Effects of immersive virtual nature on nature connectedness: A systematic review and meta-analysis.

Objective: This study systematically summarizes the extant literature on the impacts of immersive virtual nature (IVN) on nature connectedness in the general population. Methods: Papers were considered eligible if peer-reviewed, in English language, comprising experimental or quasi-experimental trials, including at least one outcome relative to nature connectedness in the general population. Database search was conducted on Scopus, Web of Science, Google Scholar, Medline, and GreenFILE (22-28 November 2021). Risk of bias was established by the Cochrane RoB 2 tool. Data synthesis was conducted through meta-analysis according with the Cochrane Consumers and Communication Group guidelines. Results: Six eligible papers (9 studies; n = 730) were selected, in which IVN was compared to (i) non-immersive virtual nature, (ii) immersive virtual built environments, (iii) non-immersive virtual built environments, and (iv) actual nature. The risk of bias was predominantly "low" or of "some concerns." Meta-analyses showed a statistically significant overall effect for the first (g = 0.26; 95% CI = 0.06-0.45; I2 = 35%) and fourth group (g = -1.98; 95% CI = -3.21 to -0.75; I2 = 96%), the former in favor of IVN and the latter in favor of actual nature. Subgroup analyses were conducted for the first and second groups of studies to explore possible sources of heterogeneity. The small number of studies available limits the validity of the outcomes of the meta-analyses. Conclusion: The findings indicate that IVN may be an effective tool for the promotion of nature connectedness, although the evidence in this field is still limited and largely mixed. Recommendations for future research are discussed.

Cross-sectional Study Exploring Vision-related Quality of Life in Dry Eye Disease in a Norwegian Optometric Practice.

SIGNIFICANCE: Dry eye disease causes ocular pain, blurred vision, reduced visual quality of life, and reduced workplace performance. This disease is underreported and underdiagnosed despite being highly prevalent in optometric care. PURPOSE: This study aimed to explore the vision-related quality of life of patients with dry eye disease and the potential benefits of screening for dry eye disease in Norwegian optometric practice. METHODS: This study adopted an observational, prospective, cross-sectional design. All patients between 18 and 70 years of age who were examined between June 8 and July 5, 2018, at Erøy Optikk, Kristiansand, Norway, were invited to participate. Dry eye disease was assessed according to Tear Film & Ocular Surface Society International Dry Eye Workshop II report recommendations. Vision-related quality of life was assessed with the National Eye Institute 25-item Visual Function Questionnaire. RESULTS: Forty-nine patients participated in the study; 29 (59%) were female, and 29 (59%) had dry eye disease. The patients with dry eye disease reported significantly more ocular pain and (vision-specific) role difficulties than the patients without dry eye disease. After adjusting for age, sex, and habitual visual acuity, dry eye disease was found to be an independent predictor of both ocular pain ( r2 = 0.328, P = .001) and (vision-specific) role difficulties ( r2 = 0.240, P = .02). Both habitual visual acuity and dry eye disease were predictors of reduced general vision, a reduced score for near activity and reduced (vision-specific) mental health. CONCLUSIONS: Dry eye disease was an independent predictor of ocular pain (vision-specific), role difficulties, and reduced general vision, near vision, and (vision-specific) mental health. Optometrists should consider dry eye disease as a cause of reduced vision and quality of vision. Furthermore, we propose that screening for dry eye disease in Norwegian optometric practice can promote better vision and health among patients.

Methods for evaluation of corneal nerve fibres in diabetes mellitus by in vivo confocal microscopy: a scoping review protocol.

INTRODUCTION: Globally, 422 million people have diabetes. Late complications of diabetes are blindness, kidney failure, heart attack, stroke and lower limb amputation. The prevalence of diabetic peripheral neuropathy and diabetic retinopathy is 50% and 35%, respectively. In vivo confocal microscopy (IVCM) is a rapid, non-invasive method to evaluate subbasal corneal nerve fibres, which are small fibres of the peripheral nervous system. Corneal nerve fibre changes can be a marker of diabetic peripheral neuropathy. There is currently no gold-standard procedure for IVCM imaging, image processing or quantitative analysis of the corneal nerve fibres in the subbasal plexus. This protocol describes a scoping review to map, summarise and critically evaluate current methods used with IVCM evaluation in people with diabetes mellitus. METHODS: The scoping review will follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping review. A comprehensive search of the literature will be conducted in MEDLINE, Embase, Cochrane, Scopus and Web of Science. The search strategy will include terms related to IVCM, diabetes and corneal nerve fibres. We will set inclusion and exclusion criteria prior to the search, and two reviewers will screen titles and abstracts independently. One reviewer will full text read eligible articles and chart data from the studies. A descriptive summary of the methods used in imaging, image processing and quantitative analysis of peripheral corneal nerve fibres by IVCM will be written. ETHICS AND DISSEMINATION: Ethical approval is not required since this is a scoping review based on previously published articles. The findings will be published in a scientific peer-reviewed journal.

Effects of immersive virtual nature on nature connectedness: A systematic review protocol.

Objective: Nature Connectedness, an individual's cognitive, affective, and behavioral connection with the natural world, has been linked to various health and well-being outcomes. As Nature Connectedness can be elicited and strengthened through direct contact with nature, in the past decade studies have investigated whether similar effects can be achieved through technologies that simulate highly immersive and realistic experiences of nature, such as Immersive Virtual Nature. This protocol describes the methodology for a systematic review that will summarize the existing evidence on the effects of Immersive Virtual Nature on Nature Connectedness in non-clinical populations. Methods: The review will be conducted following the guidelines of Preferred Reporting Items for Systematic Reviews and MetaAnalyses. Terms such as "immersive virtual environment," "natural setting*," and "contact with nature" were searched in Scopus, WebOfScience, GoogleScholar, Medline, and GreenFILE (22-28 November 2021). Papers in English, describing experimental studies, with or without control/comparison, and testing the effects of Immersive Virtual Nature interventions on Nature Connectedness outcomes in non-clinical populations were included. The risk of bias will be assessed using Cochrane's Risk of Bias 2 for randomized studies, and the Risk Of Bias In Non-randomized Studies - of Interventions. The data synthesis will be performed through meta-analysis, assuming that the Cochrane Consumers and Communication Group guidelines are met. Conclusion: The findings will be relevant for understanding the potential and challenges of Immersive Virtual Nature as a tool to promote health and well-being in the general population, providing information on the consistency and limitations of the existing literature and recommendations for future research.

Effects of Physicians' Information Giving on Patient Outcomes: a Systematic Review.

BACKGROUND: Providing diagnostic and treatment information to patients is a core clinical skill, but evidence for the effectiveness of different information-giving strategies is inconsistent. This systematic review aimed to investigate the reported effects of empirically tested communication strategies for providing information on patient-related outcomes: information recall and (health-related) behaviors. METHODS: The databases MEDLINE, Embase, PsycINFO (Ovid), Cochrane Central Register of Controlled Trials, and relevant bibliographies were systematically searched from the inception to April 24, 2020, without restrictions, for articles testing information-giving strategies for physicians (PROSPERO ID: CRD42019115791). Pairs of independent reviewers identified randomized controlled studies with a low risk of selection bias as from the Cochrane risk of bias 2 tool. Main outcomes were grouped into patient information recall and behavioral outcomes (e.g., alcohol consumption, weight loss, participation in screening). Due to high heterogeneity in the data on effects of interventions, these outcomes were descriptively reported, together with studies', interventions', and information-giving strategies' characteristics. PRISMA guidelines were followed. RESULTS: Seventeen of 9423 articles were included. Eight studies, reporting 10 interventions, assessed patient information recall: mostly conducted in experimental settings and testing a single information-giving strategy. Four of the ten interventions reported significant increase in recall. Nine studies assessed behavioral outcomes, mostly in real-life clinical settings and testing multiple information-giving strategies simultaneously. The heterogeneity in this group of studies was high. Eight of the nine interventions reported a significant positive effect on objectively and subjectively measured patients' behavioral outcomes. DISCUSSION: Using specific framing strategies for achieving specific communication goals when providing information to patients appears to have positive effects on information recall and patient health-related behaviors. The heterogeneity observed in this group of studies testifies the need for a more consistent methodological and conceptual agenda when testing medical information-giving strategies. TRIAL REGISTRATION: PROSPERO registration number: CRD42019115791.

Meibomian gland dysfunction is highly prevalent among first-time visitors at a Norwegian dry eye specialist clinic.

To investigate the prevalence of meibomian gland dysfunction (MGD) in patients presenting with subjective dry eye-related symptoms at their first-time consultation in a Norwegian specialized ocular surface clinic. Additionally, to explore the accuracy of the ocular surface disease index score (OSDI) as an extensively applied tool to assess the severity of dry eye symptoms and MGD diagnosis. Patients with subjective dry eye-related complaints (n = 900) attending the clinic for the first time, from 2012 to 2016, were included in the study. At the baseline, patients completed the OSDI questionnaire. Subsequently, objective clinical tests, including fluorescein break-up time (FBUT), Schirmer-I test, ocular surface staining (OSS), and meibomian gland function assessment using gland expressibility and meibum quality were performed. The association between MGD and its severity in relation to symptom severity defined by OSDI-score was examined. MGD was found in 93.8% of the study group. MGD prevalence was not significantly different between groups based on age (p = 0.302) or sex (p = 0.079). There was a significant association between severity of MGD and dry eye-related symptoms (p = 0.014). OSS was significantly higher in patients with severe symptoms (p = 0.031). Sensitivity and specificity of positive symptom-score (OSDI ≥ 13) for disclosing MGD were 85.5% and 30.4%, respectively. MGD was highly prevalent, not associated with age and sex. OSDI ≥ 13 had high sensitivity and high positive predictive value (PPV), but low specificity and negative predictive value (NPV) for disclosing MGD. This underscores the importance of meibomian gland assessment in patients with dry eye-related symptoms.

Older persons' expressed worries during nursing care at home: Do health complexity and nature of nursing care in the visit matter?

OBJECTIVE: Older persons receiving home care express more cues and concerns compared to other clinical contexts. Increased health condition complexity requires a corresponding increase in nursing competence. The aim of this study was to explore how complexity of older persons' health and nature of the visit influenced their expressed worries. METHODS: In this cross-sectional explorative study, we analysed older persons' expressed worries (n = 508) identified by the Verona Coding Definitions of Emotional Sequences (VR-CoDES) in 129 audio-recorded home care visits with older persons (≥65 years), collected in 3 city districts and 1 rural area in Norway. RESULTS: Expressed worries of 45 older persons were included in the analysis: 18 had low health complexity, 5 moderate and 22 high health complexity. The nature of the visit affected the number of expressed worries, health complexity did not. Most of the worries were expressed during basic nursing care visits and/or medication administration. CONCLUSION: Findings suggest that home visit type may influence the older persons' expressed worries. The complexity of the older persons' health condition seems to have little impact on the expressed worries. PRACTICE IMPLICATIONS: Knowledge about communication in different complexity of visits is important when planning care for older persons.

Tested communication strategies for providing information to patients in medical consultations: A scoping review and quality assessment of the literature.

OBJECTIVES: To systematize the scientific knowledge of empirically tested strategies for verbally providing medical information in patient-physician consultations. METHODS: A scoping review searching for terms related to physician, information, oral communication, and controlled study. Four pairs of reviewers screened articles. For each selected study, we assessed the quality and summarized aspects on participants, study, intervention, and outcomes. Information provision strategies were inductively classified by types and main categories. RESULTS: After screening 9422 articles, 39 were included. The methodological quality was moderate. We identified four differently used categories of strategies for providing information: cognitive aid (n = 13), persuasive (n = 8), relationship- (n = 3), and objectivity-oriented strategies (n = 4); plus, one "mixed" category (n = 11). Strategies were rarely theoretically derived. CONCLUSIONS: Current research of tested strategies for verbally providing medical information is marked by great heterogeneity in methods and outcomes, and lack of theory-driven approaches. The list of strategies could be used to analyse real life communication. PRACTICE IMPLICATIONS: Findings may aid the harmonization of future efforts to develop empirically-based information provision strategies to be used in clinical and teaching settings.

Emotional communication in home care: A comparison between Norway and Sweden.

OBJECTIVE: Given the free movement of workers across countries, knowledge regarding communication differences between countries is imperative. In this study, we explored and compared the supportive responses of nursing staff to older persons' emotions in home care in Norway and Sweden. METHODS: The study had an observational, cross-sectional, comparative design, which included 383 audio-recorded home-care visits. Communication was coded using Verona Coding Definitions of Emotional Sequences. Worries and responses were categorised with regard to reference, communicative function and level of person-centredness. Standard statistical tests were used to analyse the data. RESULTS: The Swedish nursing staff provided space for further disclosure of worry more frequently than the Norwegian nursing staff (75.0 % versus 60.2 %, χ2 = 20.758, p < 0.01). In all, 65 % of the responses were supportive. Multiple logistic regression analyses showed that highly person-centred responses were independently associated with worries phrasing an emotion, OR (95 % CI) 3.282 (1.524-7.067). CONCLUSION: The level of person-centredness was associated with the way in which older persons expressed their distress. The Swedish nursing staff provided opportunities for further disclosure of worries more frequently than the Norwegian nursing staff. PRACTICE IMPLICATIONS: Findings of intercultural differences should be incorporated into the training of nursing staff.

Nursing staff's evaluation of facilitators and barriers during implementation of wireless nurse call systems in residential care facilities. A cross-sectional study.

BACKGROUND: Traditional nurse call systems used in residential care facilities rely on patients to summon assistance for routine or emergency needs. Wireless nurse call systems (WNCS) offer new affordances for persons unable to actively or consciously engage with the system, allowing detection of hazardous situations, prevention and timely treatment, as well as enhanced nurse workflows. This study aimed to explore facilitators and barriers of implementation of WNCSs in residential care facilities. METHODS: The study had a cross-sectional descriptive design. We collected data from care providers (n = 98) based on the Measurement Instrument for Determinants of Innovation (MIDI) framework in five Norwegian residential care facilities during the first year of WNCS implementation. The self-reporting MIDI questionnaire was adapted to the contexts. Descriptive statistics were used to explore participant characteristics and MIDI item and determinant scores. MIDI items to which ≥20% of participants disagreed/totally disagreed were regarded as barriers and items to which ≥80% of participants agreed/totally agreed were regarded as facilitators for implementation. RESULTS: More facilitators (n = 22) than barriers (n = 6) were identified. The greatest facilitators, reported by 98% of the care providers, were the expected outcomes: the importance and probability of achieving prompt call responses and increased safety, and the normative belief of unit managers. During the implementation process, 87% became familiar with the systems, and 86 and 90%, respectively regarded themselves and their colleagues as competent users of the WNCS. The most salient barriers, reported by 37%, were their lack of prior knowledge and that they found the WNCS difficult to learn. No features of the technology were identified as barriers. CONCLUSIONS: Overall, the care providers gave a positive evaluation of the WNCS implementation. The barriers to implementation were addressed by training and practicing technological skills, facilitated by the influence and support by the manager and the colleagues within the residential care unit. WNCSs offer a range of advanced applications and services, and further research is needed as more WNCS functionalities are implemented into residential care services.

Identifying decisions in optometry: A validation study of the decision identification and classification taxonomy for use in medicine (DICTUM) in optometric consultations.

OBJECTIVE: The aim of this study was to assess the validity and reliability of the Decision Identification and Classification Taxonomy for Use in Medicine (DICTUM) applied to optometry, to compare decisions in medical and optometric consultations, and to describe decisions in optometry. METHODS: The study had a cross-sectional design. Data was collected from January to August 2016. Forty video-recorded patient-optometrist consultations were analysed. Clinical decisions were categorised according to DICTUM by two independent coders. RESULTS: The framework was applied without modification. The inter-rater reliability was moderate, Cohen's kappa 0.57. The mean duration of the consultations was 41 (±9) minutes. In all, 891 clinical decisions were identified, mean 22 (±13) per consultation. Types of decisions were significantly different between optometric and medical consultations (chi-square, p < 0.001). More frequently, optometrists conveyed interpreted test results (27.6% vs 16.7%) and gave advice (23.6% vs 8%), while doctors defined the problem (30.4% vs 24.6%) and decided on treatment (17.8% vs 13.4%). CONCLUSION: DICTUM is applicable to optometry encounters and may provide valuable insight to different health care settings. PRACTICE IMPLICATIONS: Descriptive studiesofdecisions in patient-provider consultations is a first step for normative and prescriptive exploration of decision-making processes in health care.

Nursing staff's responses to thematic content of patients' expressed worries: observing communication in home care visits.

BACKGROUND: The aim of the study was to explore the thematic content of older persons' expressed worries in home care visits, and how nursing staff respond to different thematic contents. METHODS: The study had a descriptive, observational design, including 195 audio-recorded Norwegian home care visits with 33 nursing staff and 48 older persons. In all, 638 patient cues/concerns (worries) and subsequent nursing staff's responses were identified using Verona Coding Definitions of Emotional Sequences. A novel thematic coding scheme was used to label the thematic content of the cues/concerns. The nursing staff's responses were grouped based on communicative function as emotion-focused, content-focused or ignoring/blocking the cue/concern. Group difference was analysed using Pearson's chi-squared test, Fisher's exact test, and adjusted residuals. RESULTS: The theme of worries was associated with elicitation of the cue/concern, either elicited by the nursing staff or spontaneously expressed by the patient (Chi-square, p< 0.001). "Ageing and bodily impairment" was the most common theme (66%) and was equally elicited by patients and nursing staff. Worries about "Relationships with others" (9%), "Health care-related issues" (15%) and "Life narratives and value issues" (9%) were mainly elicited by nursing staff. The nursing staff response was associated with the theme of worries (p˂0.001). For the sub-themes of "Ageing and bodily impairment", Coping with existential challenges received more frequently emotion-focused responses (adjusted residuals: 3.2) and Expression of pain felt in the moment were more frequently ignored/blocked (adjusted residuals: 4.0, Fisher's exact test, p< 0.001). For the sub-themes of "Relationships with others", Being a burden more frequently received a content-focused response (adjusted residuals: 2.8), while Losing social ties more frequently received an emotion-focused response (adjusted residuals: 3.1, Fisher's exact test, p = 0.009). CONCLUSION: "Ageing and bodily impairment" was the most common theme and more frequently elicited by the older persons than other themes. Emotionally focused nursing staff responses were most common when addressing existential challenges and fear of losing social ties. Whereas nursing staff showed a tendency to ignore patients' spontaneous expressions of pain. Further research should explore the influence of nursing staff's responses on quality of care and patient satisfaction.

The use of supportive communication when responding to older people's emotional distress in home care - An observational study.

BACKGROUND: Responding to older people's distress by acknowledging or encouraging further discussion of emotions is central to supportive, person-centred communication, and may enhance home care outcomes and thereby promote healthy aging. This observational study describes nursing staff's responses to older people's emotional distress, and identify factors that encourage further emotional disclosure. METHODS: Audio-recorded home care visits in Norway (n = 196), including 48 older people and 33 nursing staff, were analysed with the Verona Coding Definitions of Emotional Sequences, identifying expressions of emotional distress and subsequent provider responses. The inter-rater reliability (two coders), Cohen's kappa, was >0.6. Sum categories of emotional distress were constructed: a) verbal and non-verbal expressions referring to emotion, b) references to unpleasant states/circumstances, and c) contextual hints of emotion. A binary variable was constructed based on the VR response codes, differentiating between emotion-focused responses and responses that distanced emotion. Fisher's exact test was used to analyse group differences and determined variables included in a multivariate logistic regression analysis to identify factors promoting emotion-focused responses. RESULTS: Older people's expressions of emotional distress (n = 635) comprised 63 explicit concerns and 572 cues. Forty-eight per cent of nursing staff responses (n = 638) were emotion-focused. Emotion-focused responses were observed more frequently when nursing staff elicited the expression of emotional distress from the patients (54%) than when patients expressed their emotional distress on their own initiative (39%). Expressions with reference to emotion most often received emotion-focused responses (60%), whereas references to unpleasant states or circumstances and contextual hints of emotion most often received non-emotion-focused responses (59%). In a multivariate logistic model, nursing staff's elicitation of the emotional expression (vs patients initiating it) and patients' expression with a reference to an emotion (vs reference to unpleasant states or contextual hints) were both explanatory variables for emotion-focused responses. CONCLUSIONS: Emotion-focused responses were promoted when nursing staff elicited the emotional expression, and when the patient expression referred to an emotion. Staff responded most often by acknowledging the distress and using moderately person-centred supportive communication. More research is needed to establish generalizability of the findings and whether older people deem such responses supportive.

Mindfulness predicts student nurses' communication self-efficacy: A cross-national comparative study.

OBJECTIVES: The aim of this study was to compare student nurses' communication self-efficacy, empathy, and mindfulness across two countries, and to analyse the relationship between these qualities. METHODS: The study had a cross-sectional design. Data was collected from final year student nurses in Norway and Sweden. Communication self-efficacy, empathy, and mindfulness were reported by questionnaires; Clear-cut communication with patients, Jefferson Scale of Empathy, and Langer 14 items mindfulness scale. RESULTS: The study included 156 student nurses, 94 (60%) were Swedish. The mean communication self-efficacy score was 119 (95% CI 116-122), empathy score 115 (95% CI 113-117) and mindfulness score 79 (95% CI 78-81). A Mann-Whitney test showed that Swedish students scored significantly higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. When adjusted for age, gender, and country in a multiple linear regression, mindfulness was the only independent predictor of communication self-efficacy. CONCLUSION: The Swedish student nurses in this study scored higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. Student nurses scoring high on mindfulness rated their communication self-efficacy higher. PRACTICE IMPLICATIONS: A mindful learning approach may improve communication self-efficacy and possibly the effect of communication skills training.

Older persons' worries expressed during home care visits: Exploring the content of cues and concerns identified by the Verona coding definitions of emotional sequences.

OBJECTIVE: Little is known about how older persons in home care express their concerns. Emotional cues and concerns can be identified by the Verona coding definitions of emotional sequences (VR-CoDES), but the method gives no insight into what causes the distress and the emotions involved. The aims of this study are to explore (1) older persons' worries and (2) the content of these expressions. METHODS: An observational exploratory two-step approach was used to investigate audiotaped recordings from 38 Norwegian home care visits with older persons and nurse assistants. First, 206 cues and concerns were identified using VR-CoDES. Second, the content and context of these expressions were analysed inductively. RESULTS: Four main categories emerged: worries about relationships with others, worries about health care-related issues, worries about aging and bodily impairment, and life narratives and value issues, with several subcategories showing the causes of worry and emotions involved. CONCLUSION: The two-step approach provides an in-depth knowledge of older persons' worries, causes of worries, and their related emotions. PRACTICE IMPLICATIONS: The subcategories described in a language close to the experience can be useful in practice development and communication training for students and health care providers.

A cross-sectional study on person-centred communication in the care of older people: the COMHOME study protocol.

INTRODUCTION: This paper presents an international cross-sectional study on person-centred communication with older people receiving healthcare (COMHOME). Person-centred care relies on effective communication, but few studies have explored this with a specific focus on older people. The main aim of the COMHOME study is to generate knowledge on person-centred communication with older people (>65 years) in home healthcare services, radiographic and optometric practice. METHODS AND ANALYSIS: This study will explore the communication between care providers and older persons in home care services. Home healthcare visits will be audiorecorded (n=500) in Norway, the Netherlands and Sweden. Analyses will be performed with the Verona Coding Definitions for Emotional Sequences (VR-CoDES), the Roter Interaction Analysis System (RIAS) and qualitative methods. The content of the communication, communicative challenging situations as well as empathy, power distance, decision-making, preservation of dignity and respect will be explored. In Norway, an additional 100 encounters, 50 in optometric practice (video recorded) and 50 in radiographic practice (audiorecorded), will be analysed. Furthermore, healthcare providers' self-reported communication skills, empathy, mindfulness and emotional intelligence in relation to observed person-centred communication skills will be assessed using well-established standardised instruments. ETHICS AND DISSEMINATION: Depending on national legislation, approval of either the central ethical committees (eg, nation or university), the national data protection officials or the local ethical committees (eg, units of home healthcare) was obtained. Study findings will be disseminated widely through peer-reviewed publications and conference presentations. The research findings will add knowledge to improve services provided to this vulnerable group of patients. Additionally, the findings will underpin a training programme for healthcare students and care providers focusing on communication with older people.

Sensitivity and specificity of Norwegian optometrists' evaluation of diabetic retinopathy in single-field retinal images - a cross-sectional experimental study.

BACKGROUND: In the working age group, diabetic retinopathy is a leading cause of visual impairment. Regular eye examinations and early treatment of retinopathy can prevent visual loss, so screening for diabetic retinopathy is cost-effective. Dilated retinal digital photography with the additional use of ophthalmoscopy is the most effective and robust method of diabetic retinopathy screening. The aim of this study was to estimate the sensitivity and specificity of diabetic retinopathy screening when performed by Norwegian optometrists. METHODS: This study employed a cross-sectional experimental design. Seventy-four optometrists working in private optometric practice were asked to screen 14 single-field retinal images for possible diabetic retinopathy. The screening was undertaken using a web-based visual identification and management of ophthalmological conditions (VIMOC) examination. The images used in the VIMOC examination were selected from a population survey and had been previously examined by two independent ophthalmologists. In order to establish a "gold standard", images were only chosen for use in the VIMOC examination if they had elicited diagnostic agreement between the two independent ophthalmologists. To reduce the possibility of falsely high specificity occurring by chance, half the presented images were of retinas that were not affected by diabetic retinopathy. Sensitivity and specificity for diabetic retinopathy was calculated with 95% confidence intervals (CIs). RESULTS: The mean (95%CI) sensitivity for identifying eyes with any diabetic retinopathy was 67% (62% to 72%). The mean (95%CI) specificity for identifying eyes without diabetic retinopathy was 84% (80% to 89%). The mean (95%CI) sensitivity for identifying eyes with mild non-proliferative diabetic retinopathy or moderate non-proliferative diabetes was 54% (47% to 61%) and 100%, respectively. Only four optometrists (5%) met the required standard of at least 80% sensitivity and 95% specificity that has been previously set for diabetic retinopathy screening programmes. CONCLUSIONS: The evaluation of retinal images for diabetic retinopathy by Norwegian optometrists does not meet the required screening standard of at least 80% sensitivity and 95% specificity. The introduction of measures to improve this situation could have implications for both formal optometric training and continuing optometric professional education.

Retinopathy and visual impairment in diabetes, impaired glucose tolerance and normal glucose tolerance: the Nord-Trøndelag Health Study (the HUNT study).

PURPOSE: The aim of the study was to describe the prevalence of visual impairment and retinopathy and to investigate risk factors for retinopathy in persons with diabetes, screen-detected diabetes, impaired glucose tolerance and normal glucose tolerance in a subpopulation of the HUNT study. METHODS: We used a sample (n = 163) from a population-based screening survey of hyperglycaemia, undertaken in 2004-2005 in Verdal, Norway. Baseline information was accessible through the second Nord-Trøndelag Health Study (HUNT2), 1995-97. Data collection was made in 2005 and included patient history, refraction, visual acuity, cataract assessment and single-field, nonmydriatic retinal photography. Retinal photographs were graded independently by two graders blinded to patient information. Data were analysed with standard statistical methods, and p < 0.05 was considered significant. RESULTS: In all, 126 (77%) persons participated, 55% were women. The mean (SD) age was 59 (± 14) years. Four (3%) had correctable visual impairment, and none were visually impaired. Retinal photographs were gradable for both eyes in 109 (87%) participants. The prevalence of retinopathy was 11% in persons with known diabetes, 4% in persons with screen-detected diabetes, 3% in persons with impaired glucose tolerance and 10% in persons with normal glucose tolerance. Retinopathy was not associated with known history of diabetes or current glycaemic status. Nonfasting plasma glucose (in 1995-97) was an independent risk factor for retinopathy (in 2005), OR (95% CI) 1.5 (1.01, 2.13), p = 0.046. CONCLUSION: The prevalence of diabetic retinopathy in persons with diabetes in this study was low. Appropriate optical correction and regular eye examination can prevent unnecessary visual impairment in both persons with and without diabetes.

Care of vision and ocular health in diabetic members of a national diabetes organization: a cross-sectional study.

BACKGROUND: Regular examination and early treatment of diabetic retinopathy can prevent visual loss. The aim of the study was to describe the care of vision and ocular health in people with diabetes in Norway. METHODS: A cross-sectional questionnaire survey of a random sample (n = 1,887) of the Norwegian Diabetic Associations' (NDA) members was carried out in 2005. Questions were asked about care of vision and ocular health, history of ocular disease and visual symptoms, general medical history and diabetes management. The study was approved by the Regional Committee for Medical Research Ethics. RESULTS: The response rate was 74%. Forty-four questionnaires with incomplete data regarding gender, age or type of diabetes were excluded, leaving 1352 cases (52% females) for analysis. 451 (33%) had type 1 and 901 (67%) had type 2 diabetes, the mean duration of diabetes was respectively, 22 (sd +/- 14) and 10 (sd +/- 9) years. In all 1,052 (78%) had their eyes examined according to guidelines and 1,169 (87%) confirmed to have received information about regular eye examinations. One in two recalled to have received such information from their general practitioner. To have received information about the importance of eye examinations (PR 3.1, 95% CI 2.4 to 4.0), and diabetes duration > 10 years (PR 1.2, 95% CI 1.2 to 1.3), were independently associated with reporting regular eye examinations. A history of diabetic retinopathy was reported by 178 (13%) responders, of which 101 (57%) reported a history of laser treatment. Responders who had regular eye examinations reported more frequently a history of diabetic retinopathy (19% vs. 5%, p < 0.001). The frequency of retinopathy was significantly higher in responders with reported HbA1c values above treatment target (23% vs. 13%, p = 0.001). However, in responders who were not regularly examined, there was no difference in reported frequency of retinopathy with regard to HbA1c level. CONCLUSION: Eight out of ten diabetic members of the NDA had their eyes examined according to current guidelines and the majority was well informed about the risk of vision loss due to diabetes. The results indicate that the reported history of diabetic retinopathy likely underestimates the prevalence of retinopathy.

Suspected retinopathies in Norwegian optometric practice with emphasis on patients with diabetes: a cross-sectional study.

BACKGROUND: The scope of optometry differs worldwide. In Norway the vast majority of optometrists perform ophthalmoscopy as part of their routine examinations. The aim of this study was to describe the frequency of suspected retinopathies in patients seen for routine optometric examination and to determine how optometrists deal with these patients. METHODS: 212 optometrists participated in a questionnaire survey and a practice registration during November 2004 - May 2005. In the practice registration, details for 20 consecutive patient encounters were recorded. Data were analysed by chi-square tests and multiple logistic regression. RESULTS: All optometrist stated that ocular history taking was an integrated part of their routine examination, while general health and diabetes history were routinely addressed by 59% and 42% of the optometrists, respectively. During the practice registration 4,052 patient encounters were recorded. Ophthalmoscopy was performed in 88% of the patients, of which 2% were dilated fundus examinations. Retinopathy was suspected in 106 patients, of whom 31 did not report a previous history of ocular or systemic disease. Old age (75+), hypertension and diabetes strongly predicted retinopathy with odds ratio (95% CI) of 6.4 (4.2 to 9.9), 3.8 (2.4 to 6.0) and 2.5 (1.4 to 4.7), respectively. Diabetic retinopathy was seen in 10% of diabetic patients and suspected in 0.2% of patients with no established history of diabetes. Retinopathy was not confirmed in 9 out 18 patients with a history of diabetic retinopathy; seven of these had undergone laser treatment. Out of the 106 patients with findings of retinopathy, 28 were referred to an ophthalmologist or a general practitioner (GP), written reports were sent to a GP in 16 cases, ten patients were urged to contact their GP for further follow up, while 52 were considered in need of routine optometric follow up only. CONCLUSION: Optometric practice provides a low threshold setting for detecting cases of ocular disease and retinal manifestations of systemic disease in the population. At present diagnosis of retinopathy in Norwegian optometric practice is unreliable. There are potentials for improving the optometrists' routine examination, their patient management patterns and collaboration routines with medical doctors.