Mailed Letter Versus Phone Call to Increase Diabetic-Related Retinopathy Screening Engagement by Patients in a Team-Based Primary Care Practice: Prospective, Single-Masked, Randomized Trial.

BACKGROUND: Vision loss from diabetic-related retinopathy (DR) is preventable through regular screening. OBJECTIVE: The purpose of this study was to test different patient engagement approaches to expand a teleophthalmology program at a primary care clinic in the city of Toronto, Canada. METHODS: A teleophthalmology program was set up in a large, urban, academic, team-based primary care practice. Patients older than 18 years with type 1 or type 2 diabetes were randomized to one of the following 4 engagement strategies: phone call, mail, mail plus phone call, or usual care. Outreach was conducted by administrative staff within the clinic. The primary outcome was booking an appointment for DR screening. RESULTS: A total of 23 patients in the phone, 28 in the mail, 32 in the mail plus phone call, and 27 in the control (usual care) group were included in the analysis. After the intervention and after excluding patients who said they were screened, 88% (15/17) of patients in the phone, 11% (2/18) in the mail, and 100% (21/21) in the mail and phone group booked an appointment with the teleophthalmology program compared to 0% (0/12) in the control group. Phoning patients positively predicted patients booking a teleophthalmology appointment (P<.001), whereas mailing a letter had no effect. CONCLUSIONS: Patient engagement to book DR screening via teleophthalmology in an urban, academic, team-based primary care practice using telephone calls was much more effective than patient engagement using letters or usual care. Practices that have access to a local DR screening program and have resources for such engagement strategies should consider using them as a means to improve their DR screening rates. TRIAL REGISTRATION: ClinicalTrials.gov NCT03927859; https://clinicaltrials.gov/ct2/show/NCT03927859.

Perceptions of a Teleophthalmology Screening Program for Diabetic Retinopathy in Adults With Type 1 and Type 2 Diabetes in Urban Primary Care Settings.

OBJECTIVES: Teleophthalmology has improved diabetic retinopathy screening, and should be expanded in urban areas, where most unscreened individuals reside. In this study we explored facilitators and barriers of teleophthalmology in primary care settings in Toronto, Canada. METHODS: Semistructured interviews were conducted with 7 health-care providers and 7 individuals with diabetes to explore their perspectives of teleophthalmology in urban primary care settings. Interview data were analyzed using interpretive thematic analysis to generate themes. RESULTS: Six themes were identified. Facilitators included patient-centred implementation, access to teleophthalmology at primary care sites and patients' trust in their providers' recommendations. Barriers included patients' lack of understanding of diabetic retinopathy and the health-care system, providers' lack of interest and the need to streamline administrative processes. CONCLUSIONS: Although teleophthalmology was well-received by patients, there was limited interest from primary care providers. Strategies for increasing uptake include increasing primary care providers' awareness of teleophthalmology's value in urban centres, improving administrative processes and centralizing patient recruitment.

Sociodemographics Associated With Risk of Diabetic Retinopathy Detected by Tele-Ophthalmology: 5-Year Results of the Toronto Tele-Retinal Screening Program.

OBJECTIVES: Our aim in this study was to describe screening outcomes and sociodemographic characteristics of patients in an urban tele-ophthalmology screening program for diabetic retinopathy (DR). METHODS: A prospective cohort study was conducted on adults with diabetes type 1 or type 2 enrolled in the Toronto Tele-Retinal Screening Program between September 2013 and March 2019. RESULTS: A total of 1,374 screenings were completed, of which 344 (25%) detected DR. Of all participants, 17% did not have provincial health coverage and 21% had never had an eye exam. Of the 587 patients who completed sociodemographic questionnaires, the majority (84%) were born outside of Canada, and only 62% preferred English as their spoken language. Forty percent reported a household income of <$25,000, with these participants having an increased likelihood of detectable DR (odds ratio [OR], 1.83; p<0.01). CONCLUSIONS: Participants with low income are more likely to screen positive for DR. Tele-ophthalmologic screening can be effective in an urban, culturally diverse and socioeconomically disadvantaged population.

Impact of Intersecting Systems of Oppression on Diabetic Retinopathy Screening Among Those Who Identify as Women of Low Socioeconomic Status: Protocol for a Convergent Mixed Methods Study.

BACKGROUND: By 2025, 5 million Canadians will be diagnosed with diabetes, and women from lower socioeconomic groups will likely account for most new diagnoses. Diabetic retinopathy is a primary vision complication of diabetes and a leading cause of blindness among adults, with 26% prevalence among women. Tele-retina is a branch of telemedicine that delivers eye care remotely. Screening for diabetic retinopathy has great potential to reduce the incidence of blindness, yet there is an adverse association among screening, income, and gender. OBJECTIVE: We aim to explore gender disparity in the provision of tele-retina program services for diabetic retinopathy screening in a cohort of women of low socioeconomic status (SES) receiving services in South Riverdale Community Health Centre (SRCHC) between 2014 and 2019. METHODS: Using a convergent mixed methods design, we want to understand patients', providers', administrators', and decision makers' perceptions of the facilitators and barriers associated with the implementation and adoption of tele-retina. Multivariate logistic regression will be utilized to assess the association among client characteristics, referral source, and diabetic retinopathy screening. Guided by a grounded theory approach, systematic coding of data and thematic analysis will be utilized to identify key facilitators and barriers to the implementation and adoption of tele-retina. RESULTS: For the quantitative component, we anticipate a cohort of 2500 patients, and we expect to collect data on the overall patterns of tele-retina program use, including descriptions of program utilization rates (such as data on received and completed diabetic retinopathy screening referrals) along the landscape of patient populations receiving these services. For the qualitative component, we plan to interview up to 21 patients and 14 providers, administrators, and decision makers, and to conduct up to 14 hours of observations alongside review of relevant documents. The interview guide is being developed in collaboration with our patient partners. Through the use of mixed methods research, the inquiry will be approached from different perspectives. Mixed methods will guide us in combining the rich subjective insights on complex realities from qualitative inquiry with the standard generalizable data that will be generated through quantitative research. The study is under review by the University Health Network Research Ethics Board (19-5628). We expect to begin recruitment in winter 2021. CONCLUSIONS: In Ontario, the screening rate for diabetic retinopathy among low income groups remains below 65%. Understanding the facilitators and barriers to diabetic retinopathy screening may be a prerequisite in the development of a successful screening program. This study is the first Ontario study to focus on diabetic retinopathy screening practices in women of low SES, with the aim to improve their health outcomes and revolutionize access to quality care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/23492.

Tele-retina screening of diabetic retinopathy among at-risk populations: an economic analysis.

OBJECTIVES: To assess the cost-effectiveness of the pilot Toronto tele-retina screening program in comparison with existing standard of care (SOC) diabetic retinopathy (DR) screening for patients with diabetes mellitus and in a simulated Pan-Ontarian cohort. METHODS: Decision trees were constructed to compare tele-retina to SOC in the pilot and Pan-Ontarian cohort. Cost-effectiveness was assessed as cost per case detected (true-positive) and cost per case correctly diagnosed (true-positive and true-negative results). RESULTS: Pilot program screening costs were $95.77 and $137.56 for tele-retina and SOC, respectively. In the base-case analysis, cost per case correctly detected was $379.06 with tele-retina and $985.56 with SOC, and the cost per case correctly diagnosed was $109.29 and $315.22, respectively. In the sensitivity analysis, cost per case correctly detected was $467.29 with tele-retina and $894.93 with SOC, and the cost per case correctly diagnosed was $136.88 and $250.35, respectively. Pan-Ontarian screening costs were $57.58 and $137.56 for tele-retina and SOC, respectively. The cost per case correctly detected was $281.10 with tele-retina and $982.00 with SOC, and the cost per case correctly diagnosed was $82.21 and $314.14, respectively. For both pilot and Pan-Ontarian sensitivity analyses, tele-retina remained the dominant strategy (ICER <0). CONCLUSIONS: Findings from this study suggest that tele-retina is a more cost-effective means of screening for diabetic retinopathy than the SOC in urban and rural underscreened communities. Subsequent economic studies should focus on evaluations that consider the impact of tele-retina on the prevention of severe vision loss in underscreened urban and rural communities.

Toronto tele-retinal screening program for detection of diabetic retinopathy and macular edema.

BACKGROUND: There are currently low rates of screening for diabetic retinopathy (DR) and sight-threatening diabetic macular edema (DME) in Ontario. OBJECTIVE: To present results of the Toronto Tele-Retinal screening program for patients with diabetes mellitus and to evaluate thebenefit of optical coherence tomography (OCT) in combination with monoscopic colour fundus photographs for detection of DME. METHODS: All electronic medical records for adults with type I and II diabetes mellitus screened through the Toronto Tele-Retinal screening program between September 2013 to August 2017 across 7 sc~reening sites in urban and rural settings were reviewed. Monoscopic colour fundus photographs were graded for presence or absence of DR and DME alone and in combination with OCT scans. RESULTS: A total of 775 patient screens, consisting of 566 first-time screens and 209 re-screens were completed over the 48-month study period. Approximately 37% of all patients with a mean disease duration of 7years had never had an eye examination. Across the sample, 27% of patients had DR, with majority graded to have mild DR, whereas DME was detected in 5% of patients in at least 1 eye. Of all DME detected in the Toronto Tele-Retinal screening program, 38% required the use of adjunct OCT. Other pathologies, including age-related macular degeneration (19%) and glaucomatous or optic nerve findings (8%), were also identified. CONCLUSION: Tele-retinal screening programs may circumvent low rates of DR screening for patients with diabetes mellitus and increase the rate of detection of DME with monoscopic colour fundus photographs and adjunct OCT.

Do gender differences in the role of dysfunctional attitudes in depressive symptoms depend on depression history?

Gender differences in the moderating role of dysfunctional attitudes in the relationship between life stress and depressive symptoms were examined with and without controlling for the presence of lifetime history of depression. When lifetime history of depression was controlled, dysfunctional attitudes played a moderating role in the relationship between life stress and depressive symptoms for both men and women. However, when lifetime history of depression was not controlled, dysfunctional attitudes moderated the relationship of life stress and depressive symptoms for women only. The results suggest gender differences in the moderating role of dysfunctional attitudes may be contingent on lifetime history of depression and that past depression may exert differing effects for men and women.

The factor structure of the Narcissistic Personality Inventory.

In the first study, we administered the 40-item Narcissistic Personality Inventory (NPI; Raskin & Terry, 1988) to 843 female and 843 male college students, most of whom were Euro-American, to comprehensively assess the NPI factor structure using confirmatory factor analysis. Initial exploratory common factor analyses (N = 724) revealed a 2-factor model (Leadership/Authority and Exhibitionism/Entitlement). Subsequently, we used confirmatory factor analysis in a separate sample (N = 724) to evaluate the Emmons (1987) 4-factor model, the Raskin and Terry (1988) 7-factor model, the Kubarych, Deary, and Austin (2004) 2- and 3-factor models, and our 2-factor model. Finally, we assessed construct validity by correlating the scale scores with the Five-factor model of personality in an independent sample (N = 238). The 2-factor models for the NPI we obtained in this study and by Kubarych et al. (2004) appeared to be the most parsimonious models, with both a good fit to the data and satisfactory internal consistency values; so they are recommended for use. However, additional NPI research is needed to rescale, modify, or omit several NPI items and develop gender-equivalent items.

Is there really a dissociative taxon on the dissociative experiences scale?

The Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986) and MMPI (Hathaway & McKinley, 1940) were administered to 1,237 college students to evaluate MMPI differences for nonpathological (n = 90) or pathological dissociators (n = 111) and nondissociative controls (n = 476). MMPIs of both dissociation groups had multiple clinical elevations with a mean 8-9 code. People classified in the pathological dissociation group had MMPI scores remarkably similar to those in the normal dissociation group. The DES and DES-Taxon (DES-T; Waller, Putnam, & Carlson, 1996) were also highly correlated. Our findings strongly suggest the DES-T does not uniquely identify categorical dissociation.

Influence of persistent contaminants and steroid hormones on glioblastoma cell growth.

Glioblastoma multiforme (GBM), a malignancy characterized by its rapid progression, presents a lower risk of occurrence in women during their reproductive years. Necrosis of brain tissue during tumor invasion releases free lipids, and therefore might release contaminants stored in phospholipid-rich neuronal tissue. This study assesses the growth response of two human glioblastoma cell lines, T98G and U138-MG, treated with environmental chemicals known or likely to persist within the brain. Persistent chlorinated pesticides, industrial contaminants, persistent perfluorinated chemicals, and steroid hormones were assayed over a range of concentrations. Although cytotoxic effects were seen in both T98G and U138-MG cells, proliferative responses occurred only in the T98G cell line. Dichlorodiphenyltrichloroethane (DDT), dichlorodiphenyldichloroethylene (DDE), and polychlorinated biphenyl (PCB) 153 were cytotoxic in both lines at 5000 nM. Perfluorodecanoic acid (PFDA), perfluorooctane sulfonate (PFOS), and testosterone stimulated proliferation in the T98G cells at 500, 1000, and 1000 nM, respectively. However, a perfluorinated salt (ammonium perfluorooctanoate; C8) and a weak androgen (dihydroepiandrosterone; DHEA) did not affect relative cell number in this GBM line, suggesting the proliferative effect is not through the activation of an androgen receptor. Exposure to environmental chemicals that result in a mitogenic response may increase the rate of glioblastoma tumor growth and result in the development of more aggressive forms of GBM tumors.

Mutation of Thr466 in SHP2 abolishes its phosphatase activity, but provides a new substrate-trapping mutant.

Most classical phosphotyrosyl phosphatases (PTPs), including the Src homology phosphotyrosyl phosphatase 2 (SHP2) possess a Thr or a Ser residue immediately C-terminal to the invariant Arg in the active site consensus motif (H/V-C-X5-R-S/T), also known as the "signature motif". SHP2 has a Thr (Thr466) at this position, but its importance in catalysis has not been investigated. By employing site-directed mutagenesis, phosphatase assays and substrate-trapping studies, we demonstrate that Thr466 is critical for the catalytic activity of SHP2. Its mutation to Ala abolishes phosphatase activity, but provides a new substrate-trapping mutant. We further show that the nucleophilic Cys459 is not involved in substrate trapping by Thr466Ala-SHP2 (T/A-SHP2). Mutation of Thr466 does not cause significant structural changes in the active site as revealed by the trapping of the epidermal growth factor receptor (EGFR), the physiological substrate of SHP2, and by orthovanadate competition experiments. Based on these results and previous other works, we propose that the role of Thr466 in the catalytic process of SHP2 could be stabilizing the sulfhydryl group of Cys459 in its reduced state, a state that enables nucleophilic attack on the phosphate moiety of the substrate. The T/A-SHP2 harbors a single mutation and specifically interacts with the EGFR. Since the nucleophilic Cys459 and the proton donor Asp425 are intact in the T/A-SAHP2, it offers an excellent starting material for solving the structure of SHP2 in complex with its physiological substrate.

Fantasy proneness, dissociation, and DSM-IV axis II symptomatology.

Scores on the Inventory of Childhood Memories and Imaginings (S. C. Wilson & T. X. Barber, 1981) identified fantasizers and controls who were administered the Structured Interview for DSM-IV Personality (SIDP-IV; B. Pfohl, N. Blum, & M. Zimmerman, 1994) and the Dissociative Experiences Scale (DES; E. M. Bernstein & F. W. Putnam, 1986). Fantasizers had increased rates of Cluster A and B personality disorders but were equivalent to controls in Cluster C diagnoses. For both Clusters A and B, 55% of the fantasizers received clinical diagnoses. Fantasizers had significantly higher DES, DES-T (N. G. Waller, F. W. Putnam, & E. B. Carlson, 1996), and Normal Dissociative Index scores. Although nearly one half of the fantasizers' DES-T patterns were classified within the pathological dissociative taxon (N. G. Waller & C. A. Ross, 1997), none of the controls and only 10.03% of the original screening sample received this classification. Both Axis II pathology and pathological dissociation were associated with fantasy proneness.