Tablet-based tests of everyday visual function in a diabetic macular oedema (DME) clinic waiting area: A feasibility study

PURPOSE

(1) To assess the feasibility of conducting tablet-based vision tests in hospital clinic waiting areas; (2) To test the hypothesis that increasing severity of diabetic macular oedema (DME) is associated with the performance of tablet-based surrogates of everyday tasks and self-reported visual function.

METHODS

Sixty-one people with mild (n = 28), moderate (n = 24) or severe (n = 9) DME performed two tablet-based tests of 'real-world' visual function (visual search and face recognition) while waiting for appointments in a hospital outpatient clinic. Participants also completed a tablet-based version of a seven-item, visual-functioning (VF-7) patient-reported outcome measure. Test performance was compared to previously published 99% normative limits for normally sighted individuals.

RESULTS

Thirty-four participants (56%; 95% confidence interval [CI] 43%-68%) exceeded normative limits for visual search, while eight (13%; 95% CI 65%-24%) exceeded normative limits for face discrimination. Search duration was significantly longer for people with severe DME than those with mild and moderate DME (p = 0.01). Face discrimination performance was not significantly associated with DME severity. VF-7 scores were statistically similar across DME severity groups. Median time to complete all elements (eligibility screening, both tablet-based tasks and the VF-7) was 22 (quartiles 19, 25) min. Further, 98% and 87% of participants, respectively, reported the search task and face discrimination task to be enjoyable, while 25% and 97%, respectively, reported finding the two tasks to be difficult.

CONCLUSIONS

Portable tablet-based tests are quick, acceptable to patients and feasible to be performed in a clinic waiting area with minimal supervision. They have the potential to be piloted in patients' homes for self-monitoring.

Patient acceptability of intravitreal complement inhibitors in geographic atrophy (GA): protocol for a UK-based cross-sectional study

INTRODUCTION

Geographic atrophy (GA) is the advanced form of the non-neovascular ('dry') type of age-related macular degeneration (AMD). Previously untreatable, complement inhibitors delivered by regular intravitreal injections have recently been demonstrated to slow down the progression of GA lesions in phase 3 trials. One such treatment, Syfovre (pegcetacoplan), was approved by the US Food and Drug Administration in February 2023. These therapies slow down, but do not stop or reverse, the progression of GA; they may also increase the risk of developing the neovascular ('wet') type of AMD. In light of these developments, this study aims to quantify the acceptability of these new intravitreal injection treatments to patients with GA in the UK and explore factors that may influence the acceptability of these treatments.

METHODS AND ANALYSIS

In this cross-sectional, non-interventional study, the primary objective is to determine the proportion of patients with GA that find regular intravitreal therapy acceptable for slowing the progression of GA. We will use a validated acceptability questionnaire in order to quantify the acceptability of new treatments among patients with GA. The correlation between acceptability and functional and structural biomarkers of GA will be established. We will also explore demographic, general health and ocular factors that may influence acceptability. 180 individuals with a diagnosis of GA will be recruited from 7 to 8 participating National Health Service trusts across the UK. Multiple regression analysis will be conducted to determine the simultaneous effects of multiple factors on patient acceptability.

ETHICS AND DISSEMINATION

The study received ethical approval from the Health Research Authority on 14 March 2023 (IRAS Project ID: 324854). Findings will be disseminated through peer-reviewed publications and conference presentations to the medical retina community, as well as through dialogue with patients and macular disease charities.

Exploring patient acceptability of emerging intravitreal therapies for geographic atrophy: A mixed-methods study

BACKGROUND/OBJECTIVES

The acceptability of emerging intravitreal therapies for patients with Geographic Atrophy (GA) is currently unknown. This study therefore aimed to investigate the extent to which regular intravitreal injections may be acceptable to GA patients.

SUBJECTS/METHODS

Thirty UK-based individuals with GA secondary to age-related macular degeneration (AMD), recruited from two London-based hospitals, were interviewed in April-October 2021 regarding acceptability of new GA treatments. Participants responded to a structured questionnaire, as well as open-ended questions in a semi-structured interview. The Theoretical Framework of Acceptability (TFA) informed framework analysis of the qualitative data.

RESULTS

Twenty participants (67%) were female, and median (interquartile range (IQR)) age was 83 (78, 87) years. 37% of participants had foveal centre-involving GA, and better eye median (IQR) logMAR visual acuity was 0.30 (0.17, 0.58). Data suggested that 18 participants (60% (95% CI: 41-79%)) would accept the treatment, despite awareness of potential drawbacks. Eight participants (27% (95% CI: 10-43%) were ambivalent or undecided about treatment, and four (13%) (95% CI: 0-26%) would be unlikely to accept treatment. Reducing the frequency of injections from monthly to every other month increased the proportion of participants who considered the treatments acceptable. Conversely, factors limiting acceptability clustered around: the limited magnitude of treatment efficacy; concerns about side effects or the increased risk of neovascular AMD; and the logistical burden of regular clinic visits for intravitreal injections. Misunderstandings of potential benefits indicate the need for appropriately-designed patient education tools to support decision-making.

CONCLUSIONS

Our study suggests a majority of participants would be positive about intravitreal treatment for GA, in spite of potential burdens.

Piloting a forced-choice task to elicit treatment preferences in geographic atrophy

OBJECTIVE

Geographic Atrophy (GA) is the advanced form of the non-neovascular ('dry') type of age-related macular degeneration (AMD) and responsible for one-quarter of legal blindness in the UK. New therapies delivered by intravitreal injection are in late-stage development, and two such therapies (pegcetacoplan (Syfovre) and avacincaptad pegol (Izervay)) have now been approved for clinical use by the US Food and Drug Administration. These therapies slow down, but do not stop or reverse, progression of GA and they may also increase the risk of developing the neovascular ('wet') type of AMD. Within a larger study exploring the acceptability of these new treatments to people living with GA, we developed a forced-choice exercise to evaluate how participants weigh up benefits and drawbacks of different treatment regimens. This research note reports quantitative and qualitative findings from this exercise.

RESULTS

Twenty-eight participants took part in this exercise. The exercise demonstrated that participants were generally, although not unanimously, in favour of less frequent treatment for GA that was slightly less efficacious in terms of preserving visual function but presented a lower risk of developing wet AMD. Even among a small sample, the exercise demonstrated the highly personal and idiosyncratic decision-making processes influencing participants' choices of preferred hypothetical GA treatment.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Test-Retest Variability and Discriminatory Power of Measurements From Microperimetry and Dark Adaptation Assessment in People With Intermediate Age-Related Macular Degeneration - A MACUSTAR Study Report

Purpose

The purpose of this study was to assess test-retest variability and discriminatory power of measures from macular integrity assessment (S-MAIA) and AdaptDx.

Methods

This is a cross-sectional study of 167 people with intermediate age-related macular degeneration (iAMD), no AMD (controls; n = 54), early AMD (n = 28), and late AMD (n = 41), recruited across 18 European ophthalmology centers. Repeat measures of mesopic and scotopic S-MAIA average (mean) threshold (MMAT decibels [dB] and SMAT [dB]) and rod intercept time (RIT [mins]) at 2 visits 14 (±7) days apart were recorded. Repeat measures were assessed by Bland-Altman analysis, intra-class correlation coefficients (ICCs) and variability ratios. Secondary analysis assessed the area under the receiver operating characteristic curves (AUC) to determine the ability to distinguish people as having no AMD, early AMD, or iAMD.

Results

Data were available for 128, 131, and 103 iAMD participants for the mesopic and scotopic S-MAIA and AdaptDx, respectively. MMAT and SMAT demonstrate similar test-retest variability in iAMD (95% confidence interval [CI] ICC of 0.79-0.89 and 0.78-0.89, respectively). ICCs were worse in RIT (95% CI ICC = 0.55-0.77). All tests had equivalent AUCs (approximately 70%) distinguishing between subjects with iAMD and controls, whereas early AMD was indistinguishable from iAMD on all measures (AUC = <55%). A learning effect was not seen in these assessments under the operating procedures used.

Conclusions

MMAT, SMAT, and RIT have adequate test-retest variability and are all moderately good at separating people with iAMD from controls.

Translational Relevance

Expected levels of test-retest variability and discriminatory power of the AdaptDx and MAIA devices in a clinical study setting must be considered when designing future trials for people with AMD.

Towards a Therapy for Geographic Atrophy: A Patient's Experience

PURPOSE

Geographic atrophy (GA) is the advanced form of the non-neovascular (dry) type of age-related macular degeneration. Presently, GA cannot be treated. However, new therapies administered by intravitreal injection are in late-stage development. These can slow down, but do not stop or reverse, GA progression. The acceptability of these emerging therapies to people with GA is currently unknown. The present case study explores the perspectives of a person living with GA who took part in the terminated Phase 3 clinical trial of Lampalizumab, a candidate intravitreal treatment for GA. We explored this patient's perspective on the retrospective acceptability of regular Lampalizumab injections, and the prospective acceptability of future intravitreal therapies for GA.

PATIENTS AND METHODS

A 78-year-old woman living in the UK was recruited as part of a mixed-methods pilot study and interviewed by telephone, regarding: her experience of the Lampalizumab trial injections; and her thoughts regarding emerging intravitreal therapies for GA. The Framework Method was used for initial inductive analysis of the interview transcript. Subsequently, deductive analysis was undertaken, informed by the Theoretical Framework of Acceptability (TFA).

RESULTS

For this participant, intravitreal injections in the Lampalizumab trial were acceptable, although streamlining processes within the clinic would have improved the patient experience. Regarding prospective acceptability of new intravitreal therapies, the participant considered a delay in progression of GA a valuable goal. Potential discomfort, anxiety and inconvenience associated with regular intravitreal injections would be acceptable in the context of preserving her vision for as long as possible.

CONCLUSION

Analysis of one participant's experience demonstrates the value of exploring GA patients' unique views on the acceptability of new intravitreal treatments. Larger prospective studies will provide more insight that help to optimise treatment design and delivery, thereby maximising likelihood of adherence and persistence when these therapies eventually arrive in clinic.

Patient-reported outcome measures in ophthalmology: too difficult to read?

Objective

Patient-reported outcome measures (PROMs) are commonly used in clinical trials and research. Yet, in order to be effective, a PROM needs to be understandable to respondents. The aim of this cross-sectional analysis was to assess reading level of PROMs validated for use in common eye conditions.

Methods and analysis

Readability measures determine the level of education a person is expected to have attained to be able to read a passage of text; this was calculated using the Flesch-Kincaid Grade Level, FORCAST and Gunning-Fog tests within readability calculations software package Oleander Readability Studio 2012.1. Forty PROMs, previously validated for use in at least one of age-related macular degeneration, glaucoma and/or diabetic retinopathy, were identified for inclusion via a systematic literature search. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend patient materials should not exceed a sixth-grade reading level. Number of PROMs exceeding this level was calculated.

Results

Median (IQR) readability scores were 7.9 (5.4-10.5), 9.9 (8.9-10.7) and 8.4 (6.9-11.1) for Flesch-Kincaid Grade Level, FORCAST and Gunning-Fog test, respectively. Depending on metric used, this meant 61% (95% CI 45% to 76%), 100% (95% CI 91% to 100%) and 80% (95% CI 65% to 91%) exceeded the recommended threshold.

Conclusion

Most PROMs commonly used in ophthalmology require a higher reading level than that recommended by the AMA and NIH and likely contain questions that are too difficult for many patients to read. Greater care is needed in designing PROMs appropriate for the literacy level of a population.

Acceptability of intravitreal injections in geographic atrophy: protocol for a mixed-methods pilot study

INTRODUCTION

Age-related macular degeneration (AMD) is a common cause of visual impairment, affecting central vision. Geographic atrophy (GA) is an advanced form of the non-neovascular (dry) type of AMD. Late-stage clinical trials suggest that intravitreal injections of novel therapeutics may slow down the rate of GA progression by up to 30% in 1 year, thus allowing people with GA to preserve central vision for a longer period. While intravitreal injections have become an established treatment modality for neovascular (wet) AMD, it is unknown whether patients with (more gradually progressing) GA would accept regular injections that slow down, but do not stop or reverse, vision loss. Therefore, this mixed-methods pilot study will aim to explore whether regular intravitreal injections will be acceptable as treatment for patients with GA, and the factors that may affect treatment acceptability.

METHODS AND ANALYSIS

A mixed-methods survey has been designed in collaboration with a GA patient advisory group. The survey comprises of structured questionnaires, semi-structured interview questions regarding patients' perceptions of intravitreal injections and the burden of treatment, and a task eliciting preferences between different potential treatments. Due to COVID-19 restrictions, this study will be conducted remotely by telephone. Thirty individuals will be recruited from NHS Medical Retina clinics at Central Middlesex Hospital, London. Half of the participants will be naïve to intravitreal injections, while half will have previous experience of intravitreal injections for neovascular (wet) AMD. Qualitative data analysis will be conducted using the Framework Method of analysis to identify key themes from participants' accounts.

ETHICS AND DISSEMINATION

The study received Health Research Authority approval on 23 March 2021 (IRAS Project ID: 287824). Findings will be disseminated through peer-reviewed publications and conference presentations to the medical retina community, as well as through dialogue with patients and macular disease charities.

Acceptability of a home-based visual field test (Eyecatcher) for glaucoma home monitoring: a qualitative study of patients' views and experiences

OBJECTIVES

To explore the acceptability of home visual field (VF) testing using Eyecatcher among people with glaucoma participating in a 6-month home monitoring pilot study.

DESIGN

Qualitative study using face-to-face semistructured interviews. Transcripts were analysed using thematic analysis.

SETTING

Participants were recruited in the UK through an advertisement in the International Glaucoma Association (now Glaucoma UK) newsletter.

PARTICIPANTS

Twenty adults (10 women; median age: 71 years) with a diagnosis of glaucoma were recruited (including open angle and normal tension glaucoma; mean deviation=2.5 to -29.9 dB).

RESULTS

All participants could successfully perform VF testing at home. Interview data were coded into four overarching themes regarding experiences of undertaking VF home monitoring and attitudes towards its wider implementation in healthcare: (1) comparisons between Eyecatcher and Humphrey Field Analyser (HFA); (2) capability using Eyecatcher; (3) practicalities for effective wider scale implementation; (4) motivations for home monitoring.

CONCLUSIONS

Participants identified a broad range of benefits to VF home monitoring and discussed areas for service improvement. Eyecatcher was compared positively with conventional VF testing using HFA. Home monitoring may be acceptable to at least a subset of people with glaucoma.

Are Current Methods of Measuring Dark Adaptation Effective in Detecting the Onset and Progression of Age-Related Macular Degeneration? A Systematic Literature Review

INTRODUCTION

Dark adaptation (DA) has been proposed as a possible functional biomarker for age-related macular degeneration (AMD). In this systematic review we aim to evaluate current methodology used to assess DA in people with AMD, the evidence of precision in detecting the onset and progression of AMD, and the relationship between DA and other functional and structural measures.

METHODS

MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, PsycARTICLES were searched for studies published between January 2006 and January 2020 that assessed DA in people with AMD. Details of eligible studies including study design, characteristics of study population and outcomes were recorded. All included studies underwent quality appraisal using approved critical appraisal tools. This systematic review follows PRISMA guidelines (PROSPERO registration number: CRD42019129486).

RESULTS

Forty-eight studies were eligible for inclusion, reporting a variety of instruments and protocols to assess different DA parameters. Twenty of these studies used the AdaptDx (MacuLogix, Hummelstown, PA, USA) instrument and assessed rod-intercept time (RIT). Most of these reported that RIT was delayed in people with AMD and this delay worsened with AMD severity. Four studies, involving 533 participants, reported estimates of diagnostic performance of AdaptDx to separate people with AMD from visually healthy controls. DA has been compared to other measures of visual function, patient-reported outcome measures (PROMs) and structural measures. Ten studies specifically considered evidence that the presence of certain structural abnormalities was associated with impaired DA in AMD.

CONCLUSIONS

This systematic review indicates overwhelming evidence of reasonable quality for an association between impaired DA and AMD. Data on the repeatability and reproducibility of DA measurement are sparse. There is evidence that structural abnormalities such as reticular drusen are associated with prolongation of DA time. Fewer studies have explored an association between DA and other measures of visual function or PROMs. We found no studies that had compared DA with performance-based measures.

Novel computer-based assessments of everyday visual function in people with age-related macular degeneration

PURPOSE

To test the hypothesis that the performance in novel computer-based tasks of everyday visual function worsens with disease severity in people with non-neovascular age-related macular degeneration.

METHODS

Participants with and without non-neovascular age-related macular degeneration (≥60 years, minimum logMAR binocular visual acuity 0.7) performed a series of standard visual function tests and two novel computer-based tasks. In a visual search task, participants had to locate an image of a single real-world object within an array of 49 distractor images. Next, in a series of simulated dynamic driving scenes, participants were asked to identify one or two approaching real-world road signs and then select these road signs from four options. Outcome measures were median response times and total correct responses.

RESULTS

Forty-nine participants had no macular disease (n = 11), early/intermediate age-related macular degeneration (n = 16) or geographic atrophy (n = 22). Groups were age-similar with median (interquartile range) logMAR visual acuity of 0.00 (-0.08,0.12), 0.13 (-0.08,0.70) and 0.32 (0.12,0.70) respectively. Median (interquartile range) visual search response times were 1.9 (1.0,2.4), 1.8 (1.1,3.7) and 2.4 (1.2,6.0) seconds respectively. Median (interquartile range) road sign response times (single road signs) were 1.2 (0.4,1.7), 1.5 (0.9,2.8) and 1.8 (1.0,5.5) seconds respectively. Median (interquartile range) road sign response times (double road signs) were 1.7 (0.7,2.4), 2.3 (1.2,3.1) and 2.5 (1.7,6) seconds respectively. Participants with geographic atrophy recorded slower response times in all tasks and over 50% performed outside the normative limit for task performance. There were no significant differences between groups in total correct responses across all tasks.

CONCLUSIONS

In a novel computer-based assessment, people with increasing severity of age-related macular degeneration take longer to perform visual search of everyday objects and take longer to identify road signs than those with no age-related macular degeneration. These novel assessments could be useful as patient-relevant, secondary outcomes for clinical trials.

Only eye study 2 (OnES 2): 'Am I going to be able to see when the patch comes off?' A qualitative study of patient experiences of undergoing high-stakes only eye surgery

OBJECTIVES

Ocular surgery is a source of significant concern for many patients, especially in high-stakes circumstances. The purpose of this study was to explore patient experiences of undergoing surgery on their only-seeing eye.

DESIGN

A qualitative investigation using semistructured face-to-face interviews. Transcripts were analysed using thematic analysis.

SETTING

Hospital eye service in the UK.

PARTICIPANTS

Twelve participants with a diagnosis of glaucoma with worse eye visual acuity <3/60± end-stage visual field loss. All participants had experience of undergoing surgery on their better-seeing (ie, 'only') eye.

RESULTS

Data were coded into three key themes relating to (1) emotional impact of surgery, (2) burden of visual loss and (3) coping with surgery. Patients reported depressive symptoms at all stages of their surgical journey; concern about poor visual outcomes was a common feature. Only eye surgery imposes an emotional burden due to the uncertainty regarding individuals' ability to continue daily activities and maintaining social roles. Burden extended to the inconvenience of frequent hospital visits and difficulties with follow-up care. Participants' ability to cope effectively with surgery appeared to be linked to extent of support from healthcare professionals. Key areas in developing trust and support were an open and transparent dialogue between surgeons and patients, continuity of care, patient inclusion in decision-making, and observable empathy.

CONCLUSIONS

The findings indicate a need for an enhanced model of care in only eye surgery to better target patient preferences and allay concerns inherent with these procedures.

Psychological, social and everyday visual impact of diabetic macular oedema and diabetic retinopathy: a systematic review

AIMS

To synthesize the evidence on the impact of diabetic retinopathy and diabetic macular oedema from the patient perspective.

METHODS

A systematic literature review was conducted using MEDLINE Complete, PsycINFO, EMBASE and AMED. We included articles investigating the impact of the condition on quality of life, symptoms, visual functioning, activities of daily living, well-being, social functioning, and financial status. The studies evaluated were observational, including cross-sectional, prospective cohort and retrospective cohort designs. Outcome data were extracted and synthesized.

RESULTS

Searches yielded 5114 publications. After screening, 85 studies were included, measuring the following outcomes: visual functioning (n=46); quality of life (n=22); well-being (n=16); functional status (n=5); work (n=4); and visual task performance (n=2). Diabetic retinopathy has a considerable impact on visual functioning and this is greater in people with greater disease severity. Diabetic retinopathy significantly limits activities including working, driving, walking and reading, and has the potential to have a negative impact on psychological well-being.

CONCLUSIONS

Diabetic retinopathy is associated with poor self-reported visual functioning, well-being, and health-related quality of life. Ability to perform basic everyday tasks appears to diminish with disease severity. Some studies suggest impaired mobility and problems with work, but there are gaps in this evidence.

0399 The MSSA: A Novel Instrument to Assess Sleep and Sleep Disturbances in Military Men and Women

Introduction

Military personnel experience unique stressors (e.g., deployments, shift work, family separation) which can cause sleep disturbances. However, little is known regarding the general sleep quality of military personnel and how it changes throughout their service, what types of stressors precipitate sleep disturbances, and how this differs among military men and women. We present findings from a new self-report measure, the Military Service Sleep Assessment (MSSA), which was designed to assess (1) current primary problems with sleep, (2) sleep quality throughout military service (3) life events that may have impacted their sleep and (4) the specific events which most effected sleep.

Methods

A total of 69 military personnel (22 women and 47 men) completed the MSSA and 49 also completed a diagnostic polysomnogram (PSG). Chi-square tests were run to differences in responses between men and women.

Results

No significant differences were found between men and women. In general, sleep quality progressively decreased over a participant’s military career from 3 to 2 on a 5-point Likert scale (1=low, 5=high). For those with at least one deployment (n=52), 73% reported that deployment and 54% reported that a redeployment (return from deployment) negatively impacted sleep quality for 3 months. Women reported that permanent change of station (PCS) negatively impacted their sleep more frequently than men (36% vs. 28%). The reported events that most significantly impacted sleep quality were deployment, military service other than deployment and trauma.

Conclusion

The MSSA is a novel instrument that can be used to increase understanding of sleep disturbances in military men and women which can inform prevention and treatment strategies. This measure is being used to systematically evaluate the factors which may precipitate or perpetuate sleep disturbances in military men and women such as military service-associated factors, training, deployment history, changing stations, and exposure to trauma or other stressful life events.

Support

This study is supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health.

0384 Do Nurses with High Blood Pressure Have More Sleep Disturbances Than Their Peers?

Introduction

Nurses work in stressful environments and often have rotating work schedules, which may put them at risk for disturbed sleep and health. Poor quality and short sleep duration are strong risk factors for high blood pressure (HBP). Yet few studies have examined these associations in nurses, who may be a particularly at-risk sample. To address this gap, we examined group differences in self-reported and actigraphy-assessed sleep among nurses with and without self-reported HBP.

Methods

Participants were 392 nurses (91.8% female; 77.8% white, mean age = 39.54) recruited for a parent study. Participants completed baseline questionnaires including the Pittsburgh Sleep Quality Index (PSQI), followed by 14 days of actigraphy and sleep diaries to prospectively assess 14-day mean total sleep time (TST) and sleep efficiency (SE). An independent samples t-tests was used to assess group differences in sleep variables by HBP status. Linear regression was used to further examine the association between HBP status on sleep variables when controlling for age, race, gender, ethnicity, and body mass index (BMI).

Results

Twenty-nine (7%) nurses endorsed having clinically-diagnosed HBP. Nurses with HBP had higher global PSQI scores (indicating worse sleep quality; t=2.71, p=0.007), compared to nurses who did not report HBP, with a mean difference of 1.24. When adjusting for covariates, the association between HBP and the PSQI became marginally significant (p=0.054). There were no group differences in sleep diary or actigraphy TST or SE by HBP status, nor did HBP predict these sleep variables when controlling for covariates.

Conclusion

We found that nurses who reported having clinically diagnosed HBP had poorer global sleep quality. Although limited by self-reported history of HBP diagnosis, and low endorsement of HBP in our sample, our results corroborate other findings which suggest there is a strong association between high blood pressure and disturbed sleep. Future studies should examine these associations in larger samples, assess blood pressure directly, and experimentally examine the effects of HBP treatment on sleep quality.

Support

NIH/NIAID R01AI128359-01

0225 Do Associations Between Daily Stress and Sleep Vary by Work Shift? A Within-Person Analysis in Nurses

Introduction

Longitudinal studies have shown daily stress and sleep are bidirectionally associated. Nurses are particularly likely to experience sleep disturbances and high stress due to demanding work environments. Night shift work may be a unique stressor for nurses that exacerbates associations between stress and sleep. Using a within-person design, we examined the daily bidirectional associations between stress and sleep and moderation by nightly work shift (day/off shift vs. night shift) in a large sample of nurses.

Methods

Participants were 393 nurses (91% female; 77% white, mean age = 38.4 years) recruited from two hospitals. Participants completed 14 days of sleep diaries and actigraphy to assess total sleep time (TST) and sleep efficiency (SE). They simultaneously completed assessments of stress on the previous day (0 = “not at all” to 4 = “extremely”) and daily work schedule (day/off shift vs. night shift [work between 9pm-6am]).

Results

Results indicated greater daily stress was associated with shorter diary TST (b = -9.49, p&lt;.0001) and actigraphy TST (b = -4.48, p&lt;.01), as well as lower diary SE (b = -0.56, p&lt;.001). When examining reverse pathways of sleep predicting next day stress, both diary TST (b = -0.0004, p&lt;.0001) and actigraphy TST (b = -0.0002, p = .03) predicted higher next-day stress. Lower diary SE predicted higher next-day stress (b = -0.005, p&lt;.001). Only the association between daily stress and nightly diary SE was moderated by daily work shift: only when nurses worked a day or off shift did they have a negative association between daily stress and diary SE (b = -0.68, p&lt;.0001).

Conclusion

Daily stress and sleep disturbances occurred in a bidirectional fashion for night- and day-shift working nurses. Most associations were similar regardless of daily type of work shift. Objective and subjective short TST and low subjective SE may contribute to a cycle of increased stress and are prime targets for a tailored sleep intervention in nurses. More research is needed to develop interventions to address the unique sleep health challenges faced by nurses.

Support

NIAID R01AI128359-01

0483 Predictors of Cognitive Behavioral Therapy for Insomnia (CBT) Outcomes in Active Duty U.S. Army Personnel

Introduction

Cognitive behavioral therapy for insomnia (CBTi) is well established as the first-line treatment for the management of chronic insomnia. Identifying predictors of response to CBTi should enable the field to efficiently utilize resources to treat those who are likely to respond and to personalize treatment approaches to optimize outcomes for those who are less likely to respond to traditional CBTi. Although a range of studies have been conducted, no clear pattern of predictors of response to CBTi has emerged.

Methods

The purpose of this study was to examine the impact and relative importance of a comprehensive group of pretreatment predictors of insomnia outcomes in 99 active duty service members who received in-person CBTi in a randomized clinical trial.

Results

Results indicated that higher levels of baseline insomnia severity and total sleep time predicted greater improvements on the Insomnia Severity Index (ISI) following treatment. Higher depression symptoms and a history of head injury predicted a worse response to treatment (i.e., smaller improvements on the ISI).

Conclusion

Clinically meaningful improvements, as measured by the reliable change index (RCI), were found in 59% of the sample. Over and above baseline insomnia severity, only depressive symptoms predicted this outcome. Future studies should examine if modifications to CBTi based on these predictors of response can improve outcomes.

Support

This study was conducted with support from the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program award W81XWH-10-1-0828 (PI: Dr Taylor).

0178 The Cycle of Daily Stress and Sleep: Sleep Measurement Matters

Introduction

Disturbed sleep can be both a cause and a consequence of increased stress. Yet intensive longitudinal studies have demonstrated that sleep assessed via sleep diaries and actigraphy is inconsistently associated with daily stress. We expanded this research by examining daily associations between sleep and stress using a three-fold approach to assess sleep: sleep diaries, actigraphy, and ambulatory single-channel electroencephalography [EEG].

Methods

Participants were 80 adults (M age = 32.65 years, 63% female) who completed 7 days of sleep and perceived stress assessments in a naturalistic setting (resulting in 560 possible measurement occasions). Multilevel models were used to examine bidirectional associations between daily stressor occurrence (0 = stressor did not occur, 1 = stressor occurred) and stressor severity (0 = not at all severe to 3 = very severe) and sleep parameters assessed via diary, actigraphy, and EEG (e.g. total sleep time [TST], sleep efficiency [SE], and sleep onset latency [SOL], wake after sleep onset [WASO]).

Results

Participants reported at least one stressor on 37% of days. Compared to days without a stressor experienced, days with a stressor were associated with a 14.4-minute reduction in actigraphy-determined TST the subsequent night (β = -0.24, p = 0.030). Nights with greater sleep-diary determined WASO were associated with greater next-day stressor severity (β = 0.01, p = .026). No EEG-determined sleep parameters were associated with next-day stressor occurrence or severity, or vice versa.

Conclusion

Daily stress and sleep disturbances occurred in a bidirectional fashion, though specific results varied by sleep measurement technique and sleep parameter. Together, our results highlight that type of sleep measurement matters for examining associations with daily stress. We urge future researchers to treat sleep diaries, actigraphy, and EEG as complementary — not redundant — sleep measurement approaches.

Support

Funding for this study included NIH/NIAID R01AI128359-01; DoD-VA 1I01CU000144-01; the Foundation for Rehabilitation Psychology; and General Sleep Corporation.

1110 Characteristics Of Untreated Sleep Disturbance During Intensive Outpatient Treatment For Substance Use Disorders: Preliminary Results From A Longitudinal Study

Introduction

Previous studies have shown that sleep problems are commonly reported during treatment for substance use disorders (SUDs) and sleep complaints have been linked to subsequent relapse. However, most of these findings were in well-controlled clinical trials and may not generalize to the public. Little is known about the natural progression of sleep complaints during treatment in community clinics, the most common treatment approach for SUDs. The aim of this study is to longitudinally assess prevalence of clinically significant sleep disturbance at baseline and post-treatment in a community-based intensive outpatient (IOP) SUD treatment program using a multi-method approach with well-validated measures of sleep.

Methods

Adults beginning IOP SUD treatment completed the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Nightmare Disorder index (NDI), and one week of actigraphy and sleep diaries. Measures were repeated following treatment (approximately 5 weeks later).

Results

Preliminary analyses on 21 adults who have been enrolled thus far revealed 85.6% of participants experienced sleep disturbance (PSQI &gt; 5) at baseline. 28.5% of participants reached cutoff for moderate-to-severe insomnia symptoms (ISI &gt; 15) and 42.9% reported nightmares more than once per week. Sleep parameters taken from actigraphy and sleep diaries revealed mean sleep efficiency was 77.5% (TST M = 6.2 hours; TIB M = 7.9 hours). These variables did not improve from baseline to post-treatment. Further, most measures indicated a worsening of sleep, though this did not reach significance (all ps &gt; .05).

Conclusion

This preliminary data show a high prevalence of self-reported sleep complaints and objectively measured poor sleep efficiency that do not improve over the course of treatment. Data collection is ongoing and expected to at least double. More robust analyses, including differences between SUD type (e.g., cannabis vs. opioid) and relationship to relapse at post-treatment, will then be completed.

Support

K12DA031794

'You've got dry macular degeneration, end of story': a qualitative study into the experience of living with non-neovascular age-related macular degeneration

BACKGROUND/OBJECTIVES

To investigate the impact of non-neovascular (dry) age-related macular degeneration (AMD) on the person with respect to diagnosis, vision loss and coping strategies.

SUBJECTS/METHODS

Volunteers with dry AMD with a range of disease severity were given an eye examination and asked to describe aspects of their experience with dry AMD in a semi-structured interview. Interviews were audio-recorded, transcribed, and subjected to Framework analysis. Overarching themes were pre-defined, whilst subthemes were derived from the data.

RESULTS

Twenty-seven participants (81% female), with early (n = 3), intermediate (n = 16) and advanced dry AMD (GA; n = 8) were interviewed. Median (interquartile range) age (years), logMAR binocular visual acuity and Pelli-Robson contrast sensitivity were 76 (71, 80), 0.2 (0.18, 0.40) and 1.65 (1.35, 1.93), respectively. Overarching themes (and subthemes) were: diagnosis (relationship with healthcare professional, psychological impact of diagnosis, and knowledge of AMD, both pre- and post-diagnosis), impact of visual loss (functional and psychological) and coping strategies (help from others and personal strategies). Many participants reported feelings of distress at the time of diagnosis and, particularly noteworthy, several reported a constant fear of their condition worsening.

CONCLUSIONS

Dry AMD, for which there is currently no treatment, can have a significant impact on individuals, even in its early stages, before significant functional vision loss is manifest, as well as in its intermediate and advanced stages. Results from this study offer important insight into the experience of living with dry AMD not previously explored. Moreover, the results have the potential to serve as an educational resource for eyecare professionals.

Correction: 'You've got dry macular degeneration, end of story': a qualitative study into the experience of living with non-neovascular age-related macular degeneration

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Refinement and preliminary evaluation of two tablet-based tests of real-world visual function

Purpose

To describe, refine, evaluate, and provide normative control data for two freely available tablet‐based tests of real‐world visual function, using a cohort of young, normally‐sighted adults.

Methods

Fifty young (18–40 years), normally‐sighted adults completed tablet‐based assessments of (1) face discrimination and (2) visual search. Each test was performed twice, to assess test‐retest repeatability. Post‐hoc analyses were performed to determine the number of trials required to obtain stable estimates of performance. Distributions were fitted to the normative data to determine the 99% population‐boundary for normally sighted observers. Participants were also asked to rate their comprehension of each test.

Results

Both tests provided stable estimates in around 20 trials (~1–4 min), with only a further reduction of 14%–17% in the 95% Coefficient of Repeatability (CoR₉₅) when an additional 40 trials were included. When using only ~20 trials: median durations for the first run of each test were 191 s (Faces) and 51 s (Search); test‐retest CoR₉₅ were 0.27 d (Faces) and 0.84 s (Search); and normative 99% population‐limits were 3.50 d (Faces) and 3.1 s (Search). No participants exhibited any difficulties completing either test (100% completion rate), and ratings of task‐understanding were high (Faces: 9.6 out of 10; Search: 9.7 out of 10).

Conclusions

This preliminary assessment indicated that both tablet‐based tests are able to provide simple, quick, and easy‐to‐administer measures of real‐world visual function in normally‐sighted young adults. Further work is required to assess their accuracy and utility in older people and individuals with visual impairment. Potential applications are discussed, including their use in clinic waiting rooms, and as an objective complement to Patient Reported Outcome Measures (PROMs).

The Only Eye Study (OnES): a qualitative study of surgeon experiences of only eye surgery and recommendations for patient safety

OBJECTIVE

Performing surgery on patients with only one seeing-eye, where complications may result in catastrophic vision loss, presents unique challenges for the ophthalmic care team. There is currently no evidence regarding how surgeons augment their care when treating only eye patients and no guidelines for how these patients should be managed in hospital eye services. This study aimed to explore ophthalmic surgeons' experiences of only eye surgery and perceptions of current practice.

DESIGN AND PARTICIPANTS

Ten ophthalmic surgeons were asked to relate their experiences and views on performing only eye surgery in indepth, semistructured interviews. Interviews were audio-recorded and transcribed. Qualitative data were subjected to thematic analysis to identify key themes.

SETTING

Hospital eye service.

RESULTS

Five key themes emerged relating to surgeons' experiences and perceptions of only eye surgery: (1) differences in approach to consent, (2) strategies for risk reduction, (3) unmet training needs, (4) value of surgical mentor and (5) emotional impact of unsuccessful outcomes. Recommendations for improving the surgical journey for both the patient and the surgeon related primarily to better recognition and understanding of the complexities inherent with only eye surgery.

CONCLUSIONS

Outcomes of only eye surgery may be improved through a number of methods, including development of purpose-designed training fellowships, adoption of stress-reducing strategies and enhancement of available support services. The findings identify emerging themes unique to only eye surgery and the need for guidelines on the provision of care for these high-stakes surgical patients.

How do different lighting conditions affect the vision and quality of life of people with glaucoma? A systematic review

This article is a systematic review of evidence regarding the impact of different lighting conditions on the vision and quality of life (QoL) of people with primary open-angle glaucoma (POAG). A systematic literature search was carried out using CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Embase, and Ovid Nursing Database for studies: published up to April 2019; including people diagnosed with POAG; and assessing visual function or QoL in response to changing lighting/luminance levels or glare. Two researchers independently screened studies for eligibility. Data were extracted from eligible studies regarding study design, participant characteristics, outcomes, and results. Quality of included studies was critically appraised. Of 8437 studies, 56 eligible studies were included. Studies investigated the effects of lighting on the following domains among people with POAG: QoL (18/56), psychophysical measures (16/56), functional vision (10/56), activities of daily living (10/56), and qualitative findings (2/56). POAG negatively affects low-luminance contrast sensitivity, glare symptoms, and dark adaptation time and extent. In vision-related QoL questionnaires, people with POAG report problems with lighting, glare, and dark adaptation more frequently than any other domain. These problems worsen with progressing visual field loss. Early-stage POAG patients experience significantly more difficulties in low-luminance or changing lighting conditions than age-matched controls (AMCs), challenging perceptions of early-stage POAG as asymptomatic. However, performance-based studies seldom show significant differences between POAG participants and AMCs on tasks simulating daily activities under non-optimal lighting conditions. Further research with larger samples is required to optimise ambient and task-oriented lighting that can support patients' adaptation to POAG.

Feeling the pressure: a cross-sectional study exploring feasibility of a healthcare Pop-Up for intraocular pressure measurements in shopping centres in England

OBJECTIVES

To test the hypothesis that a shopping centre Pop-Up health check combining an intraocular pressure (IOP) check with a general health check (blood pressure (BP)) is more readily accepted by the general public than an IOP check only. We investigate public awareness of IOP compared with BP and the feasibility of measuring IOP in large numbers in a Pop-Up.

DESIGN

A cross-sectional study using a tailor-made healthcare Pop-Up.

SETTING

The 'Feeling the Pressure' Pop-Up was sited in eight regionally-different shopping centres in England.

PARTICIPANTS

Adult members of the public in shopping centres.

METHODS

On one day we measured IOP only and on another measured BP and IOP. IOP was measured by Icare IC100 tonometer (Helsinki, Finland). Potential participants were asked about their awareness of IOP and BP and when they last visited their optometrist.

RESULTS

More people attended the combined BP + IOP days (461; 60%; 95% CI 56% to 64%) than IOP-only days (307; 40%, 95% CI 37% to 43%) over 16 days of testing. We recorded IOP in 652 participants (median (IQR) age and IOP of 54 (42 to 68) years and 13 (11 to 15) mm Hg, respectively). Fewer people reported awareness about IOP (19%, 95% CI 16% to 23%) compared with BP (71%, 95% CI 66% to 75%). Of 768 participants, 60 (8%) reported no previous optometric eye examination and 185 (24%) reported >2 years since their most recent examination.

CONCLUSIONS

Measuring IOP in large numbers of the public via a shopping centre Pop-Up is feasible. Public engagement was greater when a BP check was offered alongside an IOP check, suggesting unfamiliar health checks can be promoted by aligning them with a more familiar check. Our findings hint at strategies for public health schemes that engage the public with their eye health.

Measuring dynamic levels of self-perceived anxiety and concern during simulated mobility tasks in people with non-neovascular age-related macular degeneration

Background/aims

To assess response to real-world mobility scenarios in people with dry age-related macular degeneration (AMD) using a computer-based test.

Methods

Participants were shown 18 point-of-view computer-based movies simulating walking through real-world scenarios, and pressed a button during scenes which would cause them self-perceived anxiety or concern in their day-to-day life. Button pressure was recorded throughout. Pressure traces were generated, which aligned with each movie time point. Group averages based on AMD severity were generated. Bootstrapped confidence intervals (CIs) for responses by group were generated around traces. Traces were examined to discover events causing the greatest differences between groups.

Results

Participants had early/no AMD (n=8), intermediate AMD (n=7) or geographic atrophy (n=15 (GA)). Median (IQR) logMAR visual acuity was 0.04 (−0.04, 0.18), 0.26 (0.10, 0.40) and 0.32 (0.20, 0.56), respectively. Participants with intermediate AMD or GA recorded greater pressure than those with early and no AMD (Kruskal-Wallis, p=0.04). Four events involving navigating stairs and three under low luminance elicited greatest differences between groups (p<0.001).

Conclusion

People with intermediate AMD or GA likely experience higher levels of concern associated with mobility. The test highlights areas of specific concern. Results should be useful in patient management and educating the public about the everyday effects of AMD.

Results of a Search for Sub-GeV Dark Matter Using 2013 LUX Data

The scattering of dark matter (DM) particles with sub-GeV masses off nuclei is difficult to detect using liquid xenon-based DM search instruments because the energy transfer during nuclear recoils is smaller than the typical detector threshold. However, the tree-level DM-nucleus scattering diagram can be accompanied by simultaneous emission of a bremsstrahlung photon or a so-called "Migdal" electron. These provide an electron recoil component to the experimental signature at higher energies than the corresponding nuclear recoil. The presence of this signature allows liquid xenon detectors to use both the scintillation and the ionization signals in the analysis where the nuclear recoil signal would not be otherwise visible. We report constraints on spin-independent DM-nucleon scattering for DM particles with masses of 0.4-5  GeV/c^{2} using 1.4×10^{4}  kg day of search exposure from the 2013 data from the Large Underground Xenon (LUX) experiment for four different classes of mediators. This analysis extends the reach of liquid xenon-based DM search instruments to lower DM masses than has been achieved previously.

Healthy shopper? Blood pressure testing in a shopping centre Pop-Up in England

BACKGROUND

Improving detection of elevated blood pressure (BP) remains a public health need. We present results from a Pop-Up health check stationed in shopping centres in England. We hypothesise the rate of case detection is related to measurable 'unhealthiness' of the shopping centres.

METHODS

A Pop-Up health check was sited in four and three shopping centres sampled from the top ten unhealthiest and top 15 healthiest shopping regions respectively, following a report ranking towns/cities based on their unhealthy and healthy retail outlets. On one day in each shopping centre, people were approached and consented to BP testing. Outcome measure was people flagged with BP ≥ 140/90 mmHg (cases).

RESULTS

We detected 45 (22.6%) and 20 (13.1%) cases from testing 199 and 152 adults in the unhealthy and healthy locations respectively (relative risk 1.72; 95% confidence interval: 1.06 to 2.78). A measure of unhealthy retail outlets (e.g. fast-food outlets) within each shopping centre was associated with detection rate (R2 = 0.61; p = 0.04).

CONCLUSION

An association exists between cases of suspect hypertension found in a health check Pop-Up and measured 'unhealthiness' of the shopping centre site. Results hint at strategies for public testing of BP, potentially in the context of reducing health inequalities.

Determining Optimal Test Parameters for Assessing Dark Adaptation in People With Intermediate Age-Related Macular Degeneration

Purpose

The primary aim was to determine optimal test conditions for evaluating dark adaptation in intermediate age-related macular degeneration (iAMD) in order to minimize test time while maintaining diagnostic sensitivity.

Methods

People with AMD and age-similar controls were recruited (aged >55 years). Rod intercept time (RIT) was assessed after a 76%, 70%, and 65% rhodopsin bleach at 5° eccentricity and 76% and 70% bleach at 12°. Test order was randomized and a 30-minute washout period added between tests. Results were compared between control and iAMD groups and receiver operating characteristics (ROC) curves were constructed.

Results

A total of 26 participants with variable grades of macular health attended for two visits. There was a statistically significant difference in average RIT between the control and iAMD groups at 5° (median, IQR controls = 5.8 minutes, 3.8-7.5; iAMD = 20.6 minutes, 11.1-30.0; Mann-Whitney, P = 0.01) and at 12° (mean, controls: 4.54 minutes ± 2.12 SD, iAMD = 7.72 minutes ± 3.37 SD; independent samples t-test, P = 0.03) following a 76% bleach. Area under the ROC curves was 0.83 (confidence interval [CI]: 0.64-1.0) and 0.79 (CI: 0.59-0.99) for these two test conditions, respectively. Five participants (45%) in the iAMD group had RITs >20 minutes for 76% bleach at 5°, but none for any other test condition.

Conclusions

Nearly half of the participants with iAMD produced unacceptably long recovery times (>20 minutes) using a 76% bleach at 5° eccentricity. The 76% bleach at 12° provided almost equivalent separation between AMD and controls but recovery was achieved within 20 minutes.

The effect of non-neovascular age-related macular degeneration on face recognition performance

Purpose

There is a well-established research base surrounding face recognition in patients with age-related macular degeneration (AMD). However, much of this existing research does not differentiate between results obtained for ‘wet’ AMD and ‘dry’ AMD. Here, we test the hypothesis that face recognition performance is worse in patients with dry AMD compared with visually healthy peers.

Methods

Patients (>60 years of age, logMAR binocular visual acuity 0.7 or better) with dry AMD of varying severity and visually healthy age-related peers (controls) completed a modified version of the Cambridge Face Memory Test (CFMT). Percentage of correctly identified faces was used as an outcome measure for performance for each participant. A 90% normative reference limit was generated from the distribution of CFMT scores recorded in the visually healthy controls. Scores for AMD participants were then specifically compared to this limit, and comparisons between average scores in the AMD severity groups were investigated.

Results

Thirty patients (median [interquartile range] age of 76 [70, 79] years) and 34 controls (median age of 70 [64, 75] years) were examined. Four, seventeen and nine patients were classified as having early, intermediate and late AMD (geographic atrophy) respectively. Five (17%) patients recorded a face recognition performance worse than the 90% limit (Fisher’s exact test, p = 0.46) set by controls; four of these had geographic atrophy. Patients with geographic atrophy identified fewer faces on average (±SD) (61% ± 22%) than those with early and intermediate AMD (75 ± 11%) and controls (74% ± 11%).

Conclusions

People with dry AMD may not suffer from problems with face recognition until the disease is in its later stages; those with late AMD (geographic atrophy) are likely to have difficulty recognising faces. The results from this study should influence the management and expectations of patients with dry AMD in both community practice and hospital clinics.

Seeing it differently: self-reported description of vision loss in dry age-related macular degeneration

PURPOSE

A realistic description of visual symptoms associated with dry age-related macular degeneration (AMD) is important for raising awareness of the condition and educating patients. This study aimed to develop a set of descriptors for dry AMD and examine the realism of images currently and frequently used to show visual symptoms of the condition.

METHODS

Volunteers with dry AMD with a range of disease severity were given an eye examination and were asked to describe visual symptoms of their condition in a conversational interview. Participants were also asked to comment on a photograph typically used to portray the visual symptoms of AMD. Interviews were audio recorded, transcribed and subjected to content analysis.

RESULTS

Twenty-nine participants were interviewed. Median (interquartile range [IQR]) age was 75 (70, 79) years. Median (IQR) binocular visual acuity (VA) and Pelli-Robson contrast sensitivity (CS) was 0.2 (0.18, 0.36) logMAR and 1.65 (1.50, 1.95) log CS respectively. Three, 17 and nine patients had early, intermediate and late (geographic atrophy, GA) AMD, respectively. The most frequently reported descriptor group was blur (n = 13) followed by missing (n = 10) and distortion (n = 7). We chose the most popular image used to portray the visual symptoms of dry AMD based on an internet search and showed this to 21 participants. Sixteen participants (76% [95% confidence interval 53-92%]), including three out of the seven people with geographic atrophy, unequivocally rejected the realism of the image.

CONCLUSIONS

People with dry AMD use a wide range of descriptors for their visual experience. Visual symptoms of dry AMD as portrayed by commonly shown images were not the experience of most people in this study.

First Searches for Axions and Axionlike Particles with the LUX Experiment

The first searches for axions and axionlike particles with the Large Underground Xenon experiment are presented. Under the assumption of an axioelectric interaction in xenon, the coupling constant between axions and electrons g_{Ae} is tested using data collected in 2013 with an exposure totaling 95 live days ×118  kg. A double-sided, profile likelihood ratio statistic test excludes g_{Ae} larger than 3.5×10^{-12} (90% C.L.) for solar axions. Assuming the Dine-Fischler-Srednicki-Zhitnitsky theoretical description, the upper limit in coupling corresponds to an upper limit on axion mass of 0.12  eV/c^{2}, while for the Kim-Shifman-Vainshtein-Zhakharov description masses above 36.6  eV/c^{2} are excluded. For galactic axionlike particles, values of g_{Ae} larger than 4.2×10^{-13} are excluded for particle masses in the range 1-16  keV/c^{2}. These are the most stringent constraints to date for these interactions.

Limits on Spin-Dependent WIMP-Nucleon Cross Section Obtained from the Complete LUX Exposure

We present experimental constraints on the spin-dependent WIMP-nucleon elastic cross sections from the total 129.5  kg yr exposure acquired by the Large Underground Xenon experiment (LUX), operating at the Sanford Underground Research Facility in Lead, South Dakota (USA). A profile likelihood ratio analysis allows 90% C.L. upper limits to be set on the WIMP-neutron (WIMP-proton) cross section of σ_{n}=1.6×10^{-41}  cm^{2} (σ_{p}=5×10^{-40}  cm^{2}) at 35  GeV c^{-2}, almost a sixfold improvement over the previous LUX spin-dependent results. The spin-dependent WIMP-neutron limit is the most sensitive constraint to date.

Results from a Search for Dark Matter in the Complete LUX Exposure

We report constraints on spin-independent weakly interacting massive particle (WIMP)-nucleon scattering using a 3.35×10^{4}  kg day exposure of the Large Underground Xenon (LUX) experiment. A dual-phase xenon time projection chamber with 250 kg of active mass is operated at the Sanford Underground Research Facility under Lead, South Dakota (USA). With roughly fourfold improvement in sensitivity for high WIMP masses relative to our previous results, this search yields no evidence of WIMP nuclear recoils. At a WIMP mass of 50  GeV c^{-2}, WIMP-nucleon spin-independent cross sections above 2.2×10^{-46}  cm^{2} are excluded at the 90% confidence level. When combined with the previously reported LUX exposure, this exclusion strengthens to 1.1×10^{-46}  cm^{2} at 50  GeV c^{-2}.

How does age-related macular degeneration affect real-world visual ability and quality of life? A systematic review

OBJECTIVES

To review systematically the evidence of age-related macular degeneration (AMD) affecting real-world visual ability and quality of life (QoL). To explore trends in specific topics within this body of the literature.

DESIGN

Systematic review.

METHODS

A systematic literature search was carried out using MEDLINE, EMBASE, CINAHL, PsycINFO, PsychARTICLES and Health and Psychosocial Instruments for articles published up to January 2015 for studies including people diagnosed with AMD, assessing real-world visual ability or QoL as an outcome. Two researchers screened studies for eligibility. Details of eligible studies including study design, characteristics of study population and outcomes measured were recorded in a data extraction table. All included studies underwent quality appraisal using the Mixed Methods Appraisal Tool 2011 Version (MMAT).

RESULTS

From 5284 studies, 123 were eligible for inclusion. A range of approaches were identified, including performance-based methods, quantitative and qualitative patient-reported outcome measures (PROMs). AMD negatively affects tasks including mobility, face recognition, perception of scenes, computer use, meal preparation, shopping, cleaning, watching TV, reading, driving and, in some cases, self-care. There is evidence for higher rates of depression among people with AMD than among community dwelling elderly. A number of adaptation strategies have been associated with AMD of varying duration. Much of the research fails to report the type of AMD studied (59% of included studies) or the duration of disease in participants (74%). Of those that do report type studied, the breakdown is as follows: wet AMD 20%, dry AMD 4% and both types 17%.

CONCLUSIONS

There are many publications highlighting the negative effects of AMD in various domains of life. Future research should focus on delivering some of this research knowledge into patient management and clinical trials and differentiating between the types of AMD.

Results on the Spin-Dependent Scattering of Weakly Interacting Massive Particles on Nucleons from the Run 3 Data of the LUX Experiment

We present experimental constraints on the spin-dependent WIMP (weakly interacting massive particle)-nucleon elastic cross sections from LUX data acquired in 2013. LUX is a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility (Lead, South Dakota), which is designed to observe the recoil signature of galactic WIMPs scattering from xenon nuclei. A profile likelihood ratio analysis of 1.4×10^{4}  kg day of fiducial exposure allows 90% C.L. upper limits to be set on the WIMP-neutron (WIMP-proton) cross section of σ_{n}=9.4×10^{-41}  cm^{2} (σ_{p}=2.9×10^{-39}  cm^{2}) at 33  GeV/c^{2}. The spin-dependent WIMP-neutron limit is the most sensitive constraint to date.

Improved Limits on Scattering of Weakly Interacting Massive Particles from Reanalysis of 2013 LUX Data

We present constraints on weakly interacting massive particles (WIMP)-nucleus scattering from the 2013 data of the Large Underground Xenon dark matter experiment, including 1.4×10^{4}  kg day of search exposure. This new analysis incorporates several advances: single-photon calibration at the scintillation wavelength, improved event-reconstruction algorithms, a revised background model including events originating on the detector walls in an enlarged fiducial volume, and new calibrations from decays of an injected tritium β source and from kinematically constrained nuclear recoils down to 1.1 keV. Sensitivity, especially to low-mass WIMPs, is enhanced compared to our previous results which modeled the signal only above a 3 keV minimum energy. Under standard dark matter halo assumptions and in the mass range above 4  GeV c^{-2}, these new results give the most stringent direct limits on the spin-independent WIMP-nucleon cross section. The 90% C.L. upper limit has a minimum of 0.6 zb at 33  GeV c^{-2} WIMP mass.

Leadership in Obstetrics and Gynaecology and Contribution to the Millenium Development Goal 5

DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11131 Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 1-2

Spin density projection-assisted R2 magnetic resonance imaging of the liver in the management of body iron stores in patients receiving multiple red blood cell transfusions: an audit and retrospective study in South Australia

AIM

To assess the impact of non-invasive monitoring of liver iron concentration (LIC) on management of body iron stores in patients receiving multiple blood transfusions.

METHOD

A retrospective audit was conducted on clinical data from 40 consecutive subjects with haemolytic anaemias or ineffective haematopoiesis who had been monitored non-invasively for LIC over a period of at least 1 year. LIC was measured with spin density projection-assisted proton transverse relaxation rate-magnetic resonance imaging.

RESULTS

Nineteen clinical decisions were explicitly documented in the case notes as being based on LIC results. Decisions comprised initiation of chelation therapy, increasing chelator dose, decreasing chelator dose and change of mode of delivery of deferioxamine from subcutaneous to intravenous. The geometrical mean LIC for the cohort dropped significantly (P= 0.008) from 6.8 mg Fe/g dry tissue at initial measurement to 4.8 mg Fe/g dry tissue at final measurement. The proportion of subjects with LIC in the range associated with greatly increased risk of cardiac disease and death (>15 mg Fe/g dry tissue) dropped significantly (P= 0.01) from 14 of 40 subjects at initial measurement to 5 of 40 subjects at final measurement. No significant changes in the geometrical mean of serum ferritin or the proportion of subjects with serum ferritin above 2500 or 1500 µg/L were observed.

CONCLUSIONS

The data are consistent with previous observations that introduction of non-invasive monitoring of LIC can contribute to a decreased body iron burden through improved clinical decision making and improved feedback to patients and hence improved adherence to chelation therapy.

Serovars, bacteriophage types and antimicrobial sensitivities associated with salmonellosis in dogs in the UK (1954-2012)

Serovars and bacteriophage (phage) types were determined for 442 isolates of Salmonella enterica from dogs in the UK submitted to the Scottish Salmonella Reference Laboratory from 1954 to 2012. The most frequent serovars were Salmonella Typhimurium (196 isolates; 44.3 per cent), Dublin (40 isolates; 9.0 per cent), Enteritidis (28 isolates; 6.3 per cent), Montevideo (19 isolates; 4.3 per cent), Virchow (10 isolates; 2.3 per cent), Heidelberg (8 isolates; 1.8 per cent) and Derby (8 isolates; 1.8 per cent), along with 55 other recognised serovars among 127 other isolates, and six incompletely classified isolates. Serovars were frequently represented by strains commonly associated with poultry, cattle or pigs and their products. Among 196 Salmonella Typhimurium isolates from dogs, the most frequent phage types (definitive types) were the multiple antimicrobial-resistant strains DT104 (62 isolates), DT204c (18 isolates) and DT193 (8 isolates), along with antimicrobial sensitive wild finch strains DT40 (13 isolates) and DT56 variant (8 isolates). Eleven of 28 isolates of Salmonella Enteritidis were phage type 4. S enterica was frequently recovered from faecal or intestinal samples of dogs with diarrhoea, although many dogs had concurrent infection with other enteric pathogens. Salmonella Dublin was recovered from the brain and/or cerebrospinal fluid of two dogs with meningoencephalitis. Salmonella Kedougou was isolated from the joint fluid of a dog with septic arthritis. Salmonella Typhimurium and Salmonella Dublin were each recovered from the vaginas of bitches that had aborted. Isolates of Salmonella Enteritidis phage types 1, 4 and 8, Salmonella Typhimurium DT104, Salmonella Dublin and Salmonella Indiana were isolated from clinically healthy dogs in households where the same strains were recovered from human beings with diarrhoea. The pattern ampicillin-chloramphenicol-spectinomycin-streptomycin-sulfamethoxazole-tetracycline (ACSpSSuT) was the most frequent resistance phenotype and was observed in 44 (13.3 per cent) of 330 isolates. Dogs in the UK are exposed to a wide variety of serovars of S enterica, sometimes associated with clinical disease, and represent a zoonotic risk.