Ethnic variations in the prevalence of diabetic retinopathy in people with diabetes attending screening in the United Kingdom (DRIVE UK)

Aims

To compare the prevalence of diabetic retinopathy (DR) in people of various ethnic groups with diabetes in the United Kingdom (UK).

Methods

The Diabetic Retinopathy In Various Ethnic groups in UK (DRIVE UK) Study is a cross-sectional study on the ethnic variations of the prevalence of DR and visual impairment in two multi-racial cohorts in the UK. People on the diabetes register in West Yorkshire and South East London who were screened, treated or monitored between April 2008 to July 2009 (London) or August 2009 (West Yorkshire) were included in the study. Data included age, sex, ethnic group, type of diabetes, presenting visual acuity and the results of grading of diabetic retinopathy. Prevalence estimates for the ethnic groups were age-standardised to the white European population for comparison purposes.

Results

Out of 57,144 people on the two diabetic registers, data were available on 50,285 individuals (88.0%), of these 3,323 had type 1 and 46,962 had type 2 diabetes. In type 2 diabetes, the prevalence of any DR was 38.0% (95% confidence interval(CI) 37.4% to 38.5%) in white Europeans compared to 52.4% (51.2% to 53.6%) in African/Afro-Caribbeans and 42.3% (40.3% to 44.2%) in South Asians. Similarly, sight threatening DR was also significantly more prevalent in Afro-Caribbeans (11.5%, 95% CI 10.7% to 12.3%) and South Asians (10.3%, 9.0% to 11.5%) compared to white Europeans (5.5%, 5.3% to 5.8%). Differences observed in Type 1 diabetes did not achieve conventional levels of statistical significance, but there were lower numbers for these analyses.

Conclusions

Minority ethnic communities with type 2 diabetes in the UK are more prone to diabetic retinopathy, including sight-threatening retinopathy and maculopathy compared to white Europeans.     

Monitoring,treatment and control of blood glucose and lipids in Ontario First Nations people with diabetes

BACKGROUND:Indigenous people worldwide are disproportionately affected by diabetes and its complications. We aimed to assess the monitoring, treatment and control of blood glucose and lipids in First Nations people in Ontario.METHODS:We conducted a longitudinal population-based study using administrative data for all people in Ontario with diabetes, stratified by First Nations status. We assessed age- and sex-specific rates of completion of recommended monitoring for low-density lipoprotein (LDL) and glycated hemoglobin (A_1c) from 2001/02 to 2014/15. We used data from 2014/15 to conduct a cross-sectional analysis of rates of achievement of A_1c and LDL targets and use of glucose-lowering medications.RESULTS:The study included 22 240 First Nations people and 1 319 503 other people in Ontario with diabetes. Rates of monitoring according to guidelines were 20%–50% for A_1c and 30%–70% for lipids and were lowest for younger First Nations men. The mean age- and sex-adjusted A_1c level was higher among First Nations people than other people (7.59 [95% confidence interval (CI) 7.57 to 7.61] v. 7.03 [95% CI 7.02 to 7.03]). An A_1c level of 8.5% or higher was observed in 24.7% (95% CI 23.6 to 25.0) of First Nations people, compared to 12.8% (95% CI 12.1 to 13.5) of other people in Ontario. An LDL level of 2.0 mmol/L or less was observed in 60.3% (95% CI 59.7 to 61.6) of First Nations people, compared to 52.0% (95% CI 51.1 to 52.9) of other people in Ontario. Among those aged 65 or older, a higher proportion of First Nations people than other Ontarians were using insulin (28.1% v. 15.1%), and fewer were taking no medications (28.3% v. 40.1%).INTERPRETATION:As of 2014/15, monitoring and achievement of glycemic control in both First Nations people and other people in Ontario with diabetes remained suboptimal. Interventions to support First Nations patients to reach their treatment goals and reduce the risk of complications need further development and study.

Diabetes and its related complications are major contributors to morbidity and mortality worldwide.^1–3 Indigenous populations in Canada and around the world are disproportionately affected by diabetes owing to the complex relations among colonization, social disadvantage, stress, trauma and metabolic health.^4–7 In addition to our own work showing persistently higher rates of peripheral vascular disease, stroke, cardiac disease, renal dysfunction and ophthalmologic complications in Ontario First Nations,^8–12 other Canadian and international studies also showed higher complication rates in diverse Indigenous populations.^6,7,13–15Glycemic control is fundamental to the management of diabetes and the prevention of complications.¹⁶ Glycated hemoglobin (A_1c) is a reliable way to estimate the average level of glucose in the blood.¹⁷ Since A_1c levels higher than 7.0% have been associated with an increased risk of microvascular complications,^18–20 treatment guidelines suggest A_1c should be measured every 3–6 months to ensure that glycemic goals are being met or maintained.²¹ Since people with diabetes also have an elevated risk for cardiovascular disease,^22–24 management and control of cardiovascular risk factors, particularly lipids such as low-density lipoprotein (LDL) cholesterol, are also important.^25–27 Guidelines further recommend that a full lipid profile be measured every 1–3 years, depending on cardiovascular risk, and suggest that LDL be consistently less than 2.0 mmol/L.²⁸ Control of A_1c and lipids has been shown to be associated with reduced morbidity and mortality in patients with diabetes.^18,29–32One possible reason for the high burden of complications among Indigenous people with diabetes may be failure to achieve control of these 2 key clinical parameters. We examined differences between Status First Nations people with diabetes in Ontario and all other Ontario residents with diabetes in rates of monitoring of A_1c and lipids, achievement of targets for A_1c and LDL outlined in clinical guidelines, and patterns of medication use to help attain these targets.     

Development of a Sightability Model for Low-Density Elk Populations in Ontario,Canada

ABSTRACT The status of recolonizing elk (Cervus elaphus) populations in Ontario, Canada, is unclear and there is a need for effective population survey methods that can be applied locally. We sought to develop a sightability model that could account for both low densities of elk and dense forest cover in elk-release areas in Ontario. We corrected winter aerial survey counts for sightability based on radiocollared animals known to be within observable distance of the aircraft. The multivariate model with the highest Akaike's Information Criterion corrected for sample size weight (w_i = 0.427) revealed that elk group size, elk activity, dominant tree type, percent canopy cover, and percent conifer cover were significant predictors of elk sightability. The group-size effect indicated that odds of sighting an elk increased by 1.353 (95% CI = 0.874-3.689) for every additional elk. Standing elk were 5.033 (95% CI = 0.936-15.541) times more likely to be observed than were resting elk, and those located in conifer cover were 0.013 (95% CI = 0.001-0.278) times less likely to be sighted than elk in deciduous cover. Furthermore, elk located in >50% canopy cover and >50% conifer cover were 0.041 (95% CI = 0.003-0.619) times and 0.484 (95% CI = 0.024-9.721) times less likely to be sighted than elk in more open habitat, respectively. During model validation, observers detected 79% (113/143) of known elk in any given area, and population and sightability model predictions (±90% CI) overlapped with the population estimate, implying that our predictive model was robust. Unsurprisingly, large groups of elk in open habitat increased model precision, which highlights difficulties of counting Ontario elk in their northern range. We conclude that our model provided increased reliability for estimating elk numbers in Ontario compared to existing methods, and that the estimator may be useful in other areas where elk density is low and sightability is poor due to dense forest cover.     

Characterization of the vitreous proteome in diabetes without diabetic retinopathy and diabetes with proliferative diabetic retinopathy

An understanding of the diabetes-induced alterations in vitreous protein composition in the absence and in the presence of proliferative diabetic retinopathy (PDR) may provide insights into factors and mechanisms responsible for this disease. We have performed a comprehensive proteomic analysis and comparison of vitreous samples from individuals with diabetes but without diabetic retinopathy (noDR) or with PDR and nondiabetic individuals (NDM). Using preparative one-dimensional SDS-PAGE and nano-LC/MS/MS of 17 independent vitreous samples, we identified 252 proteins from human vitreous. Fifty-six proteins were differentially abundant in noDR and PDR vitreous compared with NDM vitreous, including 32 proteins increased and 10 proteins decreased in PDR vitreous compared with NDM vitreous. Comparison of noDR and PDR groups revealed increased levels of angiotensinogen and decreased levels of calsyntenin-1, interphotoreceptor retinoid-binding protein, and neuroserpin in PDR vitreous. Biological pathway analysis revealed that vitreous contains 30 proteins associated with the kallikrein-kinin, coagulation, and complement systems. Five of them (complement C3, complement factor I, prothrombin, alpha-1-antitrypsin, and antithrombin III) were increased in PDR vitreous compared with NDM vitreous. Factor XII was detected in PDR vitreous but not observed in either NDM or noDR vitreous. PDR vitreous also had increased levels of peroxiredoxin-1 and decreased levels of extracellular superoxide dismutase, compared with noDR or NDM vitreous. These data provide an in depth analysis of the human vitreous proteome and reveal protein alterations that are associated with PDR.     

Chironomidae (Diptera) of peatlands in northwestern Ontario, Canada

Eighty-four species of Chironomidae were collected, using emergence traps, from three poor fens located in the Experimental Lakes Area (ELA) of northwestern Ontario. Of these, 37 were considered to be true peatland fauna. The majority (23) of the peatland species are new North American or Canadian records and, of these, 10 are previously undescribed. Numbers m⁻² yr⁻¹ emerging from the fens were similar to neighbouring lakes but biomass (mg) m⁻² yr⁻¹ emerging was much less, indicating the small average size of the fen chironomids. Emergence began in early May and was virtually completed by late July-early August in all three years of the study. Most of the emergence occurred early in the season. Eight species accounted for ≥90% of the emergence. Five of these, Gymnometriocnemus (R.) acigus Saeth., Doithrix villosa Saeth. and Subl., Pseudorthocladius (s.s.) destitutus Saeth. and Subl., P. (s.s.) curtistylus (Goetgh.), and Paramerina nr. smithae (Subl.) had univoltine life cycles and relatively stichronous emergences. Pseudosmittia forcipata (Goetgh.) was bivoltine, and Limnophyes minimus (Meig.) and Smittia nr. nudipennis Geotgh. had protracted emergence periods that made voltinism difficult to determine. Characteristic features of the chironomid fauna of peatlands at ELA are discussed. The general applicability of these features to peatlands, and needs for further research in these neglected but extensive Canadian habitats are considered.     

Five amphibian mortality events associated with ranavirus infection in south central Ontario, Canada

Using field, molecular and histological methods, an epizootic, systemic disease causing death within wood frog Rana sylvatica tadpoles and leopard frog Rana pipiens metamorphs at 3 different locations within Southern Ontario, Canada, has been investigated. Our results demonstrated that the probable cause of this disease was a ranavirus. Affected amphibians were found to exhibit necrosis within the hematopoietic cells. Liver tissue samples were found positive for the virus by PCR amplification of the ranavirus (Family: Iridoviridae) major capsid protein (MCP). Positive samples were confirmed by sequence analysis. Clinically normal, laboratory-raised wood frog egg broods were also found to test weakly positive for ranavirus. The population effects of disease on these amphibian communities have not yet been conclusively associated with population declines, but warrant more focused consideration.     

Whole-lake lead burdens in sediments of lakes in southern Ontario,Canada

The anthropogenic stable lead content of the sediments of eight softwater Precambrian lakes in southern Ontario was measured at 34–92 sites per lake. Whole-lake anthropogenic lead burdens varied between only 610 and 770 mg m^–2. There was no relationship between lead burden and either water replenishment time of the lake (T_W) or the ratio of watershed area to lake area (Ad/A₀), which varied by factors of 4 and 12 respectively. These results can be explained if a) the lead deposition in this region is uniform, and b) the only significant input of lead to the lakes is via deposition from the atmosphere directly on the lakes' surfaces. Therefore spatial differences in anthropogenic lead within a lake represent the redistribution or focusing pattern of the sediments.     

High Uptake of HIV Testing in Pregnant Women in Ontario,Canada

In 1999, Ontario implemented a policy to offer HIV counseling and testing to all pregnant women and undertook measures to increase HIV testing. We evaluated the effectiveness of the new policy by examining HIV test uptake, the number of HIV-infected women identified and, in 2002, the HIV rate in women not tested during prenatal care. We analyzed test uptake among women receiving prenatal care from 1999 to 2010. We examined HIV test uptake and HIV rate by year, age and health region. In an anonymous, unlinked study, we determined the HIV rate in pregnant women not tested. Prenatal HIV test uptake in Ontario increased dramatically, from 33% in the first quarter of 1999 to 96% in 2010. Test uptake was highest in younger women but increased in all age groups. All health regions improved and experienced similar test uptake in recent years. The HIV rate among pregnant women tested in 2010 was 0.13/1,000; in Toronto, the rate was 0.28 per 1,000. In the 2002 unlinked study, the HIV rate was 0.62/1,000 among women not tested in pregnancy compared to 0.31/1,000 among tested women. HIV incidence among women who tested more than once was 0.05/1,000 person-years. In response to the new policy in Ontario, prenatal HIV testing uptake improved dramatically among women in all age groups and health regions. A reminder to physicians who had not ordered a prenatal HIV test appeared to be very effective. In 2002, the HIV rate in women who were not tested was twice that of tested women: though 77% of pregnant women had been tested, only 63% of HIV-infected women were tested. HIV testing uptake was estimated at 98% in 2010.     

Trends in prevalence of chronic disease and multimorbidity in Ontario,Canada

BACKGROUND:New case-mix tools from the Canadian Institute for Health Information offer a novel way of exploring the prevalence of chronic disease and multimorbidity using diagnostic data. We took a comprehensive approach to determine whether the prevalence of chronic disease and multimorbidity has been rising in Ontario, Canada.METHODS:In this observational study, we applied case-mix methodology to a population-based cohort. We used 10 years of patient-level data (fiscal years 2008/09 to 2017/18) from multiple care settings to compute the rolling 5-year prevalence of 85 chronic diseases and multimorbidity (i.e., the co-occurrence of 2 or more diagnoses). Diseases were further classified based on type and severity. We report both crude and age- and sex-standardized trends.RESULTS:The number of patients with chronic disease increased by 11.0% over the 10-year study period to 9.8 million in 2017/18, and the number with multimorbidity increased 12.2% to 6.5 million. Overall increases from 2008/09 to 2017/18 in the crude prevalence of chronic conditions and multimorbidity were driven by population aging. After adjustments for age and sex, the prevalence of patients with ≥ 1 chronic conditions decreased from 70.2% to 69.1%, and the prevalence of multimorbidity decreased from 47.1% to 45.6%. This downward trend was concentrated in minor and moderate diseases, whereas the prevalence of many major chronic diseases rose, along with instances of extreme multimorbidity (≥ 8 conditions). Age- and sex-standardized resource intensity weights, which reflect relative expected costs associated with patient diagnostic profiles, increased 4.6%.INTERPRETATION:Evidence of an upward trend in the prevalence of chronic disease was mixed. However, the change in case mix toward more serious conditions, along with increasing patient resource intensity weights overall, may portend a future need for population health management and increased health system spending above that predicted by population aging.

Multimorbidity exists when a patient is diagnosed with 2 or more chronic diseases. Patients with multimorbidity present challenges for physicians managing their care and, as the proportion of these patients in the population increases, for health care system planning. The prevalence of multimorbidity and chronic disease has been strongly associated with primary care use, specialist consultations, number and intensity of inpatient hospital admissions and other types of care.^1–7 Among beneficiaries of fee-for-service Medicare in the United States, expenditures for those with 4 or more chronic diseases were reported to be 66 times higher than for those with none.⁸ One study found that most health spending growth (77.6%) in the US between 1987 and 2011 could be attributed to patients with 4 or more diseases.⁹Several recent studies have estimated the prevalence of chronic disease and multimorbidity in Canada.^3,10–13 Rates of multimorbidity ranged from 10% to 25%, owing to differences in classification systems used to identify chronic disease, including the choice of conditions, and variations in study population. Lack of standardization in measures of chronic disease prevalence and multimorbidity has hampered the evaluation of trends over time and across settings.Ontario provides an ideal setting to evaluate trends in the prevalence of chronic disease because patients have access to a comprehensive set of publicly funded services. The Canadian Institute for Health Information (CIHI) has created a system that maps patient diagnosis data from all health care settings to a set of 226 clinically meaningful health conditions, covering the full spectrum of acute and chronic morbidity (Jeffrey Hatcher, Canadian Institute for Health Information, Ottawa: personal communication, 2017). CIHI’s system has been independently compared with the Johns Hopkins ACG System; CIHI’s system was deemed to be more specific and less sensitive in classifying diagnoses, making it more conservative in identifying health conditions (S. Cheng, ICES, unpublished data, 2016). The purpose of this study was to evaluate trends in the prevalence of chronic disease and multimorbidity in Ontario using CIHI’s comprehensive disease classification system.     

Production and turnover of Hyalella azteca in central Ontario, Canada compared with other regions

• 1 Microprofiles of oxygen concentration were made in soft sediments of Lake Baikal, along three transects near the Selenga delta. This is the first time the available oxygen in the sediment has been measured in this lake.
• 2 The microprofiles had a similar and typical shape (a single exception was possibly caused by bioturbation). A positive correlation was found between the sediment oxygen penetration depth (SOP) and the bathymetric depth of the epilimnion, probably caused by a decrease in oxygen sediment consumption with increasing depth.
• 3 The observed SOP values are generally very high, which is an indication of oligotrophy. A single low SOP value, observed in the northern transect, appears to be linked to organic pollution caused by the Selenga River.

     

Woody plant encroachment in granite barrens on the Frontenac Arch,eastern Ontario,Canada

Aims

Woody plant encroachment is a widespread phenomenon affecting treeless or sparsely treed habitats. We aimed to determine the extent and timing of tree and shrub encroachment into rock barrens of eastern Ontario over the last century, and to assess implications for their ongoing management.

Location

Queen's University Biological Station in the Frontenac Arch ecoregion.

Methods

We quantified the extent of change in woody vegetation in 290 rock barrens using aerial photography from 1925, 1965, and 2008. Composition and structure of woody plant communities in 10 barrens was subsequently quantified in the field using plot-based sampling. Cores or cross-sections were obtained from individuals >1.5 m height and dendrochronological techniques were used to determine their age and identify temporal patterns of any woody encroachment.

Results

Aerial photography indicated that the mean proportion of woody plant cover in barrens increased 22.5% from 1925 to 2008. Dendroecological analysis supported this. Few trees were present prior to 1900 and most established since 1960. Fraxinus americana, Juniperus virginiana, and Juniperus communis were the most common woody species colonizing the barrens. Remnants of large Pinus strobus stumps with extensive charring were found in 90% of the sampled barrens at a mean density of 22.6 stumps ha⁻¹.

Conclusions

Rock barrens on the Frontenac Arch have changed substantially over the past century; gradually being colonized by trees and shrubs and losing their distinctly open character. Active management — including prescribed fire and mechanical thinning — may be necessary if there is a desire to maintain these barrens and the rare species they support as components of the region's biodiversity. However, identification of a reference state for restoration is complicated by the fact that the structure and composition of these habitats were undoubtedly altered by European land clearance in the 19th century, and that some of these areas likely existed as pine woodlands before that.