On the problem of type 2 diabetes-related mortality in the Canary Islands, Spain. The DARIOS Study

Developing CIRdb as a catalog of natural genetic variation in the Canary Islanders

The current inhabitants of the Canary Islands have a unique genetic makeup in the European diversity landscape due to the existence of African footprints from recent admixture events, especially of North African components (> 20%). The underrepresentation of non-Europeans in genetic studies and the sizable North African ancestry, which is nearly absent from all existing catalogs of worldwide genetic diversity, justify the need to develop CIRdb, a population-specific reference catalog of natural genetic variation in the Canary Islanders. Based on array genotyping of the selected unrelated donors and comparisons against available datasets from European, sub-Saharan, and North African populations, we illustrate the intermediate genetic differentiation of Canary Islanders between Europeans and North Africans and the existence of within-population differences that are likely driven by genetic isolation. Here we describe the overall design and the methods that are being implemented to further develop CIRdb. This resource will help to strengthen the implementation of Precision Medicine in this population by contributing to increase the diversity in genetic studies. Among others, this will translate into improved ability to fine map disease genes and simplify the identification of causal variants and estimate the prevalence of unattended Mendelian diseases.

Has stroke mortality stopped declining in Spain?

OBJECTIVES

To analyse the changes in stroke mortality trends in Spain by autonomous community and by sex during the period 1980-2016, using joinpoint regression models.

METHODS

Mortality data were obtained from the Spanish National Statistics Institute. Crude and standardised rates were calculated for each Spanish autonomous community, and for each sex. Joinpoint analysis was used to identify the best-fitting points showing a statistically significant change in the trend.

RESULTS

Joinpoint analysis enabled us to differentiate between communities in which mortality rates showed a continuous decline throughout the study period in both sexes (Asturias, Cantabria, Castile and Leon, Ceuta, and Melilla) or in men only (Extremadura). In men, in all those communities in which changes in the trend were observed (all but Aragon, the Balearic Islands, and Murcia, where rates remained stable), we observed an initial period of decline (ranging from -3.4% in Catalonia and Extremadura, to -6.0% in Madrid) and a final period where the trends diverged: mortality rates continued to fall in Andalusia, Aragon, the Balearic Islands, and Madrid, but began to stabilise in Castile-La Mancha and Murcia and to increase in the Canary Islands. In women, in those communities where changes were observed (all but Aragon, Murcia, and the Basque Country, where rates remained stable), we observed an initial period of decline (ranging from -3.1% in Catalonia to -6.4% in Navarre) and a final period where divergent trends were observed: rates continued to decline in Andalusia, Aragon, Catalonia, Galicia, Madrid, and the Basque Country, but began to stabilise in Extremadura and Murcia and to increase in the Canary Islands.

CONCLUSIONS

Current data show that stroke mortality rates have decreased (in women in Andalusia), stabilised (in both sexes in Murcia, in men in Castile-La Mancha, and in women in Extremadura), and have even reversed (in both sexes in the Canary Islands). Further study is needed to identify the causes of these trends.

Factors associated with patient empowerment in Spanish adults with type 2 diabetes: A cross-sectional analysis

OBJECTIVE

The aim of the present study is to identify factors associated with patient empowerment in people living with type 2 diabetes mellitus (T2DM) in the Canary Islands (Spain).

METHODS

Secondary cross-sectional analysis was carried out of data obtained in the INDICA study: A 24-month cluster randomized-controlled trial evaluating the effectiveness of educational interventions supported by new technology decision tools for T2DM patients. Sociodemographic variables, clinical data (years since diagnosis, glycated haemoglobin level, creatine, triglycerides, waist hip index, body mass index and number of comorbidities), diabetes knowledge (DIATEK), affective outcomes (Beck Depression Inventory-II, the State subscale of the State-Trait Anxiety Inventory and The Diabetes Distress Scale) and diabetes-related quality of life (The Audit of Diabetes-Dependent Quality of life) were assessed as potential correlates of patient empowerment, assessed using the Diabetes Empowerment Scale-Short Form. Multilevel mixed linear regression models on patient empowerment were developed.

RESULTS

The analysis included the baseline data of 2334 patients. Results showed that age (B = -0.14; p < .001), diabetes knowledge (B = 0.61; p < .001) and state-anxiety (B = -0.09; p < .001) are significantly associated with patient empowerment. Sex, education level, living alone, employment status, country of birth, time since diagnosis, number of comorbidities, glycated haemoglobin level, depression and distress were not independently associated with patient empowerment in the multivariate analyses.

CONCLUSION

Younger age, lower state-anxiety and greater diabetes-specific knowledge are important correlates of patient empowerment. In line with the results of the INDICA study, interventions based on patient-centred care might be effective in improving patient empowerment in adults with T2DM. Understanding the factors associated with empowerment may help clinicians and policymakers to identify high-risk groups, prioritize resources and target evidence-based interventions to better support people with T2DM to be actively involved in their own care.

PATIENT OR PUBLIC CONTRIBUTION

Patients with T2DM were actively involved in the design of the INDICA study. Two patient associations were included as part of the research team and actively participated in designing the interventions and selecting outcome measures.

Associated factors with functional prognosis of patients with acute ischemic stroke undergoing thrombectomy

INTRODUCTION

Mechanical thrombectomy (MT) has meant a change in natural history of acute ischemic stroke. Our aim is to assess the possible association between different factors and prognosis in patients treated with MT in a third degree Spanish hospital.

METHODS

Cross-sectional study including 198 patients underwent MT because of acute ischemic stroke between 2012 and 2020. Sociodemographic, vascular risk factors (VRF) and clinical-radiologic factors were recorded. Functional outcome was evaluated based on modified Rankin Scale (mRS) at 90 days, being mRS≤2 favorable and mRS≥3 unfavorable outcome.

RESULTS

Mean age 67.7±13.5 years, 50.5% women. Arterial hypertension was the most prevalent VRF (65.7%). National Institute of Health Stroke Scale (NIHSS) median value at admission was 17.0 (8.0; 22.0). 40.9% of cases also received fibrinolytic treatment. Conscious sedation was performed in 66.7% patients. Median passes of MT were 2, and median duration 41min. Successful recanalization was achieved in 79.9% and mRS≤2 at 90 days was registered at 59.5% cases. Age, type 2 diabetes (T2D), number of MT passes and procedure duration were associated with mRS≥3. Successful recanalization was associated with mRS≤2. Regression model confirmed these associations in age (OR: 1.56CI%: 1.11; 2.20); T2D (OR: 3.51CI%: 1.38; 8.97) and successful recanalization (OR: 0.07CI%: 0.02; 0.28).

CONCLUSION

Age, T2D and failed recanalization increase risk for unfavorable outcome at 90 days in patients with AIS treated with MT. Procedure time duration should be considered as a possible determinant factor in functional outcome.

Has stroke mortality stopped declining in Spain?

OBJECTIVES

To analyse the changes in stroke mortality trends in Spain by autonomous community and by sex during the period 1980-2016, using joinpoint regression models.

METHODS

Mortality data were obtained from the Spanish National Statistics Institute. Crude and standardised rates were calculated for each Spanish autonomous community, and for each sex. Joinpoint analysis was used to identify the best-fitting points showing a statistically significant change in the trend.

RESULTS

Joinpoint analysis enabled us to differentiate between communities in which mortality rates showed a continuous decline throughout the study period in both sexes (Asturias, Cantabria, Castile and Leon, Ceuta, and Melilla) or in men only (Extremadura). In men, in all those communities in which changes in the trend were observed (all but Aragon, the Balearic Islands, and Murcia, where rates remained stable), we observed an initial period of decline (ranging from -3.4% in Catalonia and Extremadura, to -6.0% in Madrid) and a final period where the trends diverged: mortality rates continued to fall in Andalusia, Aragon, the Balearic Islands, and Madrid, but began to stabilise in Castile-La Mancha and Murcia and to increase in the Canary Islands. In women, in those communities where changes were observed (all but Aragon, Murcia, and the Basque Country, where rates remained stable), we observed an initial period of decline (ranging from -3.1% in Catalonia to -6.4% in Navarre) and a final period where divergent trends were observed: rates continued to decline in Andalusia, Aragon, Catalonia, Galicia, Madrid, and the Basque Country, but began to stabilise in Extremadura and Murcia and to increase in the Canary Islands.

CONCLUSIONS

Current data show that stroke mortality rates have decreased (in women in Andalusia), stabilised (in both sexes in Murcia, in men in Castile-La Mancha, and in women in Extremadura), and have even reversed (in both sexes in the Canary Islands). Further study is needed to identify the causes of these trends.

Adherence to Mediterranean diet is not associated with birthweight - Results form a sample of Canarian pregnant women

Introduction

Background: the prevalence of overweight and obesity showed and increasing trend over the past few years. The burden of this epidemic represents a public health issue worldwide. Spain, and especially the Canary Islands, are not exempt. Pregnancy is a situation of weight gain, and the amount of such increase during gestation can affect the health status of both the mother and her baby. Thus, an optimal dietary style becomes of importance. Aim: given the benefits of the Mediterranean diet (MD) on various health outcomes, we aimed to study the adherence to this dietary pattern in a sample of Canarian pregnant women, and to investigate its association with their newborn's weight. Methods: adherence to MD as well as clinical history and anthropometrics were assessed in a sample of pregnant women followed at a Canarian hospital. Similarly, their newborn characteristics were studied. Results: our findings showed an overall low adherence to MD, with no association between this trend and birthweight. Conclusions: in conclusion, specific tools should be tailored to the target population to assess adherence to MD, and further efforts should be made to promote a healthy eating pattern and lifestyle among the pregnant population.

Biomarkers of acute respiratory distress syndrome in adults hospitalised for severe SARS-CoV-2 infection in Tenerife Island, Spain

OBJECTIVE

The dramatic spread of SARS-CoV-2 infections calls for reliable, inexpensive tools to quickly identify patients with a poor prognosis. In this study, acute respiratory distress syndrome (ARDS) was assessed within 72 h after admission of each of 153 consecutive, SARS-CoV-2 infected, adult patients to either of two hospitals in Tenerife, Spain, using suitable routine laboratory tests for lymphocyte counts, as well as ferritin, lactate dehydrogenase (LDH), and C-reactive protein levels. Results were correlated with the patients' respiratory function, defined through their pulse oximetric saturation/fraction of inspired oxygen (SpO2/FiO2) ratio.

RESULTS

Within 72 h from admission, criteria matched ARDS (SpO2/FiO2 < 235) in 13.1% of cases. We found a significant, negative correlation between SpO2/FiO2 ratios and D-dimer, ferritin, and LDH levels (- 0.31, - 0.32, and - 0.41; p = 0.004, 0.004, and < 0.0001, respectively). In patients with ARDS, the mean LDH was 373 U/L (CI95%: 300.6-445.3), but only 298 U/L (CI95%: 274.7-323.1) when they did not develop the syndrome (p = 0.015). None of the additionally evaluated biomarkers correlated with the SpO2/FiO2 ratios. Serum LDH levels in patients hospitalised for COVID-19 correlate with ARDS, as defined by their SpO2/FiO2 ratio, and might help to predict said complication.

Prevalence of diabetes mellitus in Spain in 2016 according to the Primary Care Clinical Database (BDCAP)

The prevalence of type 2 diabetes mellitus is increasing worldwide, including in Spain, and this disease has become a major challenge for health care. In Spain, the computerization of medical records in primary care, in the Primary Care Clinical Database (BDCAP), has made possible the diagnoses of diabetes in a representative sample of the nation as a whole. This article analyzes the prevalence of diabetes recorded in this database and compares the data of the different autonomous communities. The prevalence of diabetes in Spain is 6.66% of the total population assigned to primary care in the National Health System, is higher in men than in women (7.27% vs. 6.06%), and increases with age up to 80 years. There are significant differences in the adjusted prevalence of diabetes between autonomous communities, with lower prevalence rates in North and Central Spain and higher rates in the South and East, as well as the islands. The lowest prevalence is seen in Castile and Leon (4.51%), and the highest in the Canary Islands (9.72%).

Incidence of cancer and mortality among heavy alcoholics

BACKGROUND AND AIMS

Cancer risk is increased in alcoholics. Heavy ethanol consumption is also associated with other potentially lethal conditions such as cirrhosis, diabetes, hypertension, dyslipidemia or malnutrition, that increase mortality. The aim of the present study is to analyze the impact on mortality of new cancer development in a cohort of heavy alcoholics.

METHODS

Three hundred and thirty nine heavy alcoholics (about 200 g ethanol/daily during more than 15 years), initially admitted for organic problems to our service (reference hospital) were prospectively followed up for a maximum period of 120 months (median = 26, interquartile range = 12-60 months), either as outpatients or during successive admissions. Clinical and laboratory evaluation including incidence of new cancer and drinking habits were recorded at each appointment, as well as mortality.

RESULTS

During the study period 57 patients developed cancer and 151 died. Only 75 did not relapse in alcohol drinking. Mortality was related to deranged liver function, relapse of alcohol drinking, and malnutrition, whereas age, the development of new cancer, or the presence of diabetes, dyslipidemia or hypertension did not influence on mortality, especially in cirrhotics and among those who did not quit drinking. Cancer was related to mortality only among non-cirrhotics, together with ethanol abstention and age.

CONCLUSIONS

Heavy drinking is associated with high mortality among alcoholic patients admitted to the hospital. If a patient is already cirrhotic or if there is drinking relapse, the development of a new cancer, the concurrent presence of diabetes, hypertension, dyslipidemia, or advanced age have no impact on survival. Mortality is only related to deranged liver function, relapse of alcohol drinking, and malnutrition.

Major amputations in type 2 diabetes between 2001 and 2015 in Spain: regional differences

Background

To analyze the trend of lower extremity major amputations (MA) among patients with type 2 diabetes mellitus (T2DM) in the Regions of Spain from year 2001 until 2015.

Methods

Descriptive study of 40,392 MA. Data were obtained from the national hospital discharge database in patients with T2DM. The incidence rate was calculated in each Region, in addition to the incidence ratios (IR) between annual incidence and incidence of the year 2001. The length of hospital stay and mortality risks were analyzed using regression models adjusted for sex, age and smoking.

Results

The major amputations incidence rate per 100,000 person-years was 0.48 in Spain; Canary Islands showed the highest incidence (0.81). The trend was a slight decrease or stability of the incidence in all Regions except in the Canary Islands (IR₂₀₁₅ = 2.0 [CI95% = 1.5, 2.6]) and in Madrid (IR₂₀₁₅ = 0.1 [CI95% = 0.1, 0.2]). Mortality after major amputations was 10% in Spain; Cantabria suffered the highest risk of death [1.7 (CI95% = 1.4; 2.1), p < 0.001] and La Rioja the lowest risk (0.5 [CI95% = 0.2; 0.9]; p = 0.026). The longest hospital stay was registered in the Canary Islands [(CI95% = 11.4;13.3], p < 0.001)], and the shortest in the Valencian Community [(CI95% = − 7.3; − 5.8), p < 0.001)].

Conclusion

MA in T2DM followed a growing trend in the Canary Islands, which diverged from the downward trend in Spain. The variability of mortality and hospital stay, suggest to review the clinical management in some Regions. Sudden incidence decrease in Madrid suggests checking the record procedures of hospital discharges.

Genomic Analyses of Human European Diversity at the Southwestern Edge: Isolation, African Influence and Disease Associations in the Canary Islands

Despite the genetic resemblance of Canary Islanders to other southern European populations, their geographical isolation and the historical admixture of aborigines (from North Africa) with sub-Saharan Africans and Europeans have shaped a distinctive genetic makeup that likely affects disease susceptibility and health disparities. Based on single nucleotide polymorphism array data and whole genome sequencing (30×), we inferred that the last African admixture took place ∼14 generations ago and estimated that up to 34% of the Canary Islander genome is of recent African descent. The length of regions in homozygosis and the ancestry-related mosaic organization of the Canary Islander genome support the view that isolation has been strongest on the two smallest islands. Furthermore, several genomic regions showed significant and large deviations in African or European ancestry and were significantly enriched in genes involved in prevalent diseases in this community, such as diabetes, asthma, and allergy. The most prominent of these regions were located near LCT and the HLA, two well-known targets of selection, at which 40‒50% of the Canarian genome is of recent African descent according to our estimates. Putative selective signals were also identified in these regions near the SLC6A11-SLC6A1, KCNMB2, and PCDH20-PCDH9 genes. Taken together, our findings provide solid evidence of a significant recent African admixture, population isolation, and adaptation in this part of Europe, with the favoring of African alleles in some chromosome regions. These findings may have medical implications for populations of recent African ancestry.

Hospital Mortality in 415 798 AMI Patients: 4 Years Earlier in the Canary Islands Than in the Rest of Spain

INTRODUCTION AND OBJECTIVES

The Canary Islands has the highest mortality from diabetes in Spain. The aim of this study was to determine possible differences in mortality due to acute myocardial infarction (AMI) during hospital admission between this autonomous community and the rest of Spain, as well as the factors associated with this mortality and the population fraction attributable to diabetes.

METHODS

Cross-sectional study of hospital admissions for AMI in Spain from 2007 to 2014, registered in the Minimum Basic Data Set.

RESULTS

A total of 415 798 AMI were identified. Canary Island patients (16 317) were younger than those living in the rest of Spain (63.93 ± 13.56 vs 68.25 ± 13.94; P < .001) and death occurred 4 years earlier in the archipelago (74.03 ± 11.85 vs 78.38 ± 11.10; P < .001). This autonomous community had the highest prevalence of smoking (44% in men and 23% in women); throughout Spain, AMI occurred 13 years earlier in smokers than in nonsmokers. Patients in the Canary Islands had the highest mortality rates whether they had diabetes (8.7%) or not (7.6%), and they also showed the highest fraction of AMI mortality attributable to diabetes (9.4; 95%CI, 4.8-13.6). After adjustment for type of AMI, diabetes, dyslipidemia, hypertension, smoking, cocaine use, renal failure, sex and age, the Canary Islands showed the highest risk of mortality vs the rest of Spain (OR = 1.25; 95%CI, 1.17-1.33; P < .001) and it was one of the autonomous communities showing no significant improvement in the risk of mortality due to AMI during the study period.

CONCLUSIONS

Mortality due to AMI during hospital admission is higher in the Canary Islands than in the rest of Spain.

Clinical applicability and cost-effectiveness of DIABSCORE in screening for type 2 diabetes in primary care

AIMS

To evaluate the applicability and cost-effectiveness of a clinical risk score (DIABSCORE) to screen for type 2 diabetes in primary care patients.

METHODS

Multicenter cross-sectional study of 10,508 adult no previously diagnosed with diabetes, in 2 Spanish regions (Canary Islands and Valencian Community). The variables comprising DIABSCORE were age, waist to height ratio, family history of diabetes and gestational diabetes. ROC curves were obtained; the diabetes prevalences odds ratios (HbA1c ≥6.5%) between patients exposed and not exposed to DIABSCORE ≥100, and to fasting blood glucose ≥126mg/dL were calculated. The opinions of both the professionals and the patients concerning DIABSCORE were collected, and a cost-effectiveness analysis was performed.

RESULTS

In both regions, the valid cut-off point for diabetes (DIABSCORE=100), showed an area under the curve >0.80. The prevalences odds ratio of diabetes for DIABSCORE ≥100 was 9.5 (3.7-31.5) in Canarian and 18.3 (8.0-51.1) in Valencian; and for glucose ≥126mg/dL it was, respectively, 123.0 (58.8-259.2) and 303.1 (162.5-583.8). However, glucose ≥126mg/dL showed a low sensitivity (below 48% in both communities) as opposed to DIABSCORE ≥100 (above 90% in both regions). Professionals (100%) and patients (75%) satisfaction was greater when using DIABSCORE rather than glucose measurement for diabetes screening. The cost of each case of diabetes identified was lower with DIABSCORE ≥100 (7.6 € in Canarian and 8.3 € in Valencian) than glucose ≥126mg/dL (10.8 € and 10.5 €, respectively).

CONCLUSIONS

DIABSCORE is an applicable and cost-effective screening method for type 2 diabetes in primary care.

Trends in Mortality From Diabetes Mellitus in Spain: 1998-2013

INTRODUCTION AND OBJECTIVES

Diabetes mellitus (DM) is a leading causes of death, mainly due to cardiovascular complications. The aim of this study was to describe DM mortality in Spain from 1998 to 2013 and to compare it between distinct provinces.

METHODS

Ecological time-trend study. Data sources consisted of the population register and the death rate figures, by cause of death, from Spain's National Statistics Institute. Rates were age-standardized by the direct method. Standardized mortality rates were calculated for each province every 5 years (1998-2013). Time trends in mortality were established by joint point regression models.

RESULTS

The standardized mortality rate for DM fell markedly, by 25.3% in men and by 41.4% in women from 1998 to 2013. At the beginning of the study period, mortality rates were higher in southern than in northern regions, but this difference gradually disappeared in later years. The highest mortality rates were consistently found in the Canary Islands.

CONCLUSIONS

Mortality from DM fell substantially from 1998 to 2013. The marked geographical clustering showing higher mortality in the south and southeastern areas of the country was significantly reduced during the study period, except in the Canary Islands, where mortality remains strikingly high.