Towards a European health research and innovation cloud (HRIC).

The European Union (EU) initiative on the Digital Transformation of Health and Care (Digicare) aims to provide the conditions necessary for building a secure, flexible, and decentralized digital health infrastructure. Creating a European Health Research and Innovation Cloud (HRIC) within this environment should enable data sharing and analysis for health research across the EU, in compliance with data protection legislation while preserving the full trust of the participants. Such a HRIC should learn from and build on existing data infrastructures, integrate best practices, and focus on the concrete needs of the community in terms of technologies, governance, management, regulation, and ethics requirements. Here, we describe the vision and expected benefits of digital data sharing in health research activities and present a roadmap that fosters the opportunities while answering the challenges of implementing a HRIC. For this, we put forward five specific recommendations and action points to ensure that a European HRIC: i) is built on established standards and guidelines, providing cloud technologies through an open and decentralized infrastructure; ii) is developed and certified to the highest standards of interoperability and data security that can be trusted by all stakeholders; iii) is supported by a robust ethical and legal framework that is compliant with the EU General Data Protection Regulation (GDPR); iv) establishes a proper environment for the training of new generations of data and medical scientists; and v) stimulates research and innovation in transnational collaborations through public and private initiatives and partnerships funded by the EU through Horizon 2020 and Horizon Europe.

Changing trend in the utilisation rate of donated corneas for keratoplasty in the UK: The North East England Study.

PurposeTo report the changing trend in the utilisation rate of donated corneas for keratoplasty and to examine the reasons for unutilised corneas in the North East of England.MethodsRelevant data were retrospectively collected from a local eye retrieval database and the UK Transplant Registry for two separate years; namely, 2006 and 2010.ResultsThe utilisation rate of donated corneas for keratoplasty improved from 57% (52/92) in 2006 to 71% (220/312) in 2010 (P=0.012). Over the same period, there was a marked reduction of failed serological test results from 24% (22/92) to 5% (14/312) (P<0.001). The leading reasons for unutilised corneas were failed serological test results (22/92, 24%) in 2006 and inadequate tissue quality (23/312, 7%) in 2010. The rate of tissue contamination remained similar between 2006 (4%) and 2010 (6%) (P=0.80). Eleven (4%) corneas were not transplanted due to recipient-related factors in 2010. Donor corneas of inadequate tissue quality were associated with older age (P=0.04) but not with gender, donation site, consent method, death-to-enucleation interval, death-to-processing interval, and storage time in the eye bank.ConclusionThere was a substantial improvement in the utilisation rate of corneas donated in the North East of England between 2006 and 2010. The principal reason was a reduction in failed serological test results. High donor age was associated with increased chance of corneas not being used. Utilisation rate of corneas can be further improved if potential modifiable factors are addressed, such as recipient-related factors and microbial contamination.

Impact of telephone consent and potential for eye donation in the UK: the Newcastle Eye Centre study.

AIMS: To examine the impact of telephone consent introduced in 2007 on the eye donation rate and to report the changing trend and potential for improvement in eye donation in Newcastle upon Tyne, UK. METHODS: Relevant data were retrospectively collected from the local eye retrieval database for two separate years, namely, 2006 (before the introduction of telephone consent) and 2010. All the hospitals within Newcastle were included in the study. RESULTS: From 2006 to 2010, there was a 3.5-fold increase in eye donation from 32 (of 2479 deaths) to 111 donors per year (of 2213 deaths) in Newcastle (P<0.001). Consent was obtained via face-to-face interview in all 32 (100%) and 59 (53.2%) donors in 2006 and 2010, respectively. Introduction of telephone consent increased the donation rate by an additional 88.1% (from 59 to 111 donors) in 2010 (P<0.001). In addition, there was a significant increase in medical notes of the deceased being reviewed from 27.1% (671/2479 cases) in 2006 to 62.4% (1382/2213 cases) in 2010 (P<0.001). Acceptance rate of eye donation was 45.7% (32/70) in 2006 and 49.6% (111/224) in 2010 (P=0.575). Acceptance rate was positively associated with registration on organ donor register (P<0.001) and telephone consent (P<0.001), but not with age (P=0.883), gender (P=0.234), or location of death (P=0.984) of the potential donors. CONCLUSION: There has been a substantial improvement in eye donation rate in Newcastle over the recent years. Introduction of telephone consent and high-quality eye donation service serve as effective measures for increasing eye donation.

The impact of donor age and endothelial cell density on graft survival following penetrating keratoplasty.

PURPOSE: To determine if donor age and preoperative endothelial cell density (ECD) affect corneal endothelial failure following penetrating keratoplasty (PK). METHODS: Preoperative and postoperative data for PKs performed in the UK between April 1999 and March 2012 were analysed. Donor age was split into three groups (0-60, 61-75 and >75 years) and donor ECD was split into three groups (≤2400, 2401-2600 and >2600 cells/mm2). Cox proportional hazards regression was used to determine whether the selected subgroups of donor age and donor ECD have an impact on endothelial failure and a systematic analysis of the interaction between donor ECD and donor age was conducted. The analysis was stratified for primary corneal diagnosis (Fuchs endothelial dystrophy (FED), pseudophakic bullous keratopathy (PBK) and other) and corrected for potentially confounding factors (human leukocyte antigen matching, donor trephine diameter, deep vascularisation, the occurrence of reversible rejection episodes and receipt of systemic antiviral medication, long-term steroids or other immunosuppressive agents). RESULTS: A total of 9415 patients, from the National Health Service Blood and Transplant UK Transplant Registry, who received their first PK for visual reasons were included in this study. The overall 5-year graft survival rate due to endothelial failure was 89%. Survival rates in recipients with FED, PBK and 'all other indications' were 95%, 83% and 89%, respectively. Our analysis shows that donor ECD did not affect outcome following corneal graft within the preselected categories, irrespective of diagnosis and after allowing for any potential confounding factors. Furthermore, HRs for each level of donor ECD, relative to >2600 cells/mm2, for each combination of age group and indication, were not statistically significant. CONCLUSIONS: We were unable to detect a significant effect of donor age, up to 90 years, and preoperative donor ECD, above the lower limit of 2200 cells/mm2, on endothelial failure at 5 years following PK.

Haplotype analysis on chromosome 6p of tumor necrosis factor alpha, vascular endothelial growth factor A, and interleukin-17F alleles associated with corneal transplant rejection.

OBJECTIVE: The aim of this work was to investigate single-nucleotide polymorphisms (SNPs) in multiple genes on chromosome 6p in corneal transplant recipients known to be at increased risk of failure through immunologic rejection (ie, "high-risk" corneal transplants). Tumor necrosis factor alpha (TNF-α) is a key immunoregulatory cytokine in the ocular environment, interacting with a variety of factors in a synergistic way and playing a crucial role in many stages of the inflammatory response. Vascular endothelial growth factor (VEGF) is one of the most important angiogenic factors, supporting both hemangiogenesis and lymphangiogenesis, both key in transplant tolerance and rejection. Interleukin-17 (IL-17) is a multifunctional cytokine produced by T-helper 17 cells, exerting specific effector functions during an immune response. Association of SNPs in all 3 genes with corneal transplant outcome was therefore investigated. METHODS: Three hundred five corneal transplant recipients were followed for 3 years, and episodes of allograft rejection were recorded. With the use of patient DNA, 6 SNPs of 3 different genes on chromosome 6p were investigated. The TNF-α promoter SNP -308 G/A (rs1800629) was analyzed with the use of induced heteroduplex generation; 2 VEGF-A functional variants were analyzed, -2578 (rs699947) C/A and -1154 (rs1570360) G/A, with the use of Taqman genotyping assays; and 3 nonsynonymous IL-17F SNPs in exon 3 (negative strand), (rs2397084) A/G, (rs11465553) G/A, and (rs763780) A/G, were investigated with the use of direct sequencing. Haplotypes were inferred with the use of PHASE using positive strand alleles, and exact measures of association were determined with the use of Mid-P exact chi-square. RESULTS: Six common haplotypes were inferred, with the haplotype TNF-α (rs1800629), VEGF-A (rs699947), (rs1570360), IL-17F (rs763780), (rs11465553), and (rs2397084) ACGTCT having a significant association with corneal transplant rejection (odds ratio, 1.78; 95% confidence interval, 1.01-3.11; P = .04). CONCLUSIONS: The results suggest that patients carrying a combination of SNPs for TNF-α, VEGF-A, and IL-17F of ACGTCT haplotype may have an increased risk of corneal allograft rejection compared with patients carrying other haplotypes.

Functional tumor necrosis factor alpha polymorphisms and haplotype analysis in high-risk corneal transplantation.

BACKGROUND: Tumor necrosis factor alpha (TNF-α) plays a critical role in diverse cellular processes including ocular immune tolerance, inflammation, and allograft rejection. The ubiquitous transcription factor nuclear factor kappa B (NF-κB) regulates expression of numerous genes. Induction of the TNF-α pathway is involved in the inflammatory response and loss of transplant tolerance. OBJECTIVES: We investigated functional single nucleotide polymorphisms (SNPs) in the promoter region of TNF-α and an insertion/deletion (indel) polymorphism of NF-κB1 in corneal transplant recipients considered to be at increased risk of immunological rejection (ie, high-risk corneal transplantations) and looked for any associations with corneal transplantation outcome. PATIENTS AND METHODS: Three hundred eighty-four full thickness corneal transplant recipients were followed for 3 years and episodes of reversible and irreversible allograft rejection were recorded. Using DNA obtained from these patients, 5 SNPs located in the promoter region -1031 T/C rs1799964, -863 C/A (rs1800630), -857 C/T (rs1799724), -308 G/A (rs1800629), and -238 G/A (rs361525), and one SNP upstream from the transcription start site (+489) rs1800610 of TNF-α were analyzed using induced heteroduplex generation. A functional NF-κB1 indel (-94) was also investigated. Haplotypes were inferred by PHASE and associations with rejection were determined by chi-square analysis. RESULTS: The TNF-α haplotype TCTGGA was significantly associated with reduced risk of corneal graft rejection (Pc < .005) and TCTAGA was associated with increased risk of rejection (Pc < .005) in high-risk corneal transplants. There was no association with the NF-κB1 indel (Pc > .05). CONCLUSION: According to haplotype frequencies, our results suggest that the TCTGGA haplotype may confer additional protection against risk of immunological rejection whereas TCTAGA may increase risk of corneal allograft rejection in the high-risk setting. However, both haplotypes were relatively rare and thus would not warrant genotyping for individual patient selection for anti-TNF therapy.

Antiviral treatment following penetrating keratoplasty for herpetic keratitis.

PURPOSE: To assess the effect of antiviral treatment on corneal graft survival following penetrating keratoplasty for herpetic keratitis. METHODS: Retrospective cohort study of 454 patients receiving primary penetrating keratoplasties (PKs) for viral infection reported to NHS Blood and Transplant (NHSBT) between April 1999 and June 2005. Follow-up data were available on 403 PKs. Kaplan-Meier survival estimates were used to determine graft survival for the three treatment groups: no medication, topical antiviral, and oral antiviral medication. A Cox regression model was used to investigate the combined effects of all additional factors on graft failure. The model was fitted using all pre-operative factors first and then post-operative factors including type of antiviral medication were included. RESULTS: Patients who received oral antiviral medication post-operatively had consistently better graft survival than those receiving no medication or only topical medication. Patients receiving oral antivirals were less than a third as likely to have a failed graft at 5 years compared with those on no antiviral medication (relative risk (RR) 0.3, CI: 0.2-0.7, P=0.002). Other factors that were found to influence the risk of graft failure were the presence of deep corneal vascularisation (P=0.009), PK performed for therapeutic reasons (P=0.03), large diameter grafts (P=0.04), and experiencing a rejection episode (P=0.003). CONCLUSION: Oral antiviral treatment reduces the risk of graft failure in patients undergoing primary PK for herpetic keratitis and should be routinely used in this group of patients post-operatively unless contra-indicated.

Risk of Creutzfeldt-Jakob disease transmission by ocular surgery and tissue transplantation.

Creutzfeldt-Jakob disease (CJD) is a rare, fatal neurodegenerative disease that occurs in sporadic, genetic, variant, and iatrogenic forms. The transformation of normal prion protein (PrP(C)) to the abnormal form (PrP(Sc)) is a key step in the pathogenesis of CJD and leads to the accumulation of amyloid and spongiform changes in the brain. The presence of PrP(Sc) in tissue is a surrogate marker for CJD infectivity. Sporadic CJD, whose cause is unknown, is by far the most frequent form with 1-2 cases per million population occurring every year-the genetic forms of CJD are rather rarer. The majority of variant CJD cases have occurred in the United Kingdom, where there have been four reports of transmission of vCJD by blood transfusion. The great majority of iatrogenic transmissions of CJD have resulted from the use of pituitary-derived hormones or dura mater with only a very few cases attributable to neurosurgical instruments or corneal transplants. In the absence of a validated test for CJD infectivity in eye donors, the application of appropriate donor selection criteria and the use of single-use instruments in eye banks are currently the most effective means of reducing the risk of CJD transmission. Onward transmission by reusable ophthalmic surgical instruments has not been reported, but the risk cannot be excluded. Use of appropriate cleaning and disinfection protocols and the ability to identify and quarantine instruments that may have been used on an infected patient are important safeguards.

Corneal transplant outcome in the Palestinian territories: a 2-year follow-up study.

PURPOSE: To review the 2-year corneal transplant outcome in a cohort of patients from the Palestinian territories transplanted at the St John Eye Hospital in East Jerusalem in 2001-2002. METHODS: Two-year follow-up data were recorded on the Swedish Corneal Transplant Register for 99 of the 161 patients originally transplanted. Multiple regression analyses (linear and logistic) were carried out to determine the influence of diagnosis, preoperative risk factors, and postoperative complications on graft survival and visual outcome. RESULTS: The incidence of preoperative risk factors in keratoconus patients was similar to other diagnoses (P=0.4) but they had fewer postoperative complications (39 vs 77%, P<0.001). Graft survival was higher in the keratoconus group (96 vs 49%, P<0.001). Visual outcome was also better with 47% of patients achieving VA >or=0.5 (6/12) whereas 88% of the other patients had VA

The visual and refractive outcomes of combined and sequential penetrating keratoplasty, cataract extraction, and intraocular lens insertion.

PURPOSE: The aim of this study was to investigate the visual and refractive outcome of combined penetrating keratoplasty, cataract extraction, and intraocular lens insertion (triple procedure) compared with cataract surgery following penetrating keratoplasty (sequential surgery). METHODS: Retrospective cohort study of 1256 first penetrating keratoplasty for Fuchs' dystrophy performed between April 1999 and December 2005. In all, 1202 triple and 54 sequential procedures were reviewed. At 1 year, refractive outcomes were available for 499 triple procedure and 26 sequential surgery eyes. At 2 years, data were available for 264 triple procedure and 10 sequential surgery eyes. At 1 and 2 years postoperatively, graft survival, best-corrected visual acuity (BCVA), spherical equivalent, and cylindrical error were recorded. chi(2)-Tests were used to compare visual outcomes between the two groups. RESULTS: At 1 year after triple procedure surgery, 61% of eyes attained BCVA of >or=6/12, with 47% of eyes within+/-2 D of emmetropia. After sequential surgery, 59% achieved BCVA of >or=6/12 with 67% of eyes within+/-2 D of emmetropia (=0.05). Mean spherical equivalent (MSE) at 1 and 2 years after triple procedure was +1.20 D (SD 5.45) and +0.15 D (SD 3.58), respectively. MSE following sequential surgery at 1 and 2 years was +0.08 D (SD 3.06) and -1.50 D (SD 3.14), respectively. Mean refractive cylinder after combined surgery was +4.16 D (SD 5.11) and +3.91 D (SD 2.79) at 1 and 2 years, respectively, compared with +3.65 D (SD 2.24) and +3.70 D (SD 2.06) after sequential surgery. In all, 29% of triple procedure and 27% sequential surgery eyes had an astigmatic error >or=5.0 D after 1 year (P=0.64), which increased to 34 and 30%, respectively, by the second year. The 5-year graft survival was 85% in both groups. There were no differences in graft survival, visual or refractive outcomes between triple procedure, and sequential surgery techniques. CONCLUSIONS: This analysis provided no evidence of improved visual or refractive outcome after sequential surgery compared with triple procedure.

Corneal grafts at St John Eye Hospital, Jerusalem, January 2001-November 2002.

AIM: To compare a cohort of corneal graft patients in east Jerusalem with one in Sweden, concerning diagnosis, sex, patient age, preoperative visual acuity in both eyes, and type of operation. METHODS: Standard forms developed for the Swedish Corneal Transplant Register were used for data collection at the time of operation. RESULTS: In east Jerusalem, keratoconus accounted for 51% of the grafts compared with only 27% in Sweden and the male:female ratio was reversed. There were very few patients with endothelial disease. The Palestinian patients had overall worse visual acuity both in the eye to be operated and the fellow eye compared with patients in Sweden. CONCLUSION: Significant differences were found between the Palestinian and Swedish cohorts in the distribution of indications for transplantation and preoperative visual acuity.

Freezing monolayers of cells without gap junctions.

Cells in monolayers have been reported to be more susceptible to freezing injury than the same cell type frozen in dispersed suspensions. There appears to be an enhanced susceptibility to intracellular freezing in the monolayers, which is thought to be facilitated by the presence of gap junctions allowing the spread of ice between neighbouring cells. MDCK Type II cells do not form gap junctions in monolayer culture. When frozen at rates of 0.2 to 10 degrees C/min, monolayers in 10% (v/v) propane-1,2-diol or dimethyl sulphoxide showed little influence of cooling rate on survival. This suggested that, in the absence of gap junctions, cells in monolayers did not display enhanced susceptibility to intracellular freezing. In contrast, however, monolayers frozen in glycerol showed a marked increase in cell damage when cooled at rates higher than 0.5 degrees C/min. This does not necessarily counter the suggestion that lack of gap junctions mitigates intracellular freezing as there is evidence that glycerol may itself promote intracellular freezing.

Visual outcome in corneal grafts: a preliminary analysis of the Swedish Corneal Transplant Register.

AIM: To assess visual outcome and the incidence of complications at 2 years postoperatively in corneal grafts reported to the Swedish Corneal Transplant Register. METHODS: Preoperative and 2 year follow up data were submitted to the Swedish Corneal Transplant Register by surgeons in eight corneal transplant clinics in Sweden. Preoperative data on 1957 grafts and 520 grafts with 2 year follow up were included in the analysis. Data were analysed by multiple linear and logistic regression methods, as appropriate. RESULTS: The major diagnostic categories were keratoconus (29%), bullous keratopathy (21%), and "other diagnosis" (32%). Fuchs' endothelial dystrophy and stromal dystrophies accounted for 15% and 3% of grafts, respectively. At 2 years the overall incidence of complications, other than rejection and regrafting, was 26%, with an increasing frequency from keratoconus < Fuchs' dystrophy < bullous keratopathy < "other diagnosis." Rejection was observed in 15% of grafts and was more likely in the bullous keratopathy (OR 3.1, 95% CI 1.1 to 9.0, p=0.04) and "other diagnosis" (OR 2.6, 95% CI 1.1 to 5.9, p=0.03) groups. Regrafting, which occurred in 10% of cases, was not influenced by diagnosis, but it was related to the incidence of rejection (OR 14.8, 95% CI 6.1 to 35.9, p<0.001) and other complications (OR 4.4, 95% CI 1.9 to 10.4, p=0.001), and to the presence of other sight threatening pathology in the eye (OR 3.6, 95% CI 1.3 to 9.9, p=0.01). Visual acuity was improved in a high proportion of the patients, especially those with keratoconus and Fuchs' dystrophy where, respectively, 86% and 54% of grafts achieved a visual acuity of > or =0.5 at 2 years, compared with only 31% with bullous keratopathy and 35% in the "other diagnosis" group. 60% of grafts for keratoconus and Fuchs' dystrophy achieved a visual acuity equal to or better than the other eye. Postoperative astigmatism was higher in the bullous keratopathy (p=0.01) group. Patients with high astigmatism benefited from refractive surgery, showing a reduction from 7.9 (95%CI 6.9, 8.7) to 3.2 (95% CI 2.6, 3.9) dioptres (p<0.001). A centre effect was evident in visual outcome. CONCLUSION: The overall incidence of complications was related to diagnosis. Complications other than rejection and regrafting were most likely in the "other diagnosis" group, and further analysis of this group is therefore planned. The best improvement in visual acuity and the lowest astigmatism were achieved in the keratoconus and Fuchs' dystrophy groups; but the influence of diagnosis on astigmatism was small and, overall, the statistical model accounted for only 8% of the variability in astigmatism. Refractive surgery was, however, effective in reducing astigmatism. It is hoped that a better understanding of the factors that determine the visual outcome of grafts will emerge from future analyses of the Swedish Corneal Transplant Register, helping to refine the criteria for patient selection and to guide clinical practice.

Integrity of epithelium and endothelium in organ-cultured human corneas.

PURPOSE: To examine components of the junctional complex and the actin cytoskeleton and the incidence of apoptosis in epithelium and endothelium of organ-cultured human corneas. METHODS: Human corneas, either organ-cultured for 1 to >28 days or excised directly from eyes stored in moist chambers, were stained with antibodies to ZO-1, vinculin, and caspase 3 coupled to FITC-conjugated secondary antibody. These markers were combined with rhodamine-phalloidin staining for F-actin and DAPI labeling for DNA. The corneas were examined by confocal microscopy. RESULTS: The depth of the epithelium was reduced during organ culture, but no changes were observed in the distribution of ZO-1 or vinculin, or in the F-actin cytoskeleton. The appearance of apoptotic epithelial cells positive for caspase 3 or with condensed DNA increased with time after 14 days in organ culture, but there was no correlation with donor age. ZO-1 and F-actin staining patterns in endothelium were similarly undisturbed by organ culture, but apoptotic endothelial cells were only rarely seen and then only after >28 days in organ culture. CONCLUSIONS: Organ culture maintained the integrity of tight junctions and the actin cytoskeleton in epithelial and endothelial cell layers. Apoptosis was evident in epithelium but was observed rarely in the endothelium and then only after extended periods in organ culture.