Levels of Prebeta-1 High-Density Lipoprotein Are a Strong Independent Positive Risk Factor for Coronary Heart Disease and Myocardial Infarction: A Meta-Analysis.

Background We previously showed that levels of prebeta-1 high-density lipoprotein (HDL), the principal acceptor of cholesterol effluxed from cells, including artery wall macrophages, are positively associated with coronary heart disease (CHD) and myocardial infarction (MI) risk. Methods and Results In a multiethnic follow-up cohort of 1249 individuals from University of California-San Francisco clinics, we determined the degree to which prebeta-1 HDL levels, both absolute and percentage of apolipoprotein AI, are associated with CHD and history of MI. Independent, strong, positive associations were found. Meta-analysis revealed for the absolute prebeta-1 HDL for the top tertile versus the lowest, unadjusted odds ratios of 1.90 (95% CI, 1.40-2.58) for CHD and 1.79 (95% CI, 1.35-2.36) for MI. For CHD, adjusting for established risk factors, the top versus bottom tertiles, quintiles, and deciles yielded sizable odds ratios of 2.37 (95% CI, 1.74-3.25, P<0.001), 3.20 (95% CI, 2.07-4.94, P<0.001), and 4.00 (95% CI, 2.11-7.58, P<0.001), respectively. Men and women were analyzed separately in a combined data set of 2507 individuals. The odds ratios for CHD and MI risk were similar. Higher levels of prebeta-1 HDL were associated with all 5 metabolic syndrome features. Addition of prebeta-1 HDL to these 5 features resulted in significant improvements in risk-prediction models. Conclusions Analysis of 2507 subjects showed conclusively that levels of prebeta-1 HDL are strongly associated with a history of CHD or MI, independently of traditional risk factors. Addition of prebeta-1 HDL can significantly improve clinical assessment of risk of CHD and MI.

Levels of prebeta-1 high-density lipoprotein are elevated in 3 phenotypes of dyslipidemia.

BACKGROUND: Prebeta-1 high-density lipoprotein (HDL) is a small subspecies of HDL that functions as the HDL quantum particle and is the principal acceptor of cholesterol effluxed from macrophages through the ATP-binding cassette transporter, ABCA1. High levels of prebeta-1 HDL are associated with increased risk of structural coronary artery disease and myocardial infarction. OBJECTIVE: We aimed to compare prebeta-1 HDL levels in normal subjects and in 3 phenotypes of dyslipidemia. METHODS: We studied 2435 individuals (1388 women; 1047 men). Of these, 2018 were not taking lipid-lowering medication when enrolled: 392 were normolipidemic controls; 713 had elevated levels of low-density lipoprotein cholesterol; 623 had combined hyperlipidemia; and 290 had hypertriglyceridemia. RESULTS: Relative to controls, prebeta-1 HDL levels were increased in all 3 dyslipidemic phenotypes, particularly the combined and hypertriglyceridemia groups. This increase possibly reflects increased acceptor capacity of apolipoprotein B-100 containing lipoproteins for entropically driven transfer of cholesteryl esters from HDL via cholesteryl ester transfer protein. Multiple regression analysis revealed that the main predictor variables significantly associated with prebeta-1 HDL levels were apolipoprotein A-I (apoA-1) (ß = 0.500), triglyceride (ß = 0.285), HDL-C (ß = -0.237), and age (ß = -0.169). There was an interaction between apoA-1 and sex (female vs male; ß = -0.110). Among postmenopausal women, estrogenized subjects had a similar level of prebeta-1 HDL compared to those not receiving estrogens. CONCLUSIONS: Prebeta-1 HDL levels are elevated in the 3 most common types of hyperlipidemia and are most strongly influenced by the levels of apoA-1, triglyceride, and HDL-C.

Development and validation of an instrument to assess job satisfaction in eye-care personnel.

PURPOSE: The aim was to develop and validate an instrument to measure job satisfaction in eye-care personnel and assess the job satisfaction of one-year trained vision technicians in India. METHODS: A pilot instrument for assessing job satisfaction was developed, based on a literature review and input from a public health expert panel. Rasch analysis was used to assess psychometric properties and to undertake an iterative item reduction. The instrument was then administered to vision technicians in vision centres of Andhra Pradesh in India. Associations between vision technicians' job satisfaction and factors such as age, gender and experience were analysed using t-test and one-way analysis of variance. RESULTS: Rasch analysis confirmed that the 15-item job satisfaction in eye-care personnel (JSEP) was a unidimensional instrument with good fit statistics, measurement precisions and absence of differential item functioning. Overall, vision technicians reported high rates of job satisfaction (0.46 logits). Age, gender and experience were not associated with high job satisfaction score. Item score analysis showed non-financial incentives, salary and workload were the most important determinants of job satisfaction. CONCLUSIONS: The 15-item JSEP instrument is a valid instrument for assessing job satisfaction among eye-care personnel. Overall, vision technicians in India demonstrated high rates of job satisfaction.

Clinical Competency of 1-Year Trained Vision Technicians in Andhra Pradesh, India.

PURPOSE: To assess clinical competency of 1-year trained vision technicians (VTs) in detecting and referring causes of visual impairment in India. METHODS: Eye examination results and management plans for 328 patients examined by 24 VTs in 24 vision centers of LV Prasad Eye Institute in Andhra Pradesh were compared with those of a standard optometrist who examined the same patients. Eye examinations included retinoscopy and subjective refraction, slit lamp examination, applanation tonometry and undilated direct ophthalmoscopy. Data were analyzed for level of concordance in retinoscopy, spectacle prescription, disease detection and referral. RESULTS: VTs demonstrated moderate to good levels of agreement in refraction, disease detection and referral. Sensitivity and specificity for ocular pathology identification were 77.4% (95% confidence interval, CI, 69.4-84.2%) and 86.6% (95% CI 81.1-91.1%), respectively. The highest sensitivity was demonstrated in detecting significant cataract (91.5%) and refractive error (83.0%). VT spectacle prescriptions were accurate 76% of the time for mean spherical equivalent and 65% of the time for astigmatism. VT sensitivity in detecting posterior segment abnormalities was low (18.5%) resulting in failure to detect retinal conditions such as diabetic retinopathy and maculopathy. Despite lack of recognition of the specific pathology, referral decisions were correct in 78.4% of cases. CONCLUSION: VTs in India competently detect and manage or refer the two most common causes of visual impairment; uncorrected refractive error and cataract. Over two-thirds of patients received accurate and appropriate services from VTs, suggesting that they are a useful and competent cadre for rural and remote eye care.

Selection considerations when using a 'standard optometrist' to evaluate clinical performance of other eye-care personnel.

BACKGROUND: Selection of a standard professional is crucial for assessing the clinical performance of other eye-care personnel. This paper describes the selection considerations and the clinical competency assessment of two optometrists required to select a 'standard optometrist' (SO) for evaluating the clinical performance of vision technicians in India. METHODS: Two optometrists were short-listed from 21 optometrists who responded to an advertisement to be selected as a SO for the assessment of the performance of 24 vision technicians in rural vision centres. Each candidate optometrist performed a routine eye examination on 40 randomly selected, newly registered subjects in a tertiary hospital clinic. Their non-cycloplegic retinoscopic findings were compared with those of an experienced optometrist, while disease diagnoses were compared with the findings of an ophthalmologist. RESULTS: A comparison of retinoscopic findings showed that optometrist A produced retinoscopic values within ±0.50 D agreement for the spherical equivalent (SE) 100 per cent of the time, while optometrist B obtained agreement 91.3 per cent of the time. Similarly, optometrist A's limits of agreement (SE = -0.63 to +0.45 D) and reproducibility limits (SE = 0.78 D) were better than those of optometrist B (SE = -0.98 to +0.70 D and SE =1.18 D, respectively). Optometrist A demonstrated 89.2 per cent sensitivity in detecting ocular pathology compared to 76.3 per cent by optometrist B. CONCLUSIONS: Optometrist A achieved consistent and reproducible retinoscopic findings as well as higher sensitivity in detecting ocular pathology and was selected as the SO for a study to assess the clinical performance of one-year trained vision technicians. The concept of a SO calibrated against an ophthalmologist for disease detection and diagnosis and an experienced optometrist for retinoscopy is a useful approach for the evaluation of eye-care personnel.

Shared care for chronic eye diseases: perspectives of ophthalmologists, optometrists and patients.

OBJECTIVE: To report the perspectives of optometrists, ophthalmologists and patients on a model of shared care for patients with chronic eye diseases. DESIGN, SETTING AND PARTICIPANTS: Qualitative study of a model of shared care between optometrists and ophthalmologists for patients with stable age-related macular degeneration, diabetic retinopathy and glaucoma, trialled by the Royal Victorian Eye and Ear Hospital in Melbourne during 2007­2009. Semi-structured interviews were conducted with optometrists, ophthalmologists and patients at completion of the project to obtain their perspectives on this model. RESULTS: Seventeen optometrists submitted expressions of interest to participate, and 12 completed web-based training modules and clinical observerships and adhered to specified examination and reporting protocols. All five participating ophthalmologists and 11 of the optometrists were interviewed. Ninety-eight patients participated and 37 were interviewed. Optometrists not only met ophthalmologists' expectations but exceeded them, appropriately detecting and referring patients with additional, previously undetected conditions. Patients reported savings in travel time and were satisfied with the quality of care they received. Optometrists, ophthalmologists and patients indicated a general acceptance of shared care arrangements, although there were some issues relating to interprofessional trust. CONCLUSIONS: Shared care between local optometrists and hospital-based ophthalmologists can help to reduce patient waiting time for review and offers an opportunity for these two groups of eye care professionals to collaborate in providing localised care for the benefit of patients. However, trust and relationship building need to be further developed.

Relation of increased prebeta-1 high-density lipoprotein levels to risk of coronary heart disease.

Preß-1 high-density lipoprotein (HDL) plays a key role in reverse cholesterol transport by promoting cholesterol efflux. Our aims were (1) to test previous associations between preß-1 HDL and coronary heart disease (CHD) and (2) to investigate whether preß-1 HDL levels also are associated with risk of myocardial infarction (MI). Plasma preß-1 HDL was measured by an ultrafiltration-isotope dilution technique in 1,255 subjects recruited from the University of California-San Francisco Lipid and Cardiovascular Clinics and collaborating cardiologists. Preß-1 HDL was significantly and positively associated with CHD and MI even after adjustment for established risk factors. Inclusion of preß-1 HDL in a multivariable model for CHD led to a modest improvement in reclassification of subjects (net reclassification index 0.15, p = 0.01; integrated discrimination improvement 0.003, p = 0.2). In contrast, incorporation of preß-1 HDL into a risk model of MI alone significantly improved reclassification of subjects (net reclassification index 0.21, p = 0.008; integrated discrimination improvement 0.01, p = 0.02), suggesting that preß-1 HDL has more discriminatory power for MI than for CHD in our study population. In conclusion, these results confirm previous associations between preß-1 HDL and CHD in a large well-characterized clinical cohort. Also, this is the first study in which preß-1 HDL was identified as a novel and independent predictor of MI above and beyond traditional CHD risk factors.

Resources for the management of ocular emergencies in Australia.

The aim of the present paper is to assess the practical utility of the most common print resources used by practitioners in the management of ocular emergencies. Ten print resources were identified for review (three specialty eye texts, six general emergency medicine texts and one general practice text). The main outcome measures used were the extent a text matched crucial skills criteria in clinical assessment and treatment, and usability. No single print resource addressed all criteria. Red flag systems for clinical assessment and ease of navigation were the best match areas. Only one text inadequately stressed red flag conditions and one text was not ranked as easy to navigate. All texts made assumptions regarding the knowledge/skill level of practitioners, particularly in relation to eye examination procedures and treatment. Photographs ranged in number from 8 to 1500; 3/10 texts provided no photographs. Five texts included detailed instructions on the indications and urgency of referral and follow up for all conditions covered. The remainder lacked details. Only one text used the Australasian Triage Scale. Three texts included photographs/diagrams and instructions for the slit lamp and ophthalmoscope. None covered all procedures specified in the criteria. Only two reflected drug current practice in Australia and provided adequate details on usage. A single comprehensive reference (print and/or web-based) for dealing with ocular emergencies in Australia is clearly needed. Additionally, training and confidence levels of eye care providers must be addressed so that the risk of misdiagnosis and mismanagement of eye emergencies is reduced.

Establishing the service potential of secondary level low vision clinics.

PURPOSE: To determine the proportion of people with low vision who can be adequately managed at a secondary level low vision clinic where only low to moderate magnification low vision devices (LVDs) and basic rehabilitation services are provided. METHODS: A retrospective study of clinical records of participants who attended low vision rehabilitation services (Vision Australia) for the first time between 2000 and 2002 was conducted. Information regarding main cause of vision loss, goals of vision rehabilitation, types of LVDs purchased, and type of services received was examined. RESULTS: Of the 192 participants studied, 65% were female and the mean age was 76 years (range, 19 to 100 years). Most participants had mild (35%) to moderate (49%) vision impairment. Seventy percent (134) of participants purchased some type of LVDs. Near adds of low magnification (1 to 2×) were the most common aid preferred by participants (n=54) followed by handheld magnifiers of moderate magnification (2.5 to 5×; (n=52). Only 10 of the 134 LVDs (8%) purchased were of high magnification (>5×). In addition, only 46 of the 192 participants (24%) attended tertiary level rehabilitation with orientation and mobility (O&M) instructors and/or occupational therapists. Along with the six participants who required high magnification LVDs but no O&M or OT services, in total, 27% (52/192) required tertiary level low vision care. CONCLUSIONS: A secondary level low vision clinic is likely to meet the needs of >70% of people with vision impairment. It would play an important role in vision rehabilitation especially in countries where a wide range of services are available.

Validation of a quality of life questionnaire in the Pacific Island.

PURPOSE: To adapt an existing validated quality of life instrument, the Impact of Vision Impairment (IVI) questionnaire for Pacific Island countries. METHODS: Following in-depth interviews (n = 24) and a pilot study (n = 67), the original 32-item IVI questionnaire was translated and adapted in Vanuatu. The Melanesian IVI (IVI_M) was administered to participants not previously involved in the pilot study (n = 189). RESULTS: Participants included 117 (62%) with mild, moderate or severe vision impairment, 39 with unilateral loss and 33 with normal vision. Eighty-six percent of the original 32-items were deemed relevant by 90% of participants. Items displaying floor effects were removed (4), 2 were combined and 3 items rephrased to reflect Melanesian-specific activities, resulting in a 23-item IVI_M. Nineteen items were relevant to both the Melanesian and Australian contexts including all 8 items related to the emotional reaction to vision loss. IVI_M demonstrated content and construct validity, reliability and discriminated visually healthy populations from those with vision impairment. Vision impairment of < 6/18 negatively effected quality of life. CONCLUSION: While the adaptation process demonstrated the need for culturally relevant instruments, it also highlighted the value of adapting existing validated instrument for use in cross-cultural research rather than developing a new instrument from first principles.

The psychometric validity of the NEI VFQ-25 for use in a low-vision population.

PURPOSE: To determine the psychometric validity of the National Eye Institute-Visual Function Questionnaire (NEI VFQ-25) and its subscale structure for use in people with low vision. METHODS: Two hundred thirty-two participants completed the NEI VFQ-25. Rasch analysis was used to test the psychometric performance of the questionnaire and each subscale. Factor models were hypothesized and tested with confirmatory factor analysis (CFA) and subsequently validated with Rasch analysis. RESULTS: For the overall scale, two rating scales had to be dichotomized and three misfitting items removed to improve fit to the Rasch model. There was evidence of multidimensionality, indicating that the scale would benefit from scale splitting. For the NEI VFQ-25 subscale structure, six of the original 12 subscales could not fit the Rasch model because of item insufficiency (fewer than two items) and the remaining six displayed poor item fit characteristics indicating that the NEI VFQ-25 does not have a viable subscale structure. CFA supported a two-factor model with visual functioning (10 items) and socioemotional (9 items) scales. Most goodness-of-fit statistics were within the recommended range of values. The factor loadings of items on their respective scales were statistically significant (P < 0.001) and ranged between 0.59 and 0.84. The two scales individually fitted the Rasch model and were found to be unidimensional with adequate psychometric characteristics. CONCLUSIONS: The native NEI VFQ-25 is a better performing instrument when split into visual functioning and socioemotional scales. These scales possess valid parameters for assessment of the impact of low vision in this population.

Costs of vision impairment in childhood and youth: diary case studies.

PURPOSE: Children and youth with vision impairment face a lifetime of vision-related costs. This paper examines the little-known personal costs incurred in these early years. METHODS: Case studies of three children and one youth with vision impairment were extracted from a larger, diary-based prospective study of the personal expenditure of people with vision impairment. Diaries were maintained over a 12 month period and expenditure and resource utilization were recorded under four main headings: medicines, products and equipment; health and community services; informal care and support; and other expenses. RESULTS: The scale of direct and indirect costs incurred differed by age at onset and duration of vision impairment. The highest personal costs were accrued for equipment. Informal care and support accounted for the highest indirect costs listed. Reliance on family meant that opportunity costs of relatives rather than out-of-pocket personal costs applied. Assistance from family members was consistently required in relation to transport, personal affairs, and reading-related tasks. Minimal costs were recorded for medicines. Usage of low vision services was commonplace, reflecting the cost-free availability of low vision rehabilitation and support services for children and youths in Australia. CONCLUSIONS: This exploratory study draws attention to the complexity of factors that need to be considered when calculating the personal costs of vision impairment. Cross case comparisons showed that some personal costs were recurrent, others sporadic or once-off. By highlighting the role that age, onset and duration of vision loss, life/educational stage and lifestyle played in differentiating costs between case study participants, these diaries represent important formative work that can guide future research in this area.

Access and utilization of a new low-vision rehabilitation service.

BACKGROUND: A new low-vision service linking a public hospital and a non-governmental organization was trialled in Melbourne, Australia. The factors associated with service use were investigated. METHODS: A survey was conducted with patients who used the service, those who accepted referrals but failed to attend and those who refused a referral. Hospital and non-governmental organization representatives were also interviewed. RESULTS: Ninety-eight eligible vision impaired people who were referred to the new service were recruited. Less than half (49%) followed through with their referral and attended the service. Proximity and convenience were listed as the main facilitators to service use while issues relating to transport, needing an accompanying person, lack of information about the service and poor health were the main barriers. More than a third of the non-compliant and referral refusers spoke a language other than English. Sixty-three per cent of all participants had not previously used low-vision services. Of the two main eye conditions, 81% of referred age-related macular degeneration participants (n = 26) attended the service, but only 32% of those with diabetic retinopathy (n = 31) did so. CONCLUSION: As more than 60% of participants in each of the three groups had no prior use of low-vision services, clearly current models of care are not reaching many who could benefit from such services. This suggests that higher rates of referral are warranted. However, given that substantially more were referred than attended, referral alone is obviously not the answer. Access and attitudinal barriers also need to be addressed.

Assessing participation in daily living and the effectiveness of rehabiliation in age related macular degeneration patients using the impact of vision impairment scale.

PURPOSE: To assess if the Impact of Vision Impairment (IVI) is a valid instrument to measure participation in daily activities and rehabilitation in patients with age-related macular degeneration (AMD) and varying levels of visual impairment. METHODS: Participants, recruited from a public eye hospital and low vision centers, completed the IVI questionnaire. The IVI and its three subscales were assessed for fit to the Rasch model. Unidimensionality, item fit, response category performance, and targeting of items to patients were assessed. Confirmatory factor analysis (CFA) was used to assess the three-factor model of the IVI in this sample of AMD patients. RESULTS: 219 patients (mean +/- SD age = 83.5 +/- 7.4 yr) were recruited. Of these, 22%, 55% and 23% had mild (< 6/12-6/18), moderate (< 6/18-6/60) and severe (< 6/60) vision loss, respectively. The IVI total and three subscales displayed discrete thresholds indicating that the respondents understood the response categories. The IVI items fitted the scale and unidimensionality was established. Person separation reliability for the IVI score was substantial (0.94) indicating that the scale can discriminate between several groups of AMD patients. The IVI items were significantly targeted to the AMD patients with the means of the two distributions shown to be very close (0.0 and 0.1, respectively). Substantial targeting was also evident for the subscales. Poorer visual acuity was significantly associated (ANOVA; F (2, 216) = 23.4; p < 0.001) with greater restriction of participation suggesting that the IVI has substantial construct validity. CFA supported the IVI three-factor model which includes items from the "emotional well-being, "reading and accessing information" and "mobility and independence" subscales. CONCLUSIONS: Clinicians and researchers can reliably use the IVI to assess the impact on daily life and the effectiveness of clinical trials and rehabilitation interventions in patients with AMD across a range of vision loss.

Low vision services provided by optometrists in Victoria, Australia.

BACKGROUND: Utilisation of low vision services remains low in Australia. This study investigates low vision service provision by optometrists in Victoria and assesses the optometric human resource potential. METHODS: An eight-item questionnaire was sent to 1,050 optometrists in Victoria in December 2006. It investigated key characteristics of the optometrists and their practices, the extent of their low vision training and service provision and the influence of Medicare item 10942 on low vision service provision. RESULTS: Although only 97 replies were received they represented a significant proportion of optometrists who had undertaken postgraduate training in low vision. Almost 86 per cent of respondents worked in private practice settings. Although 87.6 per cent and 30.9 per cent had undergraduate and postgraduate low vision training, respectively, only 63.9 per cent of all respondents reported that they provided low vision services. The majority who replied to the impact of Medicare item 10942 question indicated that its introduction had not changed their low vision provision. Those who did not provide low vision services reported referrals to other low vision services as their main reason for not doing so. CONCLUSIONS: The majority of respondents represent a potential source of low vision service providers. Further work needs to explore their possible involvement in low vision care.