Retinal microvascular calibre and risk of incident diabetes: the multi-ethnic study of atherosclerosis

AIM

To prospectively examine the association of retinal microvascular signs with incident diabetes and impaired fasting glucose (IFG) in a multi-ethnic population-based cohort.

METHODS

The multi-ethnic study of atherosclerosis comprised Caucasians, African-Americans, Hispanics and Chinese aged 45-84 years. Retinal vascular calibre and retinopathy were quantified from baseline retinal photographs. Incident diabetes and IFG were ascertained prospectively.

RESULTS

After a median follow-up of 3 years, 243 (4.9%) people developed diabetes and 565 (15.0%) developed IFG. After adjusting for known risk factors, participants with wider retinal arteriolar calibre had a higher risk of developing diabetes [HR: 1.60; 95% CI: 1.12-2.29, p=0.011 comparing highest with lowest arteriolar calibre tertile]. In ethnic subgroup analysis, the association between wider retinal arteriolar calibre and incident diabetes was stronger and statistically significant only in Caucasians [HR: 2.78; 95% CI: 1.37-5.62, p=0.005]. Retinal venular calibre and retinopathy signs were not related to risk of diabetes or IFG.

CONCLUSION

Wider retinal arteriolar calibre is independently associated with an increased risk of diabetes, supporting a possible role for early arteriolar changes in diabetes development. This effect was largely seen in Caucasians, and not in other ethnic groups, and may reflect ethnic differences in susceptibility to diabetes from microvascular pathways.

Association between serum C-peptide levels and chronic microvascular complications in Korean type 2 diabetic patients

This study evaluated the association between serum C-peptide levels and chronic vascular complications in Korean patients with type 2 diabetes. Data for 1,410 patients with type 2 diabetes were evaluated cross-sectionally. Fasting and postprandial 2-hour serum C-peptide levels were analyzed with respect to diabetic micro- and macrovascular complications. In the group of patients with lower fasting serum C-peptide quartile, the prevalences of diabetic retinopathy and neuropathy were significantly higher (P = 0.035, P < 0.001, respectively). In the group of patients with lower delta C-peptide (postprandial - fasting C-peptide) quartile, the prevalences of diabetic retinopathy, nephropathy, and neuropathy were significantly higher (P < 0.001 for all). Low delta C-peptide quartile was also associated with increased severity of retinopathy and nephropathy. The age- and sex-adjusted odds ratios (ORs) for retinopathy, neuropathy, and nephropathy in the lowest versus the highest delta C-peptide quartile were 6.45 (95% confidence interval 3.41-12.22), 3.01 (2.16-4.19), and 2.65 (1.71-4.12), respectively. After further adjustment for the duration of diabetes, type of antidiabetic therapy, mean hemoglobin A1c, body mass index, and blood pressure, the ORs were reduced to 2.83 (1.32-6.08), 1.68 (1.12-2.53), and 1.61 (1.05-2.47), respectively, but remained significant. No significant difference was observed in the prevalence of macrovascular complications with respect to fasting or delta C-peptide quartiles. These results suggest that low C-peptide level is associated with diabetic microvascular, but not macrovascular complications in patients with type 2 diabetes mellitus.

Risk factors for lower extremity amputation among patients with diabetes in Singapore

BACKGROUND

Among other risk factors, renal disease and ethnicity have been associated with diabetic lower extremity amputation (LEA) in Western populations. However, little is known about risk factors for LEA among Asian patients.

OBJECTIVE

The objective was to assess the proportion of hospitalized patients with diabetes who have a LEA among all hospital patients with diabetes mellitus (DM) and to investigate risk factors for diabetic LEA (especially renal disease and ethnicity) using hospital discharge database.

METHOD

A retrospective study of hospital discharge database (2004-2009) was performed to identify patients with DM, LEA and renal disease using the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Australian Modification codes.

RESULTS

Of 44 917 hospitalized patients with DM during the 6 years, 7312 (16.3%) patients had renal disease, and 1457 (3.2%) patients had LEA. DM patients with renal disease had significant higher rates of LEA (7.1%) compared to DM patients without renal disease (2.5%, P < .001). The differences were present for foot (2.7% vs. 1.2%), ankle or leg (2.8% vs. 0.9%), and knee or above amputation (1.6% vs. 0.4%, all P<.001). Malays had the highest rate of diabetic LEA (5.1%), followed by Indians (3.0%), Chinese (3.0%), and others (2.3%, P < .001). In logistic regression analyses, renal disease and ethnicity were significant predictors of diabetic LEA (renal disease: odds ratio 3.2, 95% confidence interval 2.8-3.6; ethnicity: odds ratio, 1.6, Malays vs. Chinese, P < .001; 1.0, Indians vs. Chinese, P = .784) after adjustment for age, gender, and year of discharge.

CONCLUSION

DM patients with renal disease and Malay ethnicity had higher rates of LEA in this Asian patient population. Malay patients with DM and diabetic patients with renal disease should be considered as high-risk groups for LEA and therefore screened and monitored systematically.

Serum γ-glutamyltransferase and associated damage among a She Chinese population

OBJECTIVE

It has been suggested that serum γ-glutamyltransferase is independently associated with cardiovascular mortality and atherosclerosis. The present study is to investigate the relationship between serum γ-glutamyltransferase and potential associated damage in an adult She Chinese population.

METHOD

A multistage, stratified, cluster, random sampling method was used to select an ethnically representative group of individuals aged 20-80 years in the general population. Brachial-ankle pulse-wave velocity was used to assess arterial stiffness in the general population and the Toronto Clinical Neuropathy Scoring System was used to detect diabetic peripheral polyneuropathy among populations with diabetes.

RESULTS

A total of 5385 subjects were entered into the analysis. Serum γ-glutamyltransferase levels were classified into four groups using the 25th, 50th and 75th percentiles as cut points (males: < 20, 20-29, 29-52 and > 52 U/l; females: < 13, 13-18, 18-25 and > 25 U/l). As compared with the first quartile, the relative risks of arterial stiffness were 1.418, 1.667 and 2.394 in the other three categories, respectively (test for trend P < 0.05). After adjustment in five models, serum γ-glutamyltransferase was still a risk factor of arterial stiffness. We found inverted U-shape curves in both genders and the third quartile (male: 29 52 U/l; female: 18-25 U/l) had the highest odds ratios of 1.640 and 1.529, respectively.

CONCLUSIONS

We demonstrated that high serum γ-glutamyltransferase concentrations were directly associated with the increased risk of arterial stiffness, in general, and with peripheral polyneuropathy in subjects with diabetes in an ethnic She Chinese population. Alcohol use, gender, BMI and blood pressure were related to serum γ-glutamyltransferase and were involved in the relationship between serum γ-glutamyltransferase and brachial-ankle pulse-wave velocity.

Ethnic differences in the relationship between pericardial adipose tissue and coronary artery calcified plaque: African-American-diabetes heart study

BACKGROUND

Calcified atherosclerotic plaque (CP) is less prevalent and less severe in African-Americans (AA), relative to European Americans (EA). Because pericardial adipose tissue (PAT) is associated with CP in the neighboring coronary arteries, we explored ethnic-specific relationships between PAT and CP.

METHODS

PAT volume and coronary and aortic CP were measured in 561 EA and 575 AA subjects with type 2 diabetes using single and multidetector computed tomography. Generalized estimating equations with exchangeable correlation and the sandwich estimator of the variance were used to test for associations between PAT and CP.

RESULTS

Mean (sd) ages of AA and EA participants were 56.7 (9.5) and 62.0 (8.9) yr, respectively; diabetes duration was 10.5 (8.1) and 10.1 (7.3) yr; and PAT volume was 86.9 (38.6) and 131.7 (55.3) cm3/45 mm. In AA and EA participants, respectively, mean (sd) coronary CP mass scores were 803 (1,889) and 1,465 (2,847) mg calcium; and aortic CP, 5,407 (10,651) and 10,090 (15,087) mg calcium. Adjusting for age, gender, body mass index, blood pressure, height, smoking, lipid-lowering medications, C-reactive protein, albuminuria, high-density lipoprotein-cholesterol, and triglycerides, parameter estimates for the relationship between PAT and log(coronary CP+1) were 0.012 in AA (P<0.0001) and 0.003 (P=0.24) in EA, with a significant ethnic difference (P=0.019). No significant relationships or ethnic differences were observed between PAT and aortic CP (P=0.24, fully adjusted model).

CONCLUSIONS

Pericardial adiposity is strongly associated with coronary atherosclerosis in AA with type 2 diabetes. Novel cardiovascular disease risk factors such as PAT may contribute to ethnic disparities in susceptibility to development of coronary atherosclerosis.

Peripheral arterial disease in community-based patients with diabetes in Singapore: Results from a Primary Healthcare Study

INTRODUCTION

Peripheral arterial disease (PAD) is an important complication of diabetes mellitus (DM), significantly associated with increased morbidity and mortality secondary to amputations, strokes and coronary artery disease. Information on DM patients with PAD is limited in our ethnically diverse population in Singapore. We aimed to determine the prevalence, risk factors and co-morbidities of PAD in patients managed for DM in the primary care setting.

MATERIALS AND METHODS

A cross-sectional study was conducted among 521 diabetics in 9 of the 18 government-aided clinics in the community. Data including demographics, presence of co-morbidities and vascular risk factors were collected using an interviewer-administered questionnaire, and Ankle-Brachial Index (ABI) was calculated from systolic ankle and brachial pressure measurements.

RESULTS

The prevalence of PAD, defi ned as resting ABI of <0.9 on either leg and/or a history of gangrene or non-traumatic amputation was 15.2% [95% confidence interval (CI), 12.3-18.5]. This prevalence of PAD was higher in patients with pre-existing microvascular and other macrovascular complications. In multivariate analysis, prevalence of PAD was positively associated with increasing age (OR, 1.08; 95% CI, 1.05-1.12), Malay versus Chinese ethnicity (OR, 2.27; 95% CI, 1.09-4.70), low HDL-cholesterol (OR, 1.87; 95% CI, 1.04- 3.37), and insulin treatment (OR, 2.98; 95%CI, 1.39-6.36).

CONCLUSION

PAD is an important cause of concern among patients with diabetes, with a high prevalence which further increases with increasing age and duration of DM, and exhibits ethnic variation. Risk factors identified in this study may improve early identification of PAD, allowing for prompt interventions, with a potential to reduce long-term morbidity and mortality.

All-cause and CVD mortality in Native Hawaiians

AIMS

Cardiovascular disease (CVD) is the leading cause of death among Native Hawaiians. In this article, all-cause and cardiovascular mortality rates among Native Hawaiians are examined, along with associated CVD risk factors.

METHODS

A total of 855 Native Hawaiians (343 men and 512 women, ages 19-88) were examined as participants of the Cardiovascular Risk Clinics program (1992-1998) and underwent surveillance through September 2007. Cause of each death was determined by review of medical records, death certificates, newspapers, and through queries to community members.

RESULTS

CVD accounted for 55% of deaths. Coronary heart disease (CHD) accounted for the majority of CVD deaths. CVD increased with age and was higher in those with diabetes, hypertension, or high low-density lipoprotein cholesterol (LDL-C). CVD rates were higher in men than in women and fourfold higher in those with diabetes. In addition to age, diabetes, hypertension, and elevated LDL-C were major risk factors.

CONCLUSIONS

Diabetes is a major determinant of CVD in this population and most of the CVD is occurring in those with diabetes. Strategies to prevent diabetes and manage blood pressure and lipids should reduce CVD rates in Native Hawaiians.

Association of a unique cardiovascular risk profile with outcomes in Hispanic patients referred for percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Although previous studies have demonstrated that Hispanic patients have a higher cardiovascular risk profile than Caucasians and present at a younger age for percutaneous coronary intervention (PCI), limited studies exist examining the outcomes of Hispanics after PCI and potential explanations for differences noted. Using patients from the National Heart, Lung, and Blood Institute Dynamic Registry waves 1 to 5 (1997 to 2006), demographic features, angiographic data, and 1-year outcomes of Hispanic patients (n = 542) versus Caucasian patients (n = 1,357) undergoing PCI were evaluated. Compared to Caucasians, Hispanic patients were younger and had more hypertension and diabetes mellitus, including more insulin-treated diabetes mellitus. Although mean lesion length was longer in Hispanics (15.4 vs 14.1 mm, p <0.001), there were no differences in the number of significant lesions or in the use of drug-eluting stents. At follow-up, Hispanics were more likely to report recent anginal symptoms but had a similar incidence of 1-year hospitalizations for angina. Adjusted 1-year hazard ratios for adverse events for Hispanics versus Caucasians revealed lower rates of coronary artery bypass graft surgery (hazard ratio 0.43, confidence interval 0.22 to 0.85, p = 0.02) and a trend toward lower rates of repeat revascularization (hazard ratio 0.76, confidence interval 0.57 to 1.03, p = 0.08). In conclusion, despite the presence of diabetes in almost 50% of Hispanic patients and longer lesions than in Caucasians, Hispanic patients were less likely to undergo coronary artery bypass graft surgery 1 year after PCI and had a trend toward lower rates of repeat revascularization.

Impact of diabetes on early and mid-term survival after coronary artery bypass graft surgery in the Hong Kong Chinese population

OBJECTIVE

To determine the impact of diabetes on early and mid-term survival in the Hong Kong Chinese population undergoing coronary artery bypass graft surgery.

DESIGN

Prospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

A total of 904 consecutive patients following coronary artery bypass graft surgery from November 1999 to December 2003 were prospectively analysed. Among them, 377 (42%) diabetic and 527 (58%) non-diabetic patients were evaluated.

MAIN OUTCOME MEASURES

Hospital mortality, mid-term mortality, and percutaneous coronary intervention-free survival.

RESULTS

The diabetic group had a higher risk score than the non-diabetic group (mean+/-standard deviation: EuroSCORE 4.7+/-3.4 and 3.6+/-3.4, respectively; P<0.001). Hospital mortality was 3.4% in the diabetic group compared to 2.8% in the non-diabetic group (P=0.698). Multiple logistic regression analysis identified left ventricular ejection fraction of less than 30% and preoperative intubation as independent risk factors for early hospital death. There were 81 late deaths and the actuarial survival at 48 months for the diabetic and non-diabetic patients were 86% and 90%, respectively (P=0.298). The angina-free survival and percutaneous coronary intervention-free survival at 48 months for the diabetic and non-diabetic patients yielded no statistically significant difference.

CONCLUSIONS

Diabetes mellitus was not a predictor of early and mid-term mortality after coronary artery bypass graft surgery in our Chinese population. Furthermore, diabetes did not affect angina recurrence or intervention free-survival up to 4 years.

The effect of ethnicity on the prevalence of diabetes and associated chronic kidney disease

BACKGROUND

The effect of ethnicity on the prevalence of diabetes mellitus (DM) and associated chronic kidney disease (CKD) is unknown.

AIM

To establish the impact of ethnicity on the prevalence and severity of diabetes mellitus and associated CKD.

DESIGN

Cross-sectional study of 34 359 adult diabetic patients in three primary care trusts in the UK.

METHODS

Read coded data from general practice computers was used to analyse the relationship between ethnicity, DM and CKD.

RESULTS

The prevalence of DM was 3.5% for Whites, 11% for South Asians and 8% for Black groups. The prevalence of CKD (stages 3-5) among diabetics was 18%. CKD stage 3 was more prevalent in Whites compared to South Asians--OR 0.79 (95% CI: 0.71-0.87) and Blacks--OR 0.49 (95% CI: 0.43-0.57). Among all CKD patients severity (CKD stages 4, 5) was associated with Black (OR 1.39, 95% CI: 1.06-1.81) and South Asian (OR 1.54, 95% CI: 1.26-1.88) ethnicity compared to Whites. Less than 50% of diabetics with CKD met the target blood pressure (BP) of 130/80 mmHg. The prevalence of a blood pressure > 150/90 mmHg in diabetics with CKD was South Asian 15.6%, White 13.9%, Black 21.8% (P < 0.001). Proteinuria was present in 8.6% of all diabetic patients. However, this increased to 18.6% in patients with CKD, and was more frequent in Black (22.6%) and South Asian (21%) patients compared to White patients (14.1%) (P < 0.001).

CONCLUSION

Significant disparities exist between the major ethnic groups in both disease prevalence and management. Future studies examining the management of CKD need to take variation by ethnicity into account.

Atherogenic lipoprotein phenotype and LDL size and subclasses in women with gestational diabetes

AIMS

Women with gestational diabetes are more likely to develop Type 2 diabetes and cardiovascular disease after pregnancy; however, the exact nature of the lipid alterations present is not clear. In Mediterranean women with gestational diabetes, we measured low-density lipoprotein (LDL) size and all seven subclasses, as well as the 'atherogenic-lipoprotein phenotype'[ALP, e.g. concomitant presence of elevated triglycerides, reduced high-density lipoprotein (HDL)-cholesterol and increased small, dense LDL].

METHODS

In 27 women with gestational diabetes and 23 healthy pregnant women matched for age, weeks of gestation and body mass index, we measured plasma lipids and LDL size and subclasses by gradient gel electrophoresis between 24 and 28 weeks of gestation.

RESULTS

Although no significant differences were found in the concentrations of any of the plasma lipids, compared with control subjects women with gestational diabetes had lower LDL size (P = 0.0007) due to reduced LDL-I (P = 0.0074) and increased LDL-IVA (P = 0.0146) and -IVB (P < 0.0001) subclasses. Correlation analysis revealed that fasting glucose, homeostasis model assessment and glycated haemoglobin were inversely correlated with LDL-I and positively with LDL-IVA and -IVB (all P < 0.05). ALP due to high HDL-cholesterol levels was not seen in either group, whereas elevated small, dense LDL were more common in women with gestational diabetes than control subjects (33% vs. 4%, P = 0.0107).

CONCLUSIONS

Increased levels of small, dense LDL are common in Mediterranean women with gestational diabetes. Whether these findings affect the atherogenic process and clinical end-points in these women remains to be determined by future prospective studies.

An association between ethnicity and cardiovascular outcomes for people with Type 2 diabetes in New Zealand

AIMS

To investigate the association between ethnicity and risk of first cardiovascular (CV) event for people with Type 2 diabetes in New Zealand.

METHODS

A prospective cohort study using routinely collected data from a national primary health care diabetes annual review programme linked to national hospital admission and mortality data. Ethnicity was recorded as European, Maori, Pacific, Indo-Asian, East-Asian or Other. A Cox proportional hazards model was used to investigate factors associated with first CV event. Data was collected from 48,444 patients with Type 2 diabetes, with first data collected between 1 January 2000 and 20 December 2005, no previous cardiovascular event at entry and with complete measurements. Risk factors included ethnicity, gender, socio-economic status, body mass index, smoking, age at diagnosis, duration of diabetes, systolic blood pressure, serum lipids, glycated haemoglobin and urine albumin : creatinine ratio. The main outcome measures were time to first fatal or non-fatal CV event.

RESULTS

Median follow-up was 2.4 years. Using combined European and Other ethnicities as a reference, hazard ratios for first CV event were 1.30 for Maori (95% confidence interval 1.19-1.41), 1.04 for Pacific (0.95-1.13), 1.06 for Indo-Asian (0.91-1.24) and 0.73 for East-Asian (0.62-0.85) after controlling for all other risk factors.

CONCLUSIONS

Ethnicity was independently associated with time to first CV event in people with Type 2 diabetes. Maori were at 30% higher risk of first CV event and East-Asian 27% lower risk compared with European/Other, with no significant difference in risk for Pacific and Indo-Asian peoples.

Baseline characteristics of patients with diabetes and coronary artery disease enrolled in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial

BACKGROUND

The Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial was undertaken to determine whether early revascularization intervention is superior to deferred intervention in the presence of aggressive medical therapy and whether antidiabetes regimens targeting insulin sensitivity are more or less effective than regimens targeting insulin provision in reducing cardiovascular events among patients with type 2 diabetes mellitus and stable coronary artery disease (CAD).

METHODS

The BARI 2D trial is a National Institutes of Health-sponsored randomized clinical trial with a 2 x 2 factorial design. Between 2001 and 2005, 49 clinical sites in North America, South America, and Europe randomized 2,368 patients. At baseline, the trial collected data on clinical history, symptoms, and medications along with centralized evaluations of angiograms, electrocardiograms, and blood and urine specimens.

RESULTS

Most of the BARI 2D patients were referred from the cardiac catheterization laboratory (54%) or cardiology clinic (27%). Of the randomized participants, 30% were women, 34% were minorities, 61% had angina, and 67% had multiregion CAD. Moreover, 29% had been treated with insulin, 58% had hemoglobin A(1c) >7.0%, 41% had low-density lipoprotein cholesterol >or=100 mg/dL, 52% had blood pressure >130/80 mm Hg, and 56% had body mass index >or=30 kg/m(2).

CONCLUSIONS

Baseline characteristics in BARI 2D are well balanced between the randomized treatment groups, and the clinical profile of the study cohort is representative of the target population. As a result, the BARI 2D clinical trial is in an excellent position to evaluate alternative treatment approaches for diabetes and CAD.

Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project

BACKGROUND

Stroke is a major cause of premature mortality in Britain, but its burden is markedly greater amongst South Asians. Because of the paucity of data in this area, we investigated the magnitude and impact of risk from cardiovascular comorbidities on survival amongst South Asian stroke patients.

METHODS

We reviewed hospital case records of consecutive first in life time ischaemic stroke patients [self reported ethnicity and International Classification of Disease (ICD) 10th revision, codes 430-438] admitted to an inner city hospital in the UK between 1997 and 2001. In-hospital mortality data and CVD risk factors were analysed. Five-year mortality data was obtained from the National Health Tracing Services.

RESULTS

Of 1474 ischaemic stroke patients, 242 (16%) were South Asian of whom, 143 (59.1%) were male. The prevalence of hypertension was 70.2%, followed by diabetes 56.2%, hyperlipidaemia 7% and myocardial infarction 10.3%. At 5 years follow-up, 40.5% had died. Cumulative event-free survival at 5 years was significantly poorer in patients with diabetes (log-rank test, p=0.009). On Cox regression analysis, incorporating age, gender and other CVD risk factors, diabetes mellitus was an independent predictor of mortality odds ratio=1.65 (1.02-2.6, p=0.039). Hypertension and dyslipidaemia did not discriminate survival amongst South Asian patients.

CONCLUSION

Stroke mortality in South Asians is associated with presence of diabetes mellitus. This highlights the significance of early and intensive CVD risk modification strategies in ethnic minorities particularly in patients with diabetes. Further research is warranted in South Asians to examine the underlying basis and related pathophysiological abnormalities.

A review of evidence-based beta-blockers in special populations with heart failure

Guidelines recommend 1 of 3 beta-blockers (bisoprolol, carvedilol, metoprolol succinate) for the treatment of systolic heart failure (HF). beta-Blockers have been established to be effective in reducing mortality in more than 20 randomized, placebo-controlled clinical trials involving more than 20,000 patients with HF. However, they are not utilized in a substantial portion of eligible HF patients, possibly because physicians are unsure of the safety and benefit of beta-blockers in special populations (women, the elderly, African Americans, patients with diabetes, and patients with atrial fibrillation). The current standard of care is to treat all heart failure (HF) patients according to the recommendations for the overall population. A review of the clinical trial data reveals that there is no evidence that one evidence-based beta-blocker is preferential over the others in women or in the elderly with HF. In contrast, carvedilol may confer greater benefit in HF patients with diabetes and atrial fibrillation as well as in African American patients. Further data are needed to provide evidence-based recommendations.

Does using ethnic specific criteria improve the usefulness of the term metabolic syndrome? Controversies and suggestions

The metabolic syndrome (MetS) is an important tool that identifies populations at increased risk for cardiovascular disease (CVD) and type 2 diabetes, targeting them for preventive measures. The criteria for the identification of the MetS were initially constructed from data in Caucasian populations. Recent research suggests that the current criteria for the MetS may not accurately characterize disease risk in non-Caucasian populations, either over or underestimating the risk in certain ethnic groups. Altering the criteria for each population by making ethnic-specific cutoffs as has been done with waist circumference will help in more accurate characterization. Using different combinations of the MetS criteria for different ethnic groups based CVD risk and factor analysis needs consideration. With better characterizations of patient populations, the ultimate goal would be to make MetS more accurate for predicting CVD risk while retaining the ease of screening afforded by the MetS. The proposed alterations of definition and criteria of the MetS would ensure its continued viability and sustainability.

Ethnic and racial disparities in diagnosis, treatment, and follow-up care

Studies from four areas of musculoskeletal health care disparities were reviewed to determine the root causes of the disparities and gain insight into measurable interventions. The areas of musculoskeletal health were total joint arthroplasty, amputation for patients with diabetes, rehabilitation of and impairment in patients with stroke, and morbidity associated with unintentional injuries. The Jenkins Model on Health Disparities was used to investigate and rank the contributing causes (socioeconomic status, sociocultural beliefs, racism, biology) of the health care disparities. No single root cause was found for any of the conditions. Thus, all contributing factors must be considered when planning meaningful interventions.

Disparities in orthopaedic surgical intervention

Race- and ethnicity-based health disparities have been identified both in health care generally and in orthopaedics specifically. Despite this body of research, it remains unclear why these disparities exist. Research has been done on disparities in patients with cardiovascular disease and diabetes, as well as in patients who are candidates for hip or knee arthroplasty. With regard to disparities in orthopaedics, differences in the rates of total hip and knee replacement surgery have been studied the most extensively. To better understand health disparities in orthopaedics and in health care as a whole, patient-, provider-, and health care-related factors must be examined more fully.

Mortality in individuals with Type 2 diabetes and heart disease in a unique New Zealand population

AIMS

To determine rate and predictors of mortality in patients with Type 2 diabetes living in a population with a large proportion of Maori and Pacific peoples who were admitted to hospital with myocardial infarction (MI) or congestive cardiac failure (CCF).

METHODS

The study population included 4193 individuals with Type 2 diabetes who lived in South Auckland and who participated in a primary care audit between 1994 and 1999. We studied a subgroup of 319 patients who subsequently had a hospital admission for MI or CCF between 1999 and 2001. We examined their demographics, drug treatment, vascular risk factors and mortality up to 2003.

RESULTS

Following discharge, the prescription of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, aspirin and statins had all increased significantly. Vascular risk factors including total cholesterol, high-density lipoprotein (HDL) cholesterol, systolic blood pressure and glycated haemoglobin (HbA(1c)) improved significantly. Nevertheless, mortality remained high with individuals admitted because of an MI 7.2-fold more likely to die early and those with a CCF admission 5.9-fold more likely to die early than other individuals with Type 2 diabetes. Maori patients have an 80% excess mortality.

CONCLUSIONS

Patients with past admission for MI and/or CCF remain at exceptionally high risk of death for at least 4 years after hospital admission, even with improvements in management of cardiovascular risk factors. Maori individuals are at particular risk.

Ethnic differences in control of cardiovascular risk factors in patients with type 2 diabetes attending an Inner London diabetes clinic

BACKGROUND

South Asians have higher risk of diabetic complications compared with white Europeans. The aim of this study was to compare management of cardiovascular risk factors between Bangladeshis and white Europeans.

METHODS

A retrospective survey of all diabetic patients attending an Inner London hospital diabetic clinic over one year was undertaken. Data were obtained from the hospital diabetes database: presence of macrovascular (myocardial infarction, angina, stroke, transient ischaemic attack, cardiac intervention) and microvascular disease (neuropathy, retinopathy, and nephropathy), glycated haemoglobin, blood pressure, lipids, smoking, and body mass index (BMI) were all determined.

RESULTS

A total of 1162 white European and 912 Bangladeshi patients with full data available were included in the analyses. The groups were equivalent in age, sex, duration of diabetes. Compared with white Europeans, Bangladeshis had more macrovascular disease (19.5% v 11.9% p<0.01), sight threatening retinopathy (7.2% v 3.8%, p<0.01), and nephropathy (15.3% v 9.1%, p<0.01). In addition, Bangladeshis had significantly more male smokers (28.1% v 22.1%, p<0.01), poorer glycaemic control (mean HbA1c 8.6% v 8.1%, p = 0.039), greater proportion with uncontrolled hypercholesterolaemia (total cholesterol >5.0 mmol/l, 31.6% v 26% p = 0.05), and poorer control of blood pressure (proportion with BP >140/80 mm Hg, 43.2% v 32.1%, p<0.01).

CONCLUSIONS

South Asians with type 2 diabetes have poorer glycaemic, blood pressure, and lipid control than white Europeans. The reasons for this are probably multifactorial.

Hematocrit, independent of chronic kidney disease, predicts adverse cardiovascular outcomes in chinese patients with type 2 diabetes

OBJECTIVE

Anemia and chronic kidney disease (CKD) are risk factors for cardiovascular diseases in diabetes. We examined the association between hematocrit, stratified by the presence of CKD, and cardiovascular events in a cohort of Chinese subjects with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 3,983 patients who underwent assessment for diabetes complications were recruited. Subjects were categorized into five groups. Group I included subjects with hematocrit below the normal sex-specific range. The cutoff points for groups II-V were selected to represent the distribution of the hematocrit for each sex. CKD was defined by the estimated glomerular filtration rate <60 ml/min per 1.73 m(2). Cardiovascular events were defined as cardiovascular mortality and morbidity, including new onset of myocardial infarction, acute coronary syndrome, revascularization, heart failure, and stroke requiring hospitalization.

RESULTS

A total of 294 subjects (7.4%) developed cardiovascular events during the median of 36.4 months. The rate of cardiovascular events was highest in subjects with low hematocrit (group I, 18.6%) compared with group V (3.4%, P < 0.001). The multivariate-adjusted hazard ratio for cardiovascular events diminished with increasing hematocrit (group I, 1.0; group II, 0.73 [95% CI 0.51-1.04]; group III, 0.57 [0.39-0.83]; group IV, 0.61 [0.39-0.95]; and group V, 0.36 [0.17-0.79]). After stratifying by the presence of CKD, the previously observed reduction in the risk of developing cardiovascular events with increasing hematocrit was abolished in the cohort with CKD but persisted in the non-CKD cohort.

CONCLUSIONS

In Chinese subjects with type 2 diabetes, low levels of hematocrit and the presence of CKD are associated with increased risk of developing adverse cardiovascular events.

Cognitive decline in older Mexican Americans with diabetes

OBJECTIVE

To examine social, demographic and health factors associated with cognitive decline over a seven-year period among older Mexican Americans with diabetes.

METHODS

A population-based sample of 808 noninstitutionalized Mexican Americans aged >65 years with diabetes who had a Mini-Mental State Examination (MMSE) >17 at baseline from the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE). Measurements included sociodemographics, diabetic treatment received (oral hypoglycemic or insulin), self-reported medical conditions, self-reported diabetes-related complications, high depressive symptoms and ADL limitations.

RESULTS

The mean MMSE score at baseline was 25.3 + (SD=3.7). The rate of decline in cognitive function (MMSE) during the follow-up period was 0.37 point per year. Using general linear mixed models, we found that being male, and having high depressive symptoms and diabetic complications (kidney impairment, circulation problems or limb amputation) were factors significantly associated with greater declines in MMSE score over time.

CONCLUSION

Circulation problems, kidney impairment and depression are the major factors associated with cognitive decline in older Mexican Americans with diabetes.

Rationale and implementation of the SLICK project: Screening for Limb, I-Eye, Cardiovascular and Kidney (SLICK) complications in individuals with type 2 diabetes in Alberta's First Nations communities

OBJECTIVE

Identifying diabetes complications through screening using portable laboratory equipment in Aboriginal communities, and providing education and client empowerment for improved follow-up care and self-care.

PARTICIPANTS

First Nations people with known diabetes.

SETTING

Screening was carried out in temporary clinics and laboratories set up at the local health centre in each of Alberta's 44 First Nations.

INTERVENTION

Two mobile units ("SLICK vans"), equipped with professionally trained staff, portable lab instruments and a retinal camera, travelled to all 44 Alberta First Nations communities to facilitate implementation of the Canadian Diabetes Association Clinical Practice Guidelines (CPGs). The project provided relevant education and counselling in conjunction with screening activities.

OUTCOMES

SLICK screened 1,151 clients between December 2001 and July 2003, and the project remains ongoing. A preliminary evaluation of the project's 19-month implementation period showed screening activities and satisfaction with diabetes services were low prior to SLICK. There were modest improvements in some program outcomes at 6-12 months follow-up.

CONCLUSION

The SLICK project is designed to address the impact of diabetes by utilizing evidence-based CPGs with respect to screening for complications at the community level. It had a successful implementation period facilitated by community acceptance.

Association between plasma levels of heat shock protein 60 and cardiovascular disease in patients with diabetes mellitus

AIMS

Evidence is accumulating to support the hypothesis that the release of heat shock protein (Hsp)60 into the circulation is associated with the development of coronary heart disease (CHD). As diabetes is a risk factor for CHD, it was of interest to determine Hsp60 blood levels in a cross-sectional cohort of diabetic patients, some of whom had cardiovascular disease, and relate levels to relevant biochemical markers.

METHODS AND RESULTS

A total of 855 patients with T1DM or T2DM, recruited as part of the UCL Diabetes and Cardiovascular disease Study (UDACS), were assayed for plasma levels of Hsp60. Immunoreactive Hsp60 was detected in 54% of the samples, with 26% having plasma levels > 1 microg/mL. Levels of Hsp60 were higher in Caucasians than in other ethnic groupings, with 56.5% of Caucasian subjects, 37.5% of African-Caribbean subjects, and 47.1% of Indian subjects having detectable levels (P = 0.007), and with a higher proportion of non-smokers having detectable Hsp60 levels than smokers (54.9 vs. 43.5%, P = 0.01). Of note was the finding of an association between higher mean plasma levels of Hsp60 in subjects with clinically manifest cardiovascular disease and those with a history of myocardial infarction having an adjusted odds ratio of having detectable Hsp60 of 2.17 (CI 1.26-3.73).

CONCLUSION

This is the first report of circulating Hsp60 levels in diabetic patients, which suggests that this secreted mitochondrial cell stress protein may be playing an unexpected role in the cardiovascular pathology associated with diabetes.