OPHDIAT: a telemedical network screening system for diabetic retinopathy in the Ile-de-France

OBJECTIVE: International and national guidelines recommend an annual funduscopic examination for all diabetic patients, but such annual fundus examinations are not sufficiently performed in France. Non-mydriatic fundus photography is a valid method of evaluation for diabetic retinopathy (DR) and a viable alternative to ophthalmoscopy. After two pilot studies demonstrated the feasibility of telemedical screening for diabetic retinopathy in both hospital and primary-care settings, we developed a regional telemedical network, OPHDIAT, designed to facilitate access to regular annual evaluations of patients with diabetes while saving medical time. MATERIALS AND METHODS: OPHDIAT comprises peripheral screening centres equipped with non-mydriatic cameras, where fundus photographs are taken by technicians linked by telemedicine to a reference centre, where ophthalmologists grade the images. Currently in the Ile-de-France region, 16 screening centres are linked through a central server to an ophthalmologic reading centre and includes 11 centres located in the diabetes departments of 11 hospitals, one diabetic retinopathy screening centre located in northern Paris, three in healthcare centres and one in a prison. RESULTS: During the 28-month evaluation period, 15,307 DR screening examinations were performed. Retinal photographs of at least one eye could not be graded in 1332 patients (9.7%) and diabetic retinopathy was detected in 3350 patients (23.4%). After the screening examination, 3478 patients (25.2%) were referred to an ophthalmologist for either DR, cataract and/or non-gradable photographs. CONCLUSION: Fundus photography combined with telemedicine has the potential to improve the regular annual evaluation for diabetic retinopathy. The organization of the network around a central reading centre serves to guarantee quality control.     

OPHDIAT: quality-assurance programme plan and performance of the network

AIMS: There is a need for evaluation of screening and grading services for diabetic retinopathy (DR) in compliance with quality-assurance (QA) standards. We describe the screening/grading QA programme set up for OPHDIAT over the 2005-2006 period. METHODS: Screening and grading objectives, evaluation criteria and minimum acceptable QA standards were set. To ensure the quality of DR photos, the proportion of nongradable photos in at least one eye had to be less than 10%. To ensure grading accuracy, intergrading agreement had to be greater than 90%. Grader-generated reports had to be available in less than 48 h for more than 80% photos. Readers had to grade 500 to 3000 photos per year. RESULTS: Sixteen screening centres were opened between June 2004 and December 2006, and 14,769 patients were screened. Percentages of nongradable photos were consistently below the QA requirement (less than 10%). Overall, 800 photos were graded a second time by a reader blinded to original grading; agreement between graders ranged from 92 to 99%. More than 90% of grader-generated reports were produced within 48 h. The number of readings by each grader nearly achieved the QA standard. CONCLUSION: QA for DR telescreening should be a continuous process to provide performance feedback, thus guaranteeing a high standard for delivered results. Almost all of the predetermined QA standards in OPHDIAT for screening and grading were met. Besides the quality/sensitivity of the screening/grading modalities, it is important to evaluate at-risk patients so that they can be treated efficiently; this should be addressed in a global QA programme.     

Screening of diabetic retinopathy: effect of field number and mydriasis on sensitivity and specificity of digital fundus photography

PURPOSE: To evaluate the sensitivity and specificity of one- and three-field, nonmydriatic and mydriatic, and 45 degrees digital colour photography compared with mydriatic indirect ophthalmoscopy for diabetic retinopathy (DR) screening. METHODS: A group of 79 patients (158 eyes) were included in this prospective study. Colour fundus photographs were taken with a Topcon TRC-NW6S digital camera, using four different techniques--single-field nonmydriatic; three-field nonmydriatic; single-field mydriatic; and three-field mydriatic--followed by dilated ophthalmoscopy. Two independent ophthalmologists classified blinded photographs according to the presence or absence of specific diabetic retinal findings. The sensitivity, specificity and agreement (kappa analyses) of the four methods were calculated for the presence or absence of DR and for all diabetic retinal findings. RESULTS: The sensitivity and specificity of digital photography compared with ophthalmoscopy for detection of DR were, respectively: 77 and 99% using single-field nonmydriatic; 92 and 97% using three-field nonmydriatic; 90 and 98% using single-field mydriatic; 97 and 98% using three-field mydriatic. The degrees of agreement for the four methods were 0.82, 0.90, 0.90 and 0.95, respectively. For specific retinal findings, sensitivity was greater for detection of hard exudates, nerve fibre layer haemorrhage and venous beading, and lower for detection of microaneurysms, dot-blot haemorrhage, cotton wool spots and intraretinal microvascular anomalies. CONCLUSION: The three-field strategy without pupil dilation represents a good compromise, with reasonable sensitivity and good comfort (short examination duration, able to drive after photography) favouring patient compliance with the screening programme.     

Prevalence and impact on quality of life of peripheral neuropathy with or without neuropathic pain in type 1 and type 2 diabetic patients attending hospital outpatients clinics

AimsDiabetic polyneuropathy (DPN) without or with neuropathic pain (DPN-P) is one of the most frequent complications of diabetes. To better delineate their respective prevalences, we conducted a cross-sectional study that included 1111 patients (767 type 2 and 344 type 1 diabetic patients) followed up in diabetic outpatients clinics. The association of DPN and DPN-P with other diabetic complications, the impact on quality of life (QoL) and pain management were also investigated.MethodsTwo validated tools (Neuropen^® and the DN4 questionnaire) were used to diagnose the two conditions. Pain intensity was measured using a visual analogue scale, and participants completed the 12-item Short-Form Health Survey to evaluate the physical and mental components of QoL. Univariate and multivariate models were used for the statistical analyses.ResultsThe prevalence of DPN was 43% (95% CI 40.1–45.9), and was higher in type 2 (50.8%) than in type 1 (25.6%) diabetic patients. The prevalence of DPN-P was 14% (95% CI 12.1–16.2) which, again, was higher in type 2 (17.9%) than in type 1 (5.8%) patients. These prevalences both increased with age and diabetes duration. Nephropathy, obesity, low HDL cholesterol and high triglyceride levels were independently associated with DPN and/or DPN-P. Physical and mental components of QoL were significantly altered by DPN-P, but not DPN. Only half of the DPN-P patients were using analgesic treatment, while 28% were using anticonvulsants or antidepressants.ConclusionDPN and DPN-P are frequent complications of diabetes, especially in type 2, and can be identified with inexpensive and easy-to-use screening tools. Despite its profound impact on QoL, DPN-P remains undertreated.     

Diabetic retinopathy, PAI-1 4G/5G and −844G/A polymorphisms, and changes in circulating PAI-1 levels in Tunisian type 2 diabetes patients

AimThe association of altered plasminogen activator inhibitor (PAI)-1 levels and PAI-1 polymorphisms (4G/5G and −844G/A) with diabetic retinopathy (DR) was investigated in 856 type 2 diabetes (T2D) patients, of whom 383 presented with (DR group), and 473 presented without (DWR group), retinopathy.MethodsPAI-1 4G/5G and −844G/A genotyping were done by PCR-RFLP, and PAI-1 levels were measured by ELISA testing.ResultsThe genotype distribution of 4G/5G and −844G/A polymorphisms did not deviate from the Hardy-Weinberg equilibrium model among healthy subjects. Higher frequencies of the 4G/4G genotype, and lower frequencies of the −844A allele, −844G/A and −844A/A genotypes, were seen in DR patients, conferring disease susceptibility and protection, respectively. While PAI-1 levels were significantly elevated in the 4G/4G compared with other PAI-1 genotypes, significant differences in PAI-1 levels between DR and DWR patients were seen in the 4G/−844A, 4G/−844G and 5G/−844A haplotype carriers among DR patients. However, comparable distributions of 4G/5G and −844G/A alleles, genotypes and haplotypes, and similar PAI-1 levels, were seen in the proliferative retinopathy (PR) and non-proliferative retinopathy (NPR) patients, indicating that neither PAI-1 variants nor changes in PAI-1 levels were linked to DR severity. Multivariate analyses identified 4G/−844A and 4G/−844G haplotypes as negatively and positively associated, respectively, with DR, but not with DR severity (PR vs NPR) after adjusting for a number of covariates.ConclusionThe present study identifies changes in PAI-1 levels and genetic variations at the PAI-1 locus as risk factors for DR, but not DR severity, that may serve as useful markers of increased DR susceptibility.     

Urinary albumin excretion in latent autoimmune diabetes in adults (LADA) is more similar to type 2 than type 1 diabetes: Results of the Nord-Trøndelag Health Study 1995–1997

AimAs it is unclear, whether or not, urinary albumin excretion (UAE) differs between patients classified as latent autoimmune diabetes in adults (LADA) and other forms of diabetes, our study aimed to investigate the distribution of the albumin-to-creatinine ratio (ACR) in LADA compared with those in the “classical” types 1 (T1D) and 2 (T2D) diabetes.MethodsWe used data from the Nord-Trøndelag Health Study (HUNT) (n = 64,931) of 1995–1997. ACR (mg/mmol) was measured in three urine samples from all diabetic patients (n = 1525) and from 5% of the non-diabetic study population (n = 2104). We calculated the geometric means and 95% confidence intervals (CI) using a general linear model.ResultsThe unadjusted mean ACR in LADA was similar to that in T2D (1.45, CI: 1.23–1.71 vs 1.41, CI: 1.33–1.49, respectively) but was significantly higher than those in T1D (0.99, CI: 0.83–1.19; P = 0.002) and non-diabetics (0.72, CI: 0.69–0.74; P < 0.001). These results remained similar even after multiple adjustments.ConclusionIn this cross-sectional study, the ACR in LADA and in T2D were similar and higher than in T1D. This similarity between LADA and T2D makes it unlikely that the autoimmune processes that operate in LADA promote albuminuria.     

Multicentre, randomised, controlled study of the impact of continuous sub-cutaneous glucose monitoring (GlucoDay) on glycaemic control in type 1 and type 2 diabetes patients

AimThis randomised study was designed to investigate the impact of continuous glucose monitoring (CGM) for 48 h on glycaemic control with a 3-month follow-up in patients with type 1 (T1D) or type 2 (T2D) diabetes.MethodsA total of 48 patients with poor glycaemic control (HbA_1c: 8–10.5%) underwent CGM for 48 h using the GlucoDay^® system (A. Menarini Diagnostics), after which they were randomly assigned to treatment adjustments based on either their CGM profile (CGM group) or their usual self-monitoring of blood glucose (SMBG group). HbA_1c measurement and 48-h CGM were repeated 3 months later.ResultsAltogether, 34 patients with either T1D (n = 9) or T2D (n = 25) completed the study; seven patients chose to leave the study, and seven patients in the CGM group were excluded because their baseline CGM graphs were not interpretable. HbA_1c levels decreased significantly in the CGM group (n = 14, –0.63 ± 0.27%; P = 0.023), but not in the controls (n = 20, –0.28 ± 0.21%; P = 0.30). In T2D patients, the improvement associated with CGM vs SMBG was due to HbA_1c decreases (mean: –0.63 ± 0.34%; P = 0.05 vs –0.31 ± 0.29%; P = 0.18, respectively). However, HbA_1c did not change significantly with CGM in T1D patients. Comparisons of CGM data at baseline and after 3 months showed no significant changes in glucose control, glucose variability or hypoglycaemia. No major adverse events related to the GlucoDay^® system were reported.ConclusionThis is the first randomised study showing that CGM improves glycaemic control in patients with T2D.     

A call to incorporate the prevention and treatment of geriatric disorders in the management of diabetes in the elderly

The prevalence of type 2 diabetes increases with age. However, the management of diabetes in the elderly has received surprisingly little attention. Diabetes in the elderly is associated with a high risk of geriatric syndromes including malnutrition and sarcopenia, functional impairments, falls and fractures, incontinence, depression and dementia. Tight glycaemic control for the prevention of vascular complications is often of limited value in the elderly. However, glycaemic control and non-pharmacological therapy may prevent diabetes symptoms and delay geriatric syndromes. The prevention, screening and treatment of both conventional diabetic complications and geriatric syndromes should be integrated in a management plan to optimize the patients’ overall health status and quality of life.     

Evaluation of a structured educational programme for type 2 diabetes patients seen in private practice

AIM: Structured education is necessary in the management of a chronic disease such as diabetes and should be readily offered to patients in different settings. Our aim was to demonstrate the feasibility and advantages of a group education programme for type 2 diabetic patients in a private setting in France. METHODS: A programme of group education for patients with type 2 diabetes was initiated by a multidisciplinary group of volunteer healthcare providers, including general practitioners, specialists in diabetology and non-medical members. All volunteers received one day of training, and physicians were instructed to organize several sessions of group education for the type 2 diabetic patients who regularly attended their practice. The first 427 patients entering the programme were included in the study, and asked to fill in a questionnaire to assess their knowledge, beliefs and behaviours with regard to diabetes. Their physician filled in a medical form. Six months later, the same questionnaire and form were sent for follow-up information. RESULTS: At six months versus baseline, patients exhibited small, but consistent, improvements: (i) fasting glucose 142+/-42 mg/dL (P<0.04) vs 146+/-44 mg/dL (P<0.04); (ii) HbA(1c) 7.41+/-1.26% vs 7.57+/-1.33% (P<0.01); and (iii) all of the main parameters of diabetes self-management recorded in the study. The percentage of patients who inspected their feet at least once a week increased from 67 to 77% (P<0.001). Patients improved their knowledge of the disease and developed a more positive attitude towards their diabetes. CONCLUSION: Our study demonstrates that it is possible to organize educational sessions for diabetic patients in a private-practice setting. At six months, patients receiving these sessions showed benefits in terms of blood glucose control and other important markers of self-management of their disease.     

Smoking habits and the risk of type 2 diabetes: A case-control study

AimThe objective of the study was to assess the relationship between smoking and the risk of type 2 diabetes.Subject and methodsThis case-control study included 234 cases with newly confirmed diagnoses of type 2 diabetes and 468 controls who were free of the disease in 2001. Cases and controls were matched by gender and age (±5 years). A questionnaire was used to collect information on the possible risk factors of type 2 diabetes. Clinical measurements were taken in accordance with the recommendations of the WHO. Fasting plasma glucose and triglycerides were also measured, and the glucose tolerance test was performed in the controls. The odds ratios (OR) and 95% confidence intervals (CI) for type 2 diabetes were calculated using conditional logistic regression.ResultsThe diabetes cases had significantly less education, more first-degree relatives with a positive family history of diabetes and higher body mass index (BMI) scores compared with the controls. Also, after adjusting for possible confounders, an increased risk of type 2 diabetes was determined for current smokers (OR = 2.41; 95% CI 1.07–5.44) vs. non-smokers. In addition, there was an association between the disease and duration of smoking (OR = 2.47; 95% CI 1.03–5.93 for 40 years or more) vs. non-smokers, and those who had been smokers for 10 or more pack-years had twice the risk of diabetes (OR = 2.17; 95% CI 1.07–4.40) vs. non-smokers. There were no significant associations found between the risk of type 2 diabetes and number of cigarettes smoked per day or stopping smoking.ConclusionOur data confirms that smoking may be an independent risk factor for type 2 diabetes.     

Low levels of insulin-like growth-factor-binding protein-1 (IGFBP-1) are prospectively associated with the incidence of type 2 diabetes and impaired glucose tolerance (IGT): The Söderåkra Cardiovascular Risk Factor Study

AimTo explore the association between baseline levels of insulin-like growth-factor-binding protein-1 (IGFBP-1), a marker of insulin sensitivity, and the development of type 2 diabetes or impaired glucose tolerance (IGT) in a specifically defined middle-aged population.MethodsThis cross-sectional population-based screening study was conducted in 1989–1990 and included baseline data for 664 non-diabetic subjects aged 40–59 years. Clinical data were collected and blood samples analyzed for blood glucose, serum lipids and insulin. Blood specimens were frozen at baseline and later analyzed for IGF-I, IGFBP-1 and C-reactive protein (CRP). At the follow-up in 2006, the incidence of type 2 diabetes and IGT was reported based on primary-care medical records.ResultsDuring the 17-year observation period, 42 subjects (6.3%) developed type 2 diabetes/IGT. Those in the lowest quintile of IGFBP-1 (≤24 μg/L) at baseline had a diabetes incidence of 12.6% while, in the highest quintile of IGFBP-1 (≥59 μg/L), the incidence was 1.5%. Cox's proportional-hazards model regression analyses were used to determine the incidence of type 2 diabetes/IGT, corrected for age and gender, in relation to IGFBP-1, CRP and waist circumference. Subjects in the lowest IGFBP-1 quintile showed an independently increased risk of type 2 diabetes/IGT [hazards ratio (HR): 3.54; 95% CI 1.18–10.6; P = 0.024]. For CRP and waist circumference, the corresponding figures were HR: 6.81; 95% CI 2.50–18.6; P < 0.001 and HR: 3.33; 95% CI 1.47–7.6; P = 0.004, respectively.ConclusionLow levels of IGFBP-1 predicted the long-term development of type 2 diabetes or IGT in a middle-aged population. The association was independent of CRP and abdominal obesity.     

Increased alanine aminotransferase level and future risk of type 2 diabetes and impaired fasting glucose among the employees in a university hospital in Thailand

AIM: The purpose of this study was to determine the association between baseline alanine aminotransferase (ALT) levels, and future risk of impaired fasting glucose and type 2 diabetes among the employees of a university hospital in Bangkok, Thailand. METHODS: Totally, 2370 and 1619 workers without diabetes and impaired fasting glucose (IFG) at baseline, respectively, who were 35 years or older were followed during 2001-2005. Diagnosis of IFG and type 2 diabetes was based on the fasting plasma glucose levels of 100-125 and greater or equal to 126 mg/dl, respectively. RESULTS: Higher baseline ALT levels were associated with future diabetes risk in an obvious dose-response manner (the OR [95% CI] for the groups with baseline ALT of 17-22, 23-38, and greater than 38 mg/dl comparing to the group with baseline ALT of 1-16 mg/dl were 4.75 [1.25-18.10], 6.14 [1.54-24.45], and 7.19 [1.32-39.16], respectively). Magnitude of association were even higher among those with existing IFG at baseline. The association patterns were consistent for both genders. Concerning the IFG risk, while those who developed IFG had significantly higher baseline ALT levels than those who remained normal at the end of follow-up period, further analyses did not show that baseline ALT was significantly associated with future IFG risk. CONCLUSION: Present study provided supporting evidence from a cohort of Asian subjects about the ALT and future type 2 diabetes risk.     

The incretins: From the concept to their use in the treatment of type 2 diabetes. Part A: Incretins: Concept and physiological functions

This paper briefly reviews the concept of incretins and describes the biological effects of the two incretins identified so far: the glucose-dependent insulinotropic polypeptide (GIP); and the glucagon-like peptide-1 (GLP-1). GIP is released by the K cells of the duodenum, while GLP-1 is released by the L cells of the distal ileum, in response to nutrient absorption. GIP and GLP-1 stimulate insulin biosynthesis and insulin secretion in a glucose-dependent manner. In addition, they increase beta-cell mass. GIP has a specific effect on adipose tissue to facilitate the efficient disposal of absorbed fat and, thus, may be involved in the development of obesity. GLP-1 has specific effects on pancreatic alpha cells, the hypothalamus, and gastrointestinal and cardiovascular systems. By inhibiting glucagon secretion and delaying gastric-emptying, GLP-1 plays an important role in glucose homoeostasis and, by inhibiting food intake, prevents the increase in body weight. As the metabolic effects of GIP are blunted in type 2 diabetes, this peptide cannot be used as an efficient therapy for diabetes. In contrast, GLP-1 effects are preserved at high concentrations in type 2 diabetes, making this peptide of great interest for the treatment of diabetes, a topic that will be discussed in the second part of this review.