Helen Court

Development of the 25-item Cardiff Visual Ability Questionnaire for Children (CVAQC)

Aims To develop and validate a short questionnaire to assess self-reported visual ability in children and young people with a visual impairment. Methods A list of 121 items was generated from 13 focus groups with children and young people with and without a visual impairment. A long 89-item questionnaire was piloted with 45 visually impaired children and young people using face-to-face interviews. Rasch analysis was used to analyse the response category function and to facilitate item removal ensuring a valid unidimensional scale. The validity and reliability of the short questionnaire were assessed on a group of 109 visually impaired children (58.7% boys; median age 13 years) using Rasch analysis and intraclass correlation coefficient (ICC). Results The final 25-item questionnaire has good validity and reliability as demonstrated by a person separation index of 2.28 and reliability coefficient of 0.84. The items are well targeted to the subjects with a mean difference of −0.40 logit between item and person means, and an ICC of 0.89 demonstrates good temporal stability. Conclusion The Cardiff Visual Ability Questionnaire for Children (CVAQC) is a short, psychometrically robust and a self-reported instrument that works to form a unidimensional scale for the assessment of the visual ability in children and young people with a visual impairment.

Depression and multimorbidity: a cross-sectional study of 1,751,841 patients in primary care.

BACKGROUND Depression is common in many chronic physical health disorders, but the nature and extent of physical health comorbidities in depression, particularly within large population-based samples of patients, and how these comorbidities relate to factors such as age, sex, and social deprivation, are unknown. We aimed to assess the nature and extent of multiple physical health comorbidities in primary care patients with depression within a large and representative Scottish dataset. METHOD This study was a cross-sectional secondary data analysis of 314 primary care practices in Scotland (from the Primary Care Clinical Informatics Unit at the University of Aberdeen, Scotland, March 31, 2007), including 143,943 people with depression and 1,280,435 controls. The outcomes assessed were 32 common chronic physical health conditions, adjusted for age, sex, and social deprivation. Depression was defined as a Read code for depression recorded within last year and/or 4 or more antidepressant prescriptions (excluding low-dose tricyclic antidepressants) within the last year. RESULTS Individuals in primary care with depression were more likely than individuals without depression to have every one of the 32 comorbid physical conditions we assessed, even after adjusting for age, sex, and deprivation. The depression group was also significantly more likely to have multiple levels of comorbidity, including 2 physical health conditions (OR = 1.55; 95% CI, 1.53-1.58), 3 physical health conditions (OR = 1.84; 95% CI, 1.81-1.87), 4 physical health conditions (OR = 2.06; 95% CI, 2.01-2.11; P < .001), and 5 or more physical health conditions (OR = 2.65; 95% CI, 2.59-2.71; P < .001). CONCLUSION Depression in primary care is associated with a very wide range of physical health comorbidities and considerable medical burden. The nature and extent of this multimorbidity and the important association with social deprivation have not been previously described within a large and representative dataset of routine primary care data. Our findings have important implications for the integrated management of depression and physical health problems in the United Kingdom and throughout the world.

Visual impairment is associated with physical and mental comorbidities in older adults: a cross-sectional study

BackgroundVisual impairment is common in older people and the presence of additional health conditions can compromise health and rehabilitation outcomes. A small number of studies have suggested that comorbities are common in visual impairment; however, those studies have relied on self-report and have assessed a relatively limited number of comorbid conditions.MethodsWe conducted a cross-sectional analysis of a dataset of 291,169 registered patients (65-years-old and over) within 314 primary care practices in Scotland, UK. Visual impairment was identified using Read Code ever recorded for blindness and/or low vision (within electronic medical records). Prevalence, odds ratios (from prevalence rates standardised by stratifying individuals by age groups (65 to 69 years; 70 to 74; 75 to 79; 80 to 84; and 85 and over), gender and deprivation quintiles) and 95% confidence intervals (95% CI) of 37 individual chronic physical/mental health conditions and total number of conditions were calculated and compared for those with visual impairment to those without.ResultsTwenty seven of the 29 physical health conditions and all eight mental health conditions were significantly more likely to be recorded for individuals with visual impairment compared to individuals without visual impairment, after standardising for age, gender and social deprivation. Individuals with visual impairment were also significantly more likely to have more comorbidities (for example, five or more conditions (odds ratio (OR) 2.05 95% CI 1.94 to 2.18)).ConclusionsPatients aged 65 years and older with visual impairment have a broad range of physical and mental health comorbidities compared to those of the same age without visual impairment, and are more likely to have multiple comorbidities. This has important implications for clinical practice and for the future design of integrated services to meet the complex needs of patients with visual impairment, for example, embedding depression and hearing screening within eye care services.

Measuring low vision service outcomes: Rasch Analysis of the seven-item National Eye Institute visual function questionnaire

Purpose. To describe a short, functional visual disability instrument capable of measuring the outcomes of a government funded country-wide multicenter low vision service in Wales and to determine if postal implementation might lead to response bias. Methods. Seven items from the National Eye Institute Visual Function Questionnaire (NEI VFQ), which have previously been shown to be responsive to low vision service intervention, were incorporated into a postal questionnaire which was given to patients before they attended the all Wales Low Vision Service. Rasch analysis was used to describe the instruments psychometric properties. Results. Rasch analysis of 490 completed questionnaires showed that all seven questions worked together to form a unidimensional scale. By combining the first two response categories, category utilization and targeting was improved. There were no significant differences in the age (p = 0.29), gender (p = 0.75), distance binocular Visual Acuity (VA; p = 0.86), living situation (p = 0.34) or prevalence of macular degeneration (p = 0.31) between those who returned a completed questionnaire and those who did not. Conclusions. The seven-item National Eye Institute Visual Function Questionnaire is an appropriate and precise outcome measure that is acceptable to patients and easy to administer. It measures aspects of near, reading, and distance visual disability that have been shown to be amenable to low vision service provision and, therefore, it should be highly responsive to this intervention and facilitate inter-service assessment. We found no evidence to suggest that postal implementation results in response bias. The instrument is an appropriate measure of patient based outcomes for a large-scale, multicenter low vision service.

Apoptosis and mutation in the murine small intestine: loss of Mlh1- and Pms2-dependent apoptosis leads to increased mutation in vivo.

The mismatch repair (MMR) protein Msh2 has been shown to function in the apoptotic response to alkylating agents in vivo. Here, we extend these studies to the MutL homologues (MLH) Mlh1 and Pms2 by analysing the apoptotic response within the small intestine of gene targeted strains. We demonstrate significant differences between Msh2, Mlh1 and Pms2 mutations in influencing apoptotic signalling following 50mg/kg N-methyl-nitrosourea (NMNU), with no obvious reliance upon either Mlh1 or Pms2. However, following exposure to 100mg/kg temozolomide or lower levels of NMNU (10mg/kg) both Mlh1- and Pms2-dependent apoptosis was observed, indicating that the apoptotic response at these levels of DNA damage is dependent on the MutL homologues. Given our ability to observe a MutLalpha dependence of the apoptotic response, we tested whether perturbations of this response directly translate into increases in mutation frequency in vivo. We show that treatment with temozolomide or 10mg/kg NMNU significantly increases mutation in both the Mlh1 and Pms2 mutant mice. At higher levels of NMNU, where the apoptotic response is independent of Mlh1 and Pms2, no gene dependent increase in mutation frequency was observed. These results argue that the MutSalpha and MutLalpha are not equally important in their ability to signal apoptosis. However, when MMR does mediate apoptosis, perturbation of this response leads to long-term persistence of mutant cells in vivo.

How effective is the new community-based Welsh low vision service?

Aims To determine if there was a significant difference between user-centred and clinical outcomes in people with low vision who attended a new community-based low vision service (CLVS) or the hospital-based low vision service (HBLV). Methods A prospective controlled before and after study. Participants were recruited from the CLVS (n=343; 96 male, 247 female; median age 82 years) and from the HLVS (n=145; 55 male, 90 female; median age 80 years). The primary outcome measure was change (baseline to 3 months) in visual disability as evaluated by the seven-item National Eye Institute-Visual Function Questionnaire (NEI-VFQ). Secondary outcome measures included: use of low vision aids, satisfaction with the service provided and change in near visual acuity before and after the provision of low vision aids. Results There were no significant differences in user-centred and clinical outcome measures between the CLVS and HLVS. Self-reported visual disability was significantly reduced after low vision service intervention for participants in both groups by 0.46 and 0.57 logits in the HLVS and CLVS, respectively. Conclusion This study provides strong evidence that CLVS and HLVS are effective methods of service provision in Wales.

The newly established primary care based Welsh Low Vision Service is effective and has improved access to low vision services in Wales

Aim:  The aim of this study was to determine whether the new, primary care based, Welsh Low Vision Service (WLVS) improved access to low vision services in Wales and was effective.

Measuring Patient Anxiety in Primary Care: Rasch Analysis of the 6-item Spielberger State Anxiety Scale

OBJECTIVES The 6-item Spielberger State Anxiety Scale has been used as a replacement of the original version in many health-care studies. The purpose of this study was to evaluate the measurement properties of the shortened 6-item Spielberger State Anxiety Scale using Rasch analysis in general medical practice patients (N=297). METHODS Participants (aged 16 years or above) were recruited on a consecutive basis from three general medical practices. Prior to their appointment, participants were asked to complete a 6-item Spielberger State Anxiety Scale. RESULTS The results of the study showed that the scale is unidimentional, and each item measures a different level of patient anxiety. The rating scale operated well and item and person reliability was good. Furthermore, principal-components analysis of the residuals confirmed the scale measures a unitary concept. A scoring key was generated to allow conversion of raw scores to a continuous measurement. CONCLUSION The 6-item Spielberger State Anxiety Scale is shorter than the original version and has good psychometric properties. This would suggest the scale is a valid alternative to the full version for use in primary health-care practice and research.

Evaluating patient anxiety levels during contact lens fitting.

Purpose. Patient anxiety has been shown to be detrimental to many aspects of primary healthcare consultations. However, to date, the subject has received minimal attention within optometric practice. Therefore, the purpose of this study was to evaluate patient anxiety during a commonly conducted type of optometric examination, namely a contact lens fit. Methods. Forty participants (15 male, 25 female; mean age 28.3 ± 9.5) underwent a full contact lens fitting consultation. Skin conductance was recorded continuously to measure participant arousal; the physiological correlate of anxiety. A short form of the Speilberger state anxiety scale was also completed by participants before and after the contact lens fit. Results. Skin conductance analysis identified arousal levels peak during history and symptoms, contact lens insertion and removal and practitioner advice. The Wilcoxen test identified a significant reduction in participant anxiety measured with the shortened Speilberger state anxiety scale after the consultation. Conclusions. Patient arousal levels fluctuate in a characteristic way throughout the contact lens fitting examination. Peak arousal levels occur during periods of ‘communicative interaction’ between the patient and the optometrist. Since anxiety is associated with poor attention, this suggests that optometrists should not assume that patients remember what they are told during the consultation. Furthermore, patient anxiety is significantly reduced after the examination, which may indicate that patient anxiety is moderated by experience.

Content development of the optometric patient anxiety scale

Purpose. Patient anxiety has been shown to be detrimental to many aspects of healthcare outcomes. To date, there is no method of evaluating anxiety in optometric practice. Therefore, the purpose of this study was the content development of a questionnaire to measure optometric patient anxiety. Such a tool will have both clinical and research application; allowing the identification of anxious patients in practice and as a method to establish the success of anxiety reducing interventions. Methods. Selection of initial items was based on patient interviews, literature review, and focus group feedback. The initial 30-item Optometric Patient Anxiety Scale was piloted on 148 patients in optometric practice. Rasch analysis was used to analyze response category operation and to facilitate item removal to ensure a valid and unidimensional scale. Test-retest reliability (test-retest time, 2 weeks) was measured on 59 young adults to test the stability of the measure with time. Results. Rasch analysis identified disordering of category thresholds and underutilization of the end-response category. Therefore, categories were merged to a three response solution. Item reduction was principally driven by infit and outfit statistics. The items in the final 10-item scale all had good infit and outfit values (infit: 0.80–1.20, outfit: 0.7–1.3), good person separation (>2) and high person and item reliability coefficients, 0.84 and 0.88, respectively. Test-retest reliability also demonstrated good stability of the measure with time (intraclass correlation; ICC = 0.85). Conclusions. The Optometric Patient Anxiety Scale is the first questionnaire to measure patient anxiety specific to optometric practice. The scale was developed using Rasch analysis to ensure that all the items work together to form a valid unidimensional interval scale.