Improving parents' knowledge of early signs of paediatric eye disease: A double-blind randomized controlled trial.

IMPORTANCE: Educating parents to recognize signs of eye disease and consult a healthcare professional is critical to timely diagnosis, intervention and outcomes. BACKGROUND: We evaluate the effectiveness of an eye-health information pamphlet on parents' level of concern and help-seeking intention should they hypothetically observe leukocoria or strabismus in their child. DESIGN: Double-blind, randomized controlled trial conducted at a metropolitan antenatal outpatient clinic. PARTICIPANTS: In total, 518 pregnant women were enrolled in the study. METHODS: After completing a study-specific, pre-test survey describing hypothetical clinical scenarios at baseline, participants were randomly assigned to receive a pamphlet on either paediatric eye health (intervention) or infant play (control). The post-test survey was sent by email 2 weeks after baseline. MAIN OUTCOME MEASURES: A change in the parents' level of concern if they observed leukocoria or strabismus and a change in their help-seeking intention if they hypothetically observed leukocoria or strabismus in their child. RESULTS: Of the 518 women, 382 (73.7%) completed the post-test survey. At follow-up, women who received the intervention were more likely to report a higher level of concern if they observed leukocoria (OR 1.711 [CI: 1.176-2.497] P = .005]) and were less likely to delay help-seeking (OR 0.560 [CI 0.382-0.817] P = .003). No change in the level of concern for strabismus was identified between the groups; however, at follow-up, women who received the intervention were less likely to delay help-seeking (OR 0.318 [CI 0.125-0.806] P = .016). CONCLUSION AND RELEVANCE: Providing parents with relevant, evidence-based information can significantly improve their knowledge and positively influence help-seeking intentions if leukocoria or strabismus are observed.

Effect of a tailored leaflet to promote diabetic retinopathy screening among young adults with type 2 diabetes: a randomised controlled trial.

BACKGROUND: Young adults with type 2 diabetes (aged 18-39 years) are at risk of early onset and rapid progression of diabetic retinopathy, the leading cause of blindness and vision loss in working age adults. Early detection via retinal screening can prevent most vision loss, yet screening rates are consistently lower among this priority population than the general diabetes population. We aimed to test the effect of a tailored, evidence-based brief health behaviour change intervention (leaflet) on self-reported screening uptake, and previously identified social cognitive determinants of retinal screening. METHODS: A pragmatic, two-arm randomised controlled trial was conducted from September 2014 to April 2015. Participants were stratified by prior screening uptake (Yes/No) and randomly allocated to intervention (leaflet) or 'usual care' control (no leaflet). Primary outcome was self-reported screening uptake four weeks post-intervention for 'No' participants who had not previously screened for diabetic retinopathy. Secondary outcome variables were changes in knowledge, attitudes, normative beliefs, intention and behavioural skills for all participants, irrespective of prior screening behaviour. To assess intervention effects on secondary outcome variables, we conducted independent samples t-tests (two-tailed) on pre-post change scores. RESULTS: 129 young adults (26% no prior retinal screen) completed baseline; 101 completed post-intervention. Power to determine effect on the primary outcome was curtailed by low recruitment of individuals with no prior retinal screen and loss to follow-up. Attrition was associated significantly with country of birth, language spoken at home, and marital status. Significant intervention effect was observed for one secondary outcome variable: knowledge of diabetic retinopathy (p = .03) with moderate effect (partial eta squared η2 = .05); no adverse effects were reported. Control group participants received the leaflet at study completion. CONCLUSIONS: This study confirms that a well-designed eye health and retinal screening promotion leaflet can increase knowledge of diabetic retinopathy, an important screening predictor. The study highlights the challenges of conducting 'real-world' health behaviour change research with this priority population, providing insights for clinicians and researchers. Strategies to recruit, engage and retain hard-to-reach populations are discussed including nonconventional alternatives to randomised controlled trial designs. TRIAL REGISTRATION: ACTRN12614001110673, UTN No.: U1111-1161-9803. Registered 20 October 2014 - retrospectively registered https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367127.

High vision-related quality of life indices reduce the odds of depressive symptoms in aged care facilities.

Objective: To examine the association between vision-related quality of life (VRQoL) and depressive symptoms in residents with vision impairment (VI) in aged care facilities.Methods: In this cross-sectional study using baseline data from a cluster-randomized controlled trial (ACTRN12615000587505) assessing the effectiveness of a novel eye care model, 186 English-speaking residents (mean age 84 years, SD[standard deviation] = 8.7; 33.9% male) with VI and moderate cognitive functioning or better were recruited from 38 facilities across Victoria, Australia. VRQoL was measured using Rasch-transformed scores from the 'Reading'; 'Mobility', and 'Emotional' scales of the Impact of Vision Impairment for Residential Care (IVI-RC) questionnaire. Outcomes were presence of depressive symptoms (binary score: Cornell Scale for Depression in Dementia [CSDD] > 0 vs. CSDD = 0) and severity of depressive symptoms (continuous CSDD score; sample range 1-21). Independent associations with presence and severity of depressive symptoms were examined using zero-inflated logistic and linear multivariable models, respectively.Results: Of the 186 participants, n = 79 (42.5%), n = 94 (50.5%) and n = 13 (7%) reported no, mild (scores 1-7), and clinically significant depressive symptoms (score ≥8), respectively. Better vision-related Mobility (OR = 0.64; 95% CI: 0.44, 0.95, p = 0.02) was associated with reduced odds of depressive symptoms. With every unit improvement in vision-related Reading (ß=-0.48; 95% CI: -0.94, -0.01, p = 0.04) and Emotional (ß=-0.56; 95% CI: -1.09, -0.02, p = 0.04), severity of depressive symptoms reduced, independent of sociodemographic and medical issues.Conclusion: Better VRQoL was independently associated with reduced depressive symptoms. Supporting older people in aged care to maintain optimal levels of vision-specific functioning, independence, and emotional well-being may protect their mental health.

A Need for Better Understanding Is the Major Determinant for Public Perceptions of Human Gene Editing.

The CRISPR/Cas system could provide an efficient and reliable means of editing the human genome and has the potential to revolutionize modern medicine; however, rapid developments are raising complex ethical issues. There has been significant scientific debate regarding the acceptability of some applications of CRISPR/Cas, with leaders in the field highlighting the need for the lay public's views to shape expert discussion. As such, we sought to determine the factors that influence public opinion on gene editing. We created a 17-item online survey translated into 11 languages and advertised worldwide. Topic modeling was used to analyze textual responses to determine what factors influenced respondents' opinions toward human somatic or embryonic gene editing, and how this varied among respondents with differing attitudes and demographic backgrounds. A total of 3,988 free-text responses were analyzed. Respondents had a mean age of 32 (range, 11-90) years, and 37% were female. The most prevalent topics cited were Future Generations, Research, Human Editing, Children, and Health. Respondents who disagreed with gene editing for health-related purposes were more likely to cite the topic Better Understanding than those who agreed to both somatic and embryonic gene editing. Respondents from Western backgrounds more frequently discussed Future Generations, compared with participants from Eastern countries. Religious respondents did not cite the topic Religious Beliefs more frequently than did nonreligious respondents, whereas Christian respondents were more likely to cite the topic Future Generations. Our results suggest that public resistance to human somatic or embryonic gene editing does not stem from an inherent mistrust of genome modification, but rather a desire for greater understanding. Furthermore, we demonstrate that factors influencing public opinion vary greatly amongst demographic groups. It is crucial that the determinants of public attitudes toward CRISPR/Cas be well understood so that the technology does not suffer the negative public sentiment seen with previous genetic biotechnologies.

Experiences and perceptions of patients undergoing treatment and quality of life impact of diabetic macular edema: a systematic review.

Diabetic macular edema (DME) is a common cause of visual impairment. Current treatments for DME include laser photocoagulation, corticosteroids and Vascular Endothelial Growth Factor (VEGF) antagonists, which are administered via intravitreal injection. The purpose of this systematic review is to explore the experiences and perceptions of patients undergoing laser, corticosteroid implants and intravitreal injection treatment for DME and the impact on Quality of Life (QoL). A systematic search of the Embase, Medline, PsycINFO and Cinahl electronic databases was conducted to identify all studies with an unlimited date range, published in the English language, full text and incorporating human participants. Hand searching identified two articles. Following the application of the Critical Appraisal Skills Programme (CASP) Quantitative and Qualitative Research Checklist 21 articles were selected for inclusion, as they were deemed pertinent for the purpose of this review. Limited studies have examined DME patients' experiences and perceptions of treatment and QoL. The outcomes of these studies lack agreement on the effectiveness of treatment, treatment preferences and impact of QoL in patients with DME. Future research which enhances current knowledge will therefore serve to improve treatment outcomes and QoL in these patients.

Delivering problem-solving treatment in low-vision rehabilitation: A pilot feasibility study.

PURPOSE: To explore the feasibility and preliminary effectiveness of Problem-Solving Treatment for Primary Care (PST-PC) delivered by low-vision rehabilitation (LVR) practitioners to adult clients with depressive symptoms. DESIGN/METHOD: A single-group pre/postintervention study. Eighteen adult LVR clients with depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score of ≥5) received 6-8 weekly telephone sessions of PST-PC delivered by expertly trained practitioners (n = 14). Feasibility was determined via participating client and practitioner recruitment and intervention retention rates. Depressive symptoms (PHQ-9), health-related quality of life (HRQoL; Assessment of QoL Instrument-7D), and confidence in one's ability to cope using problem-solving strategies (Coping Self-Efficacy Scale) were assessed using pre/posttelephone assessments. RESULTS: Participating client recruitment and retention rates were 71% and 40%, respectively. Seventy percent of practitioners completed supervised training in PST-PC and demonstrated satisfactory levels of fidelity and competency. Postintervention, we observed a 53% improvement in depressive symptoms (p < .001), a 23% improvement in HRQoL (p = .001), and an 18% improvement in participants' confidence to use problem-focused coping strategies (p = .001). CONCLUSIONS: Telephone-PST-PC delivered by a trained LVR practitioner may be an effective intervention for clients of LVR services who exhibit depressive symptoms. A randomized controlled trial is now needed to confirm these preliminary findings and establish longer-term effectiveness. (PsycINFO Database Record

A tailored intervention to promote uptake of retinal screening among young adults with type 2 diabetes - an intervention mapping approach.

BACKGROUND: Young adults (18-39 years) with type 2 diabetes are at risk of early development and rapid progression of diabetic retinopathy, a leading cause of vision loss and blindness in working-age adults. Retinal screening is key to the early detection of diabetic retinopathy, with risk of vision loss significantly reduced by timely treatment thereafter. Despite this, retinal screening rates are low among this at-risk group. The objective of this study was to develop a theoretically-grounded, evidence-based retinal screening promotion leaflet, tailored to young adults with type 2 diabetes. METHODS: Utilising the six steps of Intervention Mapping, our multidisciplinary planning team conducted a mixed-methods needs assessment (Step 1); identified modifiable behavioural determinants of screening behaviour and constructed a matrix of change objectives (Step 2); designed, reviewed and debriefed leaflet content with stakeholders (Steps 3 and 4); and developed program implementation and evaluation plans (Steps 5 and 6). RESULTS: Step 1 included in-depth qualitative interviews (N = 10) and an online survey that recruited a nationally-representative sample (N = 227), both informed by literature review. The needs assessment highlighted the crucial roles of knowledge (about diabetic retinopathy and screening), perception of personal risk, awareness of the approval of significant others and engagement with healthcare team, on retinal screening intentions and uptake. In Step 2, we selected five modifiable behavioural determinants to be targeted: knowledge, attitudes, normative beliefs, intention, and behavioural skills. In Steps 3 and 4, the "Who is looking after your eyes?" leaflet was developed, containing persuasive messages targeting each determinant and utilising engaging, cohort-appropriate imagery. In Steps 5 and 6, we planned Statewide implementation and designed a randomised controlled trial to evaluate the leaflet. CONCLUSIONS: This research provides an example of a systematic, evidence-based approach to the development of a simple health intervention designed to promote uptake of screening in accordance with national guidelines. The methods and findings illustrate how Intervention Mapping can be employed to develop tailored retinal screening promotion materials for specific priority populations. This paper has implications for future program planners and is intended to assist those wishing to use Intervention Mapping to create similar theoretically-driven, tailored resources.

Individuals' Perspectives on Coping with Vision Loss from Diabetic Retinopathy.

SIGNIFICANCE: People with vision loss from diabetic retinopathy (DR) and diabetic macular edema (DME) use problem-focused and emotion-regulation strategies that may influence their short- and longer-term adaptation and psychological outcomes. Our findings can assist the development of models of adjustment to DR/DME-related vision loss and treatments focused on adaptation. PURPOSE: To qualitatively determine the coping strategies used by participants with vision loss resulting from DR/DME. METHODS: Fifty-seven participants with DR/DME engaged in one of eight focus groups or one of 18 semistructured interviews. Participants were mostly older than 55 years (mean, 58.7 years) and male (68%) and had type 2 diabetes (74%; median duration, 17 years). Almost 50% had proliferative DR, 95% had undergone laser treatment, and 42% had DME; 68%, 14% and 14% had none, mild (<0.3 logarithm of the minimum angle of resolution ≤ 0.48), and moderate-severe vision impairment (>0.48 logarithm of the minimum angle of resolution) in the better eye. Focus groups/interviews were transcribed verbatim and iteratively analyzed using the constant comparative method. Qualitative software NVivo 2008 was used to sort/store the data. Our top-down and bottom-up approach to conceptualize the data was informed by the Transactional Model of Stress and Coping. RESULTS: Coping efforts were mostly problem focused (64%) with seven subthemes: problem solving, passive coping, changing activities to suit a new ability level, active coping, rehearsing alternative outcomes, maintaining independence, and information seeking. Emotion-regulation strategies were distraction, acceptance, alternative adaptive thinking, avoidance, expressing emotions, denial, and changing emotions. Meaning-based coping strategies included mindfulness and engaging in meaningful activities. Themes relating to adaptation and moderators to coping (e.g., dispositional optimism) are outlined. CONCLUSIONS: Participants described a variety of ways to cope. Some strategies are likely to improve functioning and decrease distress, whereas others are expected to reduce immediate distress while perpetuating this in the longer term. Our findings may assist researchers to develop models of adjustment to DR/DME-related vision loss and psychosocial/educational interventions focused on adaptation.

Experiences of patients undergoing repeated intravitreal anti-vascular endothelial growth factor injections for neovascular age-related macular degeneration.

Current therapy to slow disease progression in patients with neovascular age-related macular degeneration (AMD) entails regular intravitreal anti-vascular endothelial growth factor (VEGF) injections, often indefinitely. Little is known about the burden imposed on patients by this repetitive treatment schedule and how this can be best managed. The aim of this study was to explore the psychosocial impact of repeated intravitreal injections on patients with neovascular AMD. Forty patients (16 males, 24 females) with neovascular AMD undergoing anti-VEGF treatment were recruited using purposive sampling from a private ophthalmology practice and public hospital in Melbourne. Patients were surveyed using the Macular Disease Treatment Satisfaction Questionnaire (MacTSQ; Bradley, Health Psychology Research Unit, Surrey, England) and underwent semi-structured, one-on-one interviews. Interview topics were: treatment burden and satisfaction; tolerability; barriers to adherence; treatment motivation; and patient education. Interviews were audio recorded and thematic analysis performed using NVivo 10 (QSR International, Doncaster, Australia). Patients recognised the importance of treatment to preserve eyesight, yet experienced significant psychosocial and practical burden from the treatment schedule. Important issues included treatment-related anxiety, financial considerations and transport burden placed on relatives or carers. Many patients were restricted to sedentary activities post-injection owing to treatment side effects. Patients prioritised treatment, often sacrificing family, travel and social commitments owing to a fear of losing eyesight if treatment was not received. Whilst anti-VEGF injections represent the current mainstay of treatment for neovascular AMD, the ongoing treatment protocol imposes significant burden on patients. An understanding of the factors that contribute to the burden of treatment may help inform strategies to lessen its impact and assist patients to better manage the challenges of treatment.

Can we address depression in vision rehabilitation settings? Professionals' perspectives on the barriers to integrating problem-solving treatment.

PURPOSE: Low vision rehabilitation (LVR) is a pertinent context for integrating early, evidence-based psychological interventions given the high prevalence of untreated depression in adults with vision impairment. This study aims to identify the perceived barriers and facilitators to staff-delivered telephone-based problem-solving treatment for primary care (PST-PC) offered as an integrated component of LVR. METHODS: Qualitative semi-structured interviews, developed using the theoretical domains framework (TDF) and Consolidated Framework for Implementation Research (CFIR), were conducted with 21 LVR professionals and a clinical psychologist involved in the delivery of PST-PC. Barriers and facilitators at the practitioner, client, intervention, and organizational level were identified with thematic analysis using a "theoretical" approach. RESULTS: Prominent barriers were a lack of role recognition for PST-PC practitioners (n = 32), unmet client expectation with PST-PC (n = 28), dissatisfaction with telephone delivery (n = 27), and limited organizational awareness of PST-PC (n = 39). Facilitating factors included a recognized need for evidence-based psychological services (n = 28), clients experiencing benefits in early sessions (n = 38), PST-PC promoting practical skills (n = 26), and comprehensive PST-PC training (n = 36). CONCLUSIONS: PST-PC may provide an accessible early intervention for LVR clients with depressive symptoms. Ongoing practitioner training, clinical support, and screening potential LVR clients for treatment suitability are likely to enhance delivery in this setting. Implications for rehabilitation Depression is highly prevalent in adults engaged in low vision rehabilitation (LVR) programs, yet few receive support. Clinical guidelines recommend integrated models of care be offered within rehabilitation settings as early intervention for mild to moderate levels of depressive symptoms. Integrated telephone-based problem-solving treatment for primary care (PST-PC) delivered by trained LVR practitioners is a practical, skills-based model that has potential to increase access to an early psychological intervention in LVR clients with depressive symptoms. LVR clients are often older in age, have multiple comorbid health conditions and a significant level of functional disability, requiring flexibility in the delivery of PST-PC and specialized staff training, and support in working with older and more complex clients.

Calibrating the Impact of Vision Impairment (IVI): Creation of a Sample-Independent Visual Function Measure for Patient-Centered Outcomes Research.

PURPOSE: Provide item calibrations estimated for the Impact of Vision Impairment (IVI) questionnaire by pooling data from several studies of people with vision impairment (VI) representing a variety of countries and causes of VI. METHODS: Eight data sets from six principal investigators representing responses to IVI items from 2867 VI patients were pooled for analysis. Eligible patients were 18 years or older and from Australia, India, and the United States. Rasch analysis, using the Andrich Rating Scale Model (Winsteps version 3.65), was performed on preintervention IVI responses to estimate item and person measures, reliability coefficients, and response category thresholds. Differential item functioning (DIF) analysis and analysis of variance (ANOVA) were used to examine the effects different data sets and covariates on item estimates. RESULTS: Patient age range was 18 to 103 years (median 62 years); 55% were male. Visual acuity ranged from 20/20 to no light perception and primary diagnosis was macular degeneration in 29% of patients. Item measure estimates showed good separation reliability (R 2 = 0.99). DIF magnitude did not preclude use of all IVI-28 data. ANOVA showed VA (P < 0.001) and gender (P < 0.002) were predictors of visual ability. CONCLUSIONS: Analysis from pooled data support the provision of calibrated IVI item measures for researchers and clinicians to use, thus better enabling direct comparisons of patients with VI. TRANSLATIONAL RELEVANCE: Validity testing of the IVI show that we can combine disparate data sets of patient responses to calibrate item measures and response category thresholds, and provide to others for use in comparing patients across clinical trials and on an individual basis.

What factors influence uptake of retinal screening among young adults with type 2 diabetes? A qualitative study informed by the theoretical domains framework.

AIMS: Young adults with type 2 diabetes (T2D, 18-39years) face increased risk of vision loss from diabetic retinopathy (DR). Retinal screening is essential to detect DR, yet screening rates for this group are low and little is known about the underlying factors influencing this important behavior. Using the theoretical domains framework (TDF) to guide data collection and analysis, we explored screening barriers and facilitator, contrasting them with a comparator group of older adults with T2D (40+ years). METHODS: Thirty semi-structured telephone interviews (10 younger, 20 older adults) were conducted. Data were coded into TDF domains with salience identified by "frequency" of reference. Screening facilitators and barriers were systematically compared between groups. RESULTS: Although many screening facilitators and barriers were shared by younger and older adults, additional factors highly relevant to the former included: social comparison with others ('social influences'); concern for the impact on the family unit, unrealistic optimism and perceived invulnerability ('beliefs about consequences'); lack of time and financial resources ('environmental context and resources'), and DR misconceptions ('knowledge'). CONCLUSIONS: This study demonstrated that young adult retinal screening behavior was influenced by additional social cognitive factors compared to older adults, providing a first-step evidence base for clinicians and other health professionals, and potential targets for future eye health and retinal screening interventions.

Problem-solving therapy for adults with diabetic retinopathy and diabetes-specific distress: a pilot randomized controlled trial.

OBJECTIVE: To provide preliminary evidence for the impact of problem-solving therapy for diabetes (PST-D) in adults with diabetic retinopathy (DR) and diabetes distress. RESEARCH DESIGN AND METHODS: In a pilot randomized controlled trial, 40 participants with DR and diabetes distress were allocated to the PST-D or control groups. Diabetes distress (DDS), depressive symptoms (PHQ-9), self-care activities (SDSCA), and HbA1c were assessed at baseline, and 3 and 6-month follow-ups. RESULTS: At the 6-month follow-up, the PST-D group showed significant improvements relative to the control group, in 'regimen-related distress' (PST-D: -1.3±1.4; control: -0.4±1.1), depressive symptoms (PST-D: -4.3±6.1; control: -0.3±4.6), and HbA1c (PST-D: -1.2%±1.01; control: 0.2%±1.2%) (all p<0.05). In multiple regression analysis, adjusting for baseline values and sociodemographic factors, PST-D was associated with significant improvement in 'regimen-related distress', depressive symptoms, and HbA1c at the 6-month follow-up (p<0.05). CONCLUSIONS: PST-D is a promising intervention for improving psychological outcomes and glycemic control. A fully powered study is required to confirm these findings and examine mechanisms of change in HbA1c. TRIAL REGISTRATION NUMBER: ACTRN12616001010482; results.

Study methodology and diabetes control in patients from the non-English diabetes management project (NEDMP).

BACKGROUND: To describe the clinical characteristics of non-English speaking patients from the Diabetes Management Project (NEDMP), and compare their diabetes management and severity of diabetic retinopathy (DR) with the English-speaking DMP sample (EDMP). DESIGN: A prospective study was conducted on non-English speaking adults with diabetes who attended the Royal Victorian Eye and Ear Hospital. PARTICIPANTS: 136 (90.1%) non-English speaking adults were assessed, with a mean age of 72.2 years (range: 50-88 years); 74 (54.4%) were male. METHODS: Participants completed interviewer-administered questionnaires and underwent visual acuity, fundus photography, optical coherence tomography, biochemistry and anthropometric measurements. The EDMP assessed 609 patients in 2009 using a similar protocol. MAIN OUTCOME MEASURES: Type and duration of diabetes, diabetes control and diabetic retinopathy. RESULTS: A total of 127 (93.4%) and 8 (5.9%) participants reported having type 2 and type 1 diabetes, respectively, with a median (IQR) duration of 17 (14) years. The proportion of patients with poor diabetes control (HbA1c ≥ 7%) in the NEDMP was similar to the EDMP (64.0% and 68.2%, respectively; P = 0.411). A significantly higher proportion of patients with DR in the NEDMP were found to have poor diabetes control (HbA1c ≥ 7%) compared to those without DR (80.9% vs. 50.0%, P = 0.003). Almost two-thirds of NEDMP patients (74/118) had DR and 23% (27/115) had diabetic macular edema. The prevalence of DR was similar between the NEDMP and EDMP studies, ranging from 25-30% and 28-29%. CONCLUSIONS: The clinical characteristics, diabetes control, and DR severity of English and non-English-speaking patients were similar. The high proportion of poor diabetes management in non-English speaking patients with DR suggests educational and behavioural interventions to improve glycaemic control are warranted.

Association Between Diabetes-Related Eye Complications and Symptoms of Anxiety and Depression.

IMPORTANCE: This study is needed to clarify inconsistent findings regarding the association between diabetes-related eye complications and psychological well-being. OBJECTIVE: To examine the association between severity of diabetic retinopathy (DR) and diabetic macular edema (DME) with symptoms of depression and anxiety in adults with diabetes. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study was conducted in a tertiary eye hospital in Melbourne, Australia. The study comprised 519 participants with diabetes. The median duration of diabetes was 13.0 (interquartile range, 14.0) years. The study was conducted from March 1, 2009, to December 24, 2010. EXPOSURES: Patients underwent a comprehensive eye examination in which dilated fundus photographs (disc and macula centered) were obtained and graded for the presence and severity of DR and DME. Presenting distance uniocular and binocular visual acuity were assessed using a 3-m logMAR chart. MAIN OUTCOMES AND MEASURES: Symptoms of depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS), which comprises 7 questions specific to anxiety and 7 specific to depression with scores ranging from 0 to 21; scores higher than 8 signify possible anxiety or depression. The ordinal raw scores of the HADS questionnaire were transformed to estimates of interval measure using Rasch analysis and evaluated as continuous variables. Participants also completed standardized interview-administered questionnaires. Blood samples were assessed for hemoglobin A1c, fasting blood glucose, and serum lipids. Multiple linear regression models were used to determine the associations between the severity of DR and DME with symptoms of anxiety and depression and commonality analysis was used to quantify the unique variance explained. RESULTS: Of the 519 participants in the study, 170 individuals (32.8%) were female; mean (SD) age was 64.9 (11.6) years. Raw scores indicated that 80 individuals (15.4%) screened positive for depressive symptoms and 118 persons (22.7%) screened positive for symptoms of anxiety. In multivariate analysis using Rasch scores, severe nonproliferative DR (NPDR)/PDR was independently associated with greater depressive symptoms (regression coefficient [ß] = 0.69; 95% CI, 0.03-1.34) after controlling for sociodemographic factors and clinical characteristics, including visual acuity. A history of depression or anxiety accounted for 60.6% (95% CI, 23.9%-83.2%) of the unique variance in depressive symptoms, and severe NPDR or PDR contributed to 19.1% (95% CI, 1.7%-44.4%) of the total explained variance of depressive symptoms. Diabetic macular edema was not associated with depressive symptoms. No association between DR and symptoms of anxiety was identified. CONCLUSIONS AND RELEVANCE: Severe NPDR or PDR, but not DME, was independently associated with depressive symptoms. The severity of DR could be an indicator to prompt monitoring of depression in at-risk individuals with diabetes. Further work is required to replicate these findings and determine the clinical significance of the association.

Participant understanding and recall of informed consent for induced pluripotent stem cell biobanking.

The ability to generate human induced pluripotent stem cells (iPSCs) has opened new avenues for human disease modelling and therapy. The aim of our study was to determine research participants' understanding of the information given when donating skin biopsies for the generation of patient-specific iPSCs. A customised 35-item questionnaire based on previous iPSC consent guidelines was sent to participants who had previously donated samples for iPSC research. The questionnaire asked pertinent demographic details, participants' motivation to take part in iPSC research and their attitudes towards related ethical issues. 234 participants were contacted with 141 (60.3 %) complete responses received. The median duration between recruitment and follow-up questioning was 313 days (range 10-573 days). The majority of participants (n = 129, 91.5 %) believed they understood what a stem cell was; however, only 22 (16.1 %) correctly answered questions related to basic stem cell properties. We found no statistically significant difference in responses from participants with different levels of education, or those with a health sciences background. The poor understanding amongst participants of iPSC research is unlikely to be unique to our study and may impact future research if not improved. As such, there is a need to develop an easily understood yet comprehensive consent process to ensure ongoing ethical progress of iPSC biobanking.

Illness Cognitions and Coping Self-Efficacy in Depression Among Persons With Low Vision.

PURPOSE: To investigate the mediating role of coping self-efficacy (CSE) between two types of illness cognitions (i.e., acceptance and helplessness) and depressive symptoms in persons with low vision. METHODS: This was a single-group, cross-sectional study. Patients with visual acuity < 6/12 in the better eye and at least minimal depressive symptoms (≥5 on the Patient Health Questionnaire-9 [PHQ-9]) were recruited from vision rehabilitation services and participated in telephone-administered structured interviews at one time point. Measures were the PHQ-9, CSE Scale, and Illness Cognition Questionnaire. Structural equation modeling (SEM) devised the causal flow of illness cognitions and their observed indirect effects on depressive symptoms via the CSE mediators: problem focused, emotion focused, and social support. RESULTS: The study comprised 163 patients (mean age 62 years; 61% female), most with age-related macular degeneration (26%) and moderate vision impairment (44%, <6/18-6/60). Structural equation modeling indices indicated a perfect fit (χ2 < 0.001, P = 1.00), accounting for 55% of the variance in depressive symptoms. Lower levels of acceptance and higher levels of helplessness illness cognitions were associated with lower self-efficacy in problem-focused coping (ß = 0.38, P < 0.001, ß = -0.28, P < 0.01, respectively), which in turn was associated with greater depressive symptom severity (ß = -0.54, P < 0.001). CONCLUSIONS: Lack of acceptance and greater helplessness relating to low vision led to a lack of perceived capability to engage in problem-focused coping, which in turn promoted depressive symptoms. Third-wave cognitive-behavioral treatments that focus on acceptance may be efficacious in this population.

A Global Social Media Survey of Attitudes to Human Genome Editing.

Ongoing breakthroughs with CRISPR/Cas-based editing could potentially revolutionize modern medicine, but there are many questions to resolve about the ethical implications for its therapeutic application. We conducted a worldwide online survey of over 12,000 people recruited via social media to gauge attitudes toward this technology and discuss our findings here.