Inclusion of diabetic retinopathy screening strategies in national-level diabetes care planning in low- and middle-income countries: a scoping review.

BACKGROUND: Diabetes is a major public health concern, with approximately 80% of the burden falling on low- and middle-income countries (LMICs). Diabetic retinopathy (DR) is one of the most common microvascular complications of diabetes, and early detection through diabetic eye screening programmes is essential to prevent visual impairment and blindness. Careful planning at a national level is crucial for effective implementation of such programmes. METHODS: A scoping review was conducted, and the protocol was published previously to explain the methods in detail. Data were collected from databases and searches, including grey literature. Furthermore, consultations were conducted with key informants from LMICs. RESULTS: Lower-middle-income countries (29/50, 58%) and upper-middle-income countries (27/59, 45.8%) are making more progress than low-income countries (4/29, 13.8%) in terms of DR policy planning. However, no identified data for published policies have actually implemented national DR policies. Compared to low-income and lower-middle-income countries, upper-middle-income countries are making the most progress in implementing national diabetic eye screening programmes; however, their progress is still slow, with only 5/59 (8.5%) having such programmes. CONCLUSION: There are significant gaps in the literature, with no data reported for 78/138 (56.5%) LMICs. Further research is clearly needed to support and document DR policy development in LMICs.

"The problem is people don't know how to talk to you:" How Medicaid recipients understand and use health plan report cards and instruction sheets.

This study sought to understand low income, ethnically diverse individuals' needs, comprehension, and opinions of comparative quality information as presented in state Medicaid health plan report cards (HPRCs). Twenty-two focus groups were conducted with urban and rural Medicaid recipients in three ethnic groups. Results showed the wording of some domains was misunderstood and an overabundance of domains that are irrelevant to the individual attenuated attention. Combinations of visual and verbal information and well-organized designs aided attention and comprehension. Stating where the data came from was important. Some key differences between ethnicity and geographic areas were noted.

Defining 'quality' from the patient's perspective: findings from focus groups with Medicaid beneficiaries and implications for public reporting.

BACKGROUND: With an increased emphasis on patient-centred outcomes and research, investigators seek to understand aspects of health care that are most important to patients. Such information is essential for developing report cards that present health-care quality information for consumers, which many states are adopting as a strategy to promote consumer choice. OBJECTIVE: This study examined the processes that women in Medicaid follow for selecting health plans and explored their definitions of 'good' and 'poor' quality health care. DESIGN: We conducted focus groups with Medicaid beneficiaries in four Texas communities, using quota sampling to ensure representation of different racial/ethnic, eligibility and geographic groups. RESULTS: We conducted 22 focus groups with 102 participants between October 2012 and January 2013. In a free-list exercise, 'doctors' represented the most important aspect of health care to participants, followed by cost, attention, coverage and respect. Discussions of health-care quality revealed an even mix of structural factors (e.g. timeliness) and interpersonal factors (e.g. communication), although few differences were observed by beneficiary characteristics. Participants linked themes in their overall framing of 'quality' - revealing processes of care that affect health outcomes (e.g. discontinuity of care resulting from poor communication with providers) and which were often mediated by advocate providers who assisted patients experiencing barriers to services. DISCUSSION AND CONCLUSIONS: Findings support other studies that highlight the importance of the patient-provider relationship. Patient-centred definitions of health-care quality can complement predominant provider-centred conceptual frameworks and better inform initiatives for public reporting of quality measures in these populations.

Promoting Optimal Native Outcomes (PONO) by Understanding Women's Stress Experiences.

A growing body of evidence links stress with mental illness and chronic disease. Existing scales of women's stress fail to capture the daily stressors of low-income, rural women. We explored the psychosocial stressors of local women residing in a rural Hawaii community with a large Native Hawaiian and Other Pacific Islander population. We recruited women, aged 18-35 years, at a community health center. We convened four focus groups to elicit information about women's stress. We identified key themes from the focus group data to generate questions that target concerns raised by participants. These were corroborated by additional focus groups. Thirty-six women participated in the study. Seven stressor themes emerged: intimate relationships-limited partner assistance, gender stereotype; family and home life-feeling like an outsider, lack of respect; childrearing-quality and affordable childcare, conflicting discipline styles; time for self-never-ending duties, being too tired to relax; neighborhood environment-safety concerns, not feeling part of the community; workplace-workload and transportation obstacles; and finances-making ends meet and arguments about money. Women in this study articulated a broad range of daily stressors. Sociocultural factors leading to feeling like an outsider within their own family, intercultural marriage conflicts, and perceptions of community discrimination are not included in other published scales. Our focus group investigations thus provided critical knowledge for developing a community-relevant scale. This is a prerequisite for developing and testing innovative intervention strategies designed to reduce stress in this population. We believe that reducing stress is necessary to mitigate the negative effects of stressors on physical and mental health among women in this rural community.

Psychometric Testing of the Brief Coping Orientation to Problems Experienced Inventory Among Diverse Women From a Rural Community in Hawai'i.

The Brief COPE (Coping Orientation to Problems Experienced) Inventory is a standardized and widely used scale that enables researchers to measure coping responses of persons in relation to stressors. The psychometric properties of this scale, however, have not been assessed for communities in Hawai'i. This study investigated the psychometric properties of the Brief COPE for diverse women from a rural community on the island of O'ahu in Hawai'i. This study was conducted in a federally qualified health center (FQHC) with 161 women who were of a childbearing age between the ages of 18 to 38 years. Contrary to previous research, the factor structure of the final model suggested six factors: Behavioral Disengagement, Denial, Venting, and Self-Blame; Action Coping, Positive Reframing, Acceptance, and Planning; Humor; Substance Use; Social Support; and Religion. The final model demonstrated good model fit with an RMSEA of .07 and CFI of .95. The reduced factor structure may be a more robust measure of coping strategies, which may allow for better resources and interventions that adequately address the way women of childbearing ages from rural communities respond to stressful situations. Exploring coping mechanisms of diverse women will better our understanding of the way people respond to stress and develop strengths and mechanisms that mediate stressors including those that are linked to social and cultural determinants of health. Findings from this study may also inform future research and policy that aim to foster coping, and thus, resiliency of diverse women, particularly in rural settings.

Inclusion of diabetic retinopathy screening strategies in national-level diabetes care planning in low-income and middle-income settings: protocol for a scoping review.

INTRODUCTION: The diabetes mellitus (DM) epidemic is a major public health concern globally, with the highest-burden in low-income and middle-income countries (LMICs). Diabetic retinopathy (DR) is a microvascular complication of diabetes, and if left untreated can lead to visual impairment and blindness. Epidemiological studies suggest that the incidence of sight-threatening DR is decreasing in high-income countries due to improved treatments and management of DM; however, these trends are not replicated in LMICs. In this paper, we outline a scoping review protocol that aims to identify which LMICs have included DR in their national DM, non-communicable disease or prevention of blindness plans. The scoping review also aims to assess gaps when implementing national DR screening programmes in LMICs. METHODS AND ANALYSIS: This scoping review will follow the Arksey and O'Malley (2005) methodology and the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Review guidelines. A comprehensive search of peer-reviewed and grey literature will be conducted from October 1989 (St. Vincent Declaration) to February 2020. Studies will be identified from electronic databases; Medline, Embase and CENTRAL (Cochrane Library). To identify further relevant articles, a hand search will be conducted using the reference lists of included studies. Two reviewers will independently screen records for relevant data and disagreements about eligibility will be resolved through consensus or arbitration by a third reviewer. A quantitative analysis will be performed to highlight key findings and thematic analysis will be used to identify emerging themes and subthemes from included studies. The key themes will highlight countries progress in terms of national-level DR service planning and screening implementation. ETHICS AND DISSEMINATION: No ethical approval is required because the scoping review methodology aims to synthesise information from publicly available resources. The results will be disseminated through conference presentations and peer-reviewed publication.

Automatic affective processing impairments in patients with deficit syndrome schizophrenia.

Affective impairments were examined in patients with and without deficit syndrome schizophrenia. Two Emotional Stroop tasks designed to measure automatic processing of emotional information were administered to deficit (n=15) and non-deficit syndrome (n=26) schizophrenia patients classified according to the Schedule for the Deficit Syndrome, and matched non-patient control subjects (n=22). In comparison to non-deficit patients and controls, deficit syndrome patients demonstrated a lack of attention bias for positive information, and an elevated attentional lingering effect for negative information. These findings suggest that positive information fails to automatically capture attention of deficit syndrome patients, and that when negative information captures attention, it produces difficulty in disengagement Attentional abnormalities were significantly correlated with negative symptoms, such that more severe symptoms were associated with less attention bias for positive emotion and a greater lingering effect for negative information. Results are generally consistent with a mood-congruent processing abnormality and suggest that impaired automatic processing may be core to diminished emotional experience symptoms exhibited in deficit syndrome patients.

The sensitivity and specificity of flashbacks and nightmares to trauma.

Traumatic events are commonly re-experienced by trauma survivors through nightmares and flashbacks. The current study examined the relative sensitivity and specificity of these two forms of re-experiencing trauma in female survivors of rape. The frequency of nightmares and flashbacks were assessed using the Nightmare Frequency Questionnaire (NFQ) and the Flashback Frequency Questionnaire (FFQ), respectively. The FFQ was developed for this study and is designed to assess the frequency and occurrence of flashbacks in trauma survivors. The NFQ, FFQ and a variety of other measures were completed by 34 female survivors of rape and 28 female control participants. Results provided support for the construct and criterion validity of the FFQ, and demonstrated that flashbacks are more sensitive and specific indicators of the presence of trauma than are nightmares.

AT(2) receptors mediate tonic renal medullary vasoconstriction in renovascular hypertension.

1. Renal medullary blood flow is relatively insensitive to angiotensin II (Ang II)-induced vasoconstriction, due partly to AT(1)-mediated release of nitric oxide and/or prostaglandins. AT(2)-receptor activation appears to blunt AT(1)-mediated vasodilatation within the medullary circulation. This could affect long-term efficacy of antihypertensive pharmacotherapies targeting the renin/angiotensin system, particularly in Ang II-dependent forms of hypertension. 2. We tested the effects of AT(1)- and AT(2)-receptor blockade on basal cortical and medullary laser Doppler flux (CLDF and MLDF), and on responses to renal arterial infusion of Ang II, in rats with 2 kidney, 1 clip (2K1C) hypertension and sham-operated controls. Studies were carried out in thiobutabarbital (175 mg kg(-1), i.p.) anaesthetised rats, 4 weeks after clipping, or sham surgery (n=6 in each of eight groups). 3. Candesartan (10 microg kg(-1) h(-1), intravenous (i.v.)) reduced mean arterial pressure ( approximately 17%) and increased CLDF ( approximately 24%), similarly in both sham and 2K1C rats, but did not significantly affect MLDF. PD123319 (1 mg kg(-1) h(-1), i.v.) increased basal MLDF (19%) in 2K1C but not sham rats, without significantly affecting other variables. 4. In sham rats, renal arterial infusion of Ang II (1-100 ng kg(-1) min(-1)) dose dependently decreased CLDF (up to 44%), but did not significantly affect MLDF. These effects were markedly blunted in 2K1C rats. After PD123319, Ang II dose dependently increased MLDF (up to 38%) in sham but not 2K1C rats. Candesartan abolished all effects of Ang II, including those seen after PD123319. 5. Our data indicate that AT(1) receptors mediate medullary vasodilatation, which is opposed by AT(2)-receptor activation. In 2K1C hypertension, AT(2)-receptor activation tonically constricts the medullary circulation.

Cognitive components of deficit awareness in Alzheimer's disease.

Awareness of deficit was examined in 24 patients with Alzheimer's disease (AD) and their spouses (for a total of 48 participants) using performance prediction-postdiction and questionnaire discrepancy (QD) paradigms. Participants estimated their own memory performances as well the performances of spouses and of a fictional, memory-disordered patient observed on videotape. Patients overpredicted self-performances, but the extent of overestimation decreased for postdictions. Patients and caregivers accurately estimated caregiver performances but overestimated performances of the fictional patient. QD data revealed that patients underestimated their difficulties performing daily functioning tasks as compared with caregiver reports. Awareness of deficit is a complex ability, involving dissociable cognitive processes. AD patients may display intact immediate awareness of memory dysfunction but fail to incorporate incidents of memory failure into generalized self-belief systems.

Attention, learning, and memory performances and intellectual resources in Vietnam veterans: PTSD and no disorder comparisons.

Attention, learning, memory, and estimated intellectual potential were examined in 26 Vietnam veterans diagnosed with posttraumatic stress disorder (PTSD) and in 21 Vietnam veterans without mental disorders. Results revealed PTSD-associated cognitive deficits on tasks of sustained attention, working memory, initial learning, and estimated premorbid intelligence but not on measures of focus of attention, shift of attention, or memory savings. Cognitive task performances adjusted for estimated native intelligence remained negatively correlated with PTSD severity. An intellectual measure adjusted for cognitive task performances was negatively correlated with PTSD severity, even after the authors statistically controlled the level of combat exposure. Results suggested that although intellectual resources may constitute a vulnerability-protective factor for PTSD development, PTSD was associated with cognitive impairment independent of intellectual functioning.

Posttraumatic stress disorder and negative symptoms of schizophrenia.

Posttraumatic stress disorder (PTSD) is highly comorbid with schizophrenia and may be associated with higher levels or lower levels of negative symptoms. In the current study, we attempted to clarify the relationship between PTSD and negative symptoms by examining the proportion of patients meeting various negative symptom criteria in a sample of patients diagnosed with schizophrenia alone or schizophrenia and comorbid PTSD. Results indicated that the presence of PTSD in schizophrenia was associated with increased secondary negative symptoms, with the deficit syndrome (DS) and primary negative symptoms associated with lower rates of current and lifetime diagnoses of PTSD. Furthermore, the deficit/nondeficit classification provided greater differentiation of PTSD symptoms than did negative symptoms defined more broadly using the Scale for the Assessment of Negative Symptoms or primary vs secondary distinctions. These findings suggest that DS patients are at a uniquely low risk for PTSD.

Impaired facial affect labeling and discrimination in patients with deficit syndrome schizophrenia.

Social and affective disturbances have long been thought to be core to schizophrenia. Deficits in accurately identifying and discriminating facial displays of emotion may be central components of the functional and social abnormalities seen in schizophrenia; however, their relationship with negative symptoms is less clear. The current study examined facial affect labeling and discrimination performance in a sample of 15 patients meeting criteria for deficit syndrome schizophrenia, 26 schizophrenia patients who do not meet criteria for the deficit syndrome, and 22 healthy controls. Results indicated that deficit schizophrenia patients displayed significantly greater facial affect labeling and discrimination difficulties than non-deficit patients and controls, as well as poorer performance on a basic visuoperceptual face processing task, suggesting that problems with facial affect processing may be mediated by a more general impairment in visuoperceptual processing. However, within this more generalized pattern of impairment, deficit syndrome patients were uniquely characterized by processing positive faces less accurately than negative faces. These findings suggest that abnormalities in processing facial emotion are associated with the negative symptoms of schizophrenia, with a unique deficit in the processing of positive emotions that stand out in the broader context of generalized impairment.

Neurocognitive function in schizophrenia with comorbid posttraumatic stress disorder.

Individuals with schizophrenia are at a greater risk for experiencing trauma and developing posttraumatic stress disorder (PTSD) than the general population. Despite an increased incidence of neurocognitive dysfunction in both schizophrenia and PTSD, there are few studies that have examined the potential compounding effects of these diagnoses when they co-occur. The current study examined this issue by administering comprehensive diagnostic, symptom, and neurocognitive evaluations to four groups including normal controls (C), as well as individuals with PTSD (PTSD), schizophrenia (SZ), or both schizophrenia and PTSD (SZP). Results indicated that when compared to the SZ group, the SZP group exhibited higher rates of positive symptoms, general psychopathology, and PTSD symptoms, as well as lower rates of negative symptoms. Regarding neurocognitive test performance, both schizophrenia groups performed significantly worse than the C and PTSD groups across all neurocognitive domains. However, differences were not significant between the SZP and SZ groups, although a differential pattern of performance between the groups was indicated. Results of this study do not support the idea that the presence of comorbid PTSD in SZ results in a substantial increase in cognitive impairment.

Olfactory hedonic judgment in patients with deficit syndrome schizophrenia.

Olfactory perception was examined in deficit syndrome (DS) and nondeficit syndrome (ND) schizophrenia patients. Participants included 22 controls (CN) and 41 patients with schizophrenia who were divided into DS (n = 15) and ND (n = 26) subtypes using the Schedule for the Deficit Syndrome (SDS). Olfactory perception for pleasant and unpleasant odors was assessed using the Brief Smell Identification Test. Participants were instructed to identifying each smell as well as provide hedonic judgment ratings of each smell on a 7-point scale (1 = extremely pleasant, 4 = neutral, and 7 = extremely unpleasant). Results indicated that when compared with the ND patients, the DS patients rated pleasant smells as being significantly less pleasant, although no difference between the groups was present for unpleasant smells, and both ND and DS groups significantly differed from CN on rating and identifying pleasant and unpleasant items. Additionally, lower smell identification accuracy was negatively correlated with SDS symptom severity, and valence ratings for pleasant odors were positively correlated with SDS diminished emotional range. Findings suggest that the DS is characterized by a unique pattern of olfactory valence judgment that is characterized by abnormalities in processing positively valenced stimuli.

Sensitivity of the Halstead Category Test factor scores to brain damage.

Recent factor-analytic studies of the Halstead Category Test (HCT) indicate that its seven subtests form three factors including a Counting factor (subtests I and II), a Spatial Positional Reasoning factor (subtests III, IV, and VII), and a Proportional Reasoning factor (subtests V, VI, and VII). The sensitivity and specificity of these factors to heterogeneous forms of brain damage was examined in a large sample of patients and a normal comparison sample. A prorated Impairment Index, which excluded the HCT error score, was used to assign participants with brain damage into mild, moderate, and severe impairment groups. Also, groups with various forms of neuropathology were contrasted. Results indicated that both the Spatial Positional Reasoning and the Proportional Reasoning factors were sensitive to brain damage. However, in all of the brain-damage groups, a greater percentage of errors were made on the Spatial Positional factor, suggesting that of the two it was more difficult for those with brain damage. The sensitivity and specificity of the Spatial Positional factor score for detection of brain damage was comparable to that of the total error score, which has been previously demonstrated to be an excellent indicator of brain damage. Findings provide further support for the validity of the HCT factors, and are consistent with the view that factor scores may be useful in interpreting the HCT.

AT2 receptors contribute to acute blood pressure-lowering and vasodilator effects of AT1 receptor antagonism in conscious normotensive but not hypertensive rats.

The aims of this study were to determine the contribution of the AT2 receptor to the antihypertensive and regional vasodilatory effects of AT1 receptor blockade in adult spontaneously hypertensive rats (SHR), 2-kidney, 1-clip hypertensive (2K1C) rats, and sham-operated normotensive rats. Several studies have provided evidence to support the notion that the AT2 receptor may have opposing effects to those mediated by the AT1 receptor. We therefore tested the hypothesis that the depressor and vasodilator effects of acute AT1 receptor blockade are dependent on AT2 receptor activation. Heart rate, mean arterial pressure, and regional hemodynamics were measured over a 4-day protocol in rats that received the following treatments in randomized order: saline vehicle, the AT1 receptor antagonist candesartan (0.1 mg/kg iv bolus), the AT2 receptor antagonist PD-123319 (50 microg.kg(-1).min(-1)), or both antagonists. Intravenous candesartan reduced mean arterial pressure in all groups of rats, and this was accompanied by renal and mesenteric vasodilation. Neither saline nor PD-123319 significantly affected these variables. Concomitant PD-123319 administration partially reversed the depressor and mesenteric vasodilator effects of candesartan in sham-operated normotensive rats but not in SHR or 2K1C rats. These data indicate that the AT2 receptor contributes to the blood pressure-lowering and mesenteric vasodilator effects of AT1 receptor blockade in the acute setting in conscious normotensive but not hypertensive rats.

Disparate roles of AT2 receptors in the renal cortical and medullary circulations of anesthetized rabbits.

The contributions of angiotensin II type 1 (AT1) and type 2 (AT2) receptors to the control of regional kidney blood flow were determined in pentobarbital-anesthetized rabbits. Intravenous candesartan (AT1 antagonist; 10 microg/kg plus 10 microg x kg(-1) x h(-1)) reduced mean arterial pressure (12%) and increased total renal blood flow (29%) and cortical laser-Doppler flux (18%) but not medullary laser-Doppler flux. Neither intravenous PD123319 (AT2 antagonist; 1 mg/kg plus 1 mg x kg(-1) x h(-1)) nor saline vehicle significantly affected these variables, and the responses to candesartan plus PD123319 were indistinguishable from those of candesartan alone. In vehicle-treated rabbits, renal-arterial infusions of angiotensin II (1 to 25 ng x kg(-1) x min(-1)) and angiotensin III (5 to 125 ng x kg(-1) x min(-1)) dose-dependently reduced renal blood flow (up to 51%) and cortical laser-Doppler flux (up to 50%) but did not significantly affect medullary laser-Doppler flux or arterial pressure. Angiotensin(1-7) (20 to 500 ng x kg(-1) x min(-1)) had similar effects but of lesser magnitude. CGP42112A (20 to 500 ng x kg(-1) x min(-1)) did not significantly affect these variables. After PD123319 administration, angiotensin II and angiotensin III dose-dependently increased medullary laser-Doppler flux (up to 84%), and reductions in renal blood flow in response to angiotensin II were enhanced. Candesartan abolished renal hemodynamic responses to the angiotensin peptides, even when given in combination with PD123319. We conclude that AT2 receptor activation counteracts AT1-mediated vasoconstriction in the renal cortex but also counteracts AT1-mediated vasodilatation in vascular elements controlling medullary perfusion. These mechanisms might have an important effect on the control of medullary perfusion under conditions of activation of the renin-angiotensin system.