Visual function assessment in simulated real-life situations in HIV-infected subjects.

Visual function abnormalities are common in people living with HIV disease (PLWH) without retinitis, even after improvement in immune status. Abnormalities such as reduced contrast sensitivity, altered color vision, peripheral visual field loss, and electrophysiological changes are related to a combination of retinal dysfunctions, involving inner and outer retinal structures. The standard protocol for testing vision performance in clinical practice is the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. However, this method poorly correlates with activities of daily living that require patients to assess visual stimuli in multiple light/contrast conditions, and with limited time. We utilized a novel interactive computer program (Central Vision Analyzer) to analyze vision performance in PLWH under a variety of light/contrast conditions that simulate stressful and real-world environments. The program tests vision in a time-dependent way that we believe better correlates with daily living activities than the non-timed ETDRS chart. We also aimed to correlate visual scores with retinal neuro-fiber layer thickness on optical coherence tomography. Here we show that visual acuity is more affected in PLWH in comparison to HIV-seronegative controls in varying contrast and luminance, especially if the nadir CD4+ T-cell count was lower than 100 cells/mm3. Visual impairment reflects the loss of retinal nerve fiber layer thickness especially of the temporal-inferior sector. In PLWH the ETDRS chart test led to better visual acuity compared to the Central Vision Analyzer equivalent test, likely because patients had indefinite time to guess the letters. This study confirms and strengthens the finding that visual function is affected in PLWH even in absence of retinitis, since we found that the HIV serostatus is the best predictor of visual loss. The Central Vision Analyzer may be useful in the diagnosis of subclinical HIV-associated visual loss in multiple light/contrast conditions, and may offer better understanding of this entity called "neuroretinal disorder".

Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: results of the Well Elderly 2 Randomised Controlled Trial.

BACKGROUND: Older people are at risk for health decline and loss of independence. Lifestyle interventions offer potential for reducing such negative outcomes. The aim of this study was to determine the effectiveness and cost-effectiveness of a preventive lifestyle-based occupational therapy intervention, administered in a variety of community-based sites, in improving mental and physical well-being and cognitive functioning in ethnically diverse older people. METHODS: A randomised controlled trial was conducted comparing an occupational therapy intervention and a no-treatment control condition over a 6-month experimental phase. Participants included 460 men and women aged 60-95 years (mean age 74.9 ± 7.7 years; 53% <$12000 annual income) recruited from 21 sites in the greater Los Angeles metropolitan area. RESULTS: Intervention participants, relative to untreated controls, showed more favourable change scores on indices of bodily pain, vitality, social functioning, mental health, composite mental functioning, life satisfaction and depressive symptomatology (ps<0.05). The intervention group had a significantly greater increment in quality-adjusted life years (p<0.02), which was achieved cost-effectively (US $41218/UK £24868 per unit). No intervention effect was found for cognitive functioning outcome measures. CONCLUSIONS: A lifestyle-oriented occupational therapy intervention has beneficial effects for ethnically diverse older people recruited from a wide array of community settings. Because the intervention is cost-effective and is applicable on a wide-scale basis, it has the potential to help reduce health decline and promote well-being in older people. Trial Registration clinicaltrials.gov identifier: NCT0078634.

Longitudinal changes in visual acuity and health-related quality of life: the Los Angeles Latino Eye study.

PURPOSE: To examine the association between longitudinal changes in visual acuity (VA) and health-related quality of life (HRQOL) in a population-based sample of adult Latinos. DESIGN: A population-based cohort study of eye disease in Latinos. PARTICIPANTS: We included 3169 adult Latino participants who live in the city of La Puente, California. METHODS: Data for these analyses were collected for the Los Angeles Latino Eye Study (LALES). Distance VA was measured during a detailed ophthalmologic examination using the standard Early Treatment Diabetic Retinopathy Study protocol at baseline and a 4-year follow-up examination. We assessed HRQOL by the National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and the Medical Outcomes Study 12-Item Short-Form Health Survey version 1 (SF-12). MAIN OUTCOME MEASURES: Mean differences in HRQOL composite and subscale scores between baseline and follow-up were calculated for 3169 participants with complete clinical examination and HRQOL data at both time points. Mean differences and effect sizes (ES) for NEI-VFQ and SF-12 scores were calculated for 3 categories of VA change over the 4-year follow-up period (VA improved ≥ 2 lines, no change in VA or -2 < VA < 2, VA loss ≥ 2 lines). RESULTS: For participants with a 2-line loss in VA, we noted an approximate 5-point loss in the NEI-VFQ-25 composite score, with the greatest score changes found for the driving difficulties, vision-related mental health, and vision-related dependency subscales (-12.7, -11.5, and -11.3, respectively). For participants with a 2-line improvement in VA, we also noted an approximate 5-point gain in the NEI-VFQ-25 composite score. The greatest change (ES = 0.80) was observed for the driving difficulties subscale. No measurable differences in HRQOL were observed for individuals without change in VA from baseline to follow-up. CONCLUSIONS: Clinically important, longitudinal changes in VA (≥ 2-line changes) were associated with significant changes in self-reported visual function and well-being. Both the size and direction of VA change influenced change in HRQOL scores.

Self-reported use of eye care among Latinos: the Los Angeles Latino Eye Study.

PURPOSE: To identify the prevalence and determinants of self-reported eye care use in Latinos. DESIGN: Population-based ocular epidemiologic study in Latinos aged 40+ years living in La Puente, California. PARTICIPANTS: A total of 5455 participants. METHODS: Univariate, multivariable, and stepwise logistic regression analyses were conducted to identify predisposing, enabling, and need variables associated with self-reported eye care use. MAIN OUTCOME MEASURES: Prevalence of self-reported use: eye care visit, having had a dilated examination in the past 12 months, ever having had a dilated examination, and odds ratios for factors associated with self-reported use. RESULTS: Overall, 36% of participants reported an eye care visit and 19% reported having a dilated examination in the past year. Fifty-seven percent reported ever having had a dilated eye examination. Greater eye care use was associated with older age, female gender, bilingual language proficiency (English and Spanish), more education, having health insurance, having a usual place for care, having a regular provider of care, a greater number of comorbidities, visual impairment, and lower vision-specific quality of life scores. CONCLUSIONS: Multiple modifiable factors are associated with greater use and access to eye care for Latinos. Modification of these factors should be a priority because visual impairment has significant impacts on well-being and mortality.

Prevalence of visually significant cataract and factors associated with unmet need for cataract surgery: Los Angeles Latino Eye Study.

PURPOSE: To estimate the prevalence of visually significant cataract in a US Latino population and to report predisposing, enabling, need, and health behavior characteristics associated with the unmet need for cataract surgery (UNCS). DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 6142 Latinos 40 years and older from 6 census tracts in Los Angeles County, California. METHODS: Participants completed an in-home interview and a comprehensive eye examination that included assessment of lens opacification, using the slit lamp-based Lens Opacities Classification System II (LOCS II), and best-corrected visual acuity. Visually significant cataract was defined by any LOCS II grading >or=2, best-corrected visual acuity <20/40, cataract as the primary cause of vision impairment, and self-reported vision of fair or worse. Because cataract surgery is not needed in all persons, participants with a visually significant cataract or prior cataract surgery in at least 1 eye composed the at-risk cohort needing cataract surgery. Unmet need for cataract surgery was defined as any person in the at-risk cohort who had at least 1 eye with a visually significant cataract. Univariate and stepwise logistic regression analyses were used to identify predisposing, enabling, need, and health behavior characteristics associated with UNCS. MAIN OUTCOME MEASURES: Prevalence of visually significant cataract and odds ratios (ORs) for factors associated with UNCS. RESULTS: Of 6142 participants who completed the interview and clinical examination, 118 (1.92%) had visually significant cataract in at least 1 eye. Of the 344 participants who have needed cataract surgery, 118 (34.3%) had UNCS. Independent factors associated with UNCS included health behavior: having last eye examination >or=5 years ago compared with <1 year ago (OR, 3.76; 95% confidence interval [CI], 1.71-8.25), and enabling factors: being uninsured (OR, 2.79; CI, 1.30-5.19), income less than $20,000 (OR, 2.60; CI, 1.40-5.56), and self-reported barriers to eye care (OR, 2.41; CI, 1.14-5.13). CONCLUSIONS: Latinos in our study had a substantial UNCS. Because Latinos with specific health behavior and enabling characteristics were more likely to have UNCS, interventions aimed at modifying these characteristics may be beneficial in reducing the unmet need and thus reducing the burden of visual impairment related to cataract in the United States.

The prevalence and risk indicators of uncorrected refractive error and unmet refractive need in Latinos: the Los AngelesLatino Eye Study.

PURPOSE: To determine the age- and sex-specific prevalence and risk indicators of uncorrected refractive error and unmet refractive need among a population-based sample of Latino adults. METHODS: Self-identified Latinos 40 years of age and older (n = 6129) from six census tracts in La Puente, California, underwent a complete ophthalmic examination, and a home-administered questionnaire provided self-reported data on potential risk indicators. Uncorrected refractive error was defined as a >or=2-line improvement with refraction in the better seeing eye. Unmet refractive need was defined as having <20/40 visual acuity in the better seeing eye and achieving >or=20/40 after refraction (definition 1) or having <20/40 visual acuity in the better seeing eye and achieving a >or=2-line improvement with refraction (definition 2). Sex- and age-specific prevalence and significant risk indicators for uncorrected refractive error and unmet refractive need were calculated. RESULTS: The overall prevalence of uncorrected refractive error was 15.1% (n = 926). The overall prevalence of unmet refractive need was 8.9% (n = 213, definition 1) and 9.6% (n = 218, definition 2). The prevalence of uncorrected refractive error and either definition of unmet refractive need increased with age (P < 0.0001). No sex-related difference was present. Older age, <12 years of education, and lack of health insurance were significant independent risk indicators for uncorrected refractive error and unmet refractive need. CONCLUSIONS: The data suggest that the prevalence of uncorrected refractive error and unmet refractive need is high in Latinos of primarily Mexican ancestry. Better education and access to care in older Latinos are likely to decrease the burden of uncorrected refractive error in Latinos.

Detecting cognitive impairment in primary care: performance assessment of three screening instruments.

Early detection of Alzheimer's disease and related disorders (ADRD) is important, especially in primary care settings. We compared performances of two common screening tests, the Mini-Mental State Exam (MMSE) and Clock Drawing Test (CDT), with that of the MCI Screen ({MCIS}) in 254 patients over 65. None had previous diagnosis of ADRD, and 81% were asymptomatic by Functional Assessment Staging Test ({FAST}) (FAST=1). 215 patients completed all screening tests - 141 had >or= 1 abnormal result, 121/141 completed standardized diagnostic assessment, and the remaining 74/215 (34%) screened entirely normally and weren't further evaluated. Potential bias due to unevaluated cases was statistically adjusted. Among diagnosed cases: AD=43%, cerebrovascular disease=36%, other causes=21%. Bias-adjusted MCI prevalence for FAST stages 1 and 1-3 were 13.9-20.3% and 23.0-28.3%. Bias-adjusted results for the CDT, MMSE and MCIS were: clinical diagnosis validity (kappa statistic)={-0.02 (p=0.61), 0.06 (p=0.23), 0.92 (p< 0.0001)}; sensitivity={59%, 71%, 94%}; specificity={39%, 36%, 97%}; overall accuracy={54%, 62%, 96%}; positive predictive value={16%, 17%, 86%}; and negative predictive value={83%, 87%, 96%}. The MMSE and CDT were not valid for early detection, while the MCIS had high validity and accuracy in the primary care cohort.

Assessment of retinal function in patients with HIV without infectious retinitis by multifocal electroretinogram and automated perimetry.

PURPOSE: To determine if multifocal electroretinogram (mfERG) testing shows abnormalities that correspond to perimetric defects in HIV positive patients without infectious retinitis. METHODS: We studied three groups of patients: HIV negative controls, HIV high CD4 nadir patients (lowest CD4 T cell count is over 100) and low CD4 nadir patients (below 100 for over 6 months). Twenty-six HIV positive eyes and 16 HIV negative control eyes were studied by mfERG. A subset of 10 eyes also underwent computerized perimetry for comparison. We analyzed mfERG by hexagons as well as by quadrants and rings. RESULTS: Of 103 hexagon locations there was no significant difference in the amplitudes P1 and N1 (nV/degree) between the three studied groups (p>0.05), similarly, the latencies were not different (p>0.05). All eyes with significant visual field defects at the 0.01 and 0.005 level (Humphrey pattern deviation; 24-2) were compared to mfERG amplitudes and latencies at those locations-there were no corresponding defects in mfERG data (p>0.2). CONCLUSION: In the era of HAART there are still demonstrable visual field defects and other evidence of damage to the retinal nerve fiber layer in HIV patients. Our mfERG studies show that the damage appears to affect the inner retina, the outer retina is spared. Further studies of inner retinal structure and function are indicated to elucidate this process.

Noncompliance with vision care guidelines in Latinos with type 2 diabetes mellitus: the Los Angeles Latino Eye Study.

OBJECTIVE: To determine the prevalence of and personal factors associated with noncompliance with American Diabetes Association (ADA) guidelines for vision care in a population-based sample of adult Latinos with type 2 diabetes mellitus (T2DM). DESIGN: Population-based cross-sectional study. PARTICIPANTS: Eight hundred twenty-one Los Angeles Latino Eye Study (LALES) participants with a history of T2DM and a history of treatment for T2DM. METHODS: Detailed interviews, physical examinations, and dilated eye examinations were performed on all participants. Interviews assessed sociodemographic factors, history of diabetes and eye disease, and utilization of health and eye care services. All participants with a self-reported history and treatment of diabetes were asked about health and vision care utilization and diabetes self-care. MAIN OUTCOME MEASURE: Compliance with ADA guidelines for vision care. Noncompliance was defined as having had no dilated eye examination in the previous 12 months. Logistic regression analyses were used to identify personal factors associated with noncompliance. RESULTS: Of 821 individuals who self-reported having T2DM and being on treatment for T2DM, 535 (65%) had not complied with ADA vision guidelines for persons with T2DM. When compared with those with T2DM who complied with ADA guidelines, noncompliers were more likely to be less educated (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.2), to lack health insurance (OR, 2.5; 95% CI, 1.7-3.7), to have had no routine physical examination in the 12 months before the LALES examination (OR, 1.8; 95% CI, 1.3-2.5), and to have a glycosylated hemoglobin level > or = 9.0% (OR, 1.7; 95% CI, 1.1-2.6). CONCLUSIONS: Because timely and appropriate vision care can delay the onset of ocular morbidity, visual impairment, and blindness associated with diabetic retinopathy, our data suggest the need to evaluate intervention programs aimed at a targeted group of Latinos with T2DM--those who have less than a high school education, lack health insurance, have had no routine physical examination in the previous year, and have poorly controlled T2DM.

Improving preventive health services training in chiropractic colleges: a pilot impact evaluation of the introduction of a model public health curriculum.

OBJECTIVE: To investigate the impact of the dissemination of the model public curriculum at one US chiropractic college on chiropractic interns during their outpatient clinical internship. METHODS: A retrospective pilot study was performed to evaluate the frequency of 9 patient clinical preventive health recommendations made by interns during their clinical training. The frequency of recommendations by interns completing their public health coursework after dissemination of the model curriculum was compared with those completing their coursework during the period immediately proceeding dissemination. A standardized data abstraction tool was developed to collect data from clinic charts that established a patient's need for any one of 9 preventive health services. RESULTS: Of the 408 charts examined (204 from each group), there were only 4 documented instances (1%) of recommendations for any of the 9 preventive health service categories. Two recommendations occurred in the precurriculum change period. CONCLUSION: The results of this pilot study indicate that there has been no observable impact on intern behaviors toward educating patients in preventive health services since the dissemination of the model public health curriculum at one of the chiropractic colleges in the United States. The impact of this reform in public health education may have been limited by its minimal focus on clinical preventive services and by a focus on didactic rather than a clinically relevant learning exposure.

Psychometric performance of the NEI VFQ-25 in visually normal Latinos: the Los Angeles Latino Eye Study.

PURPOSE: To characterize the psychometric performance of the National Eye Institute 25-item Visual Function Questionnaire (NEI VFQ-25) in visually normal Latinos (Mexican Americans). METHODS: The Los Angeles Latino Eye Study (LALES) is a population-based study to assess the prevalence of eye disease and self-reported visual functioning in Latinos aged 40 or more years. Self-reported visual functioning was assessed by using English and Spanish versions of the NEI VFQ-25. Psychometric properties of the NEI VFQ-25, including internal consistency of the subscales and the individual items, were assessed through the Multi-trait Analysis Program-Revised (MAP-R) analysis. Adjusted mean and median subscale scores were compared between English and Spanish speakers to identify any systematic differences. RESULTS: Of the 1917 participants from two census tracts, 1171 participants with no visual impairment were included in this analysis. The mean age of the participants was 52.3 years, 57% of the participants were female, and 67.5% of the participants were Spanish speaking. Median scores for Spanish-speaking participants were significantly lower than those of the English-speaking participants on four subscales: Ocular Pain, General Vision, Vision-Specific Mental Health, and General Health (P < 0.05). Internal consistency for three of eight measurable subscales for the study group was poor (Cronbach alpha < 0.6). CONCLUSIONS: This study reveals psychometric inconsistencies in the NEI VFQ-25 when administered to visually normal Latinos. The difference in mean subscale scores between Spanish and English speakers must be integrated into the development of population norms of visual function. Further detailed psychometric evaluation is needed to determine the validity of this instrument in Latino populations.

Cost-effectiveness of preventive occupational therapy for independent-living older adults.

OBJECTIVES: To evaluate the cost-effectiveness of a 9-month preventive occupational therapy (OT) program in the Well-Elderly Study: a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to preventive OT. DESIGN: A randomized trial. SETTING: Two government-subsidized apartment complexes. PARTICIPANTS: One hundred sixty-three culturally diverse volunteers aged 60 and older. INTERVENTION: An OT group, a social activity group (active control), and a nontreatment group (passive control). MEASUREMENTS: Use of healthcare services was determined by telephone interview during and after the treatment phase. A conversion algorithm was applied to the RAND 36-item Short Form Health Survey to derive a preference-based health-related quality of life index, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio for preventive OT relative to the combined control group. RESULTS: Costs for the 9-month OT program averaged $548 per subject. Postintervention healthcare costs were lower for the OT group ($967) than for the active control group ($1,726), the passive control group ($3,334), or a combination of the control groups ($2,593). The quality of life index showed a 4.5% QALY differential (OT vs combined control), P <.001. The cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747-$25,430). For the passive and active control groups, the corresponding costs per QALY were $13,784 and $7,820, respectively. CONCLUSION: In this study, preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures.