members of the bronchoscopy team must consider when performing this procedure on mechanically ventilated patients?
Patients on the ventilator are more susceptible to adverse events. These considerations include ensuring adequate ventilation and gas exchange before, during, and after the procedure.
16. What are the clinical situations where flexible bronchoscopy would be indicated?
Hemoptysis, Wheeze and stridor; suspected upper airway obstruction, Pulmonary infiltrate of unknown cause, Unexplained lung collapse, Suspected or known bronchogenic carcinoma, Mediastinal, and hilar lymphadenopathy, Lung transplantation, Endotracheal intubation, Evaluation of foreign body aspiration, chemical or burn-related injury to the airway, Unexplained superior vena cava syndrome, Unexplained vocal cord paralysis or hoarseness, and Suspected fistulas.
17. What are the absolute contraindications for flexible bronchoscopy?
Uncorrectable hypoxemia, Lack of patient cooperation, Lack of skilled personnel, Lack of appropriate equipment and facilities, and Unstable angina.
18. What are the relative contraindications for flexible bronchoscopy?
Unexplained or severe hypercarbia, Uncontrolled asthma attack, Lack of patient cooperation, Uncorrected coagulopathy, Recent myocardial infarction, Unstable cervical spine, and impaired neck mobility, and the Need for large size tissue specimen.
19. What is the primary goal of sedation during flexible bronchoscopy?
The goal of sedation is to improve the patient's comfort during the procedure. In addition to risks of arrhythmias and fluctuations in blood pressure related to the procedure, airway manipulation during bronchoscopy may lead to coughing, hypoxemia, vomiting, bleeding, laryngospasm, and bronchospasm. All of these responses can affect the outcomes of the procedure. Therefore, adequate sedation is an important part of the procedure.
20. What is BAL and when is it indicated?
BAL stands for Bronchoalveolar lavage and it is used to obtain specimens from the alveolar level of the lung.
21. When is rigid bronchoscopy indicated?
Although the role of rigid bronchoscopy (RB) has declined, RB remains an invaluable tool for the control of a compromised airway, massive hemoptysis, and silicone stent placement and for removing asphyxiating foreign bodies. The major indication for rigid bronchoscopy is in managing central airway obstruction.
22. What is the difference between BAL and bronchial washings?
Bronchial washings are generally obtained for the cytological examination to look for cancer and for microbiologic analysis to diagnose mycobacterial or fungal infections. Unlike BAL, bronchial washings are obtained from the large airways.
23. What should a Respiratory Therapist consider regarding oxygen delivery during thermal ablation?
During the application of "hot therapies" (thermal ablation) like a laser, electrosurgery, or argon plasma coagulation, the FiO2 should always be maintained below 40% to prevent endobronchial ignition.
24. What are endobronchial stents used for?
Stents are the devices designed for internal splinting of the airway lumen. Airway stents have been used to help reduce airway obstruction from malignant or benign processes that compress the airway from the outside. Airway stenting can offer immediate relief of acute respiratory distress, allow successful extubation, and may prolong survival.
25. What is a bronchoscopy?
It is the process of passing a bronchoscope into the airways for either diagnostic testing or therapeutic purposes.
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26. What are the four types of bronchoscopy?
Flexible bronchoscopy (FB), Rigid bronchoscopy (RB), Diagnostic bronchoscopy (DB), and Therapeutic bronchoscopy (TB).
27. A Rigid Bronchoscopy is always performed under what condition?
Under deep sedation with muscle relaxation.
28. What are the risks of flexible bronchoscopy?
Arrhythmias, fluctuations in blood pressure, and airway manipulation during bronchoscopy may lead to coughing, hypoxemia, vomiting, bleeding, laryngospasm, and bronchospasm.
29. What maneuvers used if the patient becomes over-sedated during a bronchoscopy procedure?
Chin-lift and jaw-thrust.
30. What is recommended to prevent the patient from slipping into deep sedation?
Capnography monitoring while performing flexible bronchoscopy under moderate sedation.
31. What is flexible bronchoscopy monitoring consisted of?
You must keep track of patient responses to verbal commands or spontaneous movements. Their chest movement may continue despite near-total obstruction of the airway. There should be continuous cardiac, blood pressure, and pulse oximetry monitoring. Capnography should be used to monitor and prevent the patient from entering deep sedation.
32. What are the types of therapeutic bronchoscopy?
Rigid bronchoscopy, thermal ablation of the endobronchial lesion, brachytherapy, cryotherapy, and endobronchial stents.
33. What is the major indication for rigid bronchoscopy?
Managing central airway obstructions.
34. What are the three types of thermal ablation of an endobronchial lesion?
Endobronchial electrocautery, argon plasma coagulation (APR), and laser photocoagulation.
35. What are the risks of thermal ablation of an endobronchial lesion?
Improper use of thermal modalities can lead to perforation of the airway, vascular structures, or the esophagus.
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36. What are the complications of thermal ablation of an endobronchial lesion?
Hypoxemia, pneumothorax, and bronchopleural and bronchoesophageal fistula.
37. What are the contraindications of thermal ablation of an endobronchial lesion?
Refractory hypoxemia, and extrinsic compression of the airway without an endobronchial lesion.
38. What is the relation of flexible bronchoscopy and an endotracheal tube?
You can use a flexible bronchoscope to place an ET tube through the mouth or nose. It allows for awake intubations with topical anesthesia. It is used in patients with cervical injuries, where immobilization of the neck is crucial. It may also help identify causes of acute hypoxia and help to remove secretions of blood in the airway. It is limited to experience of operator and there must be patient cooperation.
39. What is the Respiratory Therapist's role in bronchoscopy before the procedure begins?
We help identify potential need for bronchoscopy (retained secretions or foreign body removal). We verify physician's order or protocol. We review the patient's record for contraindications (excessive clotting times), hazards, and informed consent. We prepare/ensure proper function of equipment. We outline the plan for adequate oxygenation during the procedure. We evaluate the patient for bronchospasm and administer aerosolized bronchodilators if required. We assist nurses in application of topical anesthesia.
40 What is the Respiratory Therapist's role in bronchoscopy during the procedure?
We monitor the patient's vital signs (including capnography). We help identify and respond to adverse reactions, and we administer oxygen as needed. We provide proper positioning of the patient. We assist with the use of accessories (bite block, oral airways, nasopharyngeal tube, biopsy forceps, brushes, etc.) We set up instruments for rigid bronchoscopy and silicone stents. We help place chest or ET tubes in emergent situations.
41. What does a Respiratory Therapist do in bronchoscopy during mechanical ventilation?
We establish adequacy of the length and the diameter of the ET or trach tube. We ensure that the bite block is in place (to avoid equipment damage). We adjust ventilator settings for safety reasons and oxygenation purposes (and then return settings to pre-procedure).
42. What are the main complications and risks of bronchoscopy?
Bleeding, Infection, Bronchial perforation, Bronchospasm, Laryngospasm, and Pneumothorax.
43. The endoscope reaches what generation of bronchi?
4th – 5th.
44. What is the rigid tube?
An open metal tube with a distal light source and port for oxygen/ventilating equipment.
45. Who uses the rigid tube?
Otorhinolaryngologists and Thoracic surgeons.
46. What type of bronchoscope do Respiratory Therapists most often assist with?
Flexible fiberoptic.
47. Which bronchoscope can access very small airways?
Flexible fiberoptic
48. What are the channels in a flexible fiberoptic bronchoscope?
Light transmission, Visualizing, and Multipurpose open.
49. Who uses the flexible fiberoptic bronchoscope?
The pulmonologist along with assistance from the Respiratory Therapist.
50. What is the most common method of anesthesia during a bronchoscopy?
Topical anesthetic.
So there you have it. Hopefully, this study guide can help you develop a better understanding of the flexible bronchoscope medial procedure. Because, as we mentioned, a Respiratory Therapist is essential during the process.
We also have a guide on Endotracheal Intubation as well that I think you will enjoy. Thank you for reading and as always, breathe easy my friend.
The following are the sources that were used while doing research for this article:
Faarc, Kacmarek Robert PhD Rrt, et al. Egan's Fundamentals of Respiratory Care. 12th ed., Mosby, 2020. [Link]
Faarc, Cairo J. PhD Rrt. Mosby's Respiratory Care Equipment. 10th ed., Mosby, 2017. [Link]
Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019. [Link]
"Guidelines for Diagnostic Flexible Bronchoscopy in Adults: Joint Indian Chest Society/National College of Chest Physicians (I)/Indian Association for Bronchology Recommendations." PubMed Central (PMC), 1 July 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6681731.
"Flexible Fiberoptic Bronchoscopy: Indications, Diagnostic Yield and Complications." PubMed Central (PMC), 1 Oct. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7586410.
Disclosure: The links to the textbooks are affiliate links which means, at no additional cost to you, we will earn a commission if you click through and make a purchase.
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