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Importance Previous work has reported a link between diabetic retinopathy/diabetic macular edema (DR/DME) and psychosocial functioning, although the extent and direction of the association remains uncertain. Objective To determine the relationship between DR/DME and psychosocial functioning, the latter an umbrella term used to capture the emotional and social aspects of functioning which may include, for example, depression; depressive disorder; anxiety; vision-specific distress; diabetes-specific distress and emotional and social well-being. Evidence review PubMed, Embase, Medline and the Cochrane Central register were systematically searched for relevant interventional and observational quantitative studies using standardised criteria. Studies with DR/DME and psychosocial functioning as exposures or outcomes were accepted. Study quality was evaluated using the modified Newcastle–Ottawa scale for observational studies, and the modified Down’s and Black checklist for interventional studies. Findings Of 1827 titles initially identified, 42 were included in the systematic review. They comprised of four interventions (one RCT, three non-RCTs) and 38 observational studies (33 cross sectional, five prospective). In studies with DR/DME as the exposure ( n  = 28), its severity and related vision impairment were consistently associated with poor psychosocial outcomes, mostly higher incidence of depression and depressive symptoms. Baseline depression and depressive symptoms were also associated with greater DR incidence and progression of DR. Medical intervention strategies showed significant improvement in psychosocial outcomes in patients with DR, such as significant improvements in mental health domain scores of the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ 25). Conclusion and relevance Severity of DR, DME and associated vision loss are significantly associated with poor psychosocial outcomes. Aspects of depression and its symptoms show a bi-directional association, with increased incidence and progression of DR significant in those with baseline depression or depressive symptoms. Based on these findings, we propose two areas that may benefit from targeted interventions: (1) Prevention of development of poor psychological outcomes by preventing and delaying progression of DR/DME; and (2) Improved detection and management of poor psychological functioning by improving screening tools and multidisciplinary care for patients. Subsequent longitudinal studies can further help establish the underlying relationship between the two measures.

Droughts hit the most vulnerable people the hardest. When this happens, everybody in the economy loses over the medium- to long-term. Proactive policies and planning based on vulnerability and risk assessments can reduce drought risk before the worst impacts occur. The aim of this article is to inform a global initiative, led by the United Nations Convention to Combat Desertification (UNCCD), to mitigate the effects of drought on vulnerable ecosystems and communities. This is approached through a rapid review of experiences from selected nations and of the available literature documenting methodological approaches to assess drought impacts and vulnerability at the local level. The review finds that members of the most vulnerable communities can integrate available methods to assess drought risks to their land and ecosystem productivity, their livelihoods and their life-supporting hydrological systems. This integration of approaches helps to ensure inclusive assessments across communities and ecosystems. However, global economic assessments often still fail to connect to holistic consideration of vulnerability at a local scale. As a result, they routinely fall short of capturing the systemic effects of land and water management decisions that deepen vulnerability to droughts over time. To ensure proactive and inclusive drought risk mitigation, multiscale, systemic approaches to drought vulnerability and risk assessment can be further reinforced at a global level.

Rising temperatures and changing precipitation patterns across the Hindu Kush-Himalaya (HKH) region resulting from climate change have an influence on water resource availability and food security for the downstream population. This review seeks to objectively assess the available evidence of the impacts of climate change on glacier hydrology and the wider implications upon water resources within the Indus, Ganges, and Brahmaputra basins. Glacier meltwater contribution to river flows is scale dependent and varies considerably across the east-west climatic zones of the HKH. For the Ganges and Brahmaputra this contribution is estimated to be significantly less than for the Indus to the west, with summer monsoon rains dominating flows from central and easterly areas, whereas meltwater remains a significant contributor to downstream flow of westerly basins, which receive most precipitation during winter. No corroborated trends exist in observed discharge for any basin, and such analyses are hindered by a lack of good-quality long-term data. Predicted increases in temperature will drive increased shrinkage of glaciers, leading to initial increases in meltwater produced, followed by subsequent declines with reduced glacier mass. The impacts of such changes are predicted to be minimal for the overall discharge of the Ganges and Brahmaputra, where increases in rainfall may in fact lead to increased flows but with greater variability. Within the Indus basin, reduced meltwater will have significant impacts upon available runoff; however, increased uncertainties surrounding precipitation and socioeconomic changes limit any conclusive assessment of how water availability will be affected; moreover, seasonality of runoff may be a more important factor. Scientific challenges and research recommendations are identified for the region. This review proposes the need for the scientific evidence pertaining to the region's glacier systems to be approached objectively in the future, such that a robust assessment of change can be attained.

Rising temperatures and changing precipitation patterns across the Hindu Kush–Himalaya (HKH) region resulting from climate change have an influence on water resource availability and food security for the downstream population. This review seeks to objectively assess the available evidence of the impacts of climate change on glacier hydrology and the wider implications upon water resources within the Indus, Ganges, and Brahmaputra basins. Glacier meltwater contribution to river flows is scale dependent and varies considerably across the east–west climatic zones of the HKH. For the Ganges and Brahmaputra this contribution is estimated to be significantly less than for the Indus to the west, with summer monsoon rains dominating flows from central and easterly areas, whereas meltwater remains a significant contributor to downstream flow of westerly basins, which receive most precipitation during winter. No corroborated trends exist in observed discharge for any basin, and such analyses are hindered by a lack of good-quality long-term data. Predicted increases in temperature will drive increased shrinkage of glaciers, leading to initial increases in meltwater produced, followed by subsequent declines with reduced glacier mass. The impacts of such changes are predicted to be minimal for the overall discharge of the Ganges and Brahmaputra, where increases in rainfall may in fact lead to increased flows but with greater variability. Within the Indus basin, reduced meltwater will have significant impacts upon available runoff; however, increased uncertainties surrounding precipitation and socioeconomic changes limit any conclusive assessment of how water availability will be affected; moreover, seasonality of runoff may be a more important factor. Scientific challenges and research recommendations are identified for the region. This review proposes the need for the scientific evidence pertaining to the region's glacier systems to be approached objectively in the future, such that a robust assessment of change can be attained.

In patients with Type 2 diabetes, to determine the factors associated with diabetes knowledge, derived from Rasch analysis, and compare results with a traditional raw scoring method. Participants in this cross-sectional study underwent a comprehensive clinical and biochemical assessment. Diabetes knowledge (main outcome) was assessed using the Diabetes Knowledge Test (DKT) which was psychometrically validated using Rasch analysis. The relationship between diabetes knowledge and risk factors identified during univariate analyses was examined using multivariable linear regression. The results using raw and Rasch-transformed methods were descriptively compared. 181 patients (mean age±standard deviation = 66.97±9.17 years; 113 (62%) male) were included. Using Rasch-derived DKT scores, those with greater education (β = 1.14; CI: 0.25,2.04, p = 0.013); had seen an ophthalmologist (β = 1.65; CI: 0.63,2.66, p = 0.002), and spoke English at home (β = 1.37; CI: 0.43,2.31, p = 0.005) had significantly better diabetes knowledge than those with less education, had not seen an ophthalmologist and spoke a language other than English, respectively. Patients who were members of the National Diabetes Service Scheme (NDSS) and had seen a diabetes educator also had better diabetes knowledge than their counterparts. Higher HbA1c level was independently associated with worse diabetes knowledge. Using raw measures, access to an ophthalmologist and NDSS membership were not independently associated with diabetes knowledge. Sociodemographic, clinical and service use factors were independently associated with diabetes knowledge based on both raw scores and Rasch-derived scores, which supports the implementation of targeted interventions to improve patients' knowledge. Choice of psychometric analytical method can affect study outcomes and should be considered during intervention development.

To examine the association of individual and combined indicators of diabetes control with diabetic retinopathy and diabetic macular edema. In this clinical, cross-sectional study, 613 adults with type 2 diabetes (372 any diabetic retinopathy; 183 any diabetic macular edema) were examined. Diabetic retinopathy was assessed from fundus photographs; diabetic macular edema from Ocular Coherence Tomography scans; and HbA1c and serum lipid values from fasting blood samples. Poor glucose control was defined as HbA1c≥7%; poor blood pressure control as SBP≥130/DBP≥80; and poor lipid control as total cholesterol:HDL ratio≥4.0. The association of poor glucose control, poor blood pressure control and poor lipid control alone and in combination (poor glucose & blood pressure control; poor glucose & lipid control; poor blood pressure & lipid control; and poor glucose, blood pressure & lipid control) with diabetic retinopathy/diabetic macular edema was examined using multiple logistic regression models. Patients' mean±standard deviation age was 64.9±11.6 years (57% male). In adjusted models, compared to those with good control of all indicators (n = 99, 18.3%), the odds ratio (95% Confidence Interval) of having any diabetic retinopathy was 2.44 (1.34-4.46), 3.75 (1.75-8.07), 4.64 (2.13-10.12) and 2.28 (1.01-5.16) for poor glucose control only; poor glucose & blood pressure control; poor glucose & lipid control; and poor glucose, blood pressure & lipid control, respectively. Correspondingly for diabetic macular edema, they were 3.19 (1.55-6.59); 3.60 (1.58-8.22); 2.76 (1.18-6.44); and 3.01 (1.18-7.67), respectively. Odds were not significantly increased for other indicators. Compared to individual indicators of poor diabetes control, risk of diabetic retinopathy and diabetic macular edema increased three to fourfold with a combination of these indicators. Targeting combined diabetes control indicators is important to reduce risk of diabetic retinopathy/diabetic macular edema.

The Narmada river basin is a highly regulated catchment in central India, supporting a population of over 16 million people. In such extensively modified hydrological systems, the influence of anthropogenic alterations is often underrepresented or excluded entirely by large-scale hydrological models. The Global Water Availability Assessment (GWAVA) model is applied to the Upper Narmada, with all major dams, water abstractions and irrigation command areas included, which allows for the development of a holistic methodology for the assessment of water resources in the basin. The model is driven with 17 Global Circulation Models (GCMs) from the Coupled Model Intercomparison Project Phase 5 (CMIP5) ensemble to assess the impact of climate change on water resources in the basin for the period 2031–2060. The study finds that the hydrological regime within the basin is likely to intensify over the next half-century as a result of future climate change, causing long-term increases in monsoon season flow across the Upper Narmada. Climate is expected to have little impact on dry season flows, in comparison to water demand intensification over the same period, which may lead to increased water stress in parts of the basin.

Purpose We investigated whether the Chinese impact of vision impairment (IVI) questionnaire is valid to generate reliable person estimates in a population-based sample. Methods VRQoL was measured using the 32-item Chinese version of the IVI questionnaire in the Singapore Chinese Eye Study (2009-2011), a population-based study of the prevalence and risk factors for VI and eye diseases in Chinese Singaporeans. Rasch analysis was used to assess the Chinese IVI's response category functioning, precision, unidimensionality, targeting and differential item functioning. The ability of the Chinese IVI to discriminate participants along the spectrum of VI demonstrated criterion validity. Results Of the 3353 participants, 27.2 % (n = 912) had VI (presenting visual acuity <6/12, better eye). Response categories were collapsed from six to four to resolve disordered thresholds. The Chinese IVI initially demonstrated multidimensionality and was split into three scales: 'Reading and Accessing Information'; 'Mobility and Independence'; and 'Emotional Well-being'. All three scales were unidimensional and demonstrated excellent range-based precision (all reliability coefficients 0.97), following removal of three misfitting items. Mean person measures decreased with worsening VI (e.g. Reading: none (7.50 logits); mild (6.99 logits); moderate (6.44 logits); and severe (3.01 logits) VI; p < 0.001). Conclusions A three-dimensional 29-item Chinese IVI is a valid tool to assess the impact of VI on VRQoL in a large population-based sample, comprising over a quarter of participants with VI. The 28-item English IVI is also likely to be valid for use in population-based studies; however, this must be demonstrated empirically in future studies.

Background Older adults in residential aged care facilities have unnecessarily high levels of vision impairment (VI) which are largely treatable or correctable. However, no current comprehensive eye health service model exists in this setting in Australia. We aimed to determine the clinical, person-centered, and economic effectiveness of a novel eye care model, the Residential Ocular Care (ROC). Methods/design This protocol describes a multicentered, prospective, randomized controlled trial. A total of 395 participants with distance vision < 6/12 (0.30 LogMAR) and/or near vision N8 (1.00 M) or worse will be recruited from 38 urban and rural aged care facilities across Victoria, Australia. Aged care facilities will be randomized (1:1) to one of two parallel groups. Participants in the ROC group will receive a comprehensive and tailored eye care pathway that includes, as necessary, refraction and spectacle provision, cataract surgery, low vision rehabilitation, and/or a referral to an ophthalmologist for funded treatment. Usual care participants will be referred for an evaluation to the eye care service associated with the facility or an eye care provider of their choice. The primary outcome will be presenting near and distance vision assessed at the two- and six-month follow-up visits, post baseline. Secondary outcomes will include vision-specific quality of life, mobility, falls, depression, and eye care utilization at two and six months. An incremental cost-effectiveness analysis will also be undertaken. Discussion The ROC study is the first multicentered, prospective, customized, and cluster randomized controlled trial in Australia to determine the effectiveness of a comprehensive and tailored eye care model for people residing in aged care facilities. Results from this trial will assist health and social care planners in implementing similar innovative models of care for this growing segment of the population in Australia and elsewhere. Trial registration Australian and New Zealand Clinical Trials Registry, ACTRN12615000587505 . Registered on 4 June 2015 – retrospectively registered.

The Ganga River is facing mounting environmental pressures due to rapidly increasing human population, urbanisation, industrialisation and agricultural intensification, resulting in worsening water quality, ecological status and impacts on human health. A combined inorganic chemical, algal and bacterial survey (using flow cytometry and 16S rRNA gene sequencing) along the upper and middle Ganga (from the Himalayan foothills to Kanpur) was conducted under pre-monsoon conditions. The upper Ganga had total phosphorus (TP) and total dissolved nitrogen concentrations of less than 100 μg l −1 and 1.0 mg l −1 , but water quality declined at Kannauj (TP = 420 μg l −1 ) due to major nutrient pollution inputs from human-impacted tributaries (principally the Ramganga and Kali Rivers). The phosphorus and nitrogen loads in these two tributaries and the Yamuna were dominated by soluble reactive phosphorus and ammonium, with high bacterial loads and large numbers of taxa indicative of pathogen and faecal organisms, strongly suggesting sewage pollution sources. The high nutrient concentrations, low flows, warm water and high solar radiation resulted in major algal blooms in the Kali and Ramganga, which greatly impacted the Ganga. Microbial communities were dominated by members of the Phylum Proteobacteria, Bacteriodetes and Cyanobacteria, with communities showing a clear upstream to downstream transition in community composition. To improve the water quality of the middle Ganga, and decrease ecological and human health risks, future mitigation must reduce urban wastewater inputs in the urbanised tributaries of the Ramganga, Kali and Yamuna Rivers.