Risk of Diabetic Retinopathy According to Subtype of Type 2 Diabetes

Type 2 diabetes is a heterogeneous disease that can be subdivided on the basis of β-cell function and insulin sensitivity. We investigated the presence, incidence, and progression of diabetic retinopathy (DR) according to subtypes of type 2 diabetes. In a national cohort, we identified three subtypes of type 2 diabetes: classical, hyperinsulinemic, and insulinopenic type 2 diabetes, based on HOMA2 measurements. From the Danish Registry of Diabetic Retinopathy we extracted information on level of DR. We used several national health registries to link information on comorbidity, medications, and laboratory tests. We found individuals with hyperinsulinemic type 2 diabetes were less likely to have DR at entry date compared with those with classical type 2 diabetes, whereas individuals with insulinopenic type 2 diabetes were more likely to have DR. In multivariable Cox regression analysis, individuals with hyperinsulinemic type 2 diabetes had a decreased risk of both incidence and progression of DR compared to those with classical type 2 diabetes. We did not find any clear difference in risk of incident or progression of DR in individuals with insulinopenic compared to classical type 2 diabetes. These findings indicate that subcategorization of type 2 diabetes is important in evaluating the risk of DR.

ARTICLE HIGHLIGHTS

Presence and development of diabetic retinopathy in 16 999 patients with type 1 diabetes in the Danish Registry of Diabetic Retinopathy

PURPOSE

To evaluate the five-year incidence of diabetic retinopathy (DR) and associated risk markers in patients with type 1 diabetes in the national Danish DR-screening programme.

METHODS

Based on national data, we included all 16 999 patients with type 1 diabetes in the Danish Registry of Diabetic Retinopathy, who attended the national screening programme in the period 2013-2018. According to the worse eye at first screening, DR was classified (levels 0-4) and linked with various national health registries to retrieve information on diabetes duration, systemic comorbidity, and medication.

RESULTS

At first screening, median age and duration of diabetes were 45.0 and 16.7 years, and 57.5% were males. The prevalence and five-year incidences for DR and progression to proliferative DR (PDR) were 44.2%, 8.9% and 2.0%, respectively. In multivariable Cox models, the incidence endpoints were associated with duration of diabetes (hazard ratio [HR] 1.76, 95% confidence interval [CI] 1.63-1.89, and HR 2.04, 95% CI 1.73-2.40 per 10 years), moderately low Charlson Comorbidity Index score (HR 1.27, 95% CI 1.10-1.47, and HR 2.80, 95% CI 2.23-3.51), and use of blood pressure lowering medication (HR 1.20, 95% CI 1.05-1.36, and HR 1.98, 95% CI 1.53-2.57).

CONCLUSION

In a study of all patients with type 1 diabetes from the Danish DR-screening programme, we identified duration of diabetes, systemic disease and use of anti-hypertensive treatment as consistent risk markers for incident and progressive DR.

Inter-grader reliability in the Danish screening programme for diabetic retinopathy

PURPOSE

The Danish Registry of Diabetic Retinopathy includes information from >200 000 patients who attends diabetic retinopathy (DR) screening in Denmark. Screening of patients with uncomplicated type 2 diabetes is often performed by practicing ophthalmologists, while patients with type 1 and complicated type 2 diabetes attends screening at hospitals. We performed a clinical reliability study of retinal images from Danish screening facilities to explore the inter-grader agreement between the primary screening ophthalmologist and a blinded, certified grader.

METHODS

Invitations to participate were sent to screening facilities across Denmark. The primary grader uploaded fundus photographs with information on estimated level of DR (International Clinical Diabetic Retinopathy scale as 0 [no DR], 1-3 [mild, moderate or severe nonproliferative DR {NPDR}], or 4 [proliferative DR {PDR}]), region of screening, image style, and screening facility. Images were then regraded by a blinded, certified, secondary grader. Weighted kappa analysis was performed to evaluate agreement.

RESULTS

Fundus photographs from 230 patients (458 eyes) were received from practicing ophthalmologists (52.6%) and hospital-based grading centres (47.4%) from all Danish regions. Reported levels of DR by the primary graders were 66.8%, 12.2%, 13.1%, 1.3% and 5.5% for DR levels 0-4. The overall agreement between primary and secondary graders was 93% (κ = 0.83). Based on screening facility agreement was 96% (κ = 0.89) and 90% (κ = 0.76) for practicing ophthalmologists and hospital-based graders.

CONCLUSION

In this nationwide study, we observed a high overall inter-grader agreement and based on this, it is reasonable to assume that reported DR gradings in the screening programme in Denmark, accurately reflect the truth.

Bariatric surgery in individuals with type 2 diabetes is not associated with short or long-term risk of diabetic retinopathy progression: results from a nationwide cohort study

AIMS

Bariatric surgery is used to induce weight loss and glycemic stability in type 2 diabetes (T2D). It has been a concern that this may lead to early worsening of diabetic retinopathy (DR) due to a rapid decline in HbA1c. In this study, we evaluated the risk of short and long-term DR development and need for ocular intervention in an entire nation of individuals with T2D undergoing bariatric surgery.

METHODS

The study comprised a national, register-based cohort of individuals with T2D screened for DR. Cases were matched by age, sex and DR level at the date of surgery (index date) with non-bariatric controls. We extracted information on DR levels, in- and outpatient treatments, pharmaceutical prescriptions and laboratory values. We evaluated worsening of DR (incident and progressive DR) at follow-up (6 and 36 months).

RESULTS

Amongst 238,967 individuals with T2D, who attended diabetic eye screening, we identified 553 that underwent bariatric surgery (0.2%) and 2677 non-bariatric controls. Median age was 49 years, and 63% were female. Cases had more comorbidities, lower HbA1c as well as more frequent use of glucose-lowering and antihypertensive medication than controls at index date. In a fully adjusted logistic regression model, the risk of DR worsening for cases was not significantly different compared to controls, neither short-term (OR 0.41 [CI 95% 0.13; 1.33], p = 0.14) nor long-term (OR 0.64 [CI 95% 0.33; 1.24], p = 0.18).

CONCLUSIONS

In this nationwide study, bariatric surgery did not associate with increased risk of short- or long-term DR worsening.

Longitudinal bidirectional associations between diabetic retinopathy and diagnosed depression: Results from a Danish nationwide registry-based cohort study

OBJECTIVE

Diabetic retinopathy (DR) is a feared complication and a leading course of visual impairment, but the connection between DR and depression including the direction has never been studied in a nationwide cohort. We aimed to assess, whether the associations between DR and diagnosed depression are bidirectional.

METHODS

We performed a national register-based cohort study of individuals with type 2 diabetes, who attended diabetic eye screening between January 2013 and June 2022. Level of DR was extracted from the Danish Registry of Diabetic Retinopathy. The severity of DR was assessed according to the International Clinical Diabetic Retinopathy severity scale. Diagnosed depression was ascertained by physician diagnostic codes of unipolar depression (F32), recurrent depression (F33) or dysthymia (F34.1) from the Danish National Patient Register. We estimated presence of diagnosed depression according to DR level at index date and risk of diagnosed depression during follow-up using multivariable logistic and Cox regression, respectively. Secondly, we assessed whether diagnosed depression at index date could predict incident DR.

RESULTS

We included 240,893 individuals with type 2 diabetes with baseline rates of diagnosed depression ranging from 5.2 to 6.0 % for DR level 1-4. At index date, individuals with type 2 diabetes and DR were less likely to have a history of diagnosed depression (multivariable adjusted OR, 0.77 [95 % CI 0.73-0.82]). In 226,523 individuals with type 2 diabetes followed for 1,159,755 person-years, 1.7 % developed at least one episode of diagnosed depression. In a model adjusted for age and sex, individuals with DR at index date had an increased risk of incident diagnosed depression compared to those without DR (HR 1.25 [95 % CI 1.16-1.36]). Adjusting for marital status, use of glucose-, lipid- and blood pressure lowering medication, HbA1c, diabetic neuropathy and Charlson comorbidity index waived the above risk (multivariable adjusted HR 1.02 [95 % CI 0.93-1.12]). Furthermore a previous history of diagnosed depression was not associated with increased risk of incident DR (multivariable adjusted HR 0.89 [95 % CI 0.77-1.03]).

CONCLUSION

In this nationwide cohort study, individuals with DR at first screening were 23 % less likely to have a history of depression, but our data did not support a bidirectional association between DR and depression. Selection bias may have occurred as diagnosed depression is a known barrier for attending DR-screening.

Five-Year Incidence of Proliferative Diabetic Retinopathy and Associated Risk Factors in a Nationwide Cohort of 201 945 Danish Patients with Diabetes

Purpose

To evaluate the proliferative diabetic retinopathy (PDR) progression rates and identify the demographic and clinical characteristics of patients who later developed PDR compared with patients who did not progress to that state.

Design

A national 5-year register-based cohort study including 201 945 patients with diabetes.

Subjects

Patients with diabetes who had attended the Danish national screening program (2013-2018) for diabetic retinopathy (DR).

Methods

We used the first screening episode as the index date and included both eyes of patients with and without subsequent progression of PDR. Data were linked with various national health registries to investigate relevant clinical and demographic parameters. The International Clinical Retinopathy Disease Scale was used to classify DR, with no DR as level 0, mild DR as level 1, moderate DR as level 2, severe DR as level 3, and PDR as level 4.

Main Outcome Measures

Hazard ratios (HRs) for incident PDR for all relevant demographic and clinical parameters and 1-, 3-, and 5-year incidence rates of PDR according to baseline DR level.

Results

Progression to PDR within 5 years was identified in 2384 eyes of 1780 patients. Proliferative diabetic retinopathy progression rates from baseline DR level 3 at 1, 3 and 5 years were 3.6%, 10.9%, and 14.7%, respectively. The median number of visits was 3 (interquartile range, 1-4). Progression to PDR was predicted in a multivariable model by duration of diabetes (HR, 4.66 per 10 years; 95% confidence interval [CI], 4.05-5.37), type 1 diabetes (HR, 9.61; 95% CI, 8.01-11.53), a Charlson Comorbidity Index score of > 0 (score 1: HR, 4.62; 95% CI, 4.14-5.15; score 2: HR, 2.28; 95% CI, 1.90-2.74; score ≥ 3: HR, 4.28; 95% CI, 3.54-5.17), use of insulin (HR, 5.33; 95% CI, 4.49-6.33), and use of antihypertensive medications (HR, 2.23; 95% CI, 1.90-2.61).

Conclusions

In a 5-year longitudinal study of an entire screening nation, we found increased risk of PDR with increasing baseline DR levels, longer duration of diabetes, type 1 diabetes, systemic comorbidity, use of insulin, and blood pressure-lowering medications. Most interestingly, we found lower risk of progression from DR level 3 to PDR compared with that in previous studies.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Diabetic retinopathy is a predictor of chronic respiratory failure: A nationwide register-based cohort study

Purpose

Diabetic retinopathy (DR) is a hypoxic retinal disease, but so far, the association with systemic hypoxia is poorly understood. Hence, the aim of this study was to evaluate cross-sectional and longitudinal associations between DR and chronic respiratory failure (CRF) in a national cohort.

Design

Cross-sectional and 5-year longitudinal register-based cohort study.

Methods

Between 2013 and 2018, we included patients with diabetes from the Danish Registry of Diabetic Retinopathy, who were each age and sex matched with five controls without diabetes. At index date, the prevalence of CRF was compared between cases and controls, and the longitudinal relationship between DR and CRF was assessed in a five-year follow-up.

Results

At baseline, we identified 1,980 and 9,990 patients with CRF among 205,970 cases and 1,003,170 controls. The prevalence of CRF was higher among cases than controls (OR 1.75, 95% CI 1.65-1.86), but no difference between cases with and without DR was found.During follow-up, we identified 1,726 and 5,177 events of CRF among cases and controls, respectively. The incidence of CRF was higher among both cases with and without DR compared to controls (DR level 0: HR 1.24, 95% CI 1.16-1.33, DR level 1-4: HR 1.86, 95% CI 1.63-2.12), and higher among cases with DR compared to cases without DR (HR 1.54, 95% CI 1.38-1.72).

Conclusion

In this study based on nationwide data, we found an increased risk of present and incident CRF in patients with diabetes with or without DR, and we identified DR as a predictor of future CRF.

Presence and development of diabetic retinopathy in 153 238 patients with type 2 diabetes in the Danish Registry of Diabetic Retinopathy

PURPOSE

The purpose of the study was to evaluate the prevalence and incidence of diabetic retinopathy (DR) along with associated markers in patients with type 2 diabetes in the Danish DR-screening programme.

METHODS

We included all persons with type 2 diabetes in the Danish Registry of Diabetic Retinopathy, who had attended at least one episode of DR screening in 2013-2018. DR was classified as levels 0-4 indicating increasing severity. Data were linked with various national health registries to retrieve information on diabetes duration, marital status, comorbidity and systemic medication.

RESULTS

Among 153 238 persons with type 2 diabetes, median age and duration of diabetes were 66.9 and 5.3 years and 56.4% were males. Prevalence and 5-year incidences of DR, 2-step-or-more progression of DR and progression to proliferative DR (PDR) were 8.8%, 3.8%, 0.7% and 0.2%, respectively. In multivariable models, leading markers of incident DR and progression to PDR were duration of diabetes (HR 1.98, 95% CI 1.87-2.09; HR 2.89, 95% CI 2.34-3.58 per 10 years of duration) and use of insulin (HR 1.88, 95% CI 1.76-2.01; HR 2.40, 95% CI 1.84-3.13), while the use of cholesterol-lowering medicine was a protecting marker (HR 0.87, 95% CI 0.81-0.93; HR 0.70, 95% CI 0.52-0.93). From 2013 to 2015, 3-year incidence rates of PDR decreased from 1.22 to 0.45 events per 1000 person-years.

CONCLUSION

Nationally, among Danish individuals with type 2 diabetes attending DR screening, we identified duration of diabetes and use of insulin as the most important predictor for the development of DR, while cholesterol-lowering medicine was a protective factor.

Bidirectional 5-year risks of diabetic retinopathy, glaucoma and/or ocular hypertension: Results from a national screening programme

PURPOSE

We aimed to investigate if diabetic retinopathy (DR), glaucoma and/or ocular hypertension (OHT) are prospectively linked, as previous studies have proposed cross-sectional associations, but longitudinal data from larger cohorts are lacking.

METHODS

We performed a bidirectional 5 years prospective, registry-based cohort study. We extracted data from national registers, including the Danish Registry of Diabetic Retinopathy, the Danish Civil Registration System, the Danish National Patient Register and the Danish National Prescription Registry. DR level was defined by the highest level of the two eyes. Glaucoma and/or OHT was defined by diagnostic codes (H40*) or at least three redeemed prescriptions of glaucoma medication (S01E*) within 1 year. We included 205 970 persons with diabetes and 1 003 170 age- and gender-matched non-diabetes controls. Exposures were level-specific DR (i) and glaucoma and/or OHT (ii), and outcomes were hazard ratios (HRs) for 5 years incident glaucoma and/or OHT (i) and DR (ii).

RESULTS

Persons with diabetes were more likely to develop glaucoma and/or OHT (multivariable adjusted HR 1.11, 95% CI 1.06-1.15), but this did not depend on the level of DR. In persons with diabetes, those with glaucoma and/or OHT were more likely to develop DR (multivariable adjusted HR 1.12, 95% CI 1.03-1.23) within 5 years.

CONCLUSION

In a national cohort, diabetes associated with a little higher risk of upcoming glaucoma and/or OHT, and, inversely, the presence of the latter predicted a higher risk of incident DR. Nevertheless, our data do not seem to justify including glaucoma evaluation in the national Danish DR-screening programme.

Attendance in a national screening program for diabetic retinopathy: a population-based study of 205,970 patients

AIMS

A nationwide diabetic retinopathy (DR) screening program has been established in Denmark since 2013. We aimed to perform an evaluation of adherence to DR screenings and to examine whether non-adherence was correlated to DR progression.

METHODS

The population consisted of a register-based cohort, who participated in the screening program from 2013 to 2018. We analyzed age, gender, marital status, DR level (International Clinical DR severity scale, none, mild-, moderate-, severe non-proliferative DR (NPDR) and proliferative DR (PDR)), comorbidities and socioeconomic factors. The attendance pattern of patients was grouped as either timely (no delays > 33%), delayed (delays > 33%) or one-time attendance (unexplained).

RESULTS

We included 205,970 patients with 591,136 screenings. Rates of timely, delayed and one-time attendance were 53.0%, 35.5% and 11.5%, respectively. DR level at baseline was associated with delays (mild-, moderate-, severe NPDR and PDR) and one-time attendance (moderate-, severe NPDR and PDR) with relative risk ratios (RRR) of 1.68, 2.27, 3.14, 2.44 and 1.18, 2.07, 1.26, respectively (P < 0.05). Delays at previous screenings were associated with progression to severe NPDR or PDR (hazard ratio (HR) 2.27, 6.25 and 12.84 for 1, 2 and 3+ delays, respectively). Any given delay doubled the risk of progression (HR 2.28).

CONCLUSIONS

In a national cohort of 205,970 patients, almost half of the patients attended DR screening later than scheduled or dropped out after first screening episode. This was, in particular, true for patients with any levels of DR at baseline. DR progression in patients with delayed attendance, increased with the number of missed appointments.

Diabetic Retinopathy Predicts Risk of Alzheimer’s Disease: A Danish Registry-Based Nationwide Cohort Study

Background:

Retinal neurodegeneration is evident in early diabetic retinopathy (DR) which may be associated with other neurodegenerative diseases like Alzheimer's disease (AD).

Objective:

To investigate diabetes and DR as a risk marker of present and incident AD.

Methods:

A register-based cohort study was performed. We included 134,327 persons with diabetes above 60 years of age, who had attended DR screening, and 651,936 age- and gender-matched persons without diabetes.

Results:

At baseline, the prevalence of AD was 0.7% and 1.3% among patients with and without diabetes, respectively. In a multivariable regression model, patients with diabetes were less likely to have AD at baseline (adjusted OR 0.63, 95% CI 0.59–0.68). During follow-up, incident AD was registered for 1473 (0.35%) and 6,899 (0.34%) persons with and without diabetes, respectively. Compared to persons without diabetes, persons with diabetes and no DR had a lower risk to develop AD (adjusted HR 0.87, 95% CI 0.81–0.93), while persons with diabetes and DR had higher risk of AD (adjusted HR 1.24, 95% CI 1.08–1.43). When persons with diabetes and no DR were used as references, a higher risk of incident AD was observed in persons with DR (adjusted HR 1.34, 95% CI 1.18–1.53).

Conclusion:

Individuals with diabetes without DR were less likely to develop AD compared to persons without diabetes. However, individuals with DR had a 34% higher risk of incident AD, which raise the question whether screening for cognitive impairment should be done among individuals with DR.

Diabetic retinopathy as a potential marker of Parkinson's disease: a register-based cohort study

Neurodegeneration is an early event in the pathogenesis of diabetic retinopathy, and an association between diabetic retinopathy and Parkinson’s disease has been proposed. In this nationwide register-based cohort study, we investigated the prevalence and incidence of Parkinson’s disease among patients screened for diabetic retinopathy in a Danish population-based cohort. Cases (n = 173 568) above 50 years of age with diabetes included in the Danish Registry of Diabetic Retinopathy between 2013 and 2018 were matched 1:5 by gender and birth year with a control population without diabetes (n = 843 781). At index date, the prevalence of Parkinson’s disease was compared between cases and controls. To assess the longitudinal relationship between diabetic retinopathy and Parkinson’s disease, a multivariable Cox proportional hazard model was estimated. The prevalence of Parkinson’s disease was 0.28% and 0.44% among cases and controls, respectively. While diabetic retinopathy was not associated with present (adjusted odds ratio 0.93, 95% confidence interval 0.72–1.21) or incident Parkinson’s disease (adjusted hazard ratio 0.77, 95% confidence interval 0.56–1.05), cases with diabetes were in general less likely to have or to develop Parkinson’s disease compared to controls without diabetes (adjusted odds ratio 0.79, 95% confidence interval 0.71–0.87 and adjusted hazard ratio 0.88, 95% confidence interval 0.78–1.00). In a national cohort of more than 1 million persons, patients with diabetes were 21% and 12% were less likely to have prevalent and develop incident Parkinson’s disease, respectively, compared to an age- and gender-matched control population without diabetes. We found no indication for diabetic retinopathy as an independent risk factor for incident Parkinson’s disease.

OP0263-HPR MAJOR STRESSORS IN THE YEAR PRIOR TO RA DIAGNOSIS: IMPACT ON PATIENT-REPORTED OUTCOMES ONE YEAR LATER

Background:

Stress is implicated in RA onset and poorer prognoses through changes in neuro-endocrine and autoimmune function. Although many people with RA link disease onset to recent stressful life events, results from retrospective studies are unclear.

Objectives:

To describe the incidence of major stressors(+STRESS) in year prior to diagnosis and compare characteristics and patient-reported outcomes (PROs) of newly diagnosed RA patients with and without+STRESSat 0 and 12 months.

Methods:

Data were from early RA patients (symptoms <1 yr) enrolled in the Canadian Early Arthritis Cohort (CATCH) from 2007-17 who met 1987/2010 ACR/EULAR criteria and had ≥12 months of follow-up. Patients reported major psychological (death, divorce/separation, family, financial, other) and physical (motor vehicle accident, surgery, major illness/infection, other) stressors in previous year. We used independent t-tests and chi square to compare characteristics by stressors at baseline, and multivariable regression to examine the impact of+STRESSon disease activity and PROs at 1 year, adjusting for age, sex, education, fibromyalgia, and SJC.

Results:

The 1933 adults were mostly female (72%), with a mean (SD) age of 55 (15) years. 52% reported 1+ stressors in previous year; family (48%), financial stress (36%), death (35%), surgery (28%), and major illness (26%) were the most common stressors. Patients with +STRESS were more likely to be women, younger, have more comorbidities including fibromyalgia, and higher mean DAS28. Patients with +STRESS also had significantly higher mean pain, fatigue, depression, sleep disturbance, patient global, and HAQ scores at baseline.

At 1 year, SJC and the proportion in DAS28 REM was similar between groups. However, PROs (pain, HAQ, Fatigue, Pt Global, Depression, Poor Sleep) remained higher in+STRESS, with evidence of an additive effect for number of stressors and having both physical and psychological stressors (Table). The greatest impacts were on mood, sleep disturbance, and fatigue.

Conclusion:

In this pan-Canadian early RA cohort, more than half reported 1+ stressful life events in the year prior to diagnosis. Individuals reporting major stressors had significantly worse pain, patient global, disability, depression, fatigue, and sleep disturbance at diagnosis; 1 year later, though disease activity was similar between groups, the effects of +STRESS on PROs persisted. Early RA patients with recent major stressors may benefit from emotional support and stress reduction to optimize how they feel and function.

Mean (SD) or N (%)No Stress(N=928; 48%)Physical(N=131; 7%)Psychological(N=658; 34%)Both(N=216; 11%)Age56 (15)56 (15)53 (14)52 (15)Women622 (67%)82 (63%)512 (78%)174 (81%)College Education464 (50%)76 (58%)345 (52%)126 (58%)Rheum Dis Comorbid Index1.1 (1.2)1.4 (1.4)1.1 (1.3)1.4 (1.3)OA or Spinal pain168 (18%)35 (27%)117 (18%)55 (25%)Fibromyalgia diagnosis15 (2%)2 (2%)13 (2%)11 (5%)Symptom duration (months)5.6 (3.0)5.7 (3.0)5.9 (3.0)5.9 (3.0)DAS28 – mean5.0 (1.4)5.1 (1.5)5.0 (1.5)5.2 (1.4)MTX ±csDMARDs679 (73%)100 (76%)489 (74%)166 (77%)Oral Steroids295 (32%)40 (31%)215 (33%)55 (25%)Pain (0-10)5.3 (2.8)5.5 (2.9)5.7 (2.8)6.2 (2.8)HAQ-DI1.0 (0.7)1.2 (0.7)1.1 (0.7)1.3 (0.7)Fatigue (0-10)4.7 (3.1)5.0 (3.0)5.7 (2.9)5.9 (2.9)Patient Global (0-10)5.6 (2.9)6.0 (2.9)6.0 (2.9)6.4 (3.0)Depression (SF12 MCS < 45.6)329 (35%)54 (41%)356 (54%)123 (57%)Poor sleep (0-10)4.5 (3.4)4.8 (3.3)5.3 (3.2)6.0 (3.1)

Disclosure of Interests:

Nicole Andersen: None declared, Orit Schieir: None declared, Marie-France Valois: None declared, Gilles Boire Grant/research support from: Merck Canada (Registry of biologices, Improvement of comorbidity surveillance)

Amgen Canada (CATCH, clinical nurse)

Abbvie (CATCH, clinical nurse)

Pfizer (CATCH, Registry of biologics, Clinical nurse)

Hoffman-LaRoche (CATCH)

UCB Canada (CATCH, Clinical nurse)

BMS (CATCH, Clinical nurse, Observational Study Protocol IM101664. SEROPOSITIVITY IN A LARGE CANADIAN OBSERVATIONAL COHORT)

Janssen (CATCH)

Celgene (Clinical nurse)

Eli Lilly (Registry of biologics, Clinical nurse), Consultant of: Eli Lilly, Janssen, Novartis, Pfizer, Speakers bureau: Merck, BMS, Pfizer, Janet Pope Grant/research support from: AbbVie, Bristol-Myers Squibb, Eli Lilly & Company, Merck, Roche, Seattle Genetics, UCB, Consultant of: AbbVie, Actelion, Amgen, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Eicos Sciences, Eli Lilly & Company, Emerald, Gilead Sciences, Inc., Janssen, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Speakers bureau: UCB, Glen Hazlewood: None declared, Louis Bessette Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi, UCB Pharma, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Sanofi, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada, Diane Tin: None declared, Carter Thorne Consultant of: Abbvie, Centocor, Janssen, Lilly, Medexus/Medac, Pfizer

Speakers bureau: Medexus/Medac, Edward Keystone Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, F. Hoffmann-La Roche Inc, Gilead, Janssen Inc, Lilly Pharmaceuticals, Pfizer Pharmaceuticals, Sanofi-Aventis, Consultant of: AbbVie, Amgen, AstraZeneca Pharma, Biotest, Bristol-Myers Squibb Company, Celltrion,

Crescendo Bioscience, F. Hoffmann-La Roche Inc, Genentech Inc, Gilead, Janssen Inc, Lilly

Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Sandoz, UCB., Speakers bureau: Amgen, AbbVie, Bristol-Myers Squibb Canada, F. Hoffmann-La Roche Inc., Janssen Inc., Merck, Pfizer Pharmaceuticals, Sanofi Genzyme, UCB, Vivian Bykerk: None declared, Susan J. Bartlett Consultant of: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie, Speakers bureau: Pfizer, UCB, Lilly, Novartis, Merck, Janssen, Abbvie

Evidence-based Danish guidelines for screening of diabetic retinopathy

PURPOSE

Diabetic retinopathy (DR) is among the leading causes of visual loss in the working-age population. It is generally accepted that screening of DR is cost-effective and can detect DR before it becomes sight-threatening to allow timely treatment.

METHODS

A group of retinal specialists was formed by the Danish Ophthalmological Society with the aim to formulate contemporary evidence-based guidelines for screening of DR in order to implement these in the Danish screening system.

RESULTS

We hereby present evidence for DR-screening regarding (1) classification of DR, (2) examination techniques, (3) screening intervals and (4) automated screening. It is our recommendation that the International Clinical Retinopathy Disease Severity Scale should be used to classify DR. As a minimum, mydriatic two-field disc- and macular-centred images are required. In the case of suspected clinically significant diabetic macular oedema, supplementary optical coherence tomography can increase the diagnostic accuracy. There is solid evidence to support a flexible, individualized screening regimen. In particular, it is possible to prolong screening intervals to 24-48 months for patients with no or mild nonproliferative diabetic retinopathy (NPDR), but it is also possible to use extended intervals of 12-24 months for patients with moderate NPDR given that these are well-regulated regarding glycaemic control (HbA1c ≤ 53 mmol/mol) and blood pressure (≤130/80 mmHg). Automated screening of DR is encouraging but is not ready for implementation at present.

CONCLUSION

Danish evidenced-based guidelines for screening of DR support high-quality imaging and allow flexible, individualized screening intervals with a potential for extension to patients with low risk of DR progression.

Pteropods are excellent recorders of surface temperature and carbonate ion concentration

Pteropods are among the first responders to ocean acidification and warming, but have not yet been widely explored as carriers of marine paleoenvironmental signals. In order to characterize the stable isotopic composition of aragonitic pteropod shells and their variation in response to climate change parameters, such as seawater temperature, pteropod shells (Heliconoides inflatus) were collected along a latitudinal transect in the Atlantic Ocean (31° N to 38° S). Comparison of shell oxygen isotopic composition to depth changes in the calculated aragonite equilibrium oxygen isotope values implies shallow calcification depths for H. inflatus (75 m). This species is therefore a good potential proxy carrier for past variations in surface ocean properties. Furthermore, we identified pteropod shells to be excellent recorders of climate change, as carbonate ion concentration and temperature in the upper water column have dominant influences on pteropod shell carbon and oxygen isotopic composition. These results, in combination with a broad distribution and high abundance, make the pteropod species studied here, H. inflatus, a promising new proxy carrier in paleoceanography.

The Danish Registry of Diabetic Retinopathy

AIM OF DATABASE

To monitor the development of diabetic eye disease in Denmark and to evaluate the accessibility and effectiveness of diabetic eye screening programs with focus on interregional variations.

TARGET POPULATION

The target population includes all patients diagnosed with diabetes. Denmark (5.5 million inhabitants) has ~320,000 diabetes patients with an annual increase of 27,000 newly diagnosed patients. The Danish Registry of Diabetic Retinopathy (DiaBase) collects data on all diabetes patients aged ≥18 years who attend screening for diabetic eye disease in hospital eye departments and in private ophthalmological practice. In 2014-2015, DiaBase included data collected from 77,968 diabetes patients.

MAIN VARIABLES

The main variables provide data for calculation of performance indicators to monitor the quality of diabetic eye screening and development of diabetic retinopathy. Data with respect to age, sex, best corrected visual acuity, screening frequency, grading of diabetic retinopathy and maculopathy at each visit, progression/regression of diabetic eye disease, and prevalence of blindness were obtained. Data analysis from DiaBase's latest annual report (2014-2015) indicates that the prevalence of no diabetic retinopathy, nonproliferative diabetic retinopathy, and proliferative diabetic retinopathy is 78%, 18%, and 4%, respectively. The percentage of patients without diabetic maculopathy is 97%. The proportion of patients with regression of diabetic retinopathy (20%) is greater than the proportion of patients with progression of diabetic retinopathy (10%).

CONCLUSION

The collection of data from diabetic eye screening is still expanding in Denmark. Analysis of the data collected during the period 2014-2015 reveals an overall decrease of diabetic retinopathy compared to the previous year, although the number of patients newly diagnosed with diabetes has been increasing in Denmark. DiaBase is a useful tool to observe the quality of screening, prevalence, and progression/regression of diabetic eye disease.

Binding Interactions of Agents That Alter α-Synuclein Aggregation

Further examination of peptides with well-folded antiparallel β strands as inhibitors of amyloid formation from α-synuclein has resulted in more potent inhibitors. Several of these had multiple Tyr residues and represent a new lead for inhibitor design by small peptides that do not divert α-synuclein to non-amyloid aggregate formation. The most potent inhibitor obtained in this study is a backbone cyclized version of a previously studied β hairpin, designated as WW2, with a cross-strand Trp/Trp cluster. The cyclization was accomplished by adding a d-Pro-l-Pro turn locus across strand termini. At a 2:1 peptide to α-synuclein ratio, cyclo-WW2 displays complete inhibition of β-structure formation. Trp-bearing antiparallel β-sheets held together by a disulphide bond are also potent inhibitors. ¹⁵N HSQC spectra of α-synuclein provided new mechanistic details. The time course of ¹⁵N HSQC spectral changes observed during β-oligomer formation has revealed which segments of the structure become part of the rigid core of an oligomer at early stages of amyloidogenesis and that the C-terminus remains fully flexible throughout the process. All of the effective peptide inhibitors display binding-associated titration shifts in ¹⁵N HSQC spectra of α-synuclein in the C-terminal Q109-E137 segment. Cyclo-WW2, the most potent inhibitor, also displays titration shifts in the G41-T54 span of α-synuclein, an additional binding site. The earliest aggregation event appears to be centered about H50 which is also a binding site for our most potent inhibitor.

Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance?

BACKGROUND

We aimed to investigate whether fluid therapy with a goal of near-maximal stroke volume (SV) guided by oesophageal Doppler (ED) monitoring result in a better outcome than that with a goal of maintaining bodyweight (BW) and zero fluid balance in patients undergoing colorectal surgery.

METHODS

In a double-blinded clinical multicentre trial, 150 patients undergoing elective colorectal surgery were randomized to receive fluid therapy after either the goal of near-maximal SV guided by ED (Doppler, D group) or the goal of zero balance and normal BW (Zero balance, Z group). Stratification for laparoscopic and open surgery was performed. The postoperative fluid therapy was similar in the two groups. The primary endpoint was postoperative complications defined and divided into subgroups by protocol. Analysis was performed by intention-to-treat. The follow-up was 30 days. The trial had 85% power to show a difference between the groups.

RESULTS

The number of patients undergoing laparoscopic or open surgery and the patient characteristics were similar between the groups. No significant differences between the groups were found for overall, major, minor, cardiopulmonary, or tissue-healing complications (P-values: 0.79; 0.62; 0.97; 0.48; and 0.48, respectively). One patient died in each group. No significant difference was found for the length of hospital stay [median (range) Z: 5.00 (1-61) vs D: 5.00 (2-41); P=0.206].

CONCLUSIONS

Goal-directed fluid therapy to near-maximal SV guided by ED adds no extra value to the fluid therapy using zero balance and normal BW in patients undergoing elective colorectal surgery.

Sequential analysis of biomarkers in cerebrospinal fluid and serum during invasive meningococcal disease

The aim of the present study was to determine the profile of different inflammatory molecules in serum and cerebrospinal fluid (CSF) during invasive meningococcal disease (IMD). Their relationship with IMD severity was also assessed. A cohort of 12 patients with IMD was investigated. Paired serum and CSF samples were obtained at the time of diagnostic and follow-up lumbar puncture and were examined using Luminex analysis. IMD severity correlated with serum interleukin-6 (IL-6) and interleukin-1 receptor antagonist (IL-1 ra) on admission. Furthermore, the CSF levels of IL-1 beta, IL-1 ra, IL-6, IL-8, macrophage inflammatory protein-1 beta (MIP-1 beta), and monocyte chemoattractant protein-1 (MCP-1) were significantly higher than their respective serum levels. The strongest correlations were found between serum concentrations of IL-1 beta and IL-1 ra, IL-6, IL-8, and MIP-1 beta, whereas the strongest correlations in CSF were found between endotoxin and IL-8, IL-17, MIP-1 beta, and MCP-1. As was expected, the concentrations of inflammatory molecules in both serum and CSF significantly decreased after antibiotic treatment. With regard to kinetics, a severe course of IMD correlated positively with rapid declines of CSF IL-6 and cortisol levels. Sequential multiple analyses revealed patterns of inflammatory responses that were associated with the severity of IMD, as well as with the compartmentalization and kinetics of the immune reaction.

Vogt-Koyanagi-Harada syndrome in a Greenlandic Inuit

PURPOSE

To report a case of Vogt-Koyanagi-Harada syndrome (VKH) in an Inuit.

METHODS

We carried out a medical evaluation and human leucocyte antigen (HLA) genotyping.

RESULTS

A 36-year-old male Inuit developed severely decreased vision, intense headache and vertigo over a 3-week period. Ocular examination revealed panuveitis with bilateral serous retinal detachment and optic nerve head oedema. There was no history of ocular trauma or evidence suggestive of other disease entities. The patient responded well to high-dose systemic prednisolone. Vitiligo presented late in the course.

CONCLUSIONS

This case report describes the first published case of VKH in a patient of Inuit ancestry. The patient was homozygous for HLA-DR4, a genotype previously associated with VKH.

[Uveitis--a manifestation of syphilis]

We describe two cases of neurosyphilis whose diagnosis was based on ocular symptoms. Both patients were treated in the Eye Department for bilateral uveitis, and they were tested serologically positive for syphilis. The diagnoses of neurosyphilis were confirmed by demonstration of CSF pleocytosis and specific intrathecal antibody production. Both patients were treated with 21 million units of penicillin IV daily for 15 days. Ocular syphilis is an unusual manifestation of the disease but should be considered in patients with uveitis of uncertain origin, especially if the patient has a rash and/or headache.

Nordic research in ophthalmology

Nordic ophthalmologists and vision scientists are active in many fields of eye research. This is most evident at the biannual Nordic Congress of Ophthalmology, most recently held in Malmö in June 2004. The authors here review some of the research in vision and ophthalmology presented at this meeting or published recently by Nordic scientists. This paper does not represent a comprehensive review of all Nordic research in the field, but attempts to give an overview of some of the activities underway in eye research in this part of the world.

Age-related macular degeneration among the Inuit in Greenland

OBJECTIVES

To investigate the clinical appearance and prevalence of Age-related Macular Degeneration (AMD) among the Inuit in Greenland, to investigate risk factors and to initiate the search for possible genetic markers.

STUDY DESIGN

A cross-sectional population study including all individuals older than 60 years of age, born in Greenland and living in the communities of Nuuk and Sisimiut, was performed in 2000 and 2001.

METHODS

All participants underwent an ophthalmologic examination, which was complemented by fundus photography and a questionnaire.

RESULTS

689 individuals, or more than 70%, participated in the study. Data are currently being processed. The preliminary data suggest that AMD among the Inuit is characterised by a rather uniform morphology and poor visual outcome. The detection of more cases of AMD in the early and late stages in relation to intermediate stages furthermore indicates a rapid development of AMD among the Inuit.

CONCLUSION

The relative homogeneity of the Inuit population of Greenland may represent an opportunity for identifying the aetiological factors responsible for the development of AMD. The future results of this research project will hopefully also contribute towards an increased focus on the growing number of individuals with visual impairment due to AMD among the Inuit.

Neutrophil and platelet dynamics at organ level after cardiopulmonary bypass: an in vivo study in neonatal pigs

The aim was to investigate if organ dysfunction is a consequence of cell accumulation in the tissue and whether this accumulation is caused by the cardiopulmonary bypass (CPB) procedure. Twenty-six piglets were used in the sham group (sternotomy, n=12) or in the CPB group (sternotomy, CPB, n=14). Isotope-labeled autologous (99m)Tc-neutrophils (PMNs) and (111)In-platelets were infused and dynamically followed at organ level with a gamma camera before, during, and 4 h after termination of CPB. The CPB group showed a 49% increase in (99m) Tc-PMNs in the kidneys in the postoperative period compared to a decrease of 2% in the sham group. A less marked decrease was observed in the lungs and peripheral blood between the two groups. The increased radioactivity at organ level post-CPB could be due to changes in flow, extraction in the organ or accumulation of cells, especially in the kidneys and lungs, and might contribute to temporary organ dysfunction postoperatively.

Fraunhofer diffraction of atomic matter waves: electron transfer studies with a laser cooled target

We have constructed an apparatus combining the experimental techniques of cold target recoil ion momentum spectroscopy and a laser cooled target. We measure angle differential cross sections in Li(+)+Na-->Li+Na(+) electron transfer collisions in the keV energy regime with a momentum resolution of 0.12 a.u. yielding an order of magnitude better angular resolution than previous measurements. We resolve Fraunhofer-type diffraction patterns in the differential cross sections. Good agreement with predictions of the semiclassical impact parameter method is obtained.

Hydrogen and carbon isotope fractionation during aerobic biodegradation of benzene

The main aim of the study was to evaluate hydrogen and carbon isotope fractionation during biodegradation of benzene as a possible tool to trace the process in contaminated environments. Aerobic biodegradation of benzene by two bacterial isolates, Acinetobacter sp. and Burkholderia sp., was accompanied by significant hydrogen and carbon isotope fractionation with hydrogen isotope enrichment factors of -12.8 +/- 0.7 per thousand and -11.2 +/- 1.8 per thousand, respectively, and average carbon isotope enrichment factors of -1.46 +/- 0.06 per thousand and -3.53 +/- 0.26 per thousand, respectively. Inorganic carbon produced by Acinetobacter sp. was depleted in 13C by 3.6-6.2 per thousand as compared to the initial delta13C of benzene, while the produced biomass was enriched in 13C by 3.8 per thousand. The secondary aim was to determine isotope ratios of benzenes from different manufacturers with regard to the use of isotopes for source differentiation. While two of the four analyzed benzenes had similar delta13C values, each of them had a distinct delta2H-delta13C pair and delta2H values spread over a range of 66.5 per thousand. Thus, combined analyses of hydrogen and carbon isotopes may be a more promising approach to trace sources and/or biodegradation of benzene than measuring carbon isotopes only.

Use of isotopic and molecular techniques to link toluene degradation in denitrifying aquifer microcosms to specific microbial populations

Microcosms were inoculated with sediments from both a petroleum-hydrocarbon (PHC)-contaminated aquifer and from a nearby pristine aquifer and incubated under anoxic denitrifying conditions with [methyl-13C]toluene. These microcosms served as a laboratory model system to evaluate the combination of isotope (13C-labeling of polar-lipid-derived fatty acids) and molecular techniques (16S rRNA-targeting gene probes) to identify the toluene-metabolizing population. After total depletion of toluene, the following bacterial phospholipid fatty acids (PLFA) were 13C-enriched: 16:1omega7c, 16:1omega7t, 16:0, cy17:0, and 18:1omega7c. Pure culture experiments demonstrated that these compounds were also found in PLFA profiles of PHC-degrading Azoarcus spp. (beta-Proteobacteria) and related species. The origin of the CO2 evolved in the microcosms was determined by measurements of stable carbon isotope ratios. Toluene represented 11% of the total pool of mineralized substrates in the contaminated sediment and 54% in the pristine sediment. The microbial community in the microcosm incubations was characterized by using DAPI staining and whole-cell hybridization with specific fluorescently labeled 16S rRNA-targeted oligonucleotide probes. Results revealed that 6% of the DAPI-stained cells in the contaminated sediment and 32% in the pristine sediment were PHC-degrading Azoarcus spp. In biotic control microcosms (incubated under denitrifying conditions, no toluene added), Azoarcus spp. cells remained at less than 1% of the DAPI-stained cells. The results show that isotope analysis in combination with whole-cell hybridization is a promising approach to identify and to quantify denitrifying toluene degraders within microbial communities.