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Bai P, Barkmeier AJ, Hodge DO, Mohney BG. Incidence and sex differences of diabetes among youth: a 50-year population-based cohort study. Acta Diabetol 2024:10.1007/s00592-024-02314-0. [PMID: 38849657 DOI: 10.1007/s00592-024-02314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/26/2024] [Indexed: 06/09/2024]
Abstract
AIMS Although the literature on childhood diabetes has traditionally focused on Type 1 diabetes (T1D), youth-onset Type 2 diabetes (T2D) and its associated morbidities have become increasingly prevalent. This study reports on the incidence and demographics of a population-based cohort of children diagnosed with diabetes over a 50-year period. METHODS Medical records of patients < 22 years diagnosed with diabetes from January 1, 1970, through December 31, 2019, were retrospectively reviewed using the Rochester Epidemiology Project, a database of clinics and hospitals in Olmsted County, Minnesota. RESULTS Of 606 children diagnosed with diabetes, 519 (85.6%) were diagnosed with T1D at a mean age of 10.9 ± 5.3 years. 87 (14.4%) were diagnosed with T2D at a mean age of 17.4 ± 3.4 years. The incidence of T2D increased 23-fold (p < 0.001) over the five-decade period (5 per 100,000 children/year) while T1D remained stable (26 per 100,000 children/year; p = 0.08). The mean body mass index at T2D diagnosis (35.5 kg/m2 ± 10.4) was significantly higher than in T1D (18.9 kg/m2 ± 4.6 [95% CI for difference 14.2-19.0]; p < 0.0001). Sixty-nine percent of children diagnosed with T2D were female, and the hazard ratio of developing diabetic retinopathy in females with T2D compared to males was 6.83 (95% CI 1.53-30.44; p = 0.012). CONCLUSIONS The incidence of youth-onset T2D increased significantly over the 50-year period while the incidence of T1D remained stable. A higher proportion of females were diagnosed with youth-onset T2D. Females with T2D were more than six times likelier to develop diabetic retinopathy than males.
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Affiliation(s)
- Patricia Bai
- Alix School of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Andrew J Barkmeier
- Department of Ophthalmology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Brian G Mohney
- Department of Ophthalmology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
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Ekelund C, Dereke J, Nilsson C, Landin-Olsson M. Are soluble E-selectin, ICAM-1, and VCAM-1 potential predictors for the development of diabetic retinopathy in young adults, 15-34 years of age? A Swedish prospective cohort study. PLoS One 2024; 19:e0304173. [PMID: 38843125 PMCID: PMC11156360 DOI: 10.1371/journal.pone.0304173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 05/08/2024] [Indexed: 06/09/2024] Open
Abstract
The aim of this study was to determine plasma levels of three adhesion molecules that may contribute to the development of diabetic retinopathy; soluble endothelial selectin (sE-selectin), soluble intercellular adhesion molecule-1 (sICAM-1), and soluble vascular cell adhesion molecule-1 (sVCAM-1), in young adults, aged 15-34 years at diagnosis of diabetes, to find potential predictors for development of retinopathy, and to evaluate their relation to diabetes associated autoantibodies. Participants with type 1 (n = 169) and type 2 diabetes (n = 83) were selected from the complications trial of the Diabetes Incidence Study in Sweden and classified in two subgroups according to presence (n = 80) or absence (n = 172) of retinopathy as determined by retinal photography at follow-up 8-10 years after diagnosis of diabetes. Blood samples were collected at diagnosis in 1987-88. The levels of sE-selectin, sICAM-1, and sVCAM-1 were analysed by enzyme-linked immunosorbent assay and islet cell antibodies by a prolonged two-colour immunofluorescent assay. Mean HbA1c (p<0.001) and clinical characteristics: mean body mass index (p = 0.019), systolic blood pressure (p = 0.002), diastolic blood pressure (p = 0.003), male gender (p = 0.026), and young age at diagnosis of diabetes (p = 0.015) remained associated with development of retinopathy in type 1 diabetes. However, in a multivariate analysis only HbA1c remained as a risk factor. sE-selectin was significantly higher in the group with type 2 diabetes and retinopathy, compared to the group with type 2 diabetes without retinopathy (p = 0.04). Regarding sE-selectin, sICAM-1, and sVCAM-1 in participants with type 1 diabetes, no differences were observed between the groups with or without retinopathy. This trial confirmed the role of HbA1c and clinical characteristics as predictors for development of retinopathy in type 1 diabetes. sE-selectin stands out as a potential predictor for development of retinopathy in type 2 diabetes, whereas a predictive role for sICAM-1 and sVCAM-1 could not be identified neither for type 1 nor type 2 diabetes.
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Affiliation(s)
- Charlotte Ekelund
- Diabetes Research Laboratory, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Jonatan Dereke
- Diabetes Research Laboratory, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Charlotta Nilsson
- Diabetes Research Laboratory, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Pediatrics, Helsingborg Hospital, Helsingborg, Sweden
| | - Mona Landin-Olsson
- Diabetes Research Laboratory, Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
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Liu TYA, Shpigel J, Khan F, Smith K, Prichett L, Channa R, Kanbour S, Jones M, Abusamaan MS, Sidhaye A, Mathioudakis N, Wolf RM. Use of Diabetes Technologies and Retinopathy in Adults With Type 1 Diabetes. JAMA Netw Open 2024; 7:e240728. [PMID: 38446483 PMCID: PMC10918500 DOI: 10.1001/jamanetworkopen.2024.0728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/09/2024] [Indexed: 03/07/2024] Open
Abstract
Importance Diabetic retinopathy (DR) is a complication of diabetes that can lead to vision loss. Outcomes of continuous glucose monitoring (CGM) and insulin pump use in DR are not well understood. Objective To assess the use of CGM, insulin pump, or both, and DR and proliferative diabetic retinopathy (PDR) in adults with type 1 diabetes (T1D). Design, Setting, and Participants A retrospective cohort study of adults with T1D in a tertiary diabetes center and ophthalmology center was conducted from 2013 to 2021, with data analysis performed from June 2022 to April 2023. Exposure Use of diabetes technologies, including insulin pump, CGM, and both CGM and insulin pump. Main Outcomes and Measures The primary outcome was development of DR or PDR. A secondary outcome was the progression of DR for patients in the longitudinal cohort. Multivariable logistic regression models assessed for development of DR and PDR and association with CGM and insulin pump use. Results A total of 550 adults with T1D were included (median age, 40 [IQR, 28-54] years; 54.4% female; 24.5% Black or African American; and 68.4% White), with a median duration of diabetes of 20 (IQR, 10-30) years, and median hemoglobin A1c (HbA1c) of 7.8% (IQR, 7.0%-8.9%). Overall, 62.7% patients used CGM, 58.2% used an insulin pump, and 47.5% used both; 44% (244 of 550) of the participants had DR at any point during the study. On univariate analysis, CGM use was associated with lower odds of DR and PDR, and CGM with pump was associated with lower odds of PDR (all P < .05), compared with no CGM use. Multivariable logistic regression adjusting for age, sex, race and ethnicity, diabetes duration, microvascular and macrovascular complications, insurance type, and mean HbA1c, showed that CGM was associated with lower odds of DR (odds ratio [OR], 0.52; 95% CI, 0.32-0.84; P = .008) and PDR (OR, 0.42; 95% CI, 0.23-0.75; P = .004), compared with no CGM use. In the longitudinal analysis of participants without baseline PDR, 79 of 363 patients (21.8%) had progression of DR during the study. Conclusions and Relevance In this cohort study of adults with T1D, CGM use was associated with lower odds of developing DR and PDR, even after adjusting for HbA1c. These findings suggest that CGM may be useful for diabetes management to mitigate risk for DR and PDR.
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Affiliation(s)
- T. Y. Alvin Liu
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julia Shpigel
- Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Fatima Khan
- Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kerry Smith
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura Prichett
- Epidemiology and Data Management (BEAD) Core, Johns Hopkins School of Medicine Biostatistics, Baltimore, Maryland
| | - Roomasa Channa
- Department of Ophthalmology, University of Wisconsin, Madison
| | - Sarah Kanbour
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marissa Jones
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammed S. Abusamaan
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aniket Sidhaye
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Risa M. Wolf
- Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Dweib M, El Sharif N. Diabetes-Related Microvascular Complications in Primary Health Care Settings in the West Bank, Palestine. J Clin Med 2023; 12:6719. [PMID: 37959185 PMCID: PMC10649955 DOI: 10.3390/jcm12216719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Worldwide, retinopathy, nephropathy, and neuropathy are the major diabetes-related microvascular complications. In Palestine, a low-middle-income country, diabetes is the fourth reason for death. However, a few studies examined diabetes microvascular consequences and its management. Therefore, we carried out a national study that aims to investigate the factors associated with diabetes-related microvascular complications among individuals seeking care in primary healthcare settings of the West Bank of Palestine. METHOD Using a cluster systematic sampling technique, 882 participants with diabetes patients were chosen for a cross-sectional study from primary healthcare facilities operated by the Ministry of Health (PMoH), the United Nations Relief and Works Agency (UNRWA), and the Palestinian Medical Relief Society (PMRS). Data about patients related to diabetes-related complications, medication use, and other diseases were extracted from patients' medical records. In addition, an interview face-to-face questionnaire was used to collect information about patients' sociodemographic variables, medical history, smoking habits, duration of the disease, presence of concurrent conditions previous referrals, and hospital admissions, as well as their level of knowledge regarding diabetes, complications, and treatments. RESULTS Approximately 34.4% of persons with diabetes patients in Palestine encounter at least one microvascular complication associated with diabetes. The most prevalent diabetes-related microvascular complication was retinopathy (17.3%), 23.4% of participants had more than one microvascular complication, and 29% of male patients had erectile dysfunction. A higher probability of having any microvascular complications was associated with older age (over 60 years). Participants with diabetes patients with fundoscopy or ophthalmology reports, according to diabetes follow-up guidelines, were less likely to develop retinopathy. Also, those who performed regular kidney function testing were less likely to have nephropathy, and those who performed a regular foot exam were less likely to develop diabetic foot. CONCLUSIONS Diabetes-related microvascular complications were associated with patient age, low education level, residency location, and adherence to diabetes follow-up guidelines of diabetes management; i.e., having been tested for HbA1c, consulting with specialists, regular kidney function, and foot examination. These factors can be utilized in setting up proper management protocols to prevent or delay microvascular complications in many patients.
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Affiliation(s)
- Mohammad Dweib
- College of Pharmacy and Medical Sciences, Hebron University, P.O. Box 40, Hebron P720, Palestine;
- School of Public Health, Al-Quds University, Abu Dis, P.O. Box 51000, Jerusalem 20002, Palestine
| | - Nuha El Sharif
- School of Public Health, Al-Quds University, Abu Dis, P.O. Box 51000, Jerusalem 20002, Palestine
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Yafi M, Shah A, Velez K. Narrative review of the role of technology in pediatric diabetes: from testing blood glucose to subcutaneous automated therapy and hope for cure. Transl Pediatr 2023; 12:1725-1734. [PMID: 37814709 PMCID: PMC10560351 DOI: 10.21037/tp-23-145] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/24/2023] [Indexed: 10/11/2023] Open
Abstract
Background and Objective Type 1 diabetes, the most common cause of diabetes in pediatrics, is defined by the hyperglycemia that results from the permanent autoimmune damage to the pancreas. The Diabetes Control and Complications Trial (DCCT) demonstrated that strict glycemic control targeting lower HbA1c goals can both delay the onset and progression of its complications that include diabetic neuropathy, nephropathy, retinopathy, and increased cardiovascular events. Our primary objective is to review the literature available regarding the technology applied for the treatment of diabetes, not only aiding patients' quality of life but addressing its effects on hypoglycemia and reduced risk of the long-term complications. It will synthesize the evolution of glucose monitoring devices; the development of insulin: from animal to recombinant engineering, smart insulin in the future; the development of algorithm-driven insulin delivery devices, the closed loop system/artificial pancreas; and the future utilization of technology to support islet cell transplant with the goal of a long-term cure. Emphasis will be made on what is known about the impact on its outcomes in children and adolescents. Methods A literature search was conducted using PubMed for publications from 1985 to present. Keywords used: type 1 diabetes, children, adolescents, pediatrics, continuous glucose monitoring (CGM), insulin pumps. Referenced articles include other reviews, current care guidelines as supported by cross sectional studies, cohort studies and randomized clinical trials. Key Content and Findings Understanding the pathophysiology of type 1 diabetes has led to the design of technology that facilitates glucose monitoring and insulin administration in a personalized manner. The current technology has improved outcomes and quality of life by decreasing hypoglycemic events and decreasing risk of long-term metabolic complications. Barriers remain, for children and adults, often driven by patient's preference as well as their understanding of the limitations of what they are wearing. Conclusions With the progressive evolution of this technology, it is now realistic to lower the burden of diabetes self-management while reducing hypoglycemia and risk of complications that otherwise impact daily life from academics, physical activity, career choices and even life expectancy.
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Affiliation(s)
- Michael Yafi
- Division of Endocrinology, Department of Pediatrics, McGovern Medical School at the University Texas Health Houston, Houston, TX, USA
| | - Avni Shah
- Division of Endocrinology, Department of Pediatrics, McGovern Medical School at the University Texas Health Houston, Houston, TX, USA
| | - Katherine Velez
- Division of Endocrinology, Department of Pediatrics, McGovern Medical School at the University Texas Health Houston, Houston, TX, USA
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Soheilipour F, Abbasi Kasbi N, Imankhan M, Eskandari D. Complications and Treatment of Early-Onset Type 2 Diabetes. Int J Endocrinol Metab 2023; 21:e135004. [PMID: 38028250 PMCID: PMC10676662 DOI: 10.5812/ijem-135004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/12/2023] [Accepted: 07/15/2023] [Indexed: 12/01/2023] Open
Abstract
Context Global reports have revealed a dramatic rise in the number of patients diagnosed with type 2 diabetes (T2DM) over the past three decades in all age groups, even in children and adolescents. The physiologic phenomenon of insulin resistance during puberty, as well as genetic and epigenetic factors, are implicated in this phenomenon. It seems that patients with early-onset T2DM experience a more aggressive clinical course; however, limited treatments available for these patients pose a challenge. This narrative review intends to scrutinize the micro- and macrovascular complications and treatments of patients with early-onset T2DM. Methods The literature search was conducted in the PubMed database to identify all relevant original English articles published from the beginning of 2018 until January 2023. Results Vascular complications, such as albuminuria, hypertension, cardiovascular diseases, and retinopathy, were seen to be more common in early-onset T2DM compared to type 1 diabetes. The odds ratio of vascular complications was higher in early-onset compared to late-onset T2DM. In children and adolescents with T2DM, the only approved medications included metformin, insulin, and glucagon-like peptide-1 agonists. Treatment of early-onset T2DM with metformin monotherapy cannot yield durable glycemic control, and most patients need early combination therapy. Conclusions During the past years, the frequency of early-onset T2DM has been growing at an alarming rate. Vascular complications in these patients seem more aggressive and more challenging to control. Hence, further clinical trials should be conducted to develop novel therapeutic approaches and evaluate their long-term benefits in terms of glycemic control and preventing future complications.
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Affiliation(s)
- Fahimeh Soheilipour
- Minimally Invasive Surgery Research Center, Aliasghar Children Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Naghmeh Abbasi Kasbi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Delaram Eskandari
- Department of Endocrinology, Rasool Akram Medical Complex, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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AbuHammad GAR, Naser AY, Hassouneh LKM. Diabetes mellitus-related hospital admissions and prescriptions of antidiabetic agents in England and Wales: an ecological study. BMC Endocr Disord 2023; 23:102. [PMID: 37149604 PMCID: PMC10163802 DOI: 10.1186/s12902-023-01352-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 04/25/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Around 6.5% of the population in the United Kingdom has been diagnosed with diabetes. It is associated with several long-term consequences and higher hospitalization rates. AIM To examine the profile of hospital admissions related to diabetes mellitus and the prescription rates of antidiabetic medications in England and Wales. METHOD This is an ecological study that was conducted for the period between April 1999 and April 2020 using publicly available hospitalisation data in England and Wales. Hospital admission data for patients of all ages was extracted from Hospital Episode Statistics in England and the Patient Episode Database for Wales. The difference between admission rates in 1999 and 2020, as well as the difference between diabetes mellitus medication prescription rates in 2004 and 2020, were assessed using the Pearson Chi-squared test. A Poisson regression model with robust variance estimation was used to examine the trend in hospital admissions. RESULTS A total of 1,757,892 diabetes mellitus hospital admissions were recorded in England and Wales during the duration of the study. The hospital admission rate for diabetes mellitus increased by 15.2%. This increase was concomitant with an increase in the antidiabetic medication prescribing rate of 105.9% between 2004 and 2020. Males and those in the age group of 15-59 years had a higher rate of hospital admission. The most common causes of admissions were type 1 diabetes mellitus related complications, which accounted for 47.1% of all admissions. CONCLUSION This research gives an in-depth overview of the hospitalization profile in England and Wales during the previous two decades. In England and Wales, people with all types of diabetes and related problems have been hospitalized at a high rate over the past 20 years. Male gender and middle age were significant determinants in influencing admission rates. Diabetes mellitus type 1 complications were the leading cause of hospitalizations. We advocate establishing preventative and educational campaigns to promote the best standards of care for individuals with diabetes in order to lower the risk of diabetes-related complications.
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Affiliation(s)
- Gayda Abdel Rahman AbuHammad
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
| | - Abdallah Y Naser
- Department of Applied Pharmaceutical Sciences and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan.
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Cioana M, Deng J, Nadarajah A, Hou M, Qiu Y, Chen SSJ, Rivas A, Toor PP, Banfield L, Thabane L, Chaudhary V, Samaan MC. Global Prevalence of Diabetic Retinopathy in Pediatric Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e231887. [PMID: 36930156 PMCID: PMC10024209 DOI: 10.1001/jamanetworkopen.2023.1887] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
IMPORTANCE Type 2 diabetes (T2D) is increasing globally. Diabetic retinopathy (DR) is a leading cause of blindness in adults with T2D; however, the global burden of DR in pediatric T2D is unknown. This knowledge can inform retinopathy screening and treatments to preserve vision in this population. OBJECTIVE To estimate the global prevalence of DR in pediatric T2D. DATA SOURCES MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, the Web of Science, and the gray literature (ie, literature containing information that is not available through traditional publishing and distribution channels) were searched for relevant records from the date of database inception to April 4, 2021, with updated searches conducted on May 17, 2022. Searches were limited to human studies. No language restrictions were applied. Search terms included diabetic retinopathy; diabetes mellitus, type 2; prevalence studies; and child, adolescent, teenage, youth, and pediatric. STUDY SELECTION Three teams, each with 2 reviewers, independently screened for observational studies with 10 or more participants that reported the prevalence of DR. Among 1989 screened articles, 27 studies met the inclusion criteria for the pooled analysis. DATA EXTRACTION AND SYNTHESIS This systematic review and meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines for systematic reviews and meta-analyses. Two independent reviewers performed the risk of bias and level of evidence analyses. The results were pooled using a random-effects model, and heterogeneity was reported using χ2 and I2 statistics. MAIN OUTCOMES AND MEASURES The main outcome was the estimated pooled global prevalence of DR in pediatric T2D. Other outcomes included DR severity and current DR assessment methods. The association of diabetes duration, sex, race, age, and obesity with DR prevalence was also assessed. RESULTS Among the 27 studies included in the pooled analysis (5924 unique patients; age range at T2D diagnosis, 6.5-21.0 years), the global prevalence of DR in pediatric T2D was 6.99% (95% CI, 3.75%-11.00%; I2 = 95%; 615 patients). Fundoscopy was less sensitive than 7-field stereoscopic fundus photography in detecting retinopathy (0.47% [95% CI, 0%-3.30%; I2 = 0%] vs 13.55% [95% CI, 5.43%-24.29%; I2 = 92%]). The prevalence of DR increased over time and was 1.11% (95% CI, 0.04%-3.06%; I2 = 5%) at less than 2.5 years after T2D diagnosis, 9.04% (95% CI, 2.24%-19.55%; I2 = 88%) at 2.5 to 5.0 years after T2D diagnosis, and 28.14% (95% CI, 12.84%-46.45%; I2 = 96%) at more than 5 years after T2D diagnosis. The prevalence of DR increased with age, and no differences were noted based on sex, race, or obesity. Heterogeneity was high among studies. CONCLUSIONS AND RELEVANCE In this study, DR prevalence in pediatric T2D increased significantly at more than 5 years after diagnosis. These findings suggest that retinal microvasculature is an early target of T2D in children and adolescents, and annual screening with fundus photography beginning at diagnosis offers the best assessment method for early detection of DR in pediatric patients.
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Affiliation(s)
- Milena Cioana
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Jiawen Deng
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ajantha Nadarajah
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Maggie Hou
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Yuan Qiu
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sondra Song Jie Chen
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Angelica Rivas
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Parm Pal Toor
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Centre for Evaluation of Medicines, St Joseph’s Health Care, Hamilton, Ontario, Canada
- Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Varun Chaudhary
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Ophthalmology, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - M. Constantine Samaan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Division of Pediatric Endocrinology, McMaster Children's Hospital, Hamilton, Ontario, Canada
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Jotte A, Vander Kooi W, French DD. Factors Associated with Annual Vision Screening in Diabetic Adults: Analysis of the 2019 National Health Interview Survey. Clin Ophthalmol 2023; 17:613-621. [PMID: 36843957 PMCID: PMC9946010 DOI: 10.2147/opth.s402082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/09/2023] [Indexed: 02/20/2023] Open
Abstract
Purpose To determine the association(s) between receiving an annual eye exam and various economic, social, and geographic factors assessed in the 2019 National Health Interview Survey (NHIS) among adults with diabetes. Patients and Methods Data from adults 18 years of age and older relevant to self-reported non-gestational diabetes diagnosis and eye exam within the last 12 months were extracted from the 2019 NHIS dataset. A multivariate logistic regression model was used to determine associations between receiving an eye exam in the preceding 12 months and various economic, insurance-related, geographic, and social factors. Outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). Results Among diabetic adults in the US, receiving an eye exam within the last 12 months was significantly associated with female sex (OR 1.29; 95% CI 1.05-1.58), residence in the Midwestern United States (OR 1.39; 95% CI 1.01-1.92), use of Veteran's Health Administration healthcare (OR 2.15; 95% CI 1.34-3.44), having a usual place to go for healthcare (OR 3.89; 95% CI 2.16-7.01), and the use of Private, Medicare Advantage, or other insurance (OR 3.66; 95% CI 2.42-5.53), use of Medicare only excluding Medicare Advantage (OR 3.18; 95% CI 1.95-5.30), dual eligibility for Medicare and Medicaid (OR 3.88; 95% CI 2.21-6.79), and use of Medicaid and other public health insurance (OR 3.04; 95% CI 1.89-4.88) compared to those without insurance. An educational attainment of less than high school (OR 0.66; 95% CI 0.48-0.92), and an educational attainment of high school or GED without any college (OR 0.62; 95% CI 0.47-0.81) reduced the odds of having an annual eye exam. Conclusion Economic, social, and geographic factors are associated with diabetic adults receiving an annual eye exam.
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Affiliation(s)
- Alec Jotte
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Dustin D French
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Departments of Ophthalmology and Medical Social Sciences, Northwestern University, Chicago, IL, USA,Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL, USA,Veterans Affairs Health Services Research and Development Service, Chicago, IL, USA,Correspondence: Dustin D French, 645 N. Michigan Ave., Suite 440, Chicago, IL, 60611, USA, Tel +1 312 503 5590, Fax +1 312 503 8152, Email
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10
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Howe CJ, Morone J, Hawkes CP, Lipman TH. Racial Disparities in Technology Use in Children With Type 1 Diabetes: A Qualitative Content Analysis of Parents' Perspectives. Sci Diabetes Self Manag Care 2023; 49:55-64. [PMID: 36609201 DOI: 10.1177/26350106221145323] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE The purpose of the study was to describe differences in non-Hispanic Black (NHB) and non-Hispanic White (NHW) parents' perceptions of factors that influence the use of diabetes technology. METHODS Focus groups were conducted with parents of NHB and NHW children at a pediatric diabetes center in the Northeast United States. Kilbourne's health disparities framework informed the focus group guide and a priori coding for directed content analysis. Further analysis allowed subcategories to emerge inductively. RESULTS Twenty-one parents participated. Five subcategories emerged, describing differences in NHB and NHW parent decisions regarding diabetes technology: (1) child's choice, (2) shame versus pride, (3) pros and cons of technology, (4) time frame, and (5) blood glucose indications of readiness. NHB parents feared technology malfunction, worried that visible devices could worsen experienced stigma of diabetes diagnosis, and described the diabetes team as gatekeepers, who changed eligibility criteria for diabetes technology use for their research purposes. In contrast, NHW parents reported diabetes team expectation of diabetes technology use and did not report provider-related barriers. CONCLUSION This study adds to existing literature advancing our understanding of the patient and provider mechanisms underlying racial disparities in diabetes technology use. This understanding may guide development of interventions focused on patients, providers, and structural factors to improve equity in use of diabetes technology by youth with type 1 diabetes.
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Affiliation(s)
- Carol J Howe
- Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, Texas
| | - Jennifer Morone
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colin P Hawkes
- Diabetes Center for Children, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia
| | - Terri H Lipman
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia
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11
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Yirdaw BE, Debusho LK. Semiparametric modelling of diabetic retinopathy among people with type II diabetes mellitus. BMC Med Res Methodol 2023; 23:7. [PMID: 36624377 PMCID: PMC9830762 DOI: 10.1186/s12874-022-01794-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 11/16/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The proportion of patients with diabetic retinopathy (DR) has grown with increasing number of diabetes mellitus patients in the world. It is among the major causes of blindness worldwide. The main objective of this study was to identify contributing risk factors of DR among people with type II diabetes mellitus. METHOD A sample of 191 people with type II diabetes mellitus was selected from the Black Lion Specialized Hospital diabetic unit from 1 March 2018 to 1 April 2018. A multivariate stochastic regression imputation technique was applied to impute the missing values. The response variable, DR is a categorical variable with two outcomes. Based on the relationship derived from the exploratory analysis, the odds of having DR were not necessarily linearly related to the continuous predictors for this sample of patients. Therefore, a semiparametric model was proposed to identify the risk factors of DR. RESULT From the sample of 191 people with type II diabetes mellitus, 98 (51.3%) of them had DR. The results of semiparametric regression model revealed that being male, hypertension, insulin treatment, and frequency of clinical visits had a significant linear relationships with the odds of having DR. In addition, the log- odds of having DR has a significant nonlinear relation with the interaction of age by gender (for female patients), duration of diabetes, interaction of cholesterol level by gender (for female patients), haemoglobin A1c, and interaction of haemoglobin A1c by fasting blood glucose with degrees of freedom [Formula: see text], respectively. The interaction of age by gender and cholesterol level by gender appear non significant for male patients. The result from the interaction of haemoglobin A1c (HbA1c) by fasting blood glucose (FBG) showed that the risk of DR is high when the level of HbA1c and FBG were simultaneously high. CONCLUSION Clinical variables related to people with type II diabetes mellitus were strong predictive factors of DR. Hence, health professionals should be cautious about the possible nonlinear effects of clinical variables, interaction of clinical variables, and interaction of clinical variables with sociodemographic variables on the log odds of having DR. Furthermore, to improve intervention strategies similar studies should be conducted across the country.
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Affiliation(s)
- Bezalem Eshetu Yirdaw
- grid.412801.e0000 0004 0610 3238Department of Statistics, University of South Africa, c/o Christiaan de Wet Road & Pioneer Avenue, Florida 1709 Johannesburg, South Africa
| | - Legesse Kassa Debusho
- grid.412801.e0000 0004 0610 3238Department of Statistics, University of South Africa, c/o Christiaan de Wet Road & Pioneer Avenue, Private Bag X6, Florida 1710 Johannesburg, South Africa
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12
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Bjornstad P, Dart A, Donaghue KC, Dost A, Feldman EL, Tan GS, Wadwa RP, Zabeen B, Marcovecchio ML. ISPAD Clinical Practice Consensus Guidelines 2022: Microvascular and macrovascular complications in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1432-1450. [PMID: 36537531 DOI: 10.1111/pedi.13444] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Petter Bjornstad
- Section of Endocrinology, Department of Pediatrics, Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Allison Dart
- Department of Pediatrics, Divison of Nephrology, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Kim C Donaghue
- Department of Pediatrics, Division of Endocrinology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | - Axel Dost
- Department of Pediatrics, Division of Endocrinology, Jena University Hospital, Jena, Germany
| | - Eva L Feldman
- Department of Medicine, Division of Neurology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Gavin S Tan
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore.,Department of Ophthalmology and Visual Sciences, Duke-NUS Medical School, National University of Singapore, Singapore
| | - R Paul Wadwa
- Section of Endocrinology, Department of Pediatrics, Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Bedowra Zabeen
- Department of Paediatrics and Changing Diabetes in Children Program, Bangladesh Institute of Research and Rehabilitation in Diabetes Endocrine and Metabolic Disorders, Dhaka, Bangladesh
| | - M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge, and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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13
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Pauley ME, Tommerdahl KL, Snell-Bergeon JK, Forlenza GP. Continuous Glucose Monitor, Insulin Pump, and Automated Insulin Delivery Therapies for Type 1 Diabetes: An Update on Potential for Cardiovascular Benefits. Curr Cardiol Rep 2022; 24:2043-2056. [PMID: 36279036 PMCID: PMC9589770 DOI: 10.1007/s11886-022-01799-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW The incidence of type 1 diabetes (T1D) is rising in all age groups. T1D is associated with chronic microvascular and macrovascular complications but improving glycemic trends can delay the onset and slow the progression of these complications. Utilization of technological devices for diabetes management, such as continuous glucose monitors (CGM) and insulin pumps, is increasing, and these devices are associated with improvements in glycemic trends. Thus, device use may be associated with long-term prevention of T1D complications, yet few studies have investigated the direct impacts of devices on chronic complications in T1D. This review will describe common diabetes devices and combination systems, as well as review relationships between device use and cardiovascular outcomes in T1D. RECENT FINDINGS Findings from existing cohort and national registry studies suggest that pump use may aid in improving cardiovascular risk factors such as hypertension and dyslipidemia. Furthermore, pump users have been shown to have lower arterial stiffness and better measures of myocardial function. In registry and case-control longitudinal data, pump use has been associated with fewer cardiovascular events and reduction of cardiovascular disease (CVD) and all-cause mortality. CVD is the leading cause of morbidity and mortality in T1D. Consistent use of diabetes devices may protect against the development and progression of macrovascular complications such as CVD through improvement in glycemic trends. Existing literature is limited, but findings suggest that pump use may reduce acute cardiovascular risk factors as well as chronic cardiovascular complications and overall mortality in T1D.
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Affiliation(s)
- Meghan E Pauley
- Department of Pediatrics, Section of Pediatric Endocrinology, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Kalie L Tommerdahl
- Department of Pediatrics, Section of Pediatric Endocrinology, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
- Ludeman Family Center for Women's Health Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Janet K Snell-Bergeon
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gregory P Forlenza
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
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14
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Allen DW, Liew G, Cho YH, Pryke A, Cusumano J, Hing S, Chan AK, Craig ME, Donaghue KC. Thirty-Year Time Trends in Diabetic Retinopathy and Macular Edema in Youth With Type 1 Diabetes. Diabetes Care 2022; 45:2247-2254. [PMID: 35594057 DOI: 10.2337/dc21-1652] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 03/18/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine trends in diabetic retinopathy (DR) and diabetic macular edema (DME) in adolescents with type 1 diabetes between 1990 and 2019. RESEARCH DESIGN AND METHODS We analyzed 5,487 complication assessments for 2,404 adolescents (52.7% female, aged 12-20 years, diabetes duration >5 years), stratified by three decades (1990-1999, 2000-2009, 2010-2019). DR and DME were graded according to the modified Airlie House classification from seven-field stereoscopic fundal photography. RESULTS Over three decades, the prevalence of DR was 40, 21, and 20% (P < 0.001) and DME 1.4, 0.5, and 0.9% (P = 0.13), respectively, for 1990-1999, 2000-2009, and 2010-2019. Continuous subcutaneous insulin infusion (CSII) use increased (0, 12, and 55%; P < 0.001); mean HbA1c was bimodal (8.7, 8.5, and 8.7%; P < 0.001), and the proportion of adolescents meeting target HbA1c <7% did not change significantly (8.3, 7.7, and 7.1%; P = 0.63). In multivariable generalized estimating equation analysis, DR was associated with 1-2 daily injections (odds ratio 1.88, 95% CI 1.42-2.48) and multiple injections in comparison with CSII (1.38, 1.09-1.74); older age (1.11, 1.07-1.15), higher HbA1c (1.19, 1.05-1.15), longer diabetes duration (1.15, 1.12-1.18), overweight/obesity (1.27, 1.08-1.49) and higher diastolic blood pressure SDS (1.11, 1.01-1.21). DME was associated with 1-2 daily injections (3.26, 1.72-6.19), longer diabetes duration (1.26, 1.12-1.41), higher diastolic blood pressure SDS (1.66, 1.22-2.27), higher HbA1c (1.28, 1.03-1.59), and elevated cholesterol (3.78, 1.84-7.76). CONCLUSIONS One in five adolescents with type 1 diabetes had DR in the last decade. These findings support contemporary guidelines for lower glycemic targets, increasing CSII use, and targeting modifiable risk factors including blood pressure, cholesterol, and overweight/obesity.
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Affiliation(s)
- Digby W Allen
- School of Medicine, University of New South Wales, Kensington, Australia
| | - Gerald Liew
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia.,Westmead Institute for Medical Research, University of Sydney, Sydney, Australia
| | - Yoon Hi Cho
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
| | - Alison Pryke
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
| | - Janine Cusumano
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
| | - Stephen Hing
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
| | - Albert K Chan
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
| | - Maria E Craig
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Kim C Donaghue
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, Australia
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15
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Lin T, Gubitosi-Klug RA, Channa R, Wolf RM. Pediatric Diabetic Retinopathy: Updates in Prevalence, Risk Factors, Screening, and Management. Curr Diab Rep 2021; 21:56. [PMID: 34902076 DOI: 10.1007/s11892-021-01436-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Diabetic retinopathy (DR) is a microvascular complication of diabetes mellitus and a major cause of vision loss worldwide. The purpose of this review is to provide an update on the prevalence of diabetic retinopathy in youth, discuss risk factors, and review recent advances in diabetic retinopathy screening. RECENT FINDINGS While DR has long been considered a microvascular complication, recent data suggests that retinal neurodegeneration may precede the vascular changes associated with DR. The prevalence of DR has decreased in type 1 diabetes (T1D) patients following the results of the Diabetes Control and Complications Trial and implementation of intensive insulin therapy, with prevalence ranging from 14-20% before the year 2000 to 3.7-6% after 2000. In contrast, the prevalence of diabetic retinopathy in pediatric type 2 diabetes (T2D) is higher, ranging from 9.1-50%. Risk factors for diabetic retinopathy are well established and include glycemic control, diabetes duration, hypertension, and hyperlipidemia, whereas diabetes technology use including insulin pumps and continuous glucose monitors has been shown to have protective effects. Screening for DR is recommended for youth with T1D once they are aged ≥ 11 years or puberty has started and diabetes duration of 3-5 years. Pediatric T2D patients are advised to undergo screening at or soon after diagnosis, and annually thereafter, due to the insidious nature of T2D. Recent advances in DR screening methods including point of care and artificial intelligence technology have increased access to DR screening, while being cost-saving to patients and cost-effective to healthcare systems. While the prevalence of diabetic retinopathy in youth with T1D has been declining over the last few decades, there has been a significant increase in the prevalence of DR in youth with T2D. Improving access to diabetic retinopathy screening using novel screening methods may help improve detection and early treatment of diabetic retinopathy.
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Affiliation(s)
- Tyger Lin
- Department of Pediatrics, Division of Pediatric Endocrinology, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
| | - Rose A Gubitosi-Klug
- Department of Pediatrics, Division of Endocrinology, Case Western Reserve University School of Medicine and Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA
| | - Risa M Wolf
- Department of Pediatrics, Division of Pediatric Endocrinology, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA.
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