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Introduction: This study aimed to evaluate intraretinal microvascular abnormalities (IRMA) in eyes with advanced nonproliferative diabetic retinopathy (NPDR) using multimodal approach in co-located areas focusing on central retina (up to 50°) and to look at possible correlations between IRMA and other structural changes, like ischemia and presence of microaneurysms., Methods: The RICHARD study (NCT05112445) included 60 eyes from 60 patients with type 2 diabetes with moderate-severe NPDR, diabetic retinopathy severity levels 43, 47, and 53 (DRSS). IRMA were defined as capillary tortuosity covering a minimum circular area of 300 µm (calculated to correspond to the Early Treatment Diabetic Retinopathy Study standard photo 8A) and were identified using multimodal imaging with distinct fields of view (FoV): color fundus photography (CFP) using a Topcon TRC-50DX camera (Topcon Medical Systems, Japan), Optos California ultra wide field fundus fluorescein angiography (UWF-FFA) (Optos plc, UK), and swept-source optical coherence tomography angiography (SS-OCTA) (PLEX® Elite 9000, ZEISS, USA). Different areas of the retina were examined: central macula (up to 20°) and posterior pole (between 20° and 50°)., Results: Multimodal imaging was used to identify IRMA in co-located areas (FoV < 50°) including UWF-FFA, CFP, and SS-OCTA. In eyes with DRSS levels 47 and 53, IRMA were identified in both areas of the retina, while in eyes with DRSS level 43, IRMA were detected only outside of the central macula (FoV > 20°). Our results show that when evaluating the presence of IRMA (FoV < 50°), UWF-FFA detected 203 IRMA, SS-OCTA detected 133 IRMA, and CFP detected 104 IRMA. Our results also show that the presence of IRMA was positively associated with presence of microaneurysms., Conclusions: Identification of IRMA in eyes with advanced NPDR is better achieved by UWF-FFA than CFP and SS-OCTA. A statistically significant correlation was found between the presence of IRMA and the increase in number of microaneurysms., Trial Registration: ClinicalTrials.gov, identifier NCT05112445., Competing Interests: Declarations Conflicts of Interest Ana R Santos, Marta Lopes, Torcato Santos, Débora Reste-Ferreira, Inês P Marques, Telmo Miranda, Luís Mendes and António CV Martinho declare there are no conflicts of interest. Taffeta CN Yamaguchi is a Boehringer Ingelheim employee. Liz Pearce previously worked at Boehringer Ingelheim, participated in the design of the study. José Cunha-Vaz reports grants from Bayer, Boehringer Ingelheim and Carl Zeiss Meditec and is a consultant for Alimera Sciences, Bayer, Boehringer Ingelheim, Carl Zeiss Meditec and Roche. José Cunha-Vaz is an Editorial Board member of Ophthalmology and Therapy. José Cunha-Vaz was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions. Ethical Approval The tenets of the Declaration of Helsinki were followed, and approval was obtained from the AIBILI Ethics Committee for Health (CE 240 RICHARD), and the trial was registered at ClinicalTrials.gov, identifier NCT05112445. Written informed consent was obtained by each participant agreeing to participate in the study., (© 2024. The Author(s).)

Introduction: Diabetic retinopathy (DR) is both a microangiopathy and a neurodegenerative disease. However, the connections between both changes are not well known., Purpose: To characterise the longitudinal retinal ganglion cell layer + inner plexiform layer (GCL + IPL) changes and their association with microvascular changes in type-2 diabetes (T2D) patients with nonproliferative diabetic retinopathy (NPDR)., Methods: This two-year prospective study (CORDIS, NCT03696810) included 122 T2D individuals with NPDR identified as risk phenotypes B and C, which present a more rapid progression. Phenotype C was identified by decreased VD ≥ 2SD in healthy controls, and phenotype B, identified by subclinical macular oedema with only minimal vascular closure. The GCL + IPL thickness, vessel density, perfusion density and area of intercapillary spaces (AIS) were assessed by optical coherence tomography (OCT) and OCT angiography (OCTA). Linear mixed effects models were employed to evaluate the retinal GCL + IPL progression and its associations., Results: Regarding GCL + IPL thickness, T2D individuals presented on average 80.1 ± 7.49 μm, statistically significantly lower than the healthy control group, 82.5 ± 5.71 (p = 0.022), with only phenotype C differing significantly from controls (p = 0.006). GCL + IPL thickness steadily decreased during the two-year period in both risk phenotypes, with an annual decline rate of -0.372 μm/year (p < 0.001). Indeed, phenotype C showed a higher rate of progression (-0.459 μm/year, p < 0.001) when compared to phenotype B (-0.296 μm/year, p = 0.036). Eyes with ETDRS grade 20 showed GCL + IPL thickness values comparable to those of healthy control group (83.3 ± 5.80 and 82.7 ± 5.50 μm, respectively, p = 0.880), whereas there was a progressive decrease in GCL + IPL thickness in ETDRS grades 35 and 43-47 associated with the increase in severity of the retinopathy (-0.276 μm/year, p = 0.004; -0.585 μm/year, p = 0.013, respectively). Furthermore, the study showed statistically significant associations between the progressive thinning of GCL + IPL and the progressive increase in retinal capillary non-perfusion, with particular relevance for AIS (p < 0.001)., Conclusions: Our findings showed that, in eyes with NPDR and at risk for progression, retinal neurodegeneration occurs at different rates in different risk phenotypes, and it is associated with retinal microvascular non-perfusion., (© 2023 Association for Innovation and Biomedical Research on Light and Image. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose: To identify progression of nonproliferative diabetic retinopathy (NPDR) in patients with type 2 diabetes by combining optical coherence tomography angiography (OCTA) metrics and color fundus photography (CFP) images., Methods: This study was a post hoc analysis of a prospective longitudinal cohort study (CORDIS, NCT03696810) with 2-year duration. This study enrolled 122 eyes. Ophthalmological examinations included OCTA and CFP. OCTA metrics included skeletonized vessel density (SVD) and perfusion density (PD) at the superficial capillary plexus (SCP) and deep capillary plexus (DCP). Microaneurysm turnover analysis and Early Treatment Diabetic Retinopathy Study (ETDRS) grading for diabetic retinopathy (DR) severity assessment were performed on 7-field CFP., Results: Eyes graded as ETDRS level 20 showed significant capillary nonperfusion predominantly in the inner ring area in the SCP (P < 0.001), whereas eyes graded as ETDRS level 35 and ETDRS levels 43 and 47 showed significant capillary nonperfusion in both the SCP and DCP in both inner and outer rings (P < 0.001). When evaluating rates of progression in capillary nonperfusion for the 2-year period of follow-up, changes were found predominantly in the DCP for SVD and PD and were better identified in the outer ring area. Microaneurysm turnover contributes to the characterization of NPDR progression by discriminating ETDRS level 35 from ETDRS levels 43 and 47 (P < 0.001), which could not be achieved using only OCTA metrics., Conclusions: Patterns of progression of NPDR can be identified combining OCTA examinations of the superficial and deep retinal capillary plexi of central retina and determination of microaneurysm turnover from fundus photographs., Translational Relevance: Our study reports results from a registered clinical trial that advances understanding of disease progression in NPDR.

Purpose: To characterize the occurrence of diabetic macular edema and the presence of abnormal retinal fluid accumulation in nonproliferative diabetic retinopathy (NPDR)., Methods: In this two-year prospective study, a total of 122 eyes with diabetes type 2 underwent optical coherence tomography (OCT) and OCT-Angiography in association with OCT-Fluid imaging, a novel algorithm of OCT analysis allowing quantification of abnormal accumulation of fluid in the retina through low optical reflectivity ratios (LOR). Early Treatment Diabetic Retinopathy Study (ETDRS) grading for diabetic retinopathy (DR) severity assessment was performed using 7-field color fundus photography. Best corrected visual acuity was also recorded., Results: During the 2-year follow-up, 23 eyes (19%) developed central-involved diabetic macular edema (CI-DME) and 2 eyes (2%) developed clinically significant macular edema (CSME). In the two-year period of the study, eyes that developed CI-DME showed a progressive increase in central retinal thickness (CRT) ( β  = 7.7 ± 2.1 µm/year, p  < 0.001) and in LOR values ( β  = 0.009 ± 0.004 ratio/year, p  = 0.027). The increase in CRT and abnormal retinal fluid, represented by increased LOR ratios, are associated with increased retinal perfusion in the deep capillary plexus (DCP) (skeletonized vessel density, p  = 0.039). In contrast, the eyes with CSME showed decreased retinal perfusion and abnormal fluid located in the outer layers of the retina., Conclusions: CI-DME and CSME appear to represent different entities. Eyes with CI-DME show increases in abnormal retinal fluid associated with increased retinal vascular perfusion in the DCP. Eyes with CSME are apparently associated with decreased retinal vascular perfusion in the DCP and abnormal fluid in the outer retina., Competing Interests: Declaration of conflicting interestsDébora Reste-Ferreira, Torcato Santos, Inês Pereira Marques, Maria Luísa Ribeiro, Ana Rita Santos, António Cunha-Vaz Martinho and Conceição Lobo declare no conflicts of interest. José Cunha-Vaz reports grants from Carl Zeiss Meditec and is a consultant for Alimera Sciences, Bayer, Roche, Boehringer Ingelheim and Carl Zeiss Meditec.

Purpose: To determine the degree of central microvascular closure using optical coherence tomography angiography in eyes of patients with type 2 diabetes with visible lesions only in the central retina or only in the periphery., Methods: Cross-sectional study. All 127 eyes underwent ultra-widefield fundus photography 200° examinations with OPTOS California (Optos, Dunfermline, United Kingdom) and Cirrus Angioplex optical coherence tomography angiography 3 × 3 mm acquisitions (ZEISS, Dublin, CA)., Results: Twenty-five eyes showed visible lesions only in the central retina, 57 only in the peripheral retina, and 45 presented visible lesions in entire retina. The group with visible lesions only in the periphery showed definite closure in the superficial capillary plexus in 49% of the eyes, whereas the group with visible lesions only in the central seven-early treatment diabetic retinopathy study fields area showed a definite closure in 64%., Conclusion: Central capillary closure is already present in the initial stages of diabetic retinopathy even when lesions are only visible in the peripheral retina. Capillary closure in the superficial capillary plexus is three times more frequent than in the deep capillary plexus, demonstrating earlier closure of the superficial capillary plexus. Eyes with visible lesions only in the periphery show a milder form of retinopathy., Competing Interests: A.R. Santos, A.C. Almeida, A.C. Rocha, D. Reste-Ferreira, I.P. Marques, A. Cunha-Vaz Martinho, L. Mendes and T. Santos declare no conflicts of interest. W. Lewis is a consultant/contractor for Carl Zeiss Meditec. J. Cunha-Vaz reports grants from Bayer, Boehringer Ingelheim, and Carl Zeiss Meditec and is a consultant for Alimera Sciences, Bayer, Boehringer Ingelheim, Carl Zeiss Meditec, and Roche., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.)

Introduction: Characterization of 2-year progression of different risk phenotypes in eyes with mild and moderate nonproliferative diabetic retinopathy (NPDR) in type 2 diabetes (T2D)., Methods: A 2-year prospective longitudinal cohort study (CORDIS, NCT03696810) was conducted. Ophthalmological examinations were performed including best corrected visual acuity, color fundus photography and optical coherence tomography (OCT and OCTA). OCT metrics, central retinal thickness and ganglion cell layer + inner plexiform layer (GCL + IPL) thickness were analyzed. OCTA metrics, vessel density (VD), perfusion density (PD) and area of intercapillary spaces (AIS) were obtained from superficial and deep capillary plexus (SCP, DCP). Only phenotype C identified by decreased VD ≥ 2 SD of healthy controls and phenotype B identified by subclinical macular edema with decreased VD < 2 SD of healthy controls were included., Results: One hundred twenty-two eyes from T2D individuals were included in study; 65 eyes (53%) were classified as phenotype B and 57 eyes (47%) as phenotype C. For phenotype B, progression was associated with thinning of the GCL + IPL (ETDRS 35, 1 year p = 0.013, 2 year p < 0.001; ETDRS 43-47, 2 year p = 0.003) and vessel closure involving mainly the DCP for both ETDRS grades (ETDRS 35, 1 year p = 0.025, 2 year p = 0.034; ETDRS 43-47, 1 year p = 0.011). For phenotype C there was also progressive thinning of the GCL + IPL (ETDRS 35, in both years p ≤ 0.001; ETDRS 43-47, 1 year p = 0.002, 2 year p = 0.001), with vessel closure involving mainly SCP (ETDRS 35, 1 year p = 0.012, 2 year p = 0.023 in full-retina), which appeared to stabilize at maximal values in ETDRS grade 43-47 at the end of 2 years. ETDRS severity changes at the end of the 2-year period showed that worsening was associated with phenotype C with changes involving predominantly the SCP (VD, p = 0.005; PD, p = 0.008; AIS, p = 0.005)., Conclusions: Association between ETDRS classification of NPDR severity and identification of different risk phenotypes offers new perspective to predict disease progression in T2D individuals with NPDR., (© 2022. The Author(s).)

Background/objectives: To characterise the prevalence and three-year progression of centre-involving diabetic macular oedema (CI-DMO) in minimal to moderate non-proliferative diabetic retinopathy, using optical coherence tomography (OCT) and measurements of retinal fluid using tissue optical reflectivity ratios (OCT-Leakage)., Methods/methods: Seventy-four eyes from 74 patients were followed in a 3-year prospective longitudinal observational cohort of type 2 diabetes (T2D) patients using spectral-domain optical coherence tomography (SD-OCT), OCT-Angiography (OCT-A) and OCT-Leakage (OCT-L). Eyes were examined four times with 1-year intervals. Sixteen eyes (17.8%) were excluded from the analysis due to quality control standards. Retinal oedema was measured by central retinal thickness and retinal fluid by using optical reflectivity ratios obtained with the OCT-L algorithm. Vessel density was measured by OCT-A. Thinning of the ganglion cell and inner plexiform layers (GCL + IPL) was examined to identify retinal neurodegenerative changes. Diabetic retinopathy ETDRS classification was performed using the seven-field ETDRS protocol., Results: CI-DMO was identified in the first visit in 9% of eyes in ETDRS groups 10-20, 10% of eyes in ETDRS group 35 and 15% of eyes in ETDRS groups 43-47. The eyes with CI-DMO and subclinical CI-DMO showed a progressive increase in retinal extracellular fluid during the 3-year period of follow-up. The eyes with CI-DMO and increased retinal extracellular fluid accumulation were associated with vision loss., Conclusions: The prevalence of subclinical CI-DMO and CI-DMO in the initial stages of NPDR occurs independently of severity grading of the retinopathy, showing progressive increase in retinal extracellular fluid and this increase is associated with vision loss (82% 9 out of 11 cases)., (© 2022. The Author(s).)

Introduction: The aim of the study was to characterize the 2-year progression of risk phenotypes of nonproliferative diabetic retinopathy (NPDR) in type 2 diabetes (T2D) phenotype C, or ischemic phenotype, identified by decreased skeletonized retinal vessel density (VD), ≥2 SD over normal values, and phenotype B, or edema phenotype, identified by increased retinal thickness, i.e., subclinical macular edema, and no significant decrease in VD., Methods: A prospective longitudinal cohort study (CORDIS, NCT03696810) was conducted with 4 visits (baseline, 6 months, 1 year, and 2 years). Ophthalmological examinations included best-corrected visual acuity, color fundus photography (CFP), and optical coherence tomography (OCT) and OCT angiography. Early Treatment Diabetic Retinopathy Study grading was performed at the baseline and last visits based on 7-field CFP., Results: One hundred and twenty-two eyes from T2D individuals with NPDR fitted in the categories of phenotypes B and C and completed the 2-year follow-up. Sixty-five (53%) of the eyes were classified as phenotype B and 57 (47%) eyes as phenotype C. Neurodegeneration represented by thinning of the ganglion cell layer and inner plexiform layer was present in both phenotypes and showed significant progression over the 2-year period (p < 0.001). In phenotype C, significant progression in the 2-year period was identified in decreased skeletonized VD (p = 0.01), whereas in phenotype B microvascular changes involved preferentially decrease in perfusion density (PD, p = 0.012). Phenotype B with changes in VD and PD (flow) and preferential involvement of the deep capillary plexus (p < 0.001) is associated with development of center-involved macular edema., Discussion: In the 2-year period of follow-up, both phenotypes B and C showed progression in retinal neurodegeneration, with changes at the microvascular level characterized by decreases in PD in phenotype B and decreases in VD in phenotype C., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Introduction: The aim of the study was to identify retinal microvascular changes using optical coherence tomography angiography (OCTA) in type 2 diabetes (T2D) patients with preclinical retinopathy identified by ultra-widefield fundus photography (UWF-FP)., Methods: This is a cross-sectional observational study. All patients underwent UWF-FP 200° examinations with OPTOS California (Optos, Dunfermline, UK) and Cirrus AngioPlex® spectral-domain (SD)-OCTA 3 × 3 mm acquisitions (ZEISS, Dublin, CA, USA). The absence of visible lesions was identified using UWF-FP., Results: One hundred and ninety three eyes of individuals with T2D with no visible lesions in the fundus and identified in a screening setting were included in the study. Skeletonized vessel density (SVD), perfusion density (PD), and areas of capillary nonperfusion (CNP) values on SD-OCTA were significantly decreased when compared with healthy population (p &lt; 0.001). SVD and CNP values of the superficial capillary plexus (SCP) were more frequently decreased (35% and 45%, respectively) than SVD values of the deep capillary plexus (DCP) (9% and 15%, respectively), demonstrating that diabetic microvascular changes occur earlier in the SCP than in the DCP. The ischemic phenotype, identified by a definite decrease in SVD or CNP in the SCP may, therefore, be identified in the preclinical stage of diabetic retinal disease., Conclusions: Retinal capillary nonperfusion detected by OCTA metrics of SVD and CNP can be identified in the central retina in eyes with T2D before development of visible lesions in the retina. Our findings confirm the relevance of OCTA to identify macular microvascular changes in the initial stages of diabetic retinopathy, allowing the identification of its ischemic phenotype very early in the disease process., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Purpose: To test whether a single or composite set of parameters evaluated with optical coherence tomography angiography (OCTA), representing retinal capillary closure, can predict non-proliferative diabetic retinopathy (NPDR) staging according to the gold standard ETDRS grading scheme., Methods: 105 patients with diabetes, either without retinopathy or with different degrees of retinopathy (NPDR up to ETDRS grade 53), were prospectively evaluated using swept-source OCTA (SS-OCTA, PlexElite, Carl Zeiss Meditec) with 15×9 mm and 3×3 mm angiography protocols. Seven-field photographs of the fundus were obtained for ETDRS staging. Eyes from age-matched healthy subjects were also imaged as control., Results: In eyes of patients with type 2 diabetes without retinopathy or ETDRS levels 20 and 35, retinal capillary closure was in the macular area, with predominant alterations in the parafoveal retinal circulation (inner ring). Retinal capillary closure in ETDRS stages 43-53 becomes predominant in the retinal midperiphery with vessel density average values of 25.2±7.9 (p=0.001) in ETDRS 43 and 23.5±3.4 (p=0.001) in ETDRS 47-53, when evaluating extended areas of 15×9 protocol. Combination of acquisition protocols 3×3 mm and 15×9 mm, using SS-OCTA, allows discrimination between eyes with mild NPDR (ETDRS 10, 20, 35) and eyes with moderate-to-severe NPDR (ETDRS grades 43-53)., Conclusions: Retinal capillary closure, quantified by SS-OCTA, can identify NPDR severity progression. It is located mainly in the perifoveal retinal capillary circulation in the initial stages of NPDR, whereas the retinal midperiphery is predominantly affected in moderate-to-severe NPDR., Competing Interests: Competing interests: TS, ARS, IPM, LGM and MHM do not have financial disclosures. LHW, SK, LdS and MD: Carl Zeiss Meditec (E). JGC-V reports grants from Carl Zeiss Meditec and is consultant for Alimera Sciences, Allergan, Bayer, Gene Signal, Novartis, Pfizer, Precision Ocular, Roche, Sanofi-Aventis, Vifor Pharma, and Carl Zeiss Meditec., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Recognizing the central role of mental health in global health and affirming the complexity of the universalization of care policy, this paper discusses aspects of global mental health in Brazil and Italy - two countries that are a potential reference for exchange between the global North and South. Using ethnographic and action research methodologies, we conducted a study of a virtual community of practice composed of Brazilians and Italians interested in community mental health care. The results are presented in scenes that provide insights for the international debate in three categories: the doctor-centered approach to care; the institutionalization of care and medicalization of suffering; and the contribution of community practices and non-specialized local knowledge. The locally situated scenes cast light on globally shared critical knots, elucidating a plural set of relationships that run through work processes and mental health care. The sharing of knowledge and experiences highlight what should be universalized: opportunities for horizontal exchange, rather than the production of national identities that radiate universalizing practices and policies.

Introduction: We characterized the progression of different diabetic retinopathy (DR) phenotypes in type 2 diabetes (T2D)., Methods: A prospective longitudinal cohort study (CORDIS, NCT03696810) was conducted with three visits (baseline, 6 months, and 1 year). Demographic and systemic data included age, sex, diabetes duration, lipid profile, and hemoglobin A1c (HbA1c). Ophthalmological examinations included best-corrected visual acuity (BCVA), color fundus photography (CFP), and optical coherence tomography (OCT and OCTA). Phenotype classification was performed at the 6-month visit based on microaneurysm turnover (MAT, on CFP) and central retinal thickness (CRT, on OCT). Only risk phenotypes B (MAT < 6 and increased CRT) and C (MAT ≥ 6 with or without increased CRT) were included. ETDRS grading was performed at the baseline visit based on seven-field CFP., Results: A total of 133 T2D individuals were included in the study; 81 (60%) eyes were classified as phenotype B and 52 (40%) eyes as phenotype C. Of these, 128 completed the 1-year follow-up. At baseline, eyes with phenotype C showed greater capillary closure (superior capillary plexus, deep capillary plexus, and full retina, p < 0.001) and increased foveal avascular zone (FAZ) area (p < 0.001), indicating more advanced microvascular disease. Neurodegeneration represented by thinning of the ganglion cell layer + inner plexiform layer (GCL + IPL) was present in both phenotypes. When analyzing the 1-year progression of each phenotype, only phenotype C revealed a significant decrease in BCVA (p = 0.02) and enlargement of the FAZ (p = 0.03). A significant progressive decrease in the vessel density of the deep capillary layer and in MAT occurred in both phenotypes, but these changes were particularly relevant in phenotype C and ETDRS grades 43-47. During the 1-year period, both phenotypes B and C showed progression in GCL + IPL thinning (p < 0.001)., Conclusions: In the 1-year period of follow-up, both phenotypes B and C showed progression in retinal neurodegeneration, whereas phenotype C showed more marked disease progression at the microvascular level., (© 2021. The Author(s).)

Objective and Purpose: The aim of this study was to explore the relation between retinal neurodegenerative changes and vessel closure (VC) in individuals with nonproliferative diabetic retinopathy (NPDR) in a follow-up period of 3 years., Design: This is a 3-year prospective longitudinal study with four annual visits., Participants: This study involved 74 individuals with type 2 diabetes, NPDR, and Early Treatment Diabetic Retinopathy Study grades from 10 to 47, one eye/person. An age-matched healthy control population of 84 eyes was used as control group., Methods: Participants were annually examined by color fundus photography, spectral domain-optical coherence tomography (SD-OCT) and OCT-angiography (OCTA). VC was assessed by OCTA vessel density maps. SD-OCT segmentations were performed to access central retinal thickness (CRT) and retinal neurodegeneration considered as thinning of the ganglion cell plus inner plexiform layer (GCL + IPL)., Results: Type 2 diabetic individuals presented significantly higher CRT (p = 0.001), GCL + IPL thinning (p = 0.042), and decreased vessel density at the superficial capillary plexus (p < 0.001) and full retina (FR) (p = 0.001). When looking at changes occurring over the 3-year period of follow-up (Table 2), there were statistically significant decreases in GCL + IPL thickness (-0.438 μm/year; p = 0.038), foveal avascular zone circularity (-0.009; p = 0.047), and vessel density in superficial capillary plexus (-0.172 mm-1/year; p < 0.001), deep capillary plexus (DCP) (-0.350 mm-1/year; p < 0.001), and FR (-0.182 mm-1/year; p < 0.001). A statistically significant association was identified between GCL + IPL thinning and decrease in DCP vessel density (β = 0.196 [95% confidence interval: 0.037, 0.355], z = 2.410, p = 0.016), after controlling for age, gender, diabetes duration, hemoglobin A1c level, and CRT., Conclusions: Retinal neurodegenerative changes show a steady progression during a 3-year period of follow-up in eyes with NPDR and appear to be directly associated with progression in decreased vessel density including vascular closure through preferential involvement of the DCP. Our findings provide evidence that retinal neuropathy is linked with microvascular changes occurring in diabetic patients., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Diabetic retinopathy (DR) has been considered a microvascular disease, but it has become evident that neurodegeneration also plays a key role in this complex pathology. Indeed, this complexity is reflected in its progression which occurs at different rates in different type 2 diabetic (T2D) individuals. Based on this concept, our group has identified three DR progression phenotypes that might reflect the interindividual differences: phenotype A, characterized by low microaneurysm turnover (MAT <6), phenotype B, low MAT (<6) and increased central retinal thickness (CRT); and phenotype C, with high MAT (≥6). In this study, we evaluated the progression of DR neurodegeneration, considering ganglion cell+inner plexiform layers (GCL+IPL) thinning, in 170 T2D individuals followed for a period of 5 years, to explore associations with disease progression or risk phenotypes. Ophthalmological examinations were performed at baseline, first 6 months, and annually. GCL+IPL average thickness was evaluated by optical coherence tomography (OCT). Microaneurysm turnover (MAT) was evaluated using the RetMarkerDR. ETDRS level and severity progression were assessed in seven-field color fundus photography. In the overall population there was a significant loss in GCL+IPL (-0.147 μm/year), independently of glycated hemoglobin, age, sex, and duration of diabetes. Interestingly, this progressive thinning in GCL + IPL reached higher values in phenotypes B and C (-0.249 and -0.238 μm/year, respectively), whereas phenotype A remained relatively stable. The presence of neurodegeneration in all phenotypes suggests that it is the retinal vascular response to the early neurodegenerative changes that determines the course of the retinopathy in each individual. Therefore, classification of different DR phenotypes appears to offer relevant clarification of DR disease progression and an opportunity for improved management of each T2D individual with DR, thus playing a valuable role for the implementation of personalized medicine in DR., Competing Interests: JF reports being a member of Advisory Boards for Alimera, Allergan, Bayer, Bhoeringer, and No-vartis. JC-V reports being a consultant for Alimera Sciences, Allergan, Bayer, Gene Signal, Novartis, Pfizer, Precision Ocular Ltd., Roche, Sanofi-Aventis, Vifor Pharma, and Carl Zeiss Meditec. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Madeira, Marques, Ferreira, Tavares, Santos, Santos, Figueira, Lobo and Cunha-Vaz.)

Retinal vessel metrics identifying microvascular changes such as vessel closure (VC) have shown potential clinical value by identifying eyes with diabetic retinopathy (DR) at different severity levels and at increased risk for disease progression to more severe stages. We compare the performance of 11 different metrics, which include 2 metrics supplied by the manufacturer, based on OCTA for identification of VC in different Early Treatment for Diabetic Retinopathy Study (ETDRS) severity groups. OCTA en-face slabs from 84 healthy eyes (70 ± 4.8 years) and 78 eyes of diabetic individuals (67 ± 7.5 years) were processed using different methods that include abnormal intercapillary spaces (AIS), vessel density (VD), and nine metrics extracted from the en-face slab. The best separation between the eyes with DR and the control group was obtained in the superficial capillary plexus (SCP), with the full retina (FR) also performing well. In the SCP, the metrics that show better performance were the AIS and the VD with a value of area under curve (AUC) equal to 0.89 [95% CI 0.84-0.94] and 0.85 [95% CI 0.79-0.91], respectively, indicating that the VD metric supported by the manufacturer is satisfactory. The values of these metrics on the different ETDRS groups show a progressive increase in VC, which is correlated with disease severity., Competing Interests: JC-V reports grants from Carl Zeiss Meditec and is consultant for Alimera Sciences, Allergan, Bayer, Gene Signal, Novartis, Pfizer, Precision Ocular Ltd., Roche, Sanofi-Aventis, Vifor Pharma, and Carl Zeiss Meditec. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Mendes, Marques and Cunha-Vaz.)

To examine retinal vessel closure metrics and neurodegenerative changes occurring in the initial stages of nonproliferative diabetic retinopathy (NPDR) and severity progression in a three-year period. Methods: Three-year prospective longitudinal observational cohort of individuals with type 2 diabetes (T2D), one eye per person, using spectral domain-optical coherence tomography (SD-OCT) and OCT-Angiography (OCTA). Eyes were examined four times with one-year intervals. OCTA vessel density maps of the retina were used to quantify vessel closure. Thickness of the ganglion cell + inner plexiform layer (GCL + IPL) was examined to identify retinal neurodegenerative changes. Diabetic retinopathy ETDRS classification was performed using the seven-field ETDRS protocol. Results: A total of 78 eyes/patients, aged 52 to 80 years, with T2D and ETDRS grades from 10 to 47 were followed for 3 years with annual examinations. A progressive increase in retinal vessel closure was observed. Vessel density (VD) showed higher decreases with retinopathy worsening demonstrated by step-changes in ETDRS severity scale ( p < 0.001). No clear correlation was observed between neurodegenerative changes and retinopathy progression. Conclusions: Retinal vessel closure in NPDR correlates with DR severity progression. Our findings provide supporting evidence that OCTA metrics of vessel closure may be used as a surrogate for DR severity progression.

Background: Analysis of retinal microaneurysm turnover (MAT) has been previously shown to contribute to the identification of eyes at risk of developing clinically significant complications associated with diabetic retinopathy (DR). We propose to further characterize MAT as a predictive biomarker of DR progression and development of vision-threatening complications., Methods: 212 individuals with type 2 diabetes (T2D; ETDRS grades 20 and 35) were evaluated annually in a 5-year prospective, longitudinal study, by color fundus photography and optical coherence tomography. Endpoints were diabetic macular edema (DME) or proliferative retinopathy (PDR). MAT analysis included determination of MA formation and disappearance rates, automatically assessed using the RetMarkerDR ® . Retinopathy severity progression was evaluated using step increases in ETDRS severity levels., Results: Of the 212 individuals, 172 completed the 5-year follow-up study or developed an endpoint (n = 27). MAT calculated at 1 year showed a significant difference between groups of endpoint developments ( p = 0.018), particularly MA disappearance rate ( p = 0.007). MAT also showed a significant difference between eyes with different ETDRS severity progression in the 5-year period ( p = 0.035)., Conclusions: MAT is an indicator of the development of DME and/or PDR as well as of DR severity progression in T2D individuals with mild retinopathy.

Purpose: To characterize the progression in retinopathy severity of different phenotypes of mild nonproliferative diabetic retinopathy (NPDR) in patients with type 2 diabetes., Design and Methods: Patients with type 2 diabetes and mild NPDR (ETDRS 20 or 35) were followed in a 5-year longitudinal study. Examinations, including color fundus photography (CFP) and optical coherence tomography (OCT and OCTA), were performed at baseline, 6 months and then annually. Phenotype classification was performed based on microaneurysm turnover (MAT, on CFP) and central retinal thickness (CRT, on OCT). Phenotype A is characterized by low MAT (< 6) and normal CRT; Phenotype B by low MAT (< 6) and increased CRT; and Phenotype C by higher MAT (≥ 6) with or without increased CRT. ETDRS grading of seven fields CFP was performed at the initial and last visits., Results: Analysis of ETDRS grade step changes showed significant differences in diabetic retinopathy (DR) progression between the different phenotypes (p < 0.001). Of the 66 participants with phenotype A only 2 eyes (3%) presented 2-or-more-step worsening. None of the 50 participants characterized as phenotype B developed 2-step worsening, whereas 13 eyes (23.2%) characterized as phenotype C had 2-or-more-steps worsening. Phenotype C presents the higher risk for 2-or-more step worsening (OR: 15.94 95% CI: 3.45-73.71; p < 0.001) and higher sensitivity, correctly identifying 86.7% of cases at risk (AUC: 0.84 95% CI: 0.72-0.96; p < 0.001). Diabetic retinopathy severity progression was associated with HbA 1c (p = 0.019), LDL levels (p = 0.043), and ocular factors as MAT (p = 0.010), MA formation rate (p = 0.014) and MA disappearance rate (p = 0.005). Capillary closure at 5-year follow-up, identified by lower vessel density (VD) on OCTA, was also associated with diabetic DR severity progression (p = 0.035)., Conclusions: Different DR phenotypes in type 2 diabetes show different risks of retinopathy progression. Phenotype C is associated with increased HbA 1c values and presents a higher risk of a 2-or-more-step worsening of the ETDRS severity score.

Optical coherence tomography Angiography (OCT-A) represents a revolution in the noninvasive evaluation of retinal and choroidal circulation especially in detecting early clinical signs of diabetic retinal disease (DRD). With appropriate use, OCT-A characteristics and measurements have the potential to become new imaging biomarkers in managing and treating DRD. Major challenges include (a) provision of standardized outputs from different OCT-A instruments providing standardized terminology to correctly interpret data; (b) the presence of artifacts; (c) the absence of standardized grading or interpretation method in the evaluation of DRD, similar to that already established in fundus photography; and (d) establishing how OCT-A might be able to provide surrogate markers to demonstrate blood retinal barrier breakdown and vascular leakage, commonly associated with DRD. In fact, OCT-A guidelines for DRD are still evolving. The outputs of quantitative OCT-A data offer a unique opportunity to develop tools based on artificial intelligence to assist the clinicians in diagnosing, monitoring, and managing patients with diabetes. In addition, OCT-A has the potential to become a useful tool for the evaluation of cardiovascular diseases and different neurological diseases including cognitive impairment. This article written by the members of Diabetic Retinopathy expert committee of the European Vision Clinical Research network will review the available evidence on the use of OCT-A as an imaging biomarker in DRD and discuss the limits and the current application as well as future developments for its use in both clinical practice and research trials of DRD., (© 2021 The Author(s) Published by S. Karger AG, Basel.)

Our group reported that three diabetic retinopathy (DR) phenotypes: A, characterized by low microaneurysm turnover (MAT < 6) and normal central retinal thickness (CRT); B, low MAT (<6) and increased CRT, and C, high MAT (≥6), present different risks for development of macular edema (DME) and proliferative retinopathy (PDR). To test these findings, 212 persons with type 2 diabetes (T2D) and mild nonproliferative retinopathy (NPDR), one eye per person, were followed for five years with annual visits. Of these, 172 completed the follow-up or developed an outcome: PDR or DME (considering both clinically significant macular edema (CSME) and center-involved macular edema (CIME)). Twenty-seven eyes (16%) developed either CSME (14), CIME (10), or PDR (4), with one eye developing both CSME and PDR. Phenotype A showed no association with development of vision-threatening complications. Seven eyes with phenotype B and three with phenotype C developed CIME. Phenotype C showed higher risk for CSME development, with 17.41 odds ratio ( p = 0.010), compared with phenotypes A + B. All eyes that developed PDR were classified as phenotype C. Levels of HbA 1c and triglycerides were increased in phenotype C ( p < 0.001 and p = 0.018, respectively). In conclusion, phenotype C identifies eyes at higher risk for development of CSME and PDR, whereas phenotype A identifies eyes at very low risk for vision-threatening complications., Competing Interests: I.P.M., M.H.M., A.L.M., T.S. and A.C.–V.M. do not have financial disclosures. J.F.: member of Advisory board for Alimera, Allergan, Bayer, Bhoeringer, and Novartis; J.C.–V. reports grants from Carl Zeiss Meditec outside the submitted work and is consultant for Alimera Sciences, Allergan, Bayer, Gene Signal, Novartis, Pfizer, Precision Ocular Ltd., Roche, Sanofi–Aventis, Vifor Pharma, and Carl Zeiss Meditec.

Purpose: To characterize 2-year changes occurring in neurodegeneration, edema, and capillary dropout in nonproliferative diabetic retinopathy., Methods: Two-year prospective longitudinal observational cohort of eyes/patients with type 2 diabetes using spectral domain optical coherence tomography (SD-OCT) and optical coherence tomography angiography (OCTA). Eyes were examined three times with intervals of 1 year. Thickness of the full retina and layer-by-layer measurements were used to identify edema or neurodegeneration. OCTA vessel density maps of the retina were used to identify capillary dropout. Early Treatment Diabetic Retinopathy Study (ETDRS) classification was performed using the seven-field ETDRS protocol., Results: A total of 62 eyes from 62 patients with diabetes were followed for 2 years. After verification for image quality, a total of 44 eyes from 44 patients (30% women) aged 52 to 80 years were retained for data analysis. There were 18 eyes with ETDRS grades 10 to 20, 17 eyes with ETDRS grade 35, and 9 eyes with ETDRS grades 43 to 47. During the 2-year follow-up period, there was a progressive increase in capillary dropout, whereas edema and neurodegeneration remained stable. In multivariate analysis, considering a model adjusted for age, sex, hemoglobin A1C, visual acuity, and diabetes duration, vessel density remained significantly different between Diabetic Retinopathy Severity Scale groups (Wilks' λ = 0.707; P = 0.015) showing association with disease progression., Conclusions: Capillary dropout increased in a period of 2 years in eyes with minimal, mild, and moderate diabetic retinopathy, whereas the presence of edema and neurodegeneration remained stable.

The objective of this study was to evaluate the prevalence of different disease pathways (ischemia, neurodegeneration, and edema) in the initial stages of diabetic retinopathy. In this retrospective cross-sectional study, eyes were grouped by diabetic retinopathy severity using the 7-field Early Treatment Diabetic Retinopathy Study (ETDRS) protocol (levels 10-20, 35, and 43-47). Neurodegeneration was identified by thinning of the retinal nerve fiber layer and/or ganglion cell layer. Edema was identified by thickening of the inner nuclear layer, outer plexiform layer, or full retina. Ischemia was identified by metrics of retinal vessel density. Imaging was performed in 142 eyes from 142 patients (28% women) aged 52-88 years. Vessel density (ischemia) was significantly different between the ETDRS groups ( P < 0.020). On multivariate regression analysis, it remained significantly different between stages of the disease and showed associations with age ( P < 0.001), sex ( P = 0.028), and metabolic control ( P = 0.034). No significant differences between ETDRS groups were found in retinal thinning (neurodegeneration) or retinal thickness (edema). Eyes with the same ETDRS retinopathy grading from different patients with diabetes showed that the prevalence of different disease pathways varies between patients, even within the same severity group. Ischemia (capillary dropout) is the only disease pathway that shows correlation with retinopathy severity and metabolic control., (© 2018 by the American Diabetes Association.)

An intracellular β-xylosidase (AbXyl), from the thermoalkaline Anoxybacillus sp. 3M, was purified and characterized. The homodimeric enzyme (140 kDa) was optimally active at 65 °C and pH 5.5, exhibited half life of 10 h at 60 °C, 78 and 88% residual activity after 24 h, at pH 4.5 and 8.0, respectively. Fe 2+ , Cu 2+ , Al 3+ , Ag + and Hg 2+ inhibited the enzyme; the activity was moderately stimulated by SDS and not influenced by β-mercaptoethanol. In the presence of p-nitrophenyl-β-d-xylopyranoside, AbXyl exhibited Km of 0.19 mM, Kcat of 453.29 s -1 , Kcat Km -1 of 2322 s -1  mM and was moderately influenced by xylose (Ki 21.25 mM). The enzyme hydrolyzed xylo-oligomers into xylose and catalyzed transxylosilation reactions also in presence of alcohols as acceptors, producing xylo-oligosaccharides and alkyl-xylosides. Finally AbXyl was applied towards a statistically optimized process of brewery's spent grain bioconversion, highlighting the important role of this biocatalyst in reaching high yields of fermentable sugars., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Purpose: This study is aimed at characterizing the type of retinal edema in the initial stages of retinopathy in type 2 diabetes., Methods: In this retrospective cross-sectional study, spectral domain optical coherence tomography (OCT) layer by layer analysis of the retina in association with OCT-Leakage, an algorithm to detect sites of low optical reflectivity, were used to examine eyes with minimal, mild, and moderate diabetic retinopathy (DR)., Results: A total of 142 eyes from 142 patients (28% women) aged 52-88 years were imaged. Macular edema, either subclinical (SCME) or central-involved macular edema (CIME), was present in 43% of eyes in group 10-20, 41% of eyes in group 35, and 38% of eyes in group 43-47. The inner nuclear layer (INL) was the layer showing higher and most frequent increases in retinal thickness (79%). The edema was predominantly intracellular in group 10-20 (65%) and extracellular in groups 35 (77%) and 43-47 (69%)., Conclusions: Eyes from diabetic patients in the initial stages of DR with different Early Treatment Diabetic Retinopathy Study gradings show similar prevalence of SCME and CIME, independent of the severity of the retinopathy. Retinal edema is located mainly in the INL and appears to be mostly extracellular except in the earliest stages of diabetic retinal disease where intracellular edema predominates., (© 2019 S. Karger AG, Basel.)

Objectives: The aim of this study was to evaluate the clinical performance of silorane-based composite restorations applied after different surface treatments., Materials and Methods: This controlled and randomized clinical trial included 26 patients with class I restoration indications. The teeth were randomly assigned to the following treatments: control 1/G1, silorane specific self-etching adhesive (P90 self-etch primer and bond) + silorane-based composite resin (Filtek™ P90 low shrink posterior restorative); G2, 37% phosphoric acid + silorane specific self-etching adhesive + silorane-based composite resin; G3, blasting with aluminum oxide + silorane specific self-etching adhesive + silorane-based composite resin; and control 2/G4, self-etching adhesive (Adper™ SE Plus self-etch adhesive) + dimethacrylate-based composite resin (Filtek™ P60 posterior restorative). The clinical performance was evaluated at baseline and after 1 year., Results: A total of 141 restorations were made and evaluated. For all clinical criteria evaluated, no significant difference was found between the surface treatments at baseline and after 1 year (p > 0.05). After 1 year, only the group with 37% phosphoric acid + silorane specific self-etching adhesive (G2) showed a significant reduction in marginal adaptation (p < 0.05)., Conclusion: In general, all surface treatments showed an adequate clinical performance for silorane-based composite resin in class I restorations. However, a reduction in the marginal adaptation after 1 year was found when additional phosphoric acid etching was used prior to silorane specific self-etching adhesive., Clinical Relevance: The use of phosphoric acid etching prior to specific self-etching adhesive can adversely affect the marginal adaptation of silorane-based restorations.

This study evaluated the operation of a hybrid anaerobic reactor fed with algal biomass cultivated in effluent from the brewery industry. Three stages of operation were distinguished during the 72 days of semi-continuous functioning of the reactor: Stage 1 (S1), in which algal biomass was used as substrate; Stage 2 (S2), in which 10% (v/v) of the algal biomass was substituted by olive mill wastewater (OMW); and Stage 3 (S3), in which algal biomass was heat pre-treated. During S1, a loss of solids was observed, with an increment of organic matter in the outlet. The substitution of 10% of the volume of algal biomass by OMW tripled the methane productivity obtained in the previous stage by digestion of pure algal biomass. Heat pre-treatment was not efficient in rupturing the cell wall, and consequently did not have any effect on the increase in biogas production. The complementarity of substrates in the assessed conditions led to better results than the pre-treatment of the algal biomass., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose: Retinal vein occlusion (RVO) is an important cause of visual disability in the modern world. We aim to evaluate the real-world outcomes of patients with RVO treated with anti-vascular endothelial growth factor (VEGF) in Portugal., Methods: We performed a retrospective, observational, multicenter study including 8 centers across Portugal and 200 patients treated with either ranibizumab or bevacizumab. Data were collected at 3 time points: time of diagnosis (0 time point) and 6 and 12 months after initiating treatment. Demographic and clinical data were collected., Results: Median visual acuity (VA) and central macular thickness (CMT) improved in the branch RVO (BRVO), central RVO (CRVO), bevacizumab, and ranibizumab groups at 6 and 12 months compared to baseline, with CMT improving further only in the CRVO and ranibizumab groups between 6 and 12 months (p = 0.002 and p = 0.001, respectively). The CMT was lower in the ranibizumab group compared to the bevacizumab group both at 6 and 12 months (p<0.02). Median CMT improved in both the good and poor baseline VA groups at 6 and 12 months compared to baseline (p<0.001). Median VA only improved for the group with poor baseline VA at 6 and 12 months of follow-up (p<0.001). Regression analysis identified several baseline variables as predictors of visual outcomes at 6 and 12 months, with different results depending on the analyzed group., Conclusions: Both treatments were effective, although less effective than results reported in clinical trials. The morphologic response was better with ranibizumab compared to bevacizumab, although functionally there were no differences.

Purpose: To test OCT-Leakage, a new method of analyzing and mapping sites of lower optical reflectivity found on OCT, by examining eyes with various types of retinal edema to identify abnormal increases in retinal extracellular fluid., Design: Prospective analysis of a cohort of cases., Participants: Healthy eyes and eyes with retinal edema in the setting of different retinal diseases., Methods: Prospective OCT-Leakage analysis of 12 eyes with various types of retinal edema, such as diabetic macular edema, branch retinal vein occlusion, idiopathic perifoveal telangiectasia, and Irvine-Gass syndrome, representing intraretinal edema and eyes with idiopathic central serous chorioretinopathy and neovascular age-related macular degeneration representing subretinal fluid accumulation, in order to compare with OCT-Leakage analysis of a series of 41 eyes of 24 healthy controls. Raw scan data from the OCT images were exported and used to calculate lower than normal optical reflectivity maps (low optical reflectivity [LOR] ratios). Optical reflectivity LOR maps (OCT-Leakage maps) were collected for the full retina A-scan and layer by layer after segmentation. Low optical reflectivity ratios from patients with the different conditions of retinal edema and controls were compared. Fluorescein angiography (FA) and OCT angiography (OCTA) were performed in all eyes., Main Outcome Measures: Identification of areas of abnormal retinal fluid accumulation., Results: The OCT-Leakage maps based on sites of LOR (LOR ratios) delineated the location of intraretinal and subretinal fluid, always integrating the location of the sites on FA and the vascular abnormalities observed on OCTA. The areas of fluid outline in the OCT-Leakage maps were coincident and generally larger than those seen on FA. In all cases, the OCT-Leakage maps were able to identify the location of the fluid in the different segmented retinal layers., Conclusions: Mapping of lower reflectivity sites within the retina demonstrates the amount and location of retinal and subretinal fluid in different retinal diseases, showing potential to contribute to their management. Furthermore, the possibility of complementarity between OCT-Leakage and OCTA is highly promising., (Copyright © 2017 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Yeast production and biomass biorefinery processes for lipid and carotenoid extraction generate residues that can be used as substrates for anaerobic digestion. Glucose and carob pulp syrups were used as carbon sources to produce the yeast biomass. The yeast cultivation broth, yeast biomass residues (after carotenoid and lipid extraction) and the carob pulp solid residues obtained from the extraction of sugars were used to produce biogas by applying different Substrate/Inoculum ratios (S/I of 0.5 and 0.75). For all the residues studied, the digestions at the S/I ratio of 0.75 provided higher biogas yields than those carried out at the S/I ratio of 0.5. The best results in terms of biogas production and methane yield were observed for the yeast residue digestion at S/I of 0.75 (65.9mL, 333.7mLg -1 VS -1 substrate). As monitored through flow cytometry, its bacterial consortium showed the lowest proportion of injured cells., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Purpose: To analyse and compare the classification of eyes with diabetic retinopathy using fluorescein angiography (FA) and optical coherence tomography angiography (OCTA) performed either with AngioPlex or AngioVue., Methods: This was an observational cross-sectional study of 50 eyes from 26 diabetic subjects. Two independent graders classified the FA angiograms, to assess the presence and severity of several characteristics according to the ETDRS Report 11, and a similar evaluation was performed for each 3×3 mm OCTA image from the superficial retinal layer and for the full retina slab., Results: Percentages of non-gradable images for the outline of foveal avascular zone (FAZ) in the central subfield (CSF) were 29.0% for FA, 12.0% for AngioVue and 3.0% for AngioPlex. For capillary loss, percentages of non-gradable images in the CSF were 25.0% for FA, 11% for AngioVue and 0.0% for AngioPlex. For the inner ring (IR), percentages of non-gradable images were 12.5% for FA, 11.5% for AngioVue and 0.5% for AngioPlex. Agreement between graders was substantial for outline of FAZ. For capillary loss, the agreement was fair for the CSF, and moderate for the IR., Conclusions: The OCTA allows better discrimination of the CSF and parafoveal macular microvasculature than FA, especially for FAZ disruption and capillary dropout, without the need of an intravenous injection of fluorescein. In addition, FA had also a higher number of non-gradable images. The OCTA can replace with advantage the FA, as a non-invasive and more sensitive procedure for detailed morphological evaluation of central macular vascular changes., Trial Registration Number: NCT02391558, Pre-results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

We described the synthesis of a new congener series of 1,2,3-triazolyl-4-oxoquinolines and evaluated their ability to inhibit oseltamivir (OST)-resistant influenza strains. Oxoquinoline derivative 1i was the most potent compound within this series, inhibiting 94% of wild-type (WT) influenza neuraminidase (NA) activity. Compound 1i inhibited influenza virus replication with an EC50 of 0.2μM with less cytotoxicity than OST, and also inhibited different OST-resistant NAs. These results suggest that 1,2,3-triazolyl-4-oxoquinolines represent promising lead molecules for further anti-influenza drug design., (Published by Elsevier Ltd.)

Background: In addition to energy benefits, anaerobic digestion offers other interesting advantages. The cork industry is of great environmental, economic and social significance in the western Mediterranean region, with Portugal being the world-leading producer and exporter. Cork boiling wastewater (CBW) is a toxic and recalcitrant organic effluent produced by this sector, which constitutes a serious environmental hazard. However, there is no documented research on anaerobic treatment/valorization performed with this effluent. The work presented here was developed with the aim to use the anaerobic digestion process to convert the CBW polluting organic load into an energy carrier gas and valuable molecules for industry., Results: No lag phases were observed and a methane yield of 0.126 to 0.142 m(3) kg(-1) chemical oxygen demand (COD)added was registered in the mesophilic consortium experiments carried out in batch flasks at 37 ± 1°C. Anaerobic digestion can be advantageously connected to ultrafiltration or electrochemical processes, due to the following: 1) reduction of ellagic acid content and consequent decrease of CBW viscosity; and 2) increase in conductivity after the anaerobic process, avoiding the electrolyte application of the electrochemical process. The improvement of several CBW biochemical features shows that anaerobic digestion may provide additionally useful molecules. The rise in concentration of some of these compounds, belonging to the benzoic acid family (gallic, protocatechuic, vanillic and syringic acids), is responsible for the increase of antiradical activity of the phenolic fraction. Additionally, some enzymatic activity was also observed and while the laccase activity increased in the digested effluent by anaerobiosis, xylanase was formed in the process., Conclusions: The multidisciplinary approach adopted allowed the valorization of CBW in terms of energy and valuable biomolecules. By exploiting the anaerobic digestion process potential, a novel methodology to toxic and recalcitrant cork processing wastewater was developed.

Purpose: To evaluate the 36-month efficacy of intravitreal ranibizumab injections for choroidal neovascularization secondary to age-related macular degeneration (AMD) in real world clinical practice., Methods: Retrospective study involving 84 eyes of 77 patients; 52 eyes completed 3 years of follow-up. Subjects were observed initially on a monthly basis and with extended follow-up intervals if signs of quiescence were detected, according to an established protocol. A comprehensive ophthalmologic examination was performed, including best-corrected visual acuity (BCVA) determined with Early Treatment Diabetic Retinopathy Study charts, stereoscopic macular biomicroscopy and optical coherence tomography (OCT) with fluorescein angiography and indocyanine green angiography if considered necessary. Treatment was given if signs of active lesions were present., Results: The mean baseline BCVA was 49.33 and 49.52 letters at the 36-month visit. The average of treatments was 8.6 at 3 years. At this time point, 77% of treated eyes stabilized or improved their vision (VA loss ≤ 5 letters). A predictive value for better VA was found for younger age, better baseline VA, good response on OCT and more frequent treatments., Conclusion: At 3 years, intravitreal ranibizumab is able to maintain baseline VA in exudative AMD patients, with a reduced number of injections, but not to show VA improvement, in clinical practice., (Copyright © 2013 S. Karger AG, Basel.)

A novel approach was developed for the energetic valorisation and treatment of olive mill wastewater (OMW), combining anaerobic digestion and electrochemical oxidation. The electrochemical treatment was proposed as the final step to mineralize the remaining OMW fraction from the anaerobic reactor. The electrooxidation of anaerobically digested OMW was investigated over dimensionally stable anodes (DSAs). RuO(2) based anode was significantly more efficient than IrO(2)-type DSA, mainly for the COD removal. IrO(2) based anode promoted a selective oxidation of phenols and colour removal. For instance, after an electrolysis charge of 10.4 × 10(4) C L(-1), COD removals of 14 and 99%, phenols removals of 91 and 100% and colour removals of 85 and 100% were obtained for IrO(2) and RuO(2) DSAs-type, respectively. The electrochemical post-treatment was effectively performed without using a supporting electrolyte and in the presence of the solids that remained from the anaerobic process. The achievement of the required effluent quality for sewer systems disposal depends on the operating conditions of the anaerobic process. Consequently, special care must be taken with the chloride and nitrogen levels that may surpass the legal discharge limits. The electrochemical oxidation over RuO(2) based DSA is an appropriate second-step treatment for OMW disposal, after the recovery of its energetic potential., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Strategies are proposed for the anaerobic treatment of lipid and phenolic-rich effluents, specifically the raw olive mill wastewater (OMW). Two reactors were operated under OMW influent concentrations from 5 to 48 g COD L(-1) and Hydraulic Retention Time between 10 and 5 days. An intermittent feeding was applied whenever the reactors showed a severe decay in the methane yield. This strategy improved the mineralization of oleate and palmitate, which were the main accumulated Long-Chain Fatty Acids (LCFA), and also promoted the removal of resilient phenolic compounds, reaching remarkable removal efficiencies of 60% and 81% for two parallel reactors at the end of a feed-less period. A maximum biogas production of 1.4m(3)m(-3)d(-1) at an Organic Loading Rate of 4.8 kg COD m(-3)d(-1) was obtained. Patterns of individual LCFA oxidation during the OMW anaerobic digestion are presented and discussed for the first time. The supplementation of a nitrogen source boosted immediately the methane yield from 21 and 18 to 76 and 93% in both reactors. The typical problems of sludge flotation and washout during the anaerobic treatment of this oily wastewater were overcome by biomass retention, according to the Inverted Anaerobic Sludge Blanket (IASB) reactor concepts. This work demonstrates that it is possible to avoid a previous detoxification step by implementing adequate operational strategies to the anaerobic treatment of OMW., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Olive mill wastewater (OMW) was digested in its original composition (100% v/v) in an anaerobic hybrid. High concentrations (54-55 kg COD m(-3)), acid pH (5.0) and lack of alkalinity and nitrogen are some OMW adverse characteristics. Loads of 8 kg COD m(-3) d(-1) provided 3.7-3.8 m3 biogas m(-3) d(-1) (63-64% CH4) and 81-82% COD removal. An effluent with basic pH (8.1) and high alkalinity was obtained. A good performance was also observed with weekly load shocks (2.7-4.1, 8.4-10.4 kg COD m(-3) d(-1)) by introducing piggery effluent and OMW alternately. Biogas of 3.0-3.4 m3 m(-3) d(-1) (63-69% CH4) was reached. Developed biomass (350 days) was neither affected by raw OMW nor by organic shocks. Through the effluents complementarity concept, a stable process able of degrading the original OMW alone was obtained. Unlike what is referred, OMW is an energy resource through anaerobiosis without additional expenses to correct it or decrease its concentration/toxicity., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

We recently described that the chloroxoquinolinic ribonucleoside 6-chloro-1,4-dihydro-4-oxo-1-(beta-D-ribofuranosyl) quinoline-3-carboxylic acid (compound A) inhibits the human immunodeficiency virus type 1 (HIV-1) enzyme reverse transcriptase (RT), and its replication in primary cells. Based on these findings, we performed kinetic studies to investigate the mode of inhibition of compound A and its aglycan analog (compound B). We found that both molecules inhibited RT activity independently of the template/primer used. Nevertheless, compound A was 10-fold more potent than compound B. Compound A inhibited the RNA-dependent DNA polymerase (RDDP) activity of RT with an uncompetitive and a noncompetitive mode of action with respect to dTTP incorporation and to template/primer (TP) uptake, respectively. The kinetic pattern of the inhibition displayed by compound A was probably due to its greater affinity for the ternary complex (RT-TP-dNTP) than the enzyme alone or the binary complex (RT-TP). Besides, by means of molecular modeling, we show that compound A bound on the NNRTI binding pocket of RT. However, our molecule targets such a site by making novel interactions with the enzyme RT, when compared to NNRTIs. These include a hydrogen bridge between the 2'-OH of our compound and the Tyr675 of the enzyme RT's chain B. Therefore, compound A is able to synergize with both a NRTI (AZT-TP) and a NNRTI (efavirenz). Taken together, our results suggest that compound A displays a novel mechanism of action, which may be different from classical NRTIs and NNRTIs.

Bacterial infections are a significant cause of morbidity and mortality among critically ill patients. The increase of antibiotic resistance in bacteria from human microbiota-such as Staphylococcus epidermidis, an important nosocomial pathogen that affects immunocompromised patients or those with indwelling devices-increased the desire for new antibiotics. In this study we designed, synthesized, and determined the antimicrobial activity of 27 thieno[2,3-b]pyridines (1, 2, 2a-2m, 3, 3a-3m) derivatives against a drug-resistant clinical S. epidermidis strain. In addition, we performed a structure-activity relationship analysis using a molecular modeling approach, and discuss the drug absorption, distribution, metabolism, excretion, and toxicity profile and Lipinski's "rule of five," which are tools to assess the relationship between structures and drug-like properties of active compounds. Our results showed that compound 3b (5-(1H-tetrazol-5-yl)-4-(3;-methylphenylamino)thieno[2,3-b]pyridine) was as active as oxacillin and chloramphenicol but with lower theoretical toxicity risks and a better drug likeness and drug score potential than chloramphenicol. All molecular modeling and biological results reinforced the promising profile of 3b for further experimental investigation and development of new antibacterial drugs.

Electrochemical treatment of oleate using RuO2 and IrO2 type dimensionally stable anodes in alkaline medium was performed to develop a feasible anaerobic pre-treatment of fatty effluents. The results showed that the pre-treated solutions over RuO2 were faster degraded by anaerobic consortium than the raw oleate solutions or the electrolysed solutions using IrO2. In batch experiments carried out with pre-treated solutions over RuO2 (100-500mg/L), no lag phases were observed before the methane production onset. On the other hand, raw oleate and pre-treated oleate over IrO2 had originated lag phases of 0-140 and 0-210h, respectively. This study demonstrated that it is advantageous to apply the electrochemical treatment carried out on the RuO2 type DSA in order to achieve a faster biodegradation of lipid-containing effluent and consequently to obtain a faster methane production.

We describe in this paper that the chloroxoquinolinic ribonucleoside 6-chloro-1,4-dihydro-4-oxo-1-(beta-D-ribofuranosyl)-quinoline-3-carboxylic acid (compound A) inhibits the HIV-1 replication in human primary cells. We initially observed that compound A inhibited HIV-1 infection in peripheral blood mononuclear cells (PBMCs) in a dose-dependent manner, resulting in an EC(50) of 1.5 +/- 0.5 microM and in a selective index of 1134. Likewise, compound A blocked HIV-1(BA-L) replication in macrophages in a dose-dependent manner, with an EC(50) equal to 4.98 +/- 0.9 microM. The replication of HIV-1 isolates from subtypes C and F was also inhibited by compound A with the same efficiency. Compound A inhibited an early event of the HIV-1 replicative cycle, since it prevented viral DNA synthesis in PBMCs exposed to HIV-1. Kinetic assays demonstrated that compound A inhibits the HIV-1 enzyme reverse transcriptase (RT) in dose-dependent manner, with a K(I) equal to 0.5 +/- 0.04 microM. Using a panel of HIV-1 isolates harboring NNRTI resistance mutations, we found a low degree of cross-resistance between compound A and clinical available NNRTIs. In addition, compound A exhibited additive effects with the RT inhibitors AZT and nevirapine, and synergized with the protease inhibitor atazanavir. Our results encourage continuous studies about the kinetic impact of compound A towards different catalytic forms of RT enzyme, and suggest that our nucleoside represents a promising molecule for future antiretroviral drug design.

We describe in this paper that the synthetic chloroxoquinolinic ribonucleoside 6-chloro-1,4-dihydro-4-oxo-1-(beta-D-ribofuranosyl) quinoline-3-carboxylic acid (compound A) and its free aglycogene base (compound B) inhibit, with low cytotoxicity, the replication of herpes simplex virus type 1 and 2 (HSV-1 and HSV-2). Compound A inhibited HSV-1 replication in Vero cells with an EC(50) of 1.3 and 1.4 microM for an acyclovir (ACV)-sensitive strain and an ACV-resistant strain of this virus, respectively. Additionally, it inhibited HSV-2 replication with an EC(50) of 1.1 microM. Compound B also inhibited the ACV-sensitive and -resistant HSV-1 strains, and HSV-2 at EC(50) values of 1.7, 1.9 and 1.6 microM, respectively. Time-of-addition assays, performed with compound A, suggested that this molecule at an early time point of the HSV replication cycle. Kinetic assays demonstrated that compounds A and B inhibit the HSV DNA polymerase activity in a noncompetitive fashion, with a K(i) equal to 0.1 and 0.2 microM, respectively. Taken together, our results suggest that compounds A and B represent promising lead molecules for further anti-HSV drug design.