Ranibizumab 0.5 mg for Diabetic Macular Edema with Bimonthly Monitoring after a Phase of Initial Treatment: 18-Month, Multicenter, Phase IIIB RELIGHT Study.

PURPOSE: To evaluate ranibizumab 0.5 mg using bimonthly monitoring and individualized re-treatment after monthly follow-up for 6 months in patients with visual impairment due to diabetic macular edema (DME). DESIGN: A phase IIIb, 18-month, prospective, open-label, multicenter, single-arm study in the United Kingdom. PARTICIPANTS: Participants (N = 109) with visual impairment due to DME. METHODS: Participants received 3 initial monthly ranibizumab 0.5 mg injections (day 0 to month 2), followed by individualized best-corrected visual acuity (BCVA) and optical coherence tomography-guided re-treatment with monthly (months 3-5) and subsequent bimonthly follow-up (months 6-18). Laser was allowed after month 6. MAIN OUTCOME MEASURES: Mean change in BCVA from baseline to month 12 (primary end point), mean change in BCVA and central retinal thickness (CRT) from baseline to month 18, gain of ≥10 and ≥15 letters, treatment exposure, and incidence of adverse events over 18 months. RESULTS: Of 109 participants, 100 (91.7%) and 99 (90.8%) completed the 12 and 18 months of the study, respectively. The mean age was 63.7 years, the mean duration of DME was 40 months, and 77.1% of the participants had received prior laser treatment (study eye). At baseline, mean BCVA was 62.9 letters, 20% of patients had a baseline BCVA of >73 letters, and mean baseline CRT was 418.1 µm, with 32% of patients having a baseline CRT <300 µm. The mean change in BCVA from baseline to month 6 was +6.6 letters (95% confidence interval [CI], 4.9-8.3), and after institution of bimonthly treatment the mean change in BCVA at month 12 was +4.8 letters (95% CI, 2.9-6.7; P < 0.001) and +6.5 letters (95% CI, 4.2-8.8) at month 18. The proportion of participants gaining ≥10 and ≥15 letters was 24.8% and 13.8% at month 12 and 34.9% and 19.3% at month 18, respectively. Participants received a mean of 6.8 and 8.5 injections over 12 and 18 months, respectively. No new ocular or nonocular safety findings were observed during the study. CONCLUSIONS: The BCVA gain achieved in the initial 6-month treatment period was maintained with an additional 12 months of bimonthly ranibizumab PRN treatment.

Patients with early age-related macular degeneration exhibit signs of macro- and micro-vascular disease and abnormal blood glutathione levels.

BACKGROUND: This pilot study aimed to investigate systemic and retinal vascular function and their relationship to circulatory markers of cardiovascular risk in early age-related macular degeneration (AMD) patients without any already diagnosed systemic vascular pathologies. METHODS: Fourteen patients diagnosed with early AMD and 14 age- and gender-matched healthy controls underwent blood pressure, carotid intima-media thickness (C-IMT) and peripheral arterial stiffness measurements. Retinal vascular reactivity was assessed by means of dynamic retinal vessel analysis (DVA) using a modified protocol. Blood analyses were conducted for glutathione levels and plasma levels of total cholesterol (CHOL), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG). RESULTS: The AMD patients showed significantly greater C-IMT (p = 0.029) and augmentation index (AIx) (p = 0.042) than the age-matched controls. In addition, they demonstrated a shallower retinal arterial dilation slope (Slope AD) (p = 0.005) and a longer retinal venous reaction time (RT) to flickering light (p = 0.026). Blood analyses also revealed that AMD patients exhibited higher oxidized glutathione (GSSG) (p = 0.024), lower redox index (p = 0.043) and higher LDL-C (p = 0.033) levels than the controls. Venous RT parameter correlated positively with blood GSSG levels (r = 0.58, p = 0.038) in AMD subjects, but not in the controls (p > 0.05). CONCLUSIONS: Patients diagnosed with early AMD exhibit signs of systemic and retinal vascular alterations that correlated with known risk markers for future cardiovascular morbidity.

Trauma, early life stress, and mindfulness in adulthood.

This article is a review that was inspired by recent studies investigating the effects of childhood trauma or early life stress (ELS) and mindfulness in adulthood. One recent study found that some forms of abuse and neglect led to higher scores in several subscales of a self-report measure of mindfulness. The authors concluded that some forms of ELS can help cultivate certain aspects of mindfulness in adulthood. However, and in contrast to this recent finding, much of the extant literature investigating ELS and trauma are linked to emotional dysregulation, alexithymia, and a host of psychopathologies in adulthood which makes the results of this study surprising. Central to the mindfulness literature is cultivating an open, non-reactive, or non-judgment awareness of inner experiences which are important for emotional regulation. In this paper, I review some of the effects of trauma or ELS on critical neural circuits linked to mindfulness, interoception, attachment, and alexithymia which I hope may clarify some of the conflicting findings from this study and throughout the literature and provide additional context and a framework that may inform research investigating these two constructs going forward.

Relationship between research activity and general practice performance: cross sectional and longitudinal analyses.

BACKGROUND: Research activity usually improves outcomes by being translated into practice. However, there is developing evidence that research activity itself may improve the overall performance of health care organisations. However, evidence that these relationships represent a causal impact of research activity is less clear. Additionally, the bulk of the existing evidence relates to hospital settings, and it is not known if those relationships would also be found in general practice, where most patient contacts occur. AIM: We sought to (a) test whether there were significant relationships between research activity in general practice and organisational performance (b) test whether those relationships were plausibly causal. DESIGN AND SETTING: We analysed national data between 2008 and 2019 using cross sectional and longitudinal analyses, on general practices in England. METHODS: We used cross-sectional, panel and instrumental variable analyses to explore relationships between research activity (including measures from the NIHR Clinical Research Network and the Royal College of General Practitioners) and practice performance (including clinical quality of care, patient reported experience of care, prescribing quality and hospital admissions) Results: In cross-sectional analyses, research activity was positively associated with several measures of practice performance, including clinical quality of care, patient reported experience of care, and reduced hospital admissions. The associations were generally modest in magnitude. However, longitudinal analyses did not support a reliable causal relationship. CONCLUSION: Similar to findings from hospital settings, research activity in general practice is associated with practice performance. There is less evidence that research is causing those improvements, although this may reflect the limited level of research activity in most practices. We identified no negative impacts, suggesting that research activity is a potential marker of quality and something that high quality practices can deliver alongside their core responsibilities.

Age-related macular degeneration and modification of systemic complement factor H production through liver transplantation.

PURPOSE: To investigate whether modification of liver complement factor H (CFH) production, by alteration of liver CFH Y402H genotype through liver transplantation (LT), influences the development of age-related macular degeneration (AMD). DESIGN: Multicenter, cross-sectional study. PARTICIPANTS: We recruited 223 Western European patients ≥ 55 years old who had undergone LT ≥ 5 years previously. METHODS: We determined AMD status using a standard grading system. Recipient CFH Y402H genotype was obtained from DNA extracted from recipient blood samples. Donor CFH Y402H genotype was inferred from recipient plasma CFH Y402H protein allotype, measured using enzyme-linked immunosorbent assays. This approach was verified by genotyping donor tissue from a subgroup of patients. Systemic complement activity was ascertained by measuring levels of plasma complement proteins using an enzyme-linked immunosorbent assay, including substrates (C3, C4), activation products (C3a, C4a, and terminal complement complex), and regulators (total CFH, C1 inhibitor). MAIN OUTCOME MEASURES: We evaluated AMD status and recipient and donor CFH Y402H genotype. RESULTS: In LT patients, AMD was associated with recipient CFH Y402H genotype (P = 0.036; odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.4) but not with donor CFH Y402H genotype (P = 0.626), after controlling for age, sex, smoking status, and body mass index. Recipient plasma CFH Y402H protein allotype predicted donor CFH Y402H genotype with 100% accuracy (n = 49). Plasma complement protein or activation product levels were similar in LT patients with and without AMD. Compared with previously reported prevalence figures (Rotterdam Study), LT patients demonstrated a high prevalence of both AMD (64.6% vs 37.1%; OR, 3.09; P<0.001) and the CFH Y402H sequence variation (41.9% vs 36.2%; OR, 1.27; P = 0.014). CONCLUSIONS: Presence of AMD is not associated with modification of hepatic CFH production. In addition, AMD is not associated with systemic complement activity in LT patients. These findings suggest that local intraocular complement activity is of greater importance in AMD pathogenesis. The high AMD prevalence observed in LT patients may be associated with the increased frequency of the CFH Y402H sequence variation. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

The effects of a lutein-based supplement on objective and subjective measures of retinal and visual function in eyes with age-related maculopathy -- a randomised controlled trial.

Lutein and zeaxanthin are lipid-soluble antioxidants found within the macula region of the retina. Links have been suggested between increased levels of these carotenoids and reduced risk for age-related macular disease (ARMD). Therefore, the effect of lutein-based supplementation on retinal and visual function in people with early stages of ARMD (age-related maculopathy, ARM) was assessed using multifocal electroretinography (mfERG), contrast sensitivity and distance visual acuity. A total of fourteen participants were randomly allocated to either receive a lutein-based oral supplement (treated group) or no supplement (non-treated group). There were eight participants aged between 56 and 81 years (65·50 (SD 9·27) years) in the treated group and six participants aged between 61 and 83 years (69·67 (SD 7·52) years) in the non-treated group. Sample sizes provided 80% power at the 5% significance level. Participants attended for three visits (0, 20 and 40 weeks). At 60 weeks, the treated group attended a fourth visit following 20 weeks of supplement withdrawal. No changes were seen between the treated and non-treated groups during supplementation. Although not clinically significant, mfERG ring 3 N2 latency (P=0·041) and ring 4 P1 latency (P=0·016) increased, and a trend for reduction of mfERG amplitudes was observed in rings 1, 3 and 4 on supplement withdrawal. The statistically significant increase in mfERG latencies and the trend for reduced mfERG amplitudes on withdrawal are encouraging and may suggest a potentially beneficial effect of lutein-based supplementation in ARM-affected eyes.

Comparison of colour contrast sensitivity in eyes at high risk of neovascular age-related macular degeneration with and without subsequent choroidal neovascular membrane development.

BACKGROUND: Neovascular age-related macular degeneration (nAMD) is a leading cause of blind registrations in the elderly. Unfortunately, it is difficult to detect the early stage of the disease, when treatment is more likely to be successful. Subjects with very early disease are likely to have abnormal macular function, even in the pre-symptomatic stage. In this study, colour vision was evaluated to establish if subjects at high risk of developing nAMD can be identified, thus allowing earlier diagnosis and possible treatment. METHODS: Colour contrast sensitivity (CCS) was evaluated over time in the fellow unaffected eye of subjects with unilateral nAMD. Participants were divided into Group 1 (182 participants) or Group 2 (15 participants) according to whether nAMD did not or did develop in the study period respectively and the two groups were compared. RESULTS: CCS was increased (i.e. worse colour vision) compared with the age-matched reference range in a high proportion of fellow eyes in both Groups 1 and 2. Global mean CCS values did not show statistically significant differences between the two groups. However, there was a statistically significant difference between mean Group 1 CCS values and the last CCS value prior to nAMD diagnosis from Group 2 subjects. CONCLUSION: This study shows that in patients with unilateral nAMD, colour vision is frequently abnormal in the fellow unaffected eye. Abnormal CCS does not predict the development of nAMD within the 12 month period of the study and therefore it is not a viable screening tool for this pathology.

Pregnancy outcomes in a recurrent preterm birth prevention clinic.

OBJECTIVE: We sought to compare rates of recurrent spontaneous preterm birth (PTB) and neonatal morbidity between women enrolled in a recurrent PTB prevention clinic compared to those receiving usual care. STUDY DESIGN: This was a retrospective cohort study of women with a single, nonanomalous fetus and ≥1 spontaneous PTB <35 weeks. Women enrolled in a recurrent PTB prevention clinic were compared to those receiving usual care. The recurrent PTB prevention clinic was consultative and included 3 standardized visits. Usual-care patients were treated by their primary provider. The primary outcome was recurrent spontaneous PTB <37 weeks. RESULTS: Seventy recurrent PTB prevention clinic and 153 usual-care patients were included. Both groups had similar pregnancy histories. Recurrent PTB prevention clinic patients had increased utilization of resources, had lower rates of recurrent spontaneous PTB (48.6% vs 63.4%, P = .04), delivered later (mean 36.1 vs 34.9 weeks, P = .02), and had lower rates of composite major neonatal morbidity (5.7% vs 16.3%, P = .03). CONCLUSION: Women referred to a consultative recurrent PTB prevention clinic had reduced rates of recurrent spontaneous prematurity and major neonatal morbidity.

The electroretinogram: a useful tool for evaluating age-related macular disease?

With an ageing population, the number of age-related macular disease (ARMD) cases will inevitably rise. This gives greater impetus for the need to identify the disease earlier and assess treatments to slow disease progression. Differing electroretinogram (ERG) modalities have been reviewed in relation to the objective assessment of retinal function in ARMD and for monitoring the effectiveness of clinical interventions. Conflicting results have been found with regard to the efficacy of ERG findings in the investigation of ARMD in previous years. The newer multifocal ERG paradigm provides spatial topographical information about retinal function in ARMD. It has shown promising results in monitoring effectiveness of clinical interventions and studies are continuing in this area. Better knowledge of retinal function in ARMD may lead to enhanced treatments at each phase of the disease.

Skill mix and patient outcomes: A multi-country analysis of heart disease and breast cancer patients.

Policymakers are becoming aware that increasing the size of the healthcare workforce is no longer the most viable way to address the increasing demand for healthcare. Consequently, a focus of recent healthcare workforce reform has been extending existing roles and creating new roles for health professionals. However, little is known of the influence on outcomes from this variation in labour inputs within hospital production functions. Using a unique combination of primary and administrative data, this paper provides evidence of associations between the composition of care delivery teams and patient outcomes. The primary data enabled the construction of a task component-based measure of skill mix. This novel measure of skill mix has the advantage of capturing how workforce planning can restructure the relative input of nurses or physicians into task components while keeping the overall level of staff fixed. The analysis focuses on specific care pathways and individual hospitals, thus controlling for an under-investigated source of heterogeneity. Additionally, stratifying by country (England, Scotland, and Norway) enabled analysis of skill mix within different health systems. We provide evidence that variations in labour inputs within the breast cancer and heart disease care pathways are associated with both positive and adverse outcomes. The results illustrate the scope for substitution of task components within care pathways as a potential method of healthcare reform.

Working lives of GPs in Scotland and England: cross-sectional analysis of national surveys.

OBJECTIVES: The UK faces major problems in retaining general practitioners (GPs). Scotland introduced a new GP contract in April 2018, intended to better support GPs. This study compares the career intentions and working lives of GPs in Scotland with GPs in England, shortly after the new Scotland contract was introduced. DESIGN AND SETTING: Comparison of cross-sectional analysis of survey responses of GPs in England and Scotland in 2017 and 2018, respectively, using linear regression to adjust the differences for gender, age, ethnicity, urbanicity and deprivation. PARTICIPANTS: 2048 GPs in Scotland and 879 GPs in England. MAIN OUTCOME MEASURES: Four intentions to reduce work participation (5-point scales: 1='none', 5='high'): reducing working hours; leaving medical work entirely; leaving direct patient care; or continuing medical work but outside the UK. Four domains of working life: job satisfaction (7-point scale: 1='extremely dissatisfied', 7='extremely satisfied'); job stressors (5-point-scale: 1='no pressure', 5='high pressure); positive and negative job attributes (5-point scales: 1='strongly disagree', 5='strongly agree'). RESULTS: Compared with England, GPs in Scotland had lower intention to reduce work participation, including a lower likelihood of reducing work hours (2.78 vs 3.54; adjusted difference=-0.52; 95% CI -0.64 to -0.41), a lower likelihood of leaving medical work entirely (2.11 vs 2.76; adjusted difference=-0.32; 95% CI -0.42 to -0.22), a lower likelihood of leaving direct patient care (2.23 vs 2.93; adjusted difference=-0.37; 95% CI -0.47 to -0.27), and a lower likelihood of continuing medical work but outside of the UK (1.41 vs 1.61; adjusted difference=-0.2; 95% CI -0.28 to -0.12). GPs in Scotland reported higher job satisfaction, lower job stressors, similar positive job attributes and lower negative job attributes. CONCLUSION: Following the introduction of the new contract in Scotland, GPs in Scotland reported significantly better working lives and lower intention to reduce work participation than England.

Colour contrast sensitivity in eyes at high risk of neovascular age-related macular degeneration.

PURPOSE: To generate the first published reference database of colour contrast sensitivity in eyes at high risk of neovascular age-related macular degeneration and to explore this important feature in quality of vision. BACKGROUND: Quality of vision depends on many factors. Changes in chromatic contrast sensitivity remain largely unexplored in eyes at high risk of neovascular age-related macular degeneration; they may however not only be relevant for quality of life but also an early indicator of the onset of the disease, so it is important to have a means to evaluate any variation in colour contrast sensitivity, especially in view of the likely increase in neovascular age-related macular degeneration as the population ages. METHODS: This prospective longitudinal study evaluated colour contrast sensitivity along the protan and tritan colour axes in 145 eyes at high risk of neovascular age-related macular degeneration. RESULTS: Colour contrast sensitivity showed statistically significant correlations with age and visual acuity, but not gender nor laterality (i.e. whether the right or left eye was being tested). There was significant variability among individuals, especially for the tritan axis, with some subjects well within normal limits for age and others with very poor colour contrast sensitivity. CONCLUSION: This study has generated the first published colour contrast sensitivity reference database for eyes at high risk of neovascular age-related macular degeneration. It has also shown a high inter-individual variability of colour contrast sensitivity in eyes at high risk of neovascular age-related macular degeneration, but the significance of this is unclear. Further work is required to establish if eyes with high colour contrast sensitivity thresholds (i.e. poor colour vision) have a higher risk of developing neovascular age-related macular degeneration over time, and this is the subject of ongoing work.

The Usefulness of Serum Biomarkers in the Early Stages of Diabetic Retinopathy: Results of the EUROCONDOR Clinical Trial.

The main aim of this study was to evaluate the ability of serum biomarkers to predict the worsening of retinal neurodysfunction in subjects with type 2 diabetes. For this purpose, we measured selected molecules (N-epsilon-carboxy methyl lysine (CML), laminin P1 (Lam-P1), and asymmetric dimethylarginine (ADMA)) in the serum of 341 participants of the EUROCONDOR study at baseline, 24, and 48 weeks. Retinal neurodysfunction was assessed by measuring implicit time (IT) using multifocal electroretinography, and structural changes were examined by spectral domain-optical coherence tomography. The values of IT at baseline were directly correlated with baseline serum concentrations of CML (r = 0.135, p = 0.013). Furthermore, in the placebo group, increase in CML concentration throughout follow-up correlated with the IT (r = 0.20; p = 0.03). Baseline serum levels of CML also correlated with macular retinal thickness (RT) (r = 0.231; p < 0.001). Baseline Lam-P1 levels correlated with the increase of the RT at the end of follow-up in the placebo group (r = 0.22; p = 0.016). We provide evidence that CML may be a biomarker of both retinal neurodysfunction and RT, whereas Lam-P1 was associated with RT only. Therefore, circulating levels of these molecules could provide a complementary tool for monitoring the early changes of diabetic retinopathy (DR).

Mindfulness, Interoception, and the Body: A Contemporary Perspective.

Mindfulness is often used as an umbrella term to characterize a large number of practices, processes, and characteristics. Critics argue that this broad definition has led to misinformation, misunderstanding, and a general lack of methodologically rigorous research. Some of the confusion surrounding mindfulness is also believed to stem from an undifferentiated use of the term mindfulness and meditation. Mindfulness and all other forms of meditation have been shown to modulate the insula, which is the primary hub for interoception. Some have argued that interoception is foundational to mindfulness and may be the primary mechanism by which one benefits from the practice. However, much like the mindfulness literature, interoception remains broadly defined often without precision and with domain-specific meanings and implications. Research demonstrates that the insula and surrounding neural circuits are believed to be responsible for a number of other functions beyond interoception including attention, awareness, and all subjective experiences, much of which has been linked to the mindfulness literature. It has been assumed that mindfulness produces these neuroplasticity and functional effects. There is evidence that mindfulness and some of its benefits may be better described as increased interoception as a result of the neuroplasticity changes in the insula, and the development of the insula and surrounding neural circuits may cultivate dispositional mindfulness. The purposes of this article are to (1) highlight that it may be more accurate to link many of the identified benefits in the mindfulness literature to interoception and its neurological correlates and (2) propose attentional style as a means to clarify some of the confusion surrounding mindfulness, interoception, and meditation. Different meditations require different attentional styles. Attention can be analogous to a focal point with each focal point providing a unique perspective. Given that all meditative techniques modulate the insula, each meditation can provide a unique perspective from which to investigate complex interoceptive signals that may be unavailable from other meditative traditions. It may prove more useful to anchor scientific findings in the concrete body as a means to investigate those rather than a set of abstract, broadly defined meditative techniques.

Effects of Topically Administered Neuroprotective Drugs in Early Stages of Diabetic Retinopathy: Results of the EUROCONDOR Clinical Trial.

The primary objective of this study was to assess whether the topical administration of two neuroprotective drugs (brimonidine and somatostatin) could prevent or arrest retinal neurodysfunction in patients with type 2 diabetes. For this purpose, adults aged between 45 and 75 years with a diabetes duration ≥5 years and an Early Treatment of Diabetic Retinopathy Study (ETDRS) level of ≤35 were randomly assigned to one of three arms: placebo, somatostatin, or brimonidine. The primary outcome was the change in implicit time (IT) assessed by multifocal electroretinography between baseline and at the end of follow-up (96 weeks). There were 449 eligible patients allocated to brimonidine (n = 152), somatostatin (n = 145), or placebo (n = 152). When the primary end point was evaluated in the whole population, we did not find any neuroprotective effect of brimonidine or somatostatin. However, in the subset of patients (34.7%) with preexisting retinal neurodysfunction, IT worsened in the placebo group (P < 0.001) but remained unchanged in the brimonidine and somatostatin groups. In conclusion, the topical administration of the selected neuroprotective agents appears useful in preventing the worsening of preexisting retinal neurodysfunction. This finding points to screening retinal neurodysfunction as a critical issue to identify a subset of patients in whom neuroprotective treatment might be of benefit.

New professional roles and patient satisfaction: Evidence from a European survey along three clinical pathways.

This paper reports the results of an empirical analysis exploring the impact of new professions (eg a physician associate) and new professional roles on patient experiences of and satisfaction with care. A sub set of data from a patient survey conducted as part of the MUNROS programme of work was used. The overall survey aim was to describe and quantify the use of new professionals and new roles for established health care professionals other than medical doctors, in primary and secondary care sectors in three care pathways in nine European countries Ordered logit models were used to investigate the association between: (1) patient satisfaction with the last visit; (2) with their care provider; (3) with the information provided and a set of covariates explaining the involvement of new professional roles in three clinical pathways: type 2 diabetes, heart disease and breast cancer. For patients with breast cancer, high levels of satisfaction are associated with the involvement of new professions/professional roles in the provision of conditions specific education and monitoring. For patients with heart disease, the involvement of new professions/professional roles is likely to have a negative impact on satisfaction. For patients with Type 2 diabetes results are ambivalent. Patients belonging to countries experiencing innovative models of healthcare delivery and with high levels of involvement of new professions/professional roles are generally more satisfied. In conclusion, the introduction of new professions does not affect patient satisfaction negatively, therefore introducing new health professional roles is a pursuable strategy from a patient satisfaction perspective, at least for breast cancer and type 2 diabetes.

How do workplaces, working practices and colleagues affect UK doctors' career decisions? A qualitative study of junior doctors' career decision making in the UK.

OBJECTIVES: This study draws on an in-depth investigation of factors that influenced the career decisions of junior doctors. SETTING: Junior doctors in the UK can choose to enter specialty training (ST) programmes within 2 years of becoming doctors. Their specialty choices contribute to shaping the balance of the future medical workforce, with views on general practice (GP) careers of particular interest because of current recruitment difficulties. This paper examines how experiences of medical work and perceptions about specialty training shape junior doctors' career decisions. PARTICIPANTS: Twenty doctors in the second year of a Foundation Training Programme in England were recruited. Purposive sampling was used to achieve a diverse sample from respondents to an online survey. RESULTS: Narrative interviewing techniques encouraged doctors to reflect on how experiences during medical school and in medical workplaces had influenced their preferences and perceptions of different specialties. They also spoke about personal aspirations, work priorities and their wider future.Junior doctors' decisions were informed by knowledge about the requirements of ST programmes and direct observation of the pressures under which ST doctors worked. When they encountered negative attitudes towards a specialty they had intended to choose, some became defensive while others kept silent. Achievement of an acceptable work-life balance was a central objective that could override other preferences.Events linked with specific specialties influenced doctors' attitudes towards them. For example, findings confirmed that while early, positive experiences of GP work could increase its attractiveness, negative experiences in GP settings had the opposite effect. CONCLUSIONS: Junior doctors' preferences and perceptions about medical work are influenced by multiple intrinsic and extrinsic factors and experiences. This paper highlights the importance of understanding how perceptions are formed and preferences are developed, as a basis for generating learning and working environments that nurture students and motivate their professional careers.

General practitioners' views of clinically led commissioning: cross-sectional survey in England.

OBJECTIVES: Involving general practitioners (GPs) in the commissioning/purchasing of services has been an important element in English health policy for many years. The Health and Social Care Act 2012 handed responsibility for commissioning of the majority of care for local populations to GP-led Clinical Commissioning Groups (CCGs). In this paper, we explore GP attitudes to involvement in commissioning and future intentions for engagement. DESIGN AND SETTING: Survey of a random sample of GPs across England in 2015. METHOD: The Eighth National GP Worklife Survey was distributed to GPs in spring 2015. Responses were received from 2611 respondents (response rate = 46%). We compared responses across different GP characteristics and conducted two sample tests of proportions to identify statistically significant differences in responses across groups. We also used multivariate logistic regression to identify the characteristics associated with wanting a formal CCG role in the future. RESULTS: While GPs generally agree that they can add value to aspects of commissioning, only a minority feel that this is an important part of their role. Many current leaders intend to quit in the next 5 years, and there is limited appetite among those not currently in a formal role to take up such a role in the future. CCGs were set up as 'membership organisations' but only a minority of respondents reported feeling that they had 'ownership' of their local CCG and these were often GPs with formal CCG roles. However, respondents generally agree that the CCG has a legitimate role in influencing the work that they do. CONCLUSION: CCGs need to engage in active succession planning to find the next generation of GP leaders. GPs believe that CCGs have a legitimate role in influencing their work, suggesting that there may be scope for CCGs to involve GPs more fully in roles short of formal leadership.

Functional and Structural Findings of Neurodegeneration in Early Stages of Diabetic Retinopathy: Cross-sectional Analyses of Baseline Data of the EUROCONDOR Project.

This cross-sectional study evaluated the relationship between 1) functional and structural measurements of neurodegeneration in the initial stages of diabetic retinopathy (DR) and 2) the presence of neurodegeneration and early microvascular impairment. We analyzed baseline data of 449 patients with type 2 diabetes enrolled in the European Consortium for the Early Treatment of Diabetic Retinopathy (EUROCONDOR) study (NCT01726075). Functional studies by multifocal electroretinography (mfERG) evaluated neurodysfunction, and structural measurements using spectral domain optical coherence tomography (SD-OCT) evaluated neurodegeneration. The mfERG P1 amplitude was more sensitive than the P1 implicit time and was lower in patients with Early Treatment of Diabetic Retinopathy Study (ETDRS) level 20-35 than in patients with ETDRS level <20 (P = 0.005). In 58% of patients, mfERG abnormalities were present in the absence of visible retinopathy. Correspondence between SD-OCT thinning and mfERG abnormalities was shown in 67% of the eyes with ETDRS <20 and in 83% of the eyes with ETDRS level 20-35. Notably, 32% of patients with ETDRS 20-35 presented no abnormalities in mfERG or SD-OCT. We conclude that there is a link between mfERG and SD-OCT measurements that increases with the presence of microvascular impairment. However, a significant proportion of patients in our particular study population (ETDRS ≤35) had normal ganglion cell-inner plexiform layer thickness and normal mfERG findings. We raise the hypothesis that neurodegeneration may play a role in the pathogenesis of DR in many but not in all patients with type 2 diabetes.

How do older people with sight loss manage their general health? A qualitative study.

PURPOSE: Older people with sight loss experience a number of barriers to managing their health. The purpose of this qualitative study was to explore how older people with sight loss manage their general health and explore the techniques used and strategies employed for health management. METHODS: Semi-structured face-to-face interviews were conducted with 30 participants. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. RESULTS: Health management challenges experienced included: managing multiple health conditions; accessing information; engaging in health behaviours and maintaining wellbeing. Positive strategies included: joining support groups, clubs and societies; using low vision aids; seeking support from family and friends and accessing support through health and social care services. CONCLUSION: Healthcare professionals need to be more aware of the challenges faced by older people with sight loss. Improved promotion of group support and charity services which are best placed to share information, provide fora to learn about coping techniques and strategies, and give older people social support to prevent isolation is needed. Rehabilitation and support services and equipment can only be beneficial if patients know what is available and how to access them. Over-reliance on self-advocacy in current healthcare systems is not conducive to patient-centred care. Implications for Rehabilitation Sight loss in older people can impact on many factors including health management. This study identifies challenges to health management and highlights strategies used by older people with sight loss to manage their health. Access to support often relies on patients seeking information for themselves. However, self-advocacy is challenging due to information accessibility barriers. Informal groups and charities play an important role in educating patients about their condition and advising on available support to facilitate health management.