Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database

Genetically predicted type 2 diabetes mellitus mediates the causal association between plasma uric acid and ischemic stroke

OBJECTIVE

This study conducts a systematic investigation into the causal relationships between plasma uric acid levels and subtypes of ischemic stroke (IS), as well as the extent to which Type 2 diabetes mellitus (T2DM) mediates this relationship.

BACKGROUND

There is a known association between Uric acid and IS but whether they have a causal relationship remains unclear. This study aims to determine whether a genetic predisposition to uric acid is causally linked to IS, including three subtypes, and to determine the mediating role of T2DM.

METHODS

Bidirectional Mendelian randomization (MR) analyses was initially used to explore the causal relationship between uric acid and three subtypes of IS. Two-step MR methods were then used to investigate the role of T2DM in mediating the effect of uric acid and IS with its subtypes.

RESULTS

A primary analysis showed uric acid had a markedly causal association with IS (IVW, OR 1.23; 95 % CI, 1.13 - 1.34; p = 6.39 × 10-9), and two subtypes of IS, Large-vessel atherosclerotic stroke LAS (IVW, OR 1.25; 95 % CI, 1.03 - 1.53; p = 0.026) and small vessel stroke (SVS) (IVW, OR 1.20; 95 % CI, 1.00 - 1.43; p = 0.049), but not with cardioembolic stroke (CES)(IVW, OR 1.00; 95 % CI, 0.87 - 1.15; p = 0.993). Two-step MR results showed that T2DM mediated the association between uric acid and LAS and SVS, accounting for 13.85 % (p = 0.025) and 13.57 % (p = 0.028), respectively.

CONCLUSIONS

The study suggests that genetic predisposition to uric acid is linked to a greater risk of IS, especially LAS and SVS. T2DM might mediate a significant proportion of the associations between uric acid and LAS as well as SVS.

Long-term efficacy and safety of early alogliptin initiation in subjects with type 2 diabetes: an extension of the SPEAD-A study

We previously reported in the study of preventive effects of alogliptin on diabetic atherosclerosis (SPEAD-A) that alogliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, attenuated the progression of carotid atherosclerosis in subjects with type 2 diabetes and no history of cardiovascular disease. This extension study of the SPEAD-A trial investigated whether early alogliptin initiation improved long-term cardiovascular outcomes. The SPEAD-A trial randomized 341 subjects with type 2 diabetes to either alogliptin or conventional treatment to investigate the effects of alogliptin on atherosclerosis. All subjects who completed that trial were eligible for this prospective, observational cohort study. The primary endpoint was the first occurrence of a major cardiovascular event, defined as death due to any cause, acute myocardial infarction, or stroke. During the 520-week follow-up period, composite primary outcome events occurred in only a few subjects in each group [8 (5.4%) in the alogliptin group and 9 in the conventional treatment group (5.9%)]. There were no significant differences in the incidence rate of the primary outcome between the two groups. Post hoc Poisson regression analysis showed no significant difference between the two groups in the incidence rate of composite recurrence events for the same outcomes as the primary endpoint. On the other hand, this incidence rate was significantly lower in subjects who received DPP-4 inhibitors before an initial cardiovascular event than in those who did not (5.8 vs. 13.3 per 1000 person-years, respectively, p = 0.04). Early initiation of alogliptin was not associated with a reduced risk of composite cardiovascular disease, which could be attributed to fewer events and/or the addition of DPP-4 inhibitors during the follow-up period.

Incidence of Stroke in People With Diabetes Compared to Those Without Diabetes: A Systematic Review

BACKGROUND

One of the goals of the St. Vincent Declaration was to reduce serious complications of diabetes, including strokes. However, it remains uncertain whether this goal has been achieved.

STUDY AIM

To evaluate the incidence of stroke in the diabetic population and its differences regarding sex, ethnicity, age, and region, to compare the incidence rate in people with and without diabetes, and to investigate time trends.

MATERIALS AND METHODS

A systematic review was conducted according to the guidelines for meta-analysis of observational studies in epidemiology (the MOOSE group) and the PRISMA group guidelines.

RESULTS

Nineteen of the 6.470 studies retrieved were included in the analysis. The incidence of stroke in the population with diabetes ranged from 238 per 100,000 person-years in Germany in 2014 to 1191 during the 1990s in the United Kingdom. The relative risk comparing people with diabetes to those without diabetes varied between 1.0 and 2.84 for total stroke, 1.0 and 3.7 for ischemic stroke, and 0.68 and 1.6 for hemorrhagic stroke. Differences between fatal and non-fatal stroke were significant, depending on the time period and the population. We found decreasing time trends in people with diabetes and stable incidence rates of stroke over time in people without diabetes.

CONCLUSION

The considerable differences between results can partly be explained by differences in study designs, statistical methods, definitions of stroke, and methods used to identify patients with diabetes. The lack of evidence arising from these differences ought to be rectified by new studies.

Percutaneous Left Atrial Appendage Closure Among Patients With Diabetes (Insights from a National Database)

Atrial fibrillation is a major risk factor for stroke. Left atrial appendage closure (LAAC) has emerged as an alternative to anticoagulation for patients with high risk of bleeding. Diabetes mellitus (DM) is associated with adverse events after cardiac procedures. We sought to compare procedural and hospital outcomes in patients who underwent LAAC with and without DM. The Nationwide Inpatient Database was queried for patients with atrial fibrillation who underwent LAAC between January 1, 2016, and December 31, 2019. The primary outcome was all adverse events that included in-hospital death, acute myocardial infarction, cardiac arrest, stroke, pericardial effusion, pericardial tamponade, pericardiocentesis, pericardial window, and postprocedural hemorrhage requiring blood transfusion. Analysis included 62,220 patients who underwent LAAC from 2016 to 2019; 34.9% of patients had DM. There was a slight increase in the percentage of patients who underwent LAAC who had DM during the study period, from 29.92% to 34.93%. In unadjusted and adjusted analysis, there was no significant difference in all adverse events between patients with and without DM who underwent LAAC (9.18% vs 8.77%, respectively, adjusted p = 0.63), and no difference in length of stay. Patients with DM have higher risk of acute kidney injury (3.75 vs 1.96%, p <0.001). This nationwide retrospective study demonstrates that DM is not associated with an increase in adverse event rates in patients who underwent LAAC.

All-Cause, Cardiovascular and Respiratory Mortality in People with Type 2 Diabetes and Chronic Obstructive Pulmonary Disease (COPD) in England: A Cohort Study Using the Clinical Practice Research Datalink (CPRD)

Background

Type 2 diabetes (T2D) and chronic obstructive pulmonary disease (COPD) are common non-communicable diseases. Both have an inflammatory nature and similar risk factors, and there is overlap and interaction between them. To date, there is a lack of research on outcomes in people that have both conditions. The aim of this study was to investigate whether the presence of COPD in people with T2D was associated with an increased risk of all-cause, respiratory-cause and cardiovascular-cause mortality.

Methods

A three-year cohort study (2017-19) was done using the Clinical Practice Research Datalink Aurum database. The study population was 121,563 people with T2D aged ≥40. The exposure was COPD status at baseline. Incident rates for all-cause, respiratory-cause and cardiovascular-cause mortality were calculated. Poisson models for each outcome were fitted to estimate rate ratios for COPD status adjusted for age, sex, Index of Multiple Deprivation, smoking status, body mass index, prior asthma and cardiovascular disease.

Results

COPD was present in 12.1% people with T2D. People with COPD had a higher all-cause mortality rate (448.7 persons per 1000 person years) compared with people without COPD (296.6 persons per 1000 person years). People with COPD also had substantially higher respiratory mortality incidence rates and moderately raised cardiovascular mortality rates. Fully adjusted Poisson models showed that people with COPD had a 1.23 (95% CI 1.21, 1.24) times higher rate of all-cause mortality as compared with those without COPD and a 3.03 (95% CI 2.89, 3.18) times higher rate of respiratory-cause mortality. There was no evidence of an association with cardiovascular mortality after adjusting for existing cardiovascular disease.

Conclusion

Co-morbid COPD in people with T2D was associated with increased mortality overall and particularly from respiratory causes. People with both COPD and T2D are a high-risk group who would benefit from particularly intensive management of both conditions.

Association of glucose-lowering drugs with incident stroke and transient ischaemic attacks in primary care patients with type 2 diabetes: disease analyzer database

AIMS

Previous observational studies on glucose-lowering drugs and risk of stroke in type 2 diabetes yielded conflicting results. The aim was to examine the association of glucose-lowering drugs with incident stroke and transient ischaemic attacks (TIA) in newly diagnosed type 2 diabetes.

METHODS

We conducted a retrospective cohort analysis of the disease analyzer, which comprises a representative panel of 1248 general and internal medicine practices throughout Germany (01/2000-12/2019: 9.8 million patients). Incident non-fatal stroke/TIA was defined based on ICD-10 codes (I63, I64; G45) in newly diagnosed type 2 diabetes. Cox regression models were fitted to obtain hazard ratios (HR; 95%CI) for stroke/TIA adjusting for potential confounders (age, sex, health insurance, coronary heart disease, myocardial infarction, heart failure, polyneuropathy, blood pressure, eGFR) and anthropometric and metabolic intermediators (BMI, HbA1c, HDL- and LDL-cholesterol, triglycerides, lipid-lowering drugs).

RESULT

312,368 persons with newly diagnosed type 2 diabetes without previous stroke/TIA (mean age: 64 years; 52% males) were included. There were 16,701 events of non-fatal stroke/TIA corresponding to an incidence rate of 9.3 (95%CI 9.1-9.4) per 1000 person-years. Using Cox regression, adjusted HR for stroke/TIA (per 1 year of treatment) of 0.59 (0.54-0.64) for SGLT2 inhibitors and of 0.79 (0.74-0.85) for GLP-1 receptor agonists were estimated. DPP-4 inhibitors (0.84; 0.82-0.86), metformin (0.90; 0.89-0.91), insulin (0.92; 0.91-0.93) and sulfonylureas (0.98; 0.96-0.99) also showed moderately reduced HR for stroke/TIA. Sex-specific regression analyses yielded similar results (HR).

CONCLUSIONS

Treatment with SGLT2 inhibitors or GLP-1 receptor agonists might reduce non-fatal stroke/TIA in persons with newly diagnosed type 2 diabetes.

Sex- and gender-differences in chronic long-term complications of type 1 and type 2 diabetes mellitus in Italy

AIMS

This review summarizes the contribution of Italian diabetologists devoted to a better understanding of the complex relationship linking sex/gender and long-term complications of type 1 (T1DM) and type 2 diabetes (T2DM) over the last fifteen years.

DATA SYNTHESIS

Microvascular and macrovascular complications of diabetes show sex- and gender-related differences, involving pathophysiological mechanisms, epidemiological features and clinical presentation, due to the interaction between biological and psychosocial factors. These differences greatly impact on the progression of diabetes and its long-term complications, especially in the cardiovascular, renal and liver districts.

CONCLUSION

A better knowledge of such sex- and gender-related characteristics is required for a more precise patient phenotypization, and for the choice of a personalized antihyperglycemic treatment. Despite such mounting evidence, current diabetes clinical guidelines do not as yet adequately consider sex/gender differences.

Does the Structure Matter? An External Validation and Health Economic Results Comparison of Event Simulation Approaches in Severe Obesity

OBJECTIVES

As obesity-associated events impact long-term survival, health economic (HE) modelling is commonly applied, but modelling approaches are diverse. This research aimed to compare the events simulation and the HE outcomes produced by different obesity modelling approaches.

METHODS

An external validation, using the Swedish obesity subjects (SOS) study, of three main structural event modelling approaches was performed: (1) continuous body mass index (BMI) approach; (2) risk equation approach; and (3) categorical BMI-related approach. Outcomes evaluated were mortality, cardiovascular events, and type 2 diabetes (T2D) for both the surgery and the control arms. Concordance between modelling results and the SOS study were investigated by different state-of-the-art measurements, and categorized by the grade of deviation observed (grades 1-4 expressing mild, moderate, severe, and very severe deviations). Furthermore, the costs per quality-adjusted life-year (QALY) gained of surgery versus controls were compared.

RESULTS

Overall and by study arm, the risk equation approach presented the lowest average grade of deviation (overall grade 2.50; control arm 2.25; surgery arm 2.75), followed by the continuous BMI approach (overall 3.25; control 3.50; surgery 3.00) and by the categorial BMI approach (overall 3.63; control 3.50; surgery 3.75). Considering different confidence interval limits, the costs per QALY gained were fairly comparable between all structural approaches (ranging from £2,055 to £6,206 simulating a lifetime horizon).

CONCLUSION

None of the structural approaches provided perfect external event validation, although the risk equation approach showed the lowest overall deviations. The economic outcomes resulting from the three approaches were fairly comparable.

Chy NU, Alam N, Rana MM, Chowdhury NA, Hasan MM. The relationship between medical comorbidities and health-related quality of life among adults with type 2 diabetes: The experience of different hospitals in southern Bangladesh

Objective

Health-related quality of life (HRQoL) is a critical determinant to assess the severity of chronic diseases like diabetes mellitus. It has a close association with complications, comorbidities, and medical aid. This study aimed to estimate the prevalence of medical comorbidities and determine the relationship between comorbidities and HRQoL among type 2 diabetic patients of southern Bangladesh.

Method

This study was a cross-sectional study conducted through face to face interviews using a pre-tested structured questionnaire and by reviewing patient’s health records with prior written consent. The study was conducted on 2,136 patients with type 2 diabetes attending five hospitals of Chattogram, Bangladesh, during the tenure of November 2018 to July 2019. Quality of life was measured using the widely-used index of EQ-5D that considers 243 different health states and uses a scale in which 0 indicates a health state equivalent to death and 1 indicates perfect health status. The five dimensions of the quality index included mobility, self-care, usual activities, pain or discomfort, and anxiety or depression.

Results

Patients with three comorbidities and with four or more comorbidities had a higher probability of reporting “extreme problem” or “some problem” in all five dimensions of the EQ-5D index compared with those without comorbidity (Odds ratio: mobility, 3.99 [2.72–5.87], 6.22 [3.80–10.19]; usual activity, 2.67 [1.76–4.06], 5.43 [3.28–8.98]; self-care, 2.60 [1.65–4.10], 3.95 [2.33–6.69]; pain or discomfort, 2.22 [1.48–3.33], 3.44 [1.83–6.45]; anxiety or depression, 1.75 [1.07–2.88], 2.45 [1.19–5.04]). The number of comorbidities had a negative impact on quality of life.

Conclusion

Prevalent comorbidities were found to be the significant underlying cause of declined HRQoL. To raise diabetes awareness and for better disease management, the exposition of comorbidities in regards to HRQoL of people with diabetes should be considered for type 2 diabetes management schemas.

[Incidence and risk factors of ischemic stroke in patients with type 2 diabetes among urban workers in Beijing, China]

OBJECTIVE

To explore the incidence of ischemic stroke after the onset of type 2 diabetes, and further analyze the risk factors, so as to provide a basis for further research.

METHODS

The data were obtained from the database of the Beijing Urban Employee Basic Medical Insurance Database. The study used a prospective design to describe the incidence of ischemic stroke in patients with type 2 diabetes. In our study, these patients were followed up for seven years. Multivariate Logistic regression models were used to analyze the risk factors of ischemic stroke in patients with type 2 diabetes.

RESULTS

A total of 185 813 newly diagnosed type 2 diabetes patients were enrolled, with an average age of (58.5±13.2) years, and 49.0% of them were males. A total of 10 393 patients with newly diagnosed ischemic stroke occurred in 7 years, with a cumulative incidence of 5.6% and an incidence density of 8.1/1 000 person-years. Ischemic stroke occurred in all age groups in patients with type 2 diabetes. The cumulative incidence was 1.5% (95%CI: 1.3%-1.6%) in group ≤44 years old, 3.6% (95%CI: 3.4%-3.7%) in group 45-54 years old, 5.4% (95%CI: 5.2%-5.5%) in group 55-64 years old, and 9.2% (95%CI: 9.0%-9.4%) in group ≥65 years old, and the cumulative incidence increased with age (P < 0.05). Cumulative incidence rate of the males (6.8%, 95%CI: 6.7%-7.0%) was higher than the females (4.4%, 95%CI: 4.3%-4.6%). Among the patients < 80 years old, the cumulative incidence rate of the males was higher than that of the females in all the age groups. In the patients ≥80 years of age, the cumulative incidence was higher in the females (9.2%) than in the males (7.9%). Further analysis revealed that complications, such as coronary heart disease (OR=3.18, 95%CI: 2.72-3.72), heart failure (OR=1.53, 95%CI: 1.32-1.79) and kidney failure (OR=1.45, 95%CI: 1.20-1.75) were associated with ischemic stroke in the patients with type 2 diabetes.

CONCLUSION

The incidence level of ischemic stroke in patients with type 2 diabetes is high. It is necessary to strengthen the management of risk factors in elderly patients, screen the complications of type 2 diabetes as early as possible, and take active preventive and control measures.

Diabetes and Ischemic Stroke: An Old and New Relationship an Overview of the Close Interaction between These Diseases

Diabetes mellitus is a comprehensive expression to identify a condition of chronic hyperglycemia whose causes derive from different metabolic disorders characterized by altered insulin secretion or faulty insulin effect on its targets or often both mechanisms. Diabetes and atherosclerosis are, from the point of view of cardio- and cerebrovascular risk, two complementary diseases. Beyond shared aspects such as inflammation and oxidative stress, there are multiple molecular mechanisms by which they feed off each other: chronic hyperglycemia and advanced glycosylation end-products (AGE) promote ‘accelerated atherosclerosis’ through the induction of endothelial damage and cellular dysfunction. These diseases impact the vascular system and, therefore, the risk of developing cardio- and cerebrovascular events is now evident, but the observation of this significant correlation has its roots in past decades. Cerebrovascular complications make diabetic patients 2–6 times more susceptible to a stroke event and this risk is magnified in younger individuals and in patients with hypertension and complications in other vascular beds. In addition, when patients with diabetes and hyperglycemia experience an acute ischemic stroke, they are more likely to die or be severely disabled and less likely to benefit from the one FDA-approved therapy, intravenous tissue plasminogen activator. Experimental stroke models have revealed that chronic hyperglycemia leads to deficits in cerebrovascular structure and function that may explain some of the clinical observations. Increased edema, neovascularization, and protease expression as well as altered vascular reactivity and tone may be involved and point to potential therapeutic targets. Further study is needed to fully understand this complex disease state and the breadth of its manifestation in the cerebrovasculature.

Adiposity and risks of vascular and non-vascular mortality among Chinese adults with type 2 diabetes: a 10-year prospective study

INTRODUCTION

Among individuals with diabetes, high adiposity has been associated with lower cardiovascular disease (CVD) mortality (the so-called 'obesity paradox' phenomenon) in Western populations, for reasons that are still not fully elucidated. Moreover, little is known about such phenomena in Chinese adults with diabetes among whom very few were obese. We aimed to assess the associations of adiposity with vascular and non-vascular mortality among individuals with diabetes, and compare these with associations among individuals without diabetes.

RESEARCH DESIGN AND METHODS

In 2004-2008, the prospective China Kadoorie Biobank recruited >512 000 adults from 10 areas in China. After ~10 years of follow-up, 3509 deaths (1431 from CVD) were recorded among 23 842 individuals with diabetes but without prior major diseases at baseline. Cox regression yielded adjusted HRs associating adiposity with mortality.

RESULTS

Among people with diabetes, body mass index (BMI) (mean 25.0 kg/m²) was positively log linearly associated with CVD incidence (n=9943; HR=1.19 (95% CI 1.15 to 1.22) per 5 kg/m²), but showed U-shaped associations with CVD and overall mortality, with lowest risk at 22.5-24.9 kg/m². At lower BMI, risk of death (n=671) within 28 days of CVD onset was particularly elevated, with an HR of 3.26 (95% CI 2.29 to 4.65) at <18.5 kg/m² relative to 22.5-24.9 kg/m², but no higher mortality risk at BMI ≥25.0 kg/m². These associations were similar in self-reported and screen-detected diabetes, and persisted after extensive attempts to address reverse causality and confounding. Among individuals without diabetes (mean BMI 23.6 kg/m²; n=23 305 deaths), there were less extreme excess mortality risks at low BMI.

CONCLUSIONS

Among relatively lean Chinese adults with diabetes, there were contrasting associations of adiposity with CVD incidence and with mortality. The high mortality risk at low and high BMI levels highlights, if causal, the importance of maintaining normal weight among people with diabetes.

Sex-specific association of BMI change with stroke in middle-aged and older adults with type 2 diabetes

BACKGROUND AND AIMS

We aimed to evaluate the association between BMI change and stroke in middle-aged and older adults with type 2 diabetes and identify sex differences.

METHODS AND RESULTS

The China Health and Retirement Longitudinal Study is an ongoing national population-based cohort study. Participants aged 45 or above with type 2 diabetes were enrolled and followed for stroke incidence. BMI change was defined as BMI at 2013-BMI at 2011. Of 1774 participants (mean [SD] age in 2011, 60.23 [8.88] years), 795 (44.8 %) were men. A total of 112 incident stroke cases were confirmed up to 2018. The incidence rate of stroke was similar between men and women (6.79 % vs 5.92 %, P = 0.516). BMI increase was independently associated with an increased stroke risk (adjusted odds ratio, 1.15; 95 % CI, 1.05-1.31) in men, while this positive association was not significant in women (adjusted odds ratio, 1.12; 95 % CI, 0.98-1.29). In addition, the positive dose-response relationship between BMI increase and stroke was observed only in men.

CONCLUSION

Among middle-aged and older adults with type 2 diabetes, there is a sex-specific association of BMI change with stroke. An increase in BMI could result in a higher risk of incident stroke in men.

Resistin levels and inflammatory and endothelial dysfunction markers in obese postmenopausal women with type 2 diabetes mellitus

BACKGROUND

Obesity-associated coronary heart disease (CHD) risk is higher in women than in men with type 2 diabetes (T2DM). Resistin, an adipokine secreted by adispose tissue, may contribute to this higher risk.

AIMS

To explore the relationships among resistin levels and common inflammatory and endothelial dysfunction markers and CHD risk in obese post-menopausal T2DM women.

METHODS

Serum levels of resistin, hsCRP, IL-6, Soluble vascular cell adhesion molecule (sVCAM), homocysteine (tHcy), HOMA-IR and metabolic parameters were determined in a group of 132 T2DM women with and without documented CHD and in 55 non-diabetic women.

RESULTS

Resistin, sVCAM, IL-6 and tHcy levels were comparable in T2DM and controls. CHD women showed higher resistin, sVCAM and tHcy levels than those without CHD, and for resistin this difference remained significant after age-adjustment (P = 0.013); conversely hsCRP were ~ 2X higher in T2DM women than in controls (P = 0.0132) without any difference according to CHD history. At univariate analysis resistin levels were significantly associated with age, waist circumference, hypertension, tHcy, hsPCR, sVCAM, IL-6, HDL-cholesterol, triglycerides and creatinine levels, but only creatinine, triglycerides, hsCRP, IL-6 and sVCAM were independently associated to resistin levels at stepwise regression analysis. Resistin levels were independently associated to CHD, increasing the risk by 1.15 times (0.986-1.344 95% CI), together with age, tHcy, LDL-C and hypertension.

CONCLUSIONS

Circulating resistin levels were comparable in obese/overweight T2DM and control women. In T2DM women, resistin levels correlated with markers of renal function, systemic inflammation and endothelial dysfunction and were independently associated with a higher CHD risk.

Association of BMI with cardiovascular disease incidence and mortality in patients with type 2 diabetes mellitus: A systematic review and dose-response meta-analysis of cohort studies

AIMS

The relation of body mass index (BMI) with cardiovascular disease (CVD) and mortality has been extensively investigated in the general population but is less clear in individuals with type 2 diabetes mellitus (T2DM). We performed a meta-analysis of cohort studies to quantitatively evaluate the association of BMI with CVD incidence and mortality in patients with T2DM.

DATA SYNTHESIS

PubMed and Embase databases were searched for relevant cohort articles published up to June 8, 2020. Restricted cubic splines were used to evaluate the potential linear or non-linear dose-response associations. We identified 17 articles (21 studies) with 1,349,075 participants and 57,725 cases (49,354 CVD incidence and 8371 CVD mortality) in the meta-analysis. We found a linear association between BMI and risk of CVD incidence (P_{non-linearity} = 0.182); the pooled RR for CVD incidence was 1.12 (95% CI, 1.04-1.20) with a 5-unit increase in BMI. We found an overall nonlinear relationship between BMI and CVD mortality (P_{non-linearity} < 0.001). The lowest risk was at BMI about 28.4 kg/m², with increased mortality risk for higher BMI values; the RR with a 5-unit increase in BMI was 0.87 (95% CI, 0.79-0.96) and 1.11 (95% CI, 1.04-1.18) for BMI ≤28.4 kg/m² and BMI >28.4 kg/m², respectively.

CONCLUSIONS

In individuals with T2DM, BMI may have a positive linear association with risk of CVD incidence but a nonlinear association with CVD mortality. Our results can provide evidence for weight control and lifestyle intervention for preventing and managing cardiovascular disease in T2DM.

The association of diabetes with ischemic stroke and transient ischemic attacks in a tertiary center in Saudi Arabia

BACKGROUND

Diabetes mellitus increases stroke risk 1.5 to 3 fold, particularly ischemic stroke. There is limited literature on the impact of diabetes on stroke patients in Saudi Arabia.

OBJECTIVES

Determine the association of diabetes on the presentation, subtypes, in-hospital complications and outcomes of ischemic stroke and transient ischemic attacks (TIA).

DESIGN

IRB approved, retrospective chart review.

SETTING

Tertiary care center.

PATIENTS AND METHODS

All adult patients with ischemic stroke or TIA aged 18 years or older admitted from January 2016 to December 2017 were included.

MAIN OUTCOME MEASURES

Stroke severity at presentation, stroke-related complications, discharge disposition and discharge modified Rankin Scale (mRS) in relation to diabetes.

SAMPLE SIZE

802 patients.

RESULTS

Among 802 cases, 584 (72.8%) had diabetes; the majority (63.1%) were males. The mean age was younger in the non-diabetic stroke group (54.6 [15.5] years vs. 63.3 [9.9], P<.001). Hypertension (83.6% vs 49.1%, P<.001), dyslipidemia (38.9% vs. 28.9%, P=.009), prior stroke (27.7% vs. 19.3% P=.014), and ischemic heart disease (20.4% vs. 7.8%, P<.001) were more common in diabetic patients whereas smoking was more common (19.3% vs. 11.1%, P=.003) in the non-diabetic patients. The commonest subtype of stroke was large artery disease followed by small vessel disease. Both were more common in diabetic vs. non-diabetic patients (55.8% vs. 44%, P=.003), and (16.6% vs. 11%, P=.05) respectively. Diabetic stroke patients were more likely to have lacunar stroke (16.4% versus 9.2%, P=.009). TIAs occurred more commonly in the non-diabetic group (26.1% vs. 13.7%, P<.001). Non-diabetic patients had a better outcome (mRS score of 0-2) at discharge (62.4% vs. 45.9%, P=.002).

CONCLUSIONS

Almost three-fourth stroke patients were diabetic in our cohort. Diabetic stroke patients were older, had multiple vascular comorbid conditions, presented late to the hospital, and were likely to have more disability at the time of discharge. Large vessel atherosclerosis as well as lacunar infarctions were more common in diabetic stroke patients.

LIMITATIONS

Missing data about time of presentation in few patients, missing modified Rankin Scale score at discharge.

CONFLICT OF INTEREST

None.

Macro- and micro-vascular complications and their determinants among people with type 2 diabetes in Bangladesh

OBJECTIVES

To identify the prevalence of micro- and macro-vascular complications and their associated factors for type 2 diabetes mellitus in Bangladesh.

METHODS

This retrospective and cross-sectional study was conducted in six diabetes hospitals, covered urban and rural population. From April to September in 2017, a total of 1253 type 2 diabetes patients aged ≥18 years were recruited. Participants answered a pre-tested electronic questionnaire, and their medical records were reviewed for documented diabetes complications.

RESULTS

Mean age was 55.1 (±12.6) years. Among macrovascular complications, the prevalence of coronary artery disease was found to be 30.5%, 10.1% for stroke and 12.0% for diabetic foot. Among microvascular complications, nephropathy was prevalent among 34.2%, retinopathy among 25.1% and neuropathy among 5.8% of patients. Risk factors found to be associated with one or more of the complications were female gender, higher age, lower education level, an urban area of residence, higher household income, smoking, physical inactivity, hypertension, poor glycaemic control, poor adherence to treatment, longer duration of diabetes, and insulin use.

CONCLUSION

Diabetes complications are highly prevalent among type 2 diabetes population in Bangladesh. Prevention strategies should focus on increasing physical activity, weight loss, smoking cessation, and more strict control of hypertension and glycaemic level.

Diabetes and the direct secondary use of electronic health records: Using routinely collected and stored data to drive research and understanding

Introduction

Electronic health records provide an unparalleled opportunity for the use of patient data that is routinely collected and stored, in order to drive research and develop an epidemiological understanding of disease. Diabetes, in particular, stands to benefit, being a data-rich, chronic-disease state. This article aims to provide an understanding of the extent to which the healthcare sector is using routinely collected and stored data to inform research and epidemiological understanding of diabetes mellitus.

Methods

Narrative literature review of articles, published in both the medical- and engineering-based informatics literature.

Results

There has been a significant increase in the number of papers published, which utilise electronic health records as a direct data source for diabetes research. These articles consider a diverse range of research questions. Internationally, the secondary use of electronic health records, as a research tool, is most prominent in the USA. The barriers most commonly described in research studies include missing values and misclassification, alongside challenges of establishing the generalisability of results.

Discussion

Electronic health record research is an important and expanding area of healthcare research. Much of the research output remains in the form of conference abstracts and proceedings, rather than journal articles. There is enormous opportunity within the United Kingdom to develop these research methodologies, due to national patient identifiers. Such a healthcare context may enable UK researchers to overcome many of the barriers encountered elsewhere and thus to truly unlock the potential of electronic health records.

A long-term quality-of-care score for predicting the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus

AIMS

The aim of this study was to develop a long-term quality-of-care score to predict the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus, on the basis of the hypothesis that good quality of care can reduce the risk of macrovascular complications.

METHODS

Using Taiwan's Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified the incident patients diagnosed with type 2 diabetes during 1999-2003 and followed them until 2011. A summary score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1_c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA1_c), and the co-morbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of macrovascular complications.

RESULTS

Of the 4275 patients enrolled, 1928 developed macrovascular complication events after a mean follow-up period of 8.2 years. Compared to the risk of developing a macrovascular disease event in patients with scores ≤1, the risk was 64% lower in those with quality-of-care scores ≥5 (adjusted hazard ratio = 0.36; 95% confidence interval: 0.28-0.45).

CONCLUSIONS

Good quality of care can reduce the risk of macrovascular diseases in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of macrovascular complications and thus can be applied to guiding the care for these patients.

Incident ischaemic stroke and Type 2 diabetes: trends in incidence and case fatality in Scotland 2004-2013

AIM

To describe trends in first ischaemic stroke incidence and case fatality in adults with and without a diagnosis of Type 2 diabetes prior to their ischaemic stroke event in Scotland between 2004 and 2013.

METHODS

Using population-wide hospital admission, death and diabetes datasets, we conducted a retrospective cohort study. Negative binomial and logistic regression models were used to calculate year-specific incidence and case-fatality rates for people with Type 2 diabetes and for people without diabetes.

RESULTS

During 41.0 million person-years of follow-up there were 69 757 ischaemic stroke events. Type 2 diabetes prevalence among patients who experienced ischaemic stroke increased from 13.5% to 20.3% between 2004 and 2013. Stroke incidence rates declined by 2.7% (95% CI 2.4, 3.0) annually for people with and without diabetes [diabetes/year interaction: rate ratio 0.99 (95% CI 0.98, 1.01)]. Type 2 diabetes was associated with an increased risk of ischaemic stroke in men [rate ratio 1.23 (95% CI 1.17, 1.30)] and women [rate ratio 1.41 (95% CI 1.35, 1.48)]. Case-fatality rates were 14.2% and 12.7% in people with Type 2 diabetes and without diabetes, respectively. Case fatality declined by 3.5% (95% CI 2.7, 4.5) annually [diabetes/year interaction: odds ratio 1.01 (95% CI 0.98, 1.02)].

CONCLUSIONS

Ischaemic stroke incidence declined no faster in people with a diagnosis of Type 2 diabetes than in people without diabetes. Increasing prevalence of Type 2 diabetes among stroke patients may mean that declines in case fatality over time will be less marked in the future.

Incidence and relative risk of stroke in the diabetic and the non-diabetic population between 1998 and 2014: A community-based stroke register

One major objective of the St. Vincent Declaration was to reduce excess risk of stroke in people with diabetes mellitus. The aim of this study is to estimate the trend of incidence and relative risk of stroke in the diabetic and the non-diabetic populations in Germany over a 17-year period. We estimated age–sex standardised incidence rates of all stroke and ischaemic stroke in people with and without diabetes based on an ongoing prospective community-based stroke register covering 105,000 inhabitants. Time trends were analysed using Poisson regression. In total, 3,111 individuals (diabetes: 28.4%, men 46.9%, mean age 73.1 years (SD 13.2)) had a first stroke, 84.9% of which were ischaemic stroke. Among people with diabetes we observed a significant reduction in all stroke incidence by 1.5% per year (relative risk: 0.985; 95% confidence interval 0.972–0.9995) Likewise, this incidence tended to decrease for ischaemic stroke by 1% per year (0.993; 0.979–1.008). In contrast, the incidence rate for all stroke remained nearly stable among people without diabetes (1.003; 0.993–1.013) and for ischaemic stroke (1.002; 0.991–1.013). The relative risk comparing diabetic and non-diabetic population decreased for all stroke (two percent annual reduction) but not for ischaemic stroke. Time trends were similar for both sexes regarding all and ischaemic strokes. We found a reduction in risk of stroke in the diabetic population while this rate did not materially change in the non-diabetic population.

The impact of smoking on the development of diabetes and its complications

Diabetes is one of the most common metabolic disorders and emerges secondary to an interaction between genetic, environmental and lifestyle factors. This work provides an overview of the impact of smoking on the development of vascular complications in this condition and also provides an overview of the potential role of smoking in predisposition to diabetes. There are many studies documenting the impact of smoking on health (not focused on patients with diabetes), suggesting that the health exposure in these individuals is at least comparable to that observed in the general population. Distinct studies of smoking in patients with diabetes have unambiguously confirmed an increased prevalence and a higher risk of early death associated with the development of macrovascular complications. Smoking is also associated with premature development of microvascular complications and may contribute to the pathogenesis of type 2 diabetes. It has been shown that smoking is a predictor of the progression of glucose intolerance at both the transition from normoglycaemia to impaired glucose tolerance status and the increased risk of developing diabetes. The mechanisms explaining the relationship between smoking and the development of diabetes are not fully understood, although a number of hypotheses have been put forward. Current evidence indicates that smoking cessation is not only important to prevent macrovascular complications in diabetes, but also has a role in limiting microvascular disease and may also facilitate glycaemic management in this condition.

Sex-gender-related therapeutic approaches for cardiovascular complications associated with diabetes

Diabetes is a chronic disease associated with micro- and macrovascular complications and is a well-established risk factor for cardiovascular disease. Cardiovascular complications associated with diabetes are among the most important causes of death in diabetic patients. Interestingly, several sex-gender differences have been reported to significantly impact in the pathophysiology of diabetes. In particular, sex-gender differences have been reported to affect diabetes epidemiology, risk factors, as well as cardiovascular complications associated with diabetes. This suggests that different therapeutic approaches are needed for managing diabetes-associated cardiovascular complications in men and women. In this review, we will discuss about the sex-gender differences that are known to impact on diabetes, mainly focusing on the cardiovascular complications associated with the disease. We will then discuss the therapeutic approaches for managing diabetes-associated cardiovascular complications and how differences in sex-gender can influence the existing therapeutic approaches.

[Sex- and gender-aspects in regard to clinical practice recommendations for pre-diabetes and diabetes]

Metabolic diseases dramatically affect life of men and women from infancy up to old age and are a major challenge for clinicians. Health professionals are confronted with different needs of women and men. This article aims at an increase of gender awareness and the implementation of current knowledge of gender medicine in daily clinical practice with regard to pre-diabetes and diabetes. Sex and gender affect screening and diagnosis of metabolic diseases as well as treatment strategies and outcome. Impaired glucose and lipid metabolism, regulation of energy balance and body fat distribution are related to steroid hormones and therefore impose their influence on cardiovascular health in both men and women. Furthermore, education, income and psychosocial factors relate to development of obesity and diabetes differently in men and women. Males appear to be at greater risk of diabetes at younger age and at lower BMI compared to women, but women feature a dramatic increase of their cardiometabolic risk after menopause. The estimated future years of life lost owing to diabetes is somewhat higher in women than men, with higher increase of vascular death in women, but higher increase of cancer death in men. In women pre-diabetes or diabetes are more distinctly associated with a higher number of vascular risk factors, such as inflammatory parameters, unfavourable changes of coagulation and blood pressure. Pre-diabetic and diabetic women are at much higher relative risk for vascular disease. Women are more often obese and less physically active, but may even have greater benefit from increased physical activity than males. Whereas men predominantly feature impaired fasting glucose, women often show impaired glucose tolerance. A history of gestational diabetes or the presence of a PCOS or increased androgen levels in women, on the other hand the presence of erectile dysfunction (ED) or decreased testosterone levels in men are sex specific risk factors for diabetes development. ED is a common feature of obese men with the Metabolic Syndrome and an important predictor of cardiovascular disease. Diabetic women also feature sexual dysfunctions much more frequently than non-diabetic women which should be addressed in clinical care. Several studies showed that diabetic women reach their targets of metabolic control (HbA1c), blood pressure and LDL-cholesterol less often than their male counterparts, although the reasons for worse treatment outcome in diabetic females are not clear. Furthermore, sex differences in action, pharmacokinetics, and side effects of pharmacological therapy have to be taken into account.

Diabetic patients are at a higher risk of lacunar infarction and dyslipidemia: results of a comparative pilot study from King Fahad Hospital of the University, Saudi Arabia

Objective:

To describe the various risk factors and identify the characteristics of ischemic stroke in diabetic patients.

Method:

A retrospective study carried out at King Fahd Hospital of the University in Al-Khobar, kingdom of Saudi Arabia from February 2010 to December 2015. Statistical analysis was performed by the Statistical Package for the Social Sciences (version 22.0, SPSS Inc, Chicago, IL, USA).

Results:

One hundred and twenty-seven diabetic patients with ischemic stroke were compared with 127 non-diabetics. Mean age was 61±13.6 (mean±SD) years for diabetics and 60±16.6 years for non-diabetics. There were 68.5% male in the diabetic group and 62.2% in the non-diabetic group. Small vessel occlusion was the most common subtype (41.7%) in diabetics and stroke of undetermined etiology (32%) in non-diabetics. Dyslipidemia was significantly more prevalent in diabetics as compared with non-diabetics.

Conclusion:

Our study found significant differences in characteristics of ischemic stroke in diabetics compared with non-diabetics with dyslipidemia, microangiopathy, and lacunar infarction being more frequent. Further epidemiological studies are required to understand the characteristics of strokes in diabetics.

Cost burden of type 2 diabetes in Germany: results from the population-based KORA studies

OBJECTIVE

To examine the impact of type 2 diabetes on direct and indirect costs and to describe the effect of relevant diabetes-related factors, such as type of treatment or glycaemic control on direct costs.

DESIGN

Bottom-up excess cost analysis from a societal perspective based on population-based survey data.

PARTICIPANTS

9160 observations from 6803 individuals aged 31-96 years (9.6% with type 2 diabetes) from the population-based KORA (Cooperative Health Research in the Region of Augsburg) studies in Southern Germany.

OUTCOME MEASURES

Healthcare usage, productivity losses, and resulting direct and indirect costs.

METHODS

Information on diabetes status, biomedical/sociodemographic variables, medical history and on healthcare usage and productivity losses was assessed in standardised interviews and examinations. Healthcare usage and productivity losses were costed with reference to unit prices and excess costs of type 2 diabetes were calculated using generalised linear models.

RESULTS

Individuals with type 2 diabetes had 1.81 (95% CI 1.56 to 2.11) times higher direct (€3352 vs €1849) and 2.07 (1.51 to 2.84) times higher indirect (€4103 vs €1981) annual costs than those without diabetes. Cardiovascular complications, a long diabetes duration and treatment with insulin were significantly associated with increased direct costs; however, glycaemic control was only weakly insignificantly associated with costs.

CONCLUSIONS

This study illustrates the substantial direct and indirect societal cost burden of type 2 diabetes in Germany. Strong effort is needed to optimise care to avoid progression of the disease and costly complications.

Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin

AIM

To investigate whether clinical inertia, the failure to intensify treatment regimens when required, exists in people with type 2 diabetes treated with basal insulin.

METHODS

This was a retrospective cohort study involving patients with type 2 diabetes in the UK Clinical Practice Research Datalink database between January 2004 and December 2011, with follow-up until December 2013.

RESULTS

A total of 11 696 patients were included in the analysis. Among all patients, 36.5% had their treatment intensified during the study period; of these, the treatment of 50.0, 42.5 and 7.4% was intensified with bolus or premix insulin or glucagon-like peptide-1 receptor agonists, respectively. The median time from initiation of basal insulin to treatment intensification was 4.3 years [95% confidence interval (CI) 4.1, 4.6]. Among patients clinically eligible for treatment intensification [glycated haemoglobin (HbA1c) ≥7.5% (58 mmol/mol)], 30.9% had their treatment regimen intensified. The median time to intensification in this group was 3.7 years (95% CI 3.4, 4.0). Increasing age, duration of diabetes, oral antihyperglycaemic agent usage and Charlson comorbidity index score were associated with a significant delay in the time to intensification (p < 0.05). Among patients with HbA1c ≥7.5% (58 mmol/mol), 32.1% stopped basal insulin therapy.

CONCLUSIONS

Strategies should be developed to increase the number of patients undergoing therapy intensification and to reduce the delay in intensifying therapy for suitable patients on basal insulin. Initiatives to support patients continuing on insulin are also required.

Adiposity, hypertension and weight management behaviours in Ghanaian type 2 diabetes mellitus patients aged 20-70 years

OBJECTIVE

This study assessed the prevalence of general and abdominal obesity and hypertension as well the weight management behaviours of type 2 diabetes mellitus patients.

METHODS

It included 378 diabetes patients seeking care from two hospitals in Ghana. Standard methods and tools were used to assess participants' weight, height, waist circumference (WC), blood pressure (BP) and fasting plasma glucose (FPG). Weight management behaviours were measured using a questionnaire.

RESULTS

The prevalence of general obesity, abdominal obesity and hypertension was 20.1%, 46.6% and 67.7% respectively. Abdominal obesity was more likely in participants who: skipped breakfast, engaged in exercise to lose weight and were generally overweight/obese. General overweight and obesity was more likely in participants who: reported receipt of weight management counselling, engaged in exercise to lose weight, had a weight management plan/goal, and were abdominally obese. Hypertension was less likely in participants who had: no formal education, diabetes for ≥5 years and modified their dietary habits to lose weight but more likely in those who skipped breakfast.

CONCLUSION

Abdominal obesity, general overweight/obesity, and hypertension were frequent in this sample and were influenced by weight management behaviours.

Cardiovascular risk profiles of adults with type-2 diabetes treated at urban hospitals in Riyadh, Saudi Arabia

Diabetes mellitus substantially increases cardiovascular disease (CVD) risk. Among Saudi Arabian citizens with diabetes, little is known about the prevalence and control of other CVD risk factors.

We extracted data from medical records of a random selection of 422 patients seen between 2008 and 2012 at two diabetic clinics in Riyadh, Saudi Arabia. We calculated the proportion of patients who had additional CVD risk factors: obesity (body mass index ⩾ 30 kg/m²), hypertension (BP ⩾ 140/90 mmHg), elevated cholesterol fractions, and multiple risk factors). Further, we calculated the proportion of patients meeting the American Diabetes Association’s recommended care targets for each risk factor.

Of 422 patients (mean age, 52 years), half were women, 56% were obese, 45% had hypertension, and 77% had elevated LDL concentrations. In addition to diabetes, 70% had two or more CVD risk factors. Although 9% met both target HbA1c and BP values, only 3.5% had optimum HbA1c, BP, and lipid values.

In Saudi Arabia’s best diabetes clinics, most patients have poor control of their disease. This huge disease burden and related care gaps have important health and financial implications for the country.

In sickness and in health: A cross-sectional analysis of concordance for musculoskeletal pain in 13,507 couples

Background

Musculoskeletal pain conditions are common and create substantial burden for the individual and society. While research has shown concordance between couples for risk of some diseases, e.g. heart disease or diabetes, little information is available on such effects for musculoskeletal pain conditions. Our aims were to investigate the presence of concordance between couples for consultations about pain, and to examine theoretical influences on such concordance.

Methods

This was a 1‐year cross‐sectional study of musculoskeletal pain consultations in a UK primary care database. In total 27,014 patients (13,507 couples) aged between 30 and 74 years were included. The main outcome measure was the presence of a musculoskeletal morbidity read code indicating a consultation for musculoskeletal conditions (any, back, neck, knee, shoulder, foot, osteoarthritis). Logistic regression was used to test associations with odds ratios (OR) and 95% confidence intervals (95% CI).

Results

Patients whose partner had a musculoskeletal pain consultation were also more likely to consult for a musculoskeletal condition (OR 1.22, 95% CI 1.12–1.32). This association was found to be strongest for shoulder disorders (OR 1.91, 95% CI 1.06–3.47). No significant associations were found for other pain conditions.

Conclusion

Results show that partner concordance is present for consultations for some musculoskeletal conditions but not others. Possible explanations for concordance include the shared health behaviours between couples leading to potential heightened awareness of symptoms. Given the high prevalence of musculoskeletal pain within populations, it may be worth considering further the mechanisms that explain partner concordance.

A study about the relevance of adding acetylsalicylic acid in primary prevention in subjects with type 2 diabetes mellitus: effects on some new emerging biomarkers of cardiovascular risk

AIM

To evaluate the relevance of adding acetylsalicylic acid (ASA) in primary prevention in subjects with type 2 diabetes mellitus.

METHODS

213 patients with type 2 diabetes mellitus and hypertension were randomized to amlodipine 5 mg, or amlodipine 5 mg + ASA 100 mg for 3 months (Phase A); then, if adequate blood pressure control was reached patients terminated the study; otherwise, amlodipine was up-titrated to 10 mg/day for further 3 months and compared to amlodipine 10 mg + ASA 100 mg (Phase B). We assessed at baseline, at the end of Phase A, and at the end of Phase B the levels of some new emerging biomarkers of cardiovascular risk including: high sensitivity C-reactive protein (Hs-CRP), adiponectin (ADN), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), myeloperoxidase (MPO), soluble CD40 ligand (sCDL40).

RESULTS

Compared to baseline, at the end of Phase A, patients treated with amlodipine 5 mg + ASA 100 mg showed a statistically significant reduction of Hs-CRP (-15.0%), TNF-α (-21.7%), MPO (-9.7%), and sCDL40 (-15.7%), and a statistically significant increase of ADN (+15.0%). These values were significantly better than the ones obtained with amlodipine alone. Similarly, at the end of Phase B, amlodipine 10 mg + ASA significantly lowered Hs-CRP (-18.8%), TNF-α (-15.0%), MPO (-9.2%), and sCDL40 (-20.0%) and increased ADN (+11.8%), with a better effect compared to amlodipine alone.

CONCLUSION

All biomarkers considered were significantly improved by ASA addition. These data suggest that the use of ASA in primary prevention could be useful in patients with type 2 diabetes mellitus and hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02064218.

Gender difference in diabetes-associated risk of first-ever and recurrent ischemic stroke

OBJECTIVE

To evaluate the effect of diabetes by gender on the peak-risk of first-ever-ischemic stroke and its recurrence.

METHODS

Administrative datasets including all hospital discharges for ischemic stroke (N = 43,332) in the diabetic (N = 207,568) and non-diabetic (N = 2,808,554) population of the Tuscany region, Italy were used to calculate Hazard ratios (HR) after Cox-regression, of first-ever and recurrent ischemic strokes, between 2005 and 2011.

RESULTS

Overall, diabetes increased the HR of first-ever ischemic stroke by about 50% in both genders. However, this risk significantly declined with age and was higher in women aged 55-74 yr than in men of the same age (HR; 95% CI: 1.392; 1.228-1.579 in age-class 55-64 yr and 1.203; 1.110-1.304 in age class 65-74 yr; p < 0.001). Diabetes also increased the adjusted risk of three-year-stroke recurrence (N = 5,998) in women, independently of age, whereas this was the case in men < 70 yr.

CONCLUSIONS

Diabetes is associated with increased risk of ischemic stroke although it declines with age though at lower rate among women than men. Moreover, diabetic women have greater risk of recurrence than in men > 70 yrs old, supporting a high-risk "time-window" in postmenopausal-elderly diabetic women.

Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1·9 million people

BACKGROUND

The contemporary associations of type 2 diabetes with a wide range of incident cardiovascular diseases have not been compared. We aimed to study associations between type 2 diabetes and 12 initial manifestations of cardiovascular disease.

METHODS

We used linked primary care, hospital admission, disease registry, and death certificate records from the CALIBER programme, which links data for people in England recorded in four electronic health data sources. We included people who were (or turned) 30 years or older between Jan 1, 1998, to March 25, 2010, who were free from cardiovascular disease at baseline. The primary endpoint was the first record of one of 12 cardiovascular presentations in any of the data sources. We compared cumulative incidence curves for the initial presentation of cardiovascular disease and used Cox models to estimate cause-specific hazard ratios (HRs). This study is registered at ClinicalTrials.gov (NCT01804439).

FINDINGS

Our cohort consisted of 1 921 260 individuals, of whom 1 887 062 (98·2%) did not have diabetes and 34 198 (1·8%) had type 2 diabetes. We observed 113 638 first presentations of cardiovascular disease during a median follow-up of 5·5 years (IQR 2·1-10·1). Of people with type 2 diabetes, 6137 (17·9%) had a first cardiovascular presentation, the most common of which were peripheral arterial disease (reported in 992 [16·2%] of 6137 patients) and heart failure (866 [14·1%] of 6137 patients). Type 2 diabetes was positively associated with peripheral arterial disease (adjusted HR 2·98 [95% CI 2·76-3·22]), ischaemic stroke (1·72 [1·52-1·95]), stable angina (1·62 [1·49-1·77]), heart failure (1·56 [1·45-1·69]), and non-fatal myocardial infarction (1·54 [1·42-1·67]), but was inversely associated with abdominal aortic aneurysm (0·46 [0·35-0·59]) and subarachnoid haemorrhage (0·48 [0·26-0.89]), and not associated with arrhythmia or sudden cardiac death (0·95 [0·76-1·19]).

INTERPRETATION

Heart failure and peripheral arterial disease are the most common initial manifestations of cardiovascular disease in type 2 diabetes. The differences between relative risks of different cardiovascular diseases in patients with type 2 diabetes have implications for clinical risk assessment and trial design.

FUNDING

Wellcome Trust, National Institute for Health Research, and Medical Research Council.

The triglycerides-to-HDL-cholesterol ratio and cardiovascular disease risk in obese patients with type 2 diabetes: an observational study from the Swedish National Diabetes Register (NDR)

AIMS

Assessing the association between BMI and risk of coronary heart disease (CHD), cardiovascular disease (CVD) and mortality in patients with type 2 diabetes, also with regard to higher or lower levels of the ratio triglycerides-to-HDL-cholesterol (TG:HDL).

METHODS

54,061 patients with BMI≥18.5kg/m(2), mean age and duration 61.5±8 and 6.9±6 years, 59% males, 14% with CVD history, from the Swedish National Diabetes Register, followed for mean 4.8 years.

RESULTS

Adjusting at Cox regression for non-BMI-linked (age, sex, smoking, CVD history) and BMI-linked (blood lipids, blood pressure, HbA1c, albuminuria) covariates, hazard ratios (HR) for fatal/nonfatal CHD and CVD were mainly increased with prominent obesity (BMI≥35kg/m(2)), 1.19 (p=0.01) and 1.17 (p=0.009), compared to normal weight (BMI 18.5-24.9kg/m(2)), although increased also with obesity (BMI 30-34.9kg/m(2)), 1.34 and 1.30 (p<0.001), when adjusting only for non-BMI-linked covariates. Stratifying by 75th percentile of TG:HDL, with normal weight and TG:HDL<1.9 as reference, obese and prominently obese with TG:HDL≥1.9 had considerably increased HR around 1.7 for fatal/nonfatal CHD and 1.6 for CVD (p<0.001), while obese and prominently obese with TG:HDL<1.9 only had HR 1.2-1.3 for CHD and CVD (p0.003-<0.01).

CONCLUSION

Obese T2D patients with high TG:HDL, associated with increased insulin resistance, had considerably increased risk of CHD and CVD.

Clinical utility of brachial-ankle pulse wave velocity in the prediction of cardiovascular events in diabetic patients

Background

Brachial-ankle pulse wave velocity (baPWV) is a method to estimate arterial stiffness, which reflects the stiffness of both the aorta and peripheral artery; it would be applicable to general practice, since its measurementis automated. The aim of this study was to evaluate whether baPWV can be predictors of future cardiovascular events (CVE) in diabetic patients.

Methods

We prospectively evaluated the association between baPWV or carotid intima-media thickness (carotid IMT) at baseline and new onset of CVE in 1040 type 2 diabetic patients without CVE. The predictability of baPWV and/or carotid IMT for identifying patients at high risk for CVE was evaluated by time-dependent receiver-operating-characteristic (ROC) curve analysis.

Results

During a median follow-up of 7.5 years, 113 had new CVD events. The cumulative incidence rates of CVE were significantly higher in patients with high baPWV values (≥1550 cm/s) as compared to those with low baPWV values (<1550 cm/s) (p < 0.001, log-rank test). Similarly, the cumulative incidence rate of CVE was significantly higher in patients with higher maximum carotid IMT (maxIMT) values (≥1.0 mm) as compared to those with lower maxIMT values (<1.0 mm) (p < 0.001, log-rank test). Subjects with both “high PWV” and “high IMT” had a significantly higher risk of developing CVE as compared to those with either “high PWV” or “high IMT,” as well as those with neither. A multivariate Cox proportional hazards regression model revealed that both baPWV (HR = 1.30, [95%CI: 1.07-1.57]; p = 0.009) and maxIMT (HR = 1.20, [95%CI: 1.01-1.41]; p = 0.033) were independent predictors for CVE, even after adjustment for the conventional risk factors. Time-dependent ROC curve analyses revealed that the addition of maxIMT to the Framingham risk score resulted in significant increase in AUC (from 0.60 [95%CI: 0.54-0.67] to 0.63 [95%CI: 0.60-0.82]; p = 0.01). Notably, the addition of baPWV to the Framingham risk score and maxIMT resulted in further and significant (p = 0.02) increase in AUC (0.72 [95%CI: 0.67-0.78]).

Conclusions

Evaluation of baPWV, in addition to carotid IMT and conventional risk factors, improved the ability to identify the diabetic individuals with high risk for CVE.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-014-0128-5) contains supplementary material, which is available to authorized users.

Accumulation of oxidative stress-related gene polymorphisms and the risk of coronary heart disease events in patients with type 2 diabetes--an 8-year prospective study

OBJECTIVE

Oxidative stress, which is provoked in patients with diabetes, plays critical roles in the pathogenesis of coronary heart disease (CHD). We simultaneously determined 5 relatively common genetic variants related to oxidative stress and evaluated the combined effect on CHD.

METHODS

We enrolled 1977 Japanese type 2 diabetic subjects without history of CVD (males 66.1%, 59.5 ± 10.0 years old), determined their genotypes regarding glutamate-cysteine ligase modifier subunit (GCLM) C-588T, manganese superoxide dismutase (SOD2) Val16Ala, endothelial nitric oxide synthase (NOS3) G894T, NAD(P)H oxidase p22phox (CYBA) C242T, and myeloperoxidase (MPO) G-463A polymorphisms, and prospectively evaluated the association between these polymorphisms and CHD events.

RESULTS

The median follow-up period was 7.5 years and there were 85 new CHD events. The single association analysis revealed that there were no statistically significant associations between each polymorphism and the prevalence of CHD. Interestingly, the risk of CHD event was higher with the increase of the total number of 10 concomitant unfavorable "pro-oxidant alleles" in each subject (p for trend = 0.018, log-rank test). Especially, the carriers of ≥8 pro-oxidant alleles had a significantly increased risk as compared to the carriers of <8 pro-oxidant alleles, whether the other clinical variables were adjusted (HR 2.92 with 95%CI 1.50-5.67, p = 0.002) or not (HR 2.89 with 95%CI 1.49-5.59, p = 0.002)..

CONCLUSIONS

Accumulation of gene polymorphisms related to oxidative stress is likely associated with the development of CHD in patients with type 2 diabetes, suggesting that the combined information about these variants is useful to assess the risk of CHD.

Prevalence of hypertension and obesity in patients with type 2 diabetes mellitus in observational studies: a systematic literature review

BACKGROUND

Hypertension and obesity are known to contribute, directly or indirectly, to the development of long-term complications of type 2 diabetes mellitus (T2DM). Knowing the prevalence of these comorbidities is important for determining the size of the population that may benefit from strategies that reduce blood pressure and weight while controlling blood glucose.

METHODS

In this systematic literature review, electronic searches of PubMed, Embase, and the Cochrane Library were conducted to identify observational studies of hypertension and/or obesity prevalence in patients with T2DM throughout the world. The searches were limited to studies reported in English from January 1, 2001 to February 16, 2012.

RESULTS

From a total of 2,688 studies, 92 observational studies provided prevalence rates for hypertension and/or obesity specifically in adults with T2DM. Fifteen studies of specific subtypes of hypertension or subpopulations with T2DM were subsequently excluded, leaving 78 studies (in 77 articles) for inclusion in this article. Of these, 61studies reported hypertension prevalence, 44 reported obesity prevalence, and 12 reported the prevalence of hypertension with obesity. Most studies had a low risk of bias regarding diagnosis of T2DM (70/78), hypertension (59/69), or obesity (45/47). The continental regions with the most observational studies of hypertension or obesity prevalence were Europe (n = 30) and Asia (n = 26). Hypertension rates typically were high in all regions; most studies presented rates above 50%, and many presented rates above 75%. Obesity rates exceeded 30% in 38 of 44 studies and 50% in 14 of 44 studies, especially those assessing central obesity (based on waist circumference). Among obese adults, hypertension rates were at or above 70% in Asia and above 80% in Europe; rates were lower in North and South America but still above 30%.

CONCLUSION

Around the world, hypertension and obesity, separately or together, are common comorbidities in adults with T2DM.

Feasibility and effectiveness in clinical practice of a multifactorial intervention for the reduction of cardiovascular risk in patients with type 2 diabetes: the 2-year interim analysis of the MIND.IT study: a cluster randomized trial

OBJECTIVE

To evaluate the feasibility and effectiveness of an intensive, multifactorial cardiovascular risk reduction intervention in a clinic-based setting.

RESEARCH DESIGN AND METHODS

The study was a pragmatic, cluster randomized trial, with the diabetes clinic as the unit of randomization. Clinics were randomly assigned to either continue their usual care (n = 5) or to apply an intensive intervention aimed at the optimal control of cardiovascular disease (CVD) risk factors and hyperglycemia (n = 4). To account for clustering, mixed model regression techniques were used to compare differences in CVD risk factors and HbA1c. Analyses were performed both by intent to treat and as treated per protocol.

RESULTS

Nine clinics completed the study; 1,461 patients with type 2 diabetes and no previous cardiovascular events were enrolled. After 2 years, participants in the interventional group had significantly lower BMI, HbA1c, LDL cholesterol, and triglyceride levels and significantly higher HDL cholesterol level than did the usual care group. The proportion of patients reaching the treatment goals was systematically higher in the interventional clinics (35% vs. 24% for LDL cholesterol, P = 0.1299; 93% vs. 82% for HDL cholesterol, P = 0.0005; 80% vs. 64% for triglycerides, P = 0.0002; 39% vs. 22% for HbA1c, P = 0.0259; 13% vs. 5% for blood pressure, P = 0.1638). The analysis as treated per protocol confirmed these findings, showing larger and always significant differences between the study arms for all targets.

CONCLUSIONS

A multifactorial intensive intervention in type 2 diabetes is feasible and effective in clinical practice and it is associated with significant and durable improvement in HbA1c and CVD risk profile.

Type and timing of heralding in ST-elevation and non-ST-elevation myocardial infarction: an analysis of prospectively collected electronic healthcare records linked to the national registry of acute coronary syndromes

AIMS

It is widely thought that ST-elevation myocardial infarction (STEMI) is more likely to occur without warning (i.e. an unanticipated event in a previously healthy person) than non-ST-elevation myocardial infarction (NSTEMI), but no large study has evaluated this using prospectively collected data. The aim of this study was to compare the evolution of atherosclerotic disease and cardiovascular risk between people going on to experience STEMI and NSTEMI.

METHODS

We identified patients experiencing STEMI and NSTEMI in the national registry of myocardial infarction for England and Wales (Myocardial Ischaemia National Audit Project), for whom linked primary care records were available in the General Practice Research Database (as part of the CALIBER collaboration). We compared the prevalence and timing of atherosclerotic disease and major cardiovascular risk factors including smoking, hypertension, diabetes, and dyslipidaemia, between patients later experiencing STEMI to those experiencing NSTEMI.

RESULTS

A total of 8174 myocardial infarction patients were included (3780 STEMI, 4394 NSTEMI). Myocardial infarction without heralding by previously diagnosed atherosclerotic disease occurred in 71% STEMI (95% CI 69-72%) and 50% NSTEMI patients (95% CI 48-51%). The proportions of myocardial infarctions with no prior atherosclerotic disease, major risk factors, or chest pain was 14% (95% CI 13-16%) in STEMI and 9% (95% CI 9-10%) in NSTEMI. The rate of heralding coronary diagnoses was particularly high in the 12 months before infarct; 4.1-times higher (95% CI 3.3-5.0) in STEMI and 3.6-times higher (95% CI 3.1-4.2) in NSTEMI compared to the rate in earlier years.

CONCLUSIONS

Acute myocardial infarction occurring without prior diagnosed coronary, cerebrovascular, or peripheral arterial disease was common, especially for STEMI. However, there was a high prevalence of risk factors or symptoms in patients without previously diagnosed disease. Better understanding of the antecedents in the year before myocardial infarction is required.

Carotid intima-media thickness progression predicts cardiovascular events in Japanese patients with type 2 diabetes

AIMS

The aim of this retrospective study was to investigate the relationship between progression of carotid intima-media thickness (cIMT) and cardiovascular events in Japanese patients with type 2 diabetes mellitus (T2DM) and free of history of cardiovascular events.

METHODS

Patients with T2DM (n=342) without history of cardiovascular events whose cIMT was assessed more than twice by ultrasonography were recruited and followed up for cardiovascular events.

RESULTS

During a mean follow-up of 7.6 years, 56 (16.4%) cardiovascular events (27 coronary events and 29 cerebrovascular events) were recorded. Multivariate analysis with the Cox proportional hazard model identified cIMT progression as a significant determinant of cardiovascular events, with a hazard ratio (HR) of 2.24 (95% confidence interval; CI, 1.25-4.03, P<0.01), in addition to baseline cIMT. The Kaplan-Meier curves also showed significantly higher event rate in patients with high cIMT progression compared with those with low cIMT progression (log-rank χ(2)=6.65; P<0.01). Furthermore, the combination of high baseline cIMT and high cIMT progression was a significant predictor of cardiovascular events.

CONCLUSION

Our findings suggest that cIMT progression, in addition to baseline cIMT, is a predictor of cardiovascular events in patients with T2DM without history of cardiovascular events, and that the combination of cIMT progression and baseline cIMT has a strong predictive power for such events.

The role of triglyceride in cardiovascular disease in asian patients with type 2 diabetes--a systematic review

In Asian populations, diabetes mellitus is increasing and has become an important health problem in recent decades. Cardiovascular disease (CVD) is one of the most important complications and the most common cause of death in diabetic patients. Among the risk factors of CVD, elevated low-density lipoprotein cholesterol has been a major concern. Studies suggested that serum triglyceride may also play a role in predicting CVD in patients with type 2 diabetes mellitus, but the association is still debated. In this review, we summarized published studies focusing on the relationship between serum triglyceride and CVD disease in Asian diabetic patients. Ten studies conducted in six different Asian countries (three from Hong Kong, two from Taiwan, tow from Japan, one from Indonesia, one from South India, and one from South Korea) were summarized and discussed. CVD was subdivided into coronary heart disease, stroke, and peripheral arterial disease. Of the ten studies analyzed, one focused on CVD, five on coronary heart disease, three on stroke, three on peripheral arterial disease, and one on mortality from CVD. Studies from Hong Kong, Taiwan, and Japan suggested that triglyceride is a significant and independent risk factor for coronary heart disease, but not a significant risk factor for stroke (studies conducted in Japan and South Korea) or peripheral arterial disease (studies conducted in Taiwan, Indonesia, and South India). Although serum triglyceride may be a significant risk factor for coronary heart disease in Asian diabetic patients, clinical trials evaluating whether lowering triglycerides using fibrates can reduce the risk of coronary heart disease in these patients need to be initiated.

[Sex- and gender-aspects in regard to clinical practice recommendations for pre-diabetes and diabetes]

Metabolic diseases dramatically affect life of men and women from infancy up to old age and are a major challenge for clinicians. Health professionals are confronted with different needs of women and men. This article aims at an increase of gender awareness and the implementation of current knowledge of gender medicine in daily clinical practice with regard to pre-diabetes and diabetes. Sex and gender affect screening and diagnosis of metabolic diseases as well as treatment strategies and outcome. Impaired glucose and lipid metabolism, regulation of energy balance and body fat distribution are related to steroid hormones and therefore impose their influence on cardiovascular health in both men and women. Furthermore, education, income and psychosocial factors relate to development of obesity and diabetes differently in men and women. Males appear to be at greater risk of diabetes at younger age and at lower BMI compared to women, but women feature a dramatic increase of their cardiometabolic risk after menopause. The estimated future years of life lost owing to diabetes is somewhat higher in women than men, with higher increase of vascular death in women, but higher increase of cancer death in men. In women pre-diabetes or diabetes are more distinctly associated with a higher number of vascular risk factors, such as inflammatory parameters, unfavourable changes of coagulation and blood pressure. Pre-diabetic and diabetic women are at much higher risk for vascular disease (3-6 times compared to non-diabetic women) than diabetic men (2-3 times compared to healthy males). Women are more often obese and less physically active, but may even have greater benefit from increased physical activity than males. Whereas men predominantly feature impaired fasting glucose, women often show impaired glucose tolerance. A history of gestational diabetes or the presence of a PCOS or increased androgen levels in women, on the other hand the presence of erectile dysfunction (ED) or decreased testosterone levels in men are sex specific risk factors for diabetes development. ED is a common feature of obese men with the Metabolic Syndrome and an important predictor of cardiovascular disease. Several studies showed that diabetic women reach their targets of metabolic control (HbA1c), blood pressure and LDL-cholesterol less often than their male counterparts, although the reasons for worse treatment outcome in diabetic females are not clear. Furthermore, sex differences in action, pharmacokinetics, and side effects of pharmacological therapy have to be taken into account.

Diabetes mellitus: a risk factor for ischemic stroke in a large biracial population

BACKGROUND AND PURPOSE

We previously reported increased incidence of ischemic stroke among both blacks and whites with diabetes mellitus, especially in those aged <55 years. With rising prevalence of diabetes mellitus in the past decade, we revisit the impact of diabetes mellitus on stroke incidence in the same population (≈1.3 million) 5 and 10 years later.

METHODS

This is a population-based study. First ischemic strokes among black and white residents of the 5-county Greater Cincinnati/Northern Kentucky region, aged ≥ 20 years, for periods 7/1993 to 6/1994, 1999, and 2005, were included in this analysis. Incidence rates were adjusted for sex, race, and age, as appropriate, to the 2000 US population.

RESULTS

History of diabetes mellitus among first ischemic strokes was reported for 493/1709 (28%) in 1993/1994, 522/1778 (29%) in 1999, and 544/1680 (33%) in 2005. Risk ratios (95% confidence interval) for rates of stroke in those with versus without diabetes mellitus for blacks reduced significantly from 5.6 in 1993/1994 to 3.2 in 2005; for whites the risk ratio remained stable at 3.8 in 1993/1994 and 2005. However, risk ratios varied with age, with an overall 5- to 14-fold increased risk observed in those aged 20 to 65 years.

CONCLUSIONS

Those with diabetes mellitus remain at greatly increased risk for stroke at all ages, especially <65 years, regardless of race. The rates and risk ratios for 1999 and 2005, although similar to those previously reported for the mid-1990s, take on increased significance, given the epidemic of diabetes mellitus and metabolic syndrome throughout the US and the world.

Smoking and type 2 diabetes mellitus

Cigarette smoking is a well-known risk factor in many diseases, including various kinds of cancer and cardiovascular disease. Many studies have also reported the unfavorable effects of smoking for diabetes mellitus. Smoking increases the risk of developing diabetes, and aggravates the micro- and macro-vascular complications of diabetes mellitus. Smoking is associated with insulin resistance, inflammation and dyslipidemia, but the exact mechanisms through which smoking influences diabetes mellitus are not clear. However, smoking cessation is one of the important targets for diabetes control and the prevention diabetic complications.

Area-based socioeconomic status, type 2 diabetes and cardiovascular mortality in Scotland

AIMS/HYPOTHESIS

The aim of this study was to explore the relationships between type 2 diabetes mellitus, area-based socioeconomic status (SES) and cardiovascular disease mortality in Scotland.

METHODS

We used an area-based measure of SES, Scottish national diabetes register data linked to mortality records, and general population cause-specific mortality data to investigate the relationships between SES, type 2 diabetes and mortality from ischaemic heart disease (IHD) and cerebrovascular disease (CbVD), for 2001-2007. We used negative binomial regression to obtain age-adjusted RRs of mortality (by sex), comparing people with type 2 diabetes with the non-diabetic population.

RESULTS

Among 216,652 people aged 40 years or older with type 2 diabetes (980,687 person-years), there were 10,554 IHD deaths and 4,378 CbVD deaths. Age-standardised mortality increased with increasing deprivation, and was higher among men. IHD mortality RRs were highest among the least deprived quintile and lowest in the most deprived quintile (men: least deprived, RR 1.94 [95% CI 1.61, 2.33]; most deprived, RR 1.46 [95% CI 1.23, 1.74]) and were higher in women than men (women: least deprived, RR 2.84 [95% CI 2.12, 3.80]; most deprived, RR 2.04 [95% CI 1.55, 2.69]). A similar, weaker, pattern was observed for cerebrovascular mortality.

CONCLUSIONS/INTERPRETATION

Absolute risk of cardiovascular mortality is higher in people with diabetes than in the non-diabetic population and increases with increasing deprivation. The relative impact of diabetes on cardiovascular mortality differs by SES, and further efforts to reduce cardiovascular risk both in deprived groups and people with diabetes are required. Prevention of diabetes may reduce socioeconomic health inequalities.

Type 2 diabetes management: Patient knowledge and health care team perceptions, South Africa

Background

South African research indicates that the highest death rates between 2004 and 2005 were from diabetes mellitus. There is minimal research information on interactions between what patients know about their disease and what health professionals perceive that patients should know to control their disease well.

Objectives

This study determined the knowledge that patients with type 2 diabetes have about the management of their disease, as well as the perceptions of the health care team about the services given to patients.

Method

Qualitative data were collected using two focus groups and in-depth interviews. Patient focus group (n = 10) explored patients’ knowledge about management of type 2 diabetes. Patients were recruited from Dr George Mukhari Hospital outpatients’ diabetes clinic. Professional focus group (n = 8) explored the health care team's experiences, barriers and facilitators in managing the disease. Professional focus group participants were recruited because of their expertise in chronic disease management, working in the community (public health) or working directly with patients with type 2 diabetes. Five health care professionals were interviewed using the same guide of questions as for the focus group.

Results

Participants identified type 2 diabetes as a chronic disease that needs behaviour change for good control. Five major themes were identified: patients’ knowledge; education programmes; behaviour change; support; and a patient-centred approach.

Conclusion

Management of type 2 diabetes may be enhanced by reinforcing patients’ knowledge, encouraging behaviour change whilst taking into consideration patients’ backgrounds. The health care team needs to utilise a patient-centred approach.

Gender-specific care of diabetes

Diabetic men have benefited in the last 30 years from a significant improvement in total and cardiovascular mortality, whereas diabetic women have had no improvement at all. Moreover, recent research focused on the role of sex hormones in glucose homeostasis, and might account for different pathophysiologic mechanisms in the development of diabetes-related complications. Thus, care of diabetic women is a challenge that requires particular attention. The available data regarding gender-specific care of diabetes mellitus are uneven, rich in some domains but very poor in others. The large prospective trials performed in the last 20 years have assumed that the natural history of diabetes mellitus in men and women, as well as the efficiency of glucose-lowering therapies and management of hyperglycemic-related complications, could be attributable without distinction to men and women. We propose in this paper to analyze the published medical literature according to the specific management of diabetes mellitus in women, and to try to distinguish some particular features. We found important distinctions between diabetic men and women regarding the patterns of abnormalities of glucose regulation, epidemiology, development of diabetes-related complications, ischemic heart disease, morbidity and mortality, impact of cardiovascular risk factors, development of the metabolic syndrome, depression and osteoporosis, as well as the impact of lifestyle modifications or primary and secondary preventions on cardiovascular risk factors, and finally medical therapeutics. Moreover, special considerations were given to some particular aspects of the medical life in diabetic women, such as the features of gestational diabetes mellitus and the management of pregnancy in pregestational diabetic women, use of contraception, hormone-replacement therapy and polycystic ovary syndrome.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement

OBJECTIVE

The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society.

CONCLUSIONS

Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

Time-dependent impact of diabetes on mortality in patients with stroke: survival up to 5 years in a health insurance population cohort in Germany

OBJECTIVE

To estimate the impact of diabetes on mortality in patients after first stroke event.

RESEARCH DESIGN AND METHODS

Using claims data from a nationwide statutory health insurance fund (Gmünder ErsatzKasse), we assessed all deaths in a cohort of 5,757 patients with a first stroke between 2005 and 2007 (69.3% male, mean age 68.1 years, 32.2% with diabetes) up to 2009. By use of Cox regression, we estimated time-dependent hazard ratios (HRs) to compare patients with and without diabetes stratified by sex.

RESULTS

The cumulative 5-year mortality was 40.0 and 54.2% in diabetic men and women, and 32.3 and 38.1% in their nondiabetic counterparts, respectively. In males, mortality was significantly lower in diabetic compared with nondiabetic patients in the first 30 days (multiple-adjusted HR 0.67 [95% CI 0.53-0.84]). After approximately a quarter of a year, the diabetes risk increased, yielding crossed survival curves. Later on, mortality risk tended to be similar in diabetic and nondiabetic men (1-2 years: 1.42 [1.09-1.85]; 3-5 years: 1.00 [0.67-1.41]; time dependency of diabetes, P = 0.008). In women, the pattern was similar; however, time dependency was not statistically significant (P = 0.89). Increasing age, hemorrhagic stroke, renal failure (only in men), levels of care dependency, and number of prescribed medications were significantly associated with mortality.

CONCLUSIONS

We found a time-dependent mortality risk of diabetes after first stroke in men. Possible explanations may be type of stroke or earlier and more intensive treatment of risk factors in diabetic patients.

The disparity in long-term survival after a first stroke in patients with and without diabetes persists: the Northern Sweden MONICA study

BACKGROUND

Diabetes is an established risk factor for stroke. Compared to nondiabetic patients, diabetic patients also have an increased risk of new vascular events and death after stroke. We analyzed how differences in long-term survival between diabetic and nondiabetic stroke patients have changed over time, and if differences varied with respect to sex and age.

METHODS

This population-based study included 12,375 first-ever stroke patients, 25-74 years old, who were registered in the Northern Sweden MONICA Stroke Registry 1985-2005. Uniform diagnostic criteria for stroke case ascertainment were used throughout the study period. The diagnosis of diabetes was based on medical records or diabetes diagnosed during the acute stroke event. Patients were separated into four cohorts according to year of stroke and followed for survival until August 30, 2008.

RESULTS

The diabetes prevalence at stroke onset was 21%, similar in men and women, and remained stable throughout the study period. The diabetic patients were an average of 2 years older, more often nonsmokers and more likely to have antihypertensive treatment, antithrombotics, atrial fibrillation, and a history of myocardial infarction or transient ischemic attack than the nondiabetic patients. The total follow-up time was 86,086 patient-years during which a total of 1,930 (75.7%) of the diabetic patients and 5,744 (58.5%) of the nondiabetic patients died (p < 0.001). Median survival was 60 months (95% CI: 57-64) in diabetic patients and 117 months (113-120) in the nondiabetic patients. Survival improved significantly in both groups (p < 0.001). A Cox regression, adjusting for possible confounders (age, sex, antihypertensive medication, antithrombotics or other thrombolytic agents, history of myocardial infarction, type of stroke, diabetes, cohort and the diabetes-by-sex, diabetes-by-age and diabetes-by-cohort interactions), showed a hazard ratio of 1.67 (1.58-1.76) comparing survival in diabetic versus nondiabetic patients. The reduced survival in diabetic stroke patients was more pronounced in women (p = 0.02) and younger patients (p < 0.001). There was a tendency that the difference in survival decreased between the earlier cohorts and the 2000-2005 cohort, but the test for interaction did not reach statistical significance (p = 0.08).

CONCLUSION

Long-term survival after a first stroke has improved in both diabetic and nondiabetic patients. Survival is markedly lower in diabetics, especially in women and younger patients, and the disparity persisted over 24 years. Decreasing the disparity in stroke survival is a challenge for stroke and diabetes care. New treatment methods in combination with intense secondary prevention in diabetic patients, especially in younger women, are needed.