Importance:Previous studies of the role of dietary and supplementary calcium in age-related macular degeneration (AMD) have produced mixed results, suggesting that supplementation and decreased dietary intake are both harmful.Objective:To evaluate the association of baseline dietary and supplementary calcium intake with progression of AMD.Design, Setting, and Participants:This study involved secondary analyses of participants enrolled in the Age-Related Eye Disease Study (AREDS). The AREDS study (1992-2001) enrolled patients from academic and community-based retinal practices in the United States. Men and women with varying severity of AMD were included. Data analysis for this article occurred from September 2015 to December 2018.Exposures:Baseline self-reported dietary or supplementary calcium intake.Main Outcomes and Measures:Development of late AMD, geographic atrophy (central or noncentral), or neovascular AMD detected on centrally graded baseline and annual fundus photographs.Results:A total of 4751 participants were included (mean [SD] age, 69.4 [5.1] years); 4543 (95.6%) were white, and 2655 (55.9%) were female. Compared with those who were in the lowest quintile, the participants in the highest quintile of dietary calcium intake had a lower risk of developing late AMD (hazard ratio [HR], 0.73 [95% CI, 0.59-0.90]), central geographic atrophy (HR, 0.64 [95% CI, 0.48-0.86]), and any geographic atrophy (HR, 0.80 [95% CI, 0.64-1.00]). The participants in the highest tertile of supplementary calcium intake had a lower risk of developing neovascular AMD (HR, 0.70 [95% CI, 0.50-0.97]) compared with those who did not take calcium supplements. When stratified by sex, women in the highest quintile of dietary calcium intake had a lower risk of developing late AMD (HR, 0.73 [95% CI, 0.56-0.97]) compared with those in the lowest quintile. Women in the highest tertile of calcium supplementation had a lower risk of progression to neovascular AMD (HR, 0.67 [95% CI, 0.48-0.94]) compared with those who did not take calcium supplements. Similar findings were found in men for dietary calcium. Too few men took calcium supplements to allow for analyses.Conclusions and Relevance:In this secondary analysis, higher levels of dietary and supplementary calcium intake were associated with lower incidence of progression to late AMD in AREDS participants. The results may be owing to uncontrolled confounding or chance and should be considered hypothesis development requiring additional study.

PURPOSETo establish continuity with the grading procedures and outcomes from the historical data of the Age-Related Eye Disease Study (AREDS), color photographic imaging and evaluation procedures for the assessment of age-related macular degeneration (AMD) were modified for digital imaging in the AREDS2. The reproducibility of the grading of index AMD lesion components and for the AREDS severity scale was tested at the AREDS2 reading center.METHODSDigital color stereoscopic fundus photographs from 4203 AREDS2 subjects collected at baseline and annual follow-up visits were optimized for tonal balance and graded according to a standard protocol slightly modified from AREDS. The reproducibility of digital grading of AREDS2 images was assessed by reproducibility exercises, temporal drift (regrading a subset of baseline annually, n = 88), and contemporaneous masked regrading (ongoing, monthly regrade on 5% of submissions, n = 1335 eyes).RESULTSIn AREDS2, 91% and 96% of images received replicate grades within two steps of the baseline value on the AREDS severity scale for temporal drift and contemporaneous assessment, respectively (weighted Kappa of 0.73 and 0.76). Historical data for temporal drift in replicate gradings on the AREDS film-based images were 88% within two steps (weighted Kappa = 0.88). There was no difference in AREDS2-AREDS concordance for temporal drift (exact P = 0.57).CONCLUSIONSDigital color grading has nearly the same reproducibility as historical film grading. There is substantial agreement for testing the predictive utility of the AREDS severity scale in AREDS2 as a clinical trial outcome. (ClinicalTrials.gov number, NCT00345176.)

Objective: To characterize progression of geographic atrophy (GA) associated with age-related macular degeneration in AREDS as measured by digitized fundus photographs.Methods: Fundus photographs from 181 of 4757 AREDS participants with a GA area of at least 0.5 disc areas at baseline or from participants who developed bilateral GA during follow-up were scanned, digitized, and evaluated longitudinally. Geographic atrophy area was determined using planimetry. Rates of progression from noncentral to central GA and of vision loss following development of central GA included the entire AREDS cohort.Results: Median initial lesion size was 4.3 mm(2). Average change in digital area of GA from baseline was 2.03 mm(2) standard error of the mean, 0.24 mm(2)) at 1 year, 3.78 mm(2) (0.24 mm(2)) at 2 years, 5.93 mm(2) (0.34 mm(2)) at 3 years, and 1.78 mm(2) (0.086 mm(2)) per year overall. Median time to developing central GA after any GA diagnosis was 2.5 years (95% confidence interval, 2.0-3.0). Average visual acuity decreased by 3.7 letters at first documentation of central GA, and by 22 letters at year 5.Conclusions: Growth of GA area can be reliably measured using standard fundus photographs that are digitized and subsequently graded at a reading center. Development of GA is associated with subsequent further growth of GA, development of central GA, and loss in central vision.

PURPOSE:To determine specific retinal precursor lesions and sequence of events preceding the onset of geographic atrophy (GA) in eyes with age-related macular degeneration (AMD).DESIGN:Retrospective review.PARTICIPANTS:All participants in the Age-Related Eye Disease Study (AREDS) at 2 clinical centers (Devers Eye Institute, Portland, Oregon, and University of Wisconsin, Madison, Wisconsin) in whom GA initially appeared in at least one eye a minimum of 4 years after the baseline study visit.METHODS:All stereoscopic fundus photographs taken before the appearance of GA in the involved (study) eye were reviewed. Fundus features at the site of future GA were graded and recorded. Three graders reviewed photographs, with independent grading and adjudication by mutual agreement. Features graded included drusen (classified by size and confluence), focal hyperpigmentation, hypopigmentation, and refractile deposits. The time between first appearance of these features and initial appearance of GA was recorded.MAIN OUTCOME MEASURE:Appearance of GA.RESULTS:Of all AREDS participants at the 2 sites, 95 eyes of 77 developed GA at least 4 years after entrance into the study. Average time from baseline to initial appearance of GA was 6.6 years (range, 4-11). Drusen were found in 100% of eyes at the site of later developing GA, drusen >125 mum in diameter in 96% of eyes, confluent drusen in 94%, hyperpigmentation in 96%, drusen > 250 mum in 83%, hypopigmentation in 82%, and refractile deposits in 23%. Time from lesion appearance to onset of GA varied by lesion type, ranging from 5.9 years for drusen confluence to 2.5 years for hypopigmentation or refractile deposits. Lesions generally followed a uniform sequence of appearance.CONCLUSIONS:By focusing on the location of initial GA appearance and then retrospectively analyzing prior photographs, we were able to identify specific precursor lesions and the most common sequence of events leading to GA formation in eyes with AMD. The progression was usually characterized by large drusen formation and development of hyperpigmentation, followed by regression of drusen, appearance of hypopigmentation, and ultimately development of GA, sometimes preceded by the appearance of refractile deposits.

Background The Best Start Resource Centre launched Ontario's first provincial, public-awareness campaign on alcohol use and pregnancy in 2004. The combination of provincial and local strategies resulted in a multi- level approach with the Best Start Resource Centre planning large-scale provincial strategies, and local groups planning innovative community activities. Objectives The objective was to raise awareness about the risks of alcohol use in pregnancy amongst Ontario women of childbearing age through a multi-level awareness campaign. Methods The campaign was assessed through formative, process and outcome evaluations. Evaluation components included both qualitative and quantitative aspects. The primary evaluation approach was a pre- and post- campaign phone survey of Ontario women of childbearing age. Results There was a significant increase of 15% in rate of top-of-mind awareness that "stopping alcohol use in pregnancy" is one of the most important things that pregnant women can do to have a healthy baby. There were significant decreases in the amount of alcohol considered safe in pregnancy, and of the proportion of respondents who thought beer was safe in pregnancy. There were significant increases in the proportion of respondents that thought that women should stop drinking prior to conception. The results show significant increases in awareness that alcohol use in pregnancy can result in problems with alcohol or drug use (11% increase), trouble getting along others (8% increase), trouble with school (7% increase) and difficulties learning (3% increase). There was a significant 65% increase in the proportion of respondents who volunteered that birth defects could result from prenatal exposure to alcohol. Discussion Despite high pre-campaign levels of knowledge, these evaluation results suggest that the Ontario 2004 campaign was successful in increasing knowledge about alcohol use in pregnancy amongst women of childbearing age. The qualitative and quantitative results show that this multi-level approach, combining local and provincial strategies, was an effective model for campaign implementation.

January Last fall you could have died. You were in serious trouble, your doctor told you. The serious trouble still weighs you down, even as your body disappears by increments. You take a yoga class to gain strength and cultivate balance. But it leaves you feeling mostly gray, curled inside yourself, concentrating on your breath, pulling slowly in, pushing slowly out. Five to seven seconds on an inhalation. Five to seven seconds on an exhalation. You know you aren't ready, but you try to do Urdhva Dhanurasana, Upward Facing Bow, pushing yourself up from the ground into a backbend. Your yoga teacher says, "Lift your heart to heaven." You can't find heaven. You can't even find your heart. But your unsteady arms hold you somehow, and you attain the backbend. Your chest stretches open, and you perceive darkness there that you hadn't noticed before. You hear your yoga teacher's deep voice between the loud pulses at your temples. He's somewhere behind you, but you can't see him, your face facing upside down. You hear him laughing. You hear him say, "The heart greets the sky," and his voice sinks into the empty space in your chest. February You modify the backbend so that you can do it naked on top of your husband. "I thought you were dead," he says. "I'm a real live girl," you say. [End Page 10] March Your doctor explains the risks of refusing treatment. He's got the films of your brain and spinal cord arrayed across the white paper covering the examination table. You can see the white spots on the dark panels, and you know what they mean. "In the long term . . ." he starts in on you again. You don't care about the long term. You don't believe in the long term. You no longer grant the long term power. "Let me ask you a question," you say. You turn to your doctor and twist your left leg around your right leg, tucking your left foot behind your right calf. Then you wrap your right arm around your left arm and hold your hands in prayer position at your forehead and balance like that. You listen to your breath, but you don't move. You stare at your doctor, staring at you, smirking. You incline your head toward the pictures on the table. "Look at those," you say. "Should I be able to do this?" Your doctor looks down, shakes his head. He says, "No, you shouldn't be doing this." And just like that, you deal Science a decisive blow. April To commemorate the decisive blow dealt to Science, you get a tattoo—a pink flower on your right hip. An identifiable body. They always ask: "Any birthmarks, scars, tattoos, or identifying marks?" May Your lexicon is shifting. You hear yourself saying words that you had never before uttered without irony or contempt: forgiveness, redemption, peace, delight. You hear other words as well. Friends use words like luminous, serene. Former friends say: "phony," "fucking freak." June You drive very, very fast. Every day, there is no rain. No rain is expected. The convertible's top is always down, and every day you drive fast in the [End Page 21] sun, running red lights, clipping around the other cars which seem to be standing still. You alone are speeding forward, the world flashing by in streaks of color, fragmented landscapes in quick glimpses, familiar streets now patches of strobing light. You drive faster than the spin of the earth. July You travel south to escape the drought and visit rain. You house-sit your friend's grand house and fine gardens. There are two fig trees at the edge of the property. No one has been picking the figs. Whenever you walk near the trees your feet crush the overripe figs scattered on the lawn. You've never tasted a fresh fig...

Background The Best Start Resource Centre launched Ontario’s first provincial, public-awareness campaign on alcohol use and pregnancy in 2004. The combination of provincial and local strategies resulted in a multilevel approach with the Best Start Resource Centre planning large-scale provincial strategies, and local groups planning innovative community activities. Objectives The objective was to raise awareness about the risks of alcohol use in pregnancy amongst Ontario women of childbearing age through a multi-level awareness campaign. Methods The campaign was assessed through formative, process and outcome evaluations. Evaluation components included both qualitative and quantitative aspects. The primary evaluation approach was a pre- and postcampaign phone survey of Ontario women of childbearing age. Results There was a significant increase of 15% in rate of top-of-mind awareness that “stopping alcohol use in pregnancy” is one of the most important things that pregnant women can do to have a healthy baby. There were significant decreases in the amount of alcohol considered safe in pregnancy, and of the proportion of respondents who thought beer was safe in pregnancy. There were significant increases in the proportion of respondents that thought that women should stop drinking prior to conception. The results show significant increases in awareness that alcohol use in pregnancy can result in problems with alcohol or drug use (11% increase), trouble getting along others (8% increase), trouble with school (7% increase) and difficulties learning (3% increase). There was a significant 65% increase in the proportion of respondents who volunteered that birth defects could result from prenatal exposure to alcohol. Discussion Despite high pre-campaign levels of knowledge, these evaluation results suggest that the Ontario 2004 campaign was successful in increasing knowledge about alcohol use in pregnancy amongst women of childbearing age. The qualitative and quantitative results show that this multi-level approach, combining local and provincial strategies, was an effective model for campaign implementation.

The purpose of this study was to examine the effect of changing key factors in survey questions on public opinion regarding end-of-life decisions. These factors were: (a) patient prognosis (likely vs unlikely to recover from the illness); (b) end-of-life practice (foregoing treatment vs assisted suicide vs euthanasia); and (c) and decision making process (competent patient vs incompetent patient based on living will vs incompetent patient based on family wishes). A representative quota sample of 2019 Canadians 18 years of age or older were surveyed using a 13-item questionnaire with 12 items eliciting attitudes towards end-of-life decisions. The questions were systematically varied according to three key factors: patient prognosis, end-of-life practice and decision making process. One item assessed whether respondents had completed a living will. In the case of a decision to forgo life-sustaining treatment in a competent patient, public approval was 85% if the person was unlikely to recover and 35% if the person was likely to recover. In the case of a competent patient unlikely to recover, public approval was 85% for forgoing life-sustaining treatment, 58% for assisted suicide, and 66% for euthanasia. In the case of forgoing life-sustaining treatment for a patient unlikely to recover, public approval was 85% for a competent patient, 88% for an incompetent patient who had expressed his/her wishes in advance through a living will, and 76% for an incompetent patient based on a family's request. The influence of these key factors was similar in other cases examined. Ten percent of Canadians said they had completed a living will. It was concluded that patient prognosis has a major effect, end-of-life practice a moderate effect, and decision making process a minor effect on public opinion regarding end-of-life decisions.

ObjectiveTo examine public opinion regarding certain elements of consent: disclosure, advance directives, substitute decisions, emergency treatment, and advocacy.DesignCross‐sectional random‐digit‐dialing telephonic survey.SettingGeneral public.ParticipantsOne thousand randomly‐selected adults living in Ontario.InterventionsNone.Main Outcome MeasuresSelf‐reported attitudes and behaviors.ResultsOf 5,708 telephone numbers drawn, 641 were non‐valid or non‐residential, 1,283 were not in service, 1,068 had no answer, a busy line, or an unavailable respondent, 147 subjects had a language barrier, 1,497 subjects refused, 72 interviews were incomplete, and 1,000 interviews were completed. With regard to disclosure, 33% of respondents said that a doctor should withhold information from a patient if asked to do so by the patient's family. With regard to advance directives, 36% of respondents had had advance discussions with their families, and 12% had completed a living will. With regard to substitute decisions, 77% of respondents said that they would want their wishes followed if they were unable to make medical decisions for themselves; 58% wanted their spouse or partner to make such decisions for them. With regard to emergency treatment, 48% of respondents stated that a doctor should give a life‐saving blood transfusion to an unconscious adult carrying a card stating that blood transfusion was against his or her religious beliefs. With regard to advocacy, 78% of respondents supported mandatory advocacy services for serious health decisions such as whether to have heart surgery; 33% supported advocacy services for less serious decisions such as whether to have a dental filling.ConclusionsThese data highlight the need to reconsider legislative provisions regarding and/or target public education programs toward specific consent‐related issues including disclosure, advance directives, substitute decisions, emergency treatment, and advocacy.

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