The annual incidence of diabetic complications in a population of patients with Type 1 and Type 2 diabetes

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.

Medical Costs Associated With Diabetes Complications in Medicare Beneficiaries Aged 65 Years or Older With Type 1 Diabetes

OBJECTIVE

To estimate medical costs associated with 17 diabetes complications and treatment procedures among Medicare beneficiaries aged ≥65 years with type 1 diabetes.

RESEARCH DESIGN AND METHODS

With use of the 2006-2017 100% Medicare claims database for beneficiaries enrolled in fee-for-service plans and Part D, we estimated the annual cost of 17 diabetes complications and treatment procedures. Type 1 diabetes and its complications and procedures were identified using ICD-9/ICD-10, procedure, and diagnosis-related group codes. Individuals with type 1 diabetes were followed from the year when their diabetes was initially identified in Medicare (2006-2015) until death, discontinuing plan coverage, or 31 December 2017. Fixed-effects regression was used to estimate costs in the complication occurrence year and subsequent years. The cost proportion of a complication was equal to the total cost of the complication, calculated by multiplying prevalence by the per-person cost divided by the total cost for all complications. All costs were standardized to 2017 U.S. dollars.

RESULTS

Our study included 114,879 people with type 1 diabetes with lengths of follow-up from 3 to 10 years. The costliest complications per person were kidney failure treated by transplant ($77,809 in the occurrence year and $13,556 in subsequent years), kidney failure treated by dialysis ($56,469 and $41,429), and neuropathy treated by lower-extremity amputation ($40,698 and $7,380). Sixteen percent of the total medical cost for diabetes complications was for treating congestive heart failure.

CONCLUSIONS

Costs of diabetes complications were large and varied by complications. Our results can assist in cost-effectiveness analysis of treatments and interventions for preventing or delaying diabetes complications in Medicare beneficiaries aged ≥65 years with type 1 diabetes.

Microvascular basis of cognitive impairment in type 1 diabetes

The complex computations of the brain require a constant supply of blood flow to meet its immense metabolic needs. Perturbations in blood supply, even in the smallest vascular networks, can have a profound effect on neuronal function and cognition. Type 1 diabetes is a prevalent and insidious metabolic disorder that progressively and heterogeneously disrupts vascular signalling and function in the brain. As a result, it is associated with an array of adverse vascular changes such as impaired regulation of vascular tone, pathological neovascularization and vasoregression, capillary plugging and blood brain barrier disruption. In this review, we highlight the link between microvascular dysfunction and cognitive impairment that is commonly associated with type 1 diabetes, with the aim of synthesizing current knowledge in this field.

Cost-effectiveness analysis for HbA1c test intervals to screen patients with type 2 diabetes based on risk stratification

BACKGROUND

The best HbA1c test interval strategy for detecting new type 2 diabetes mellitus (T2DM) cases in healthy individuals should be determined with consideration of HbA1c test characteristics, risk stratification towards T2DM and cost effectiveness.

METHODS

State transition models were constructed to investigate the optimal screening interval for new cases of T2DM among each age- and BMI-stratified health individuals. Age was stratified into 30-44-, 45-59-, and 60-74-year-old age groups, and BMI was also stratified into underweight, normal, overweight and obesity. In each model, different HbA1c test intervals were evaluated with respect to the incremental cost-effectiveness ratio (ICER) and costs per quality-adjusted life year (QALY). Annual intervals (Japanese current strategy), every 3 years (recommendations in US and UK) and intervals which are tailored to each risk stratification group were compared. All model parameters, including costs for screening and treatment, rates for complications and mortality and utilities, were taken from published studies. The willingness-to-pay threshold in the cost-effectiveness analysis was set to US $50,000/QALY.

RESULTS

The HbA1c test interval for detecting T2DM in healthy individuals varies by age and BMI. Three-year intervals were the most cost effective in obesity at all ages-30-44: $15,034/QALY, 45-59: $11,849/QALY, 60-74: $8685/QALY-compared with the other two interval strategies. The three-year interval was also the most cost effective in the 60-74-year-old age groups-underweight: $11,377/QALY, normal: $18,123/QALY, overweight: $12,537/QALY-and in the overweight 45-59-year-old group; $18,918/QALY. In other groups, the screening interval for detecting T2DM was found to be longer than 3 years, as previously reported. Annual screenings were dominated in many groups with low BMI and in younger age groups. Based on the probability distribution of the ICER, results were consistent among any groups.

CONCLUSIONS

The three-year screening interval was optimal among elderly at all ages, the obesity at all ages and the overweight in 45-59-year-old group. For those sin the low-BMI and younger age groups, the optimal HbA1c test interval could be longer than 3 years. Annual screening to detect T2DM was not cost effective and should not be applied in any population.

Metabolic Control and Determinants Among HIV-Infected Type 2 Diabetes Mellitus Patients Attending a Tertiary Clinic in Botswana

PURPOSE

We primarily aimed at determining the prevalence of metabolic syndrome and abnormal individual metabolic control variables in HIV-infected participants as compared to HIV-uninfected participants given current concerns. Our secondary objective was to determine the predictors of metabolic syndrome and individual metabolic control variables among the study participants to guide future management.

PATIENTS AND METHODS

A descriptive, case-matched cross-sectional study for four months from 15th June 2019 to 15th October 2019 at Block 6 Diabetes Reference Clinic in Gaborone, Botswana. We compared the proportions of metabolic syndrome and individual metabolic control variables based on gender and HIV status by means of bivariate analysis (Chi-squared test or Fisher's exact test) to determine factors associated with metabolic control. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Overall, 86% of the study participants were found to have metabolic syndrome by International Diabetes Federation (IDF) criteria with 79.8% among HIV-infected and 89.1% among HIV-negative participants (p-value = 0.018). Older age was significantly associated with metabolic syndrome (p-value = 0.008). Female gender was significantly associated with metabolic syndrome as compared to male gender (P-value < 0.001), and with a statistically significant higher proportion of low HDL-C compared to males (P-value < 0.001). Female participants were significantly more likely to be obese as compared to males (P-value < 0.001). High triglycerides were more common in HIV-infected compared to HIV-negative participants (P-value = 0.004). HIV-negative participants were more likely to be obese as compared to HIV-infected participants (P-value = 0.003).

CONCLUSION

Metabolic syndrome is an appreciable problem in this tertiary clinic in Botswana for both HIV-infected and HIV-negative participants. Future prospective studies are warranted in our setting and similar sub-Saharan settings to enhance understanding of the role played by HAART in causing the metabolic syndrome, and the implications for future patient management.

Age- and sex-specific incidence of non-traumatic lower limb amputation in patients with type 2 diabetes mellitus in a U.S. claims database

AIM

To estimate age- and sex-specific incidence rates (IRs) of non-traumatic lower limb amputations (LLA) in patients with type 2 diabetes mellitus (T2DM) using a claims database from the United States (US).

METHODS

Patients with T2DM 18 years and older were identified using the Truven Health MarketScan database from January 1, 2007 to September 30, 2018. The overall and age- and sex-specific IRs of all non-traumatic LLA, minor LLA (amputation at or below the ankle), and major LLA (amputation above ankle) were calculated.

RESULTS

Among the 6,117,981 patients with T2DM, 14,627 LLA events occurred (minor LLA; 72.8%; major LLA: 27.2%). The IRs (95% CI) of all LLA, minor LLA, and major LLA per 1000 person-years or PY were 0.86 (0.85, 0.88), 0.63 (0.62, 0.64), and 0.23 (0.23, 0.24), respectively. The IR (95% CI) of all LLA per 1000 PY in males was higher compared to females [1.24 (1.22, 1.26) vs. 0.46 (0.45, 0.48)]. The incidence of all LLA increased with an increasing age (highest IR in age-group of ≥80 years).

CONCLUSIONS

This study identified males and older patients with T2DM at higher risk of developing LLA in the US, warranting further exploration of risk factors of LLA in these subgroups.

Real-world evidence studies into treatment adherence, thresholds for intervention and disparities in treatment in people with type 2 diabetes in the UK

PURPOSE

The University of Surrey-Lilly Real World Evidence (RWE) diabetes cohort has been established to provide insights into the management of type 2 diabetes mellitus (T2DM). There are 3 areas of study due to be conducted to provide insights into T2DM management: exploration of medication adherence, thresholds for changing diabetes therapies, and ethnicity-related or socioeconomic-related disparities in management. This paper describes the identification of a cohort of people with T2DM which will be used for these analyses, through a case finding algorithm, and describes the characteristics of the identified cohort.

PARTICIPANTS

A cohort of people with T2DM was identified from the Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) data set. This data set comprises electronic patient records collected from a nationally distributed sample of 130 primary care practices across England with scope to increase the number of practices to 200.

FINDINGS TO DATE

A cohort (N=58 717) of adults with T2DM was identified from the RCGP RSC population (N=1 260 761), a crude prevalence of diabetes of 5.8% in the adult population. High data quality within the practice network and an ontological approach to classification resulted in a high level of data completeness in the T2DM cohort; ethnicity identification (82.1%), smoking status (99.3%), alcohol use (93.3%), glycated haemoglobin (HbA1c; 97.9%), body mass index (98.0%), blood pressure (99.4%), cholesterol (87.4%) and renal function (97.8%). Data completeness compares favourably to other, similarly large, observational cohorts. The cohort comprises a distribution of ages, socioeconomic and ethnic backgrounds, diabetes complications, and comorbidities, enabling the planned analyses.

FUTURE PLANS

Regular data uploads from the RCGP RSC practice network will enable this cohort to be followed prospectively. We will investigate medication adherence, explore thresholds and triggers for changing diabetes therapies, and investigate any ethnicity-related or socioeconomic-related disparities in diabetes management.

Event and Cost Offsets of Switching 20% of the Type 1 Diabetes Population in Germany From Multiple Daily Injections to Continuous Subcutaneous Insulin Infusion: A 4-Year Simulation Model

BACKGROUND

Most patients with type 1 diabetes (T1D) administer insulin by multiple daily injections (MDI). However, continuous subcutaneous insulin infusion (CSII) therapy has been shown to improve glycemic control compared with MDI.

OBJECTIVE

The objective was to determine the key medical event and cost offsets generated over a 4-year period by introducing CSII to T1D patients who have inadequately controlled glucose metabolism on MDI in Germany.

METHODS

A decision-analytic budget impact model, simulating a treatment switch scenario, was developed. In the base case, all T1D patients received MDI, while in the switch scenario, 20% of the eligible T1D population, randomly selected, moved to CSII. The model focused on 2 medical endpoints and their corresponding cost offsets: severe hypoglycemic events requiring hospitalization (SHEH) and complication-borne diabetic events (CDEs) avoided. Event rates and costs were taken from the literature and official sources, adopting a health insurance perspective.

RESULTS

Compared with the base case, treating 20% of patients with CSII in the switch scenario resulted in 47 864 fewer SHEH and 5543 fewer CDEs. This led to total cost offsets of €183 085 281 within the 4-year time horizon. Of these, 92% were driven by avoided SHEH. Compared to an expected budget impact (cost increase) of 83%, only treatment costs considered, the total impact of the switch scenario amounted merely to a 24.5% increase in costs (reduction by 58.5% points; a factor of 3.4).

CONCLUSION

The use of CSII resulted in fewer SHEH and CDEs compared to MDI. The incurred CSII implementation costs are hence offset to a substantial degree by cost savings in complication treatment.

Glucocorticoids Suppress Mitochondrial Oxidant Production via Upregulation of Uncoupling Protein 2 in Hyperglycemic Endothelial Cells

Diabetic complications are the leading cause of morbidity and mortality in diabetic patients. Elevated blood glucose contributes to the development of endothelial and vascular dysfunction, and, consequently, to diabetic micro- and macrovascular complications, because it increases the mitochondrial proton gradient and mitochondrial oxidant production. Therapeutic approaches designed to counteract glucose-induced mitochondrial reactive oxygen species (ROS) production in the vasculature are expected to show efficacy against all diabetic complications, but direct pharmacological targeting (scavenging) of mitochondrial oxidants remains challenging due to the high reactivity of some of these oxidant species. In a recent study, we have conducted a medium-throughput cell-based screening of a focused library of well-annotated pharmacologically active compounds and identified glucocorticoids as inhibitors of mitochondrial superoxide production in microvascular endothelial cells exposed to elevated extracellular glucose. The goal of the current study was to investigate the mechanism of glucocorticoids' action. Our findings show that glucocorticoids induce the expression of the mitochondrial UCP2 protein and decrease the mitochondrial potential. UCP2 silencing prevents the protective effect of the glucocorticoids on ROS production. UCP2 induction also increases the oxygen consumption and the "proton leak" in microvascular endothelial cells. Furthermore, glutamine supplementation augments the effect of glucocorticoids via further enhancing the expression of UCP2 at the translational level. We conclude that UCP2 induction represents a novel experimental therapeutic intervention in diabetic vascular complications. While direct repurposing of glucocorticoids may not be possible for the therapy of diabetic complications due to their significant side effects that develop during chronic administration, the UCP2 pathway may be therapeutically targetable by other, glucocorticoid-independent pharmacological means.

Cardiovascular event rates and healthcare resource utilisation among high-risk adults with type 2 diabetes mellitus in a large population-based study

OBJECTIVE

This study ascertained the incidence and resource utilisation of non-fatal myocardial infarction (MI), stroke, coronary bypass surgery or angioplasty among adults with type 2 diabetes mellitus (T2DM) at high risk for cardiovascular disease (CVD) over 3 and 5 years.

METHODS

Respondents from the US, population-based SHIELD study with T2DM and at cardiovascular risk were stratified into an established CVD cohort and a risk factors cohort. Proportion of respondents self-reporting a new MI, stroke or revascularisation was calculated. Multivariate discrete logistic hazards models were utilised.

RESULTS

Incidence rate in the established CVD cohort (n = 1198) was 26.3% over 3 years (31.2%, 5 years) and in the risk factors cohort (n = 924) 18.8% over 3 years (26.0%, 5 years). Healthcare resource use was significantly greater among respondents who had a new CV event than among those not experiencing an event (p < 0.001).

CONCLUSIONS

Individuals with T2DM at risk for CVD had a high incidence of CV events in this large US study, which represents a significant burden on the healthcare system.

Body composition in adults with newly diagnosed type 2 diabetes: effects of metformin

Background

The aim of this study was to measure the body composition in adults with newly diagnosed type 2 diabetes mellitus and to explore the effect of metformin therapy on the various components of body composition, insulin sensitivity, and glucose homeostasis.

Methods

This was an observational study consisted of 51 newly diagnosed people with type 2 diabetes on 1000 mg metformin twice daily for 6 months. The body composition of each subject was measured by dual energy X-ray absorptiometry at enrollment and 24 weeks after metformin mono-therapy. Sarcopenia was defined and compared based on the ratio of appendicular skeletal muscle and height squared, skeletal muscle index and residual methods.

Homeostasis model assessment-insulin resistance and Quantitative Insulin Sensitivity Check Index were used for estimating insulin sensitivity. The level of physical activity was assessed using self-administered International physical Activity questionnaire.

Results

Forty one subjects (80.4%) completed the study. The mean age of the participants was 52.67 ± 10.43 years. Metformin treatment was associated with a significant decrease in total fat mass (−1.6 kg, P = 0.000). By week 24, the lean to fat ratio increased (P = 0.04) with men showing greater significant changes. Twenty percent of the female participants were detected to have sarcopenia.

In addition, there was a significant improvement of glucose homeostasis and insulin sensitivity.

Conclusions

Metformin therapy results in significant improvement in body composition and insulin sensitivity of adults with newly diagnosed type 2 diabetes. Furthermore, sarcopenia begins in women with diabetes much earlier than expected as an age related phenomenon.

Prospective study on the incidences of cardiovascular-renal complications in Chinese patients with young-onset type 1 and type 2 diabetes

OBJECTIVE We examined metabolic profiles and cardiovascular-renal outcomes in a prospective cohort of Chinese patients with young-onset diabetes defined by diagnosis age <40 years. Patients with type 1 diabetes and normal-weight (BMI <23 kg/m(2)) and overweight (BMI ≥23 kg/m(2)) patients with type 2 diabetes were compared. RESEARCH DESIGN AND METHODS Between 1995 and 2004, 2,323 patients (type 1 diabetes, n = 209; normal-weight type 2 diabetes, n = 636; and overweight type 2 diabetes, n = 1,478) underwent detailed clinical assessment. Incident cardiovascular disease (CVD) including coronary heart disease, stroke, and peripheral vascular disease were identified using hospital discharge diagnoses. End-stage renal disease (ESRD) was defined by glomerular filtration rate <15 mL/min/1.73 m(2) or dialysis. RESULTS Overweight patients with type 2 diabetes had the worst metabolic profile and highest prevalence of microvascular complications. Over a median follow-up of 9.3 years, incidences of CVD were 0.6, 5.1, and 9.6 per 1,000 person-years in patients with type 1 diabetes, normal-weight patients with type 2 diabetes, and overweight patients with type 2 diabetes. The respective figures for ESRD were 2.2, 6.4, and 8.4 per 1,000 person-years. Compared with type 1 diabetes, the overweight type 2 diabetes group had a greater hazard of progression to CVD (hazard ratio [HR] 15.3 [95% CI 2.1-112.4]) and ESRD (HR 5.4 [95% CI 1.8-15.9]), adjusted for age, sex, and disease duration. The association became nonsignificant upon additional adjustment for BMI, blood pressure, and lipid. CONCLUSIONS Young patients with type 2 diabetes had greater risks of developing cardiovascular-renal complications compared with patients with type 1 diabetes. The increased risk was driven primarily by accompanying metabolic risk factors.

Epidemiology of blindness attributable to diabetes in Scotland: change over 20 years in a defined population

AIMS

To establish the incidence and prevalence of blindness attributable to diabetes in a defined population in Scotland during the period 2000-2009, and to compare these figures with published data from the previous decade in the same population.

METHODS

All blind registrations during 2000-2009 in Fife, Scotland, UK were examined and included if diabetic retinopathy/maculopathy was the main cause of blindness. The annual incidence and point prevalence on 31 December 2009 of registered blindness attributable to diabetes were calculated in both the total population and the population with diabetes. These data were compared with figures for the period 1990-1999, using a two-tailed t-test, and subjected to Poisson regression analysis.

RESULTS

In the population with diabetes, the mean incidence of blindness attributable to diabetes was 42.7 (sd 24.2, 95% CI 25- 60) per 100 000 per year for 2000-2009, compared with 64.3 for 1990-1999 (P = 0.062). The relative risk of developing blindness per year was 0.894 (95% CI 0.811- 0.988, P = 0.028) for 2000- 2009. The point prevalence on 31 December 2009 was 167 per 100 000 in the population with diabetes, vs 210 on 31 December 1999.

CONCLUSION

Compared with the previous decade, the prevalence of blindness attributable to diabetes has decreased in the population with diabetes, with a trend towards a decrease in its incidence. This may be a consequence of an increased denominator population, resulting from better recording of diabetes and changes to the diagnostic criteria. Over the decade 2000-2009, the incidence of blindness attributable to diabetes fell by a mean of 10.6% per year in the population with diabetes.

The pathway to foot ulceration in diabetes

It should now be possible to achieve a reduction in the incidence of foot ulceration and amputations as knowledge about pathways that result in both these events increases. However, despite the universal use of patient education and the hope of reducing the incidence of ulcers in high-risk patients, there are no appropriately designed large, randomized controlled trials actually confirming that education works. It has been recognized for some years that education as part of a multidisciplinary approach to care of the diabetic foot can help to reduce the incidence of amputations in certain settings. Ultimately, however, a reduction in neuropathic foot problems will only be achieved if we remember that the patients with neuropathic feet have lost their prime warning signal—pain—that ordinarily brings patients to their doctor. Very little training is offered to health care professionals as to how to deal with such patients. Much can be learned about the management of such patients from the treatment of individuals with leprosy: if we are to succeed, we must realize that with loss of pain there is also diminished motivation in the healing of and prevention of injury.

Lower incidence of recorded cardiovascular outcomes in patients with type 2 diabetes using insulin aspart vs. those on human regular insulin: observational evidence from general practices

AIMS

Insulin aspart has a higher ability to treat postprandial glucose than regular human insulin, which may have favourable cardiovascular effects. The aim was to collect and compare the incidence of recorded macro- and microvascular events in patients with type 2 diabetes with insulin aspart or regular human insulin in general practices.

METHODS

Computerized data from 3154 aspart and 3154 regular insulin users throughout Germany (Disease Analyzer, January 2000 to July 2011) were analysed after matching for age (60 ± 10 years), sex (men: 57%), health insurance (private: 5.8%) and diabetes treatment period in practice (2.2 ± 2.5 years). Hazard ratios (HR; Cox regression) for macro- or microvascular outcomes (follow-up: 3.5 years) were further adjusted for diabetologist care, practice region, hypertension, hyperlipidaemia, co-medication (basal insulin, oral antidiabetics, antihypertensives, lipid-lowering agents and antithrombotic drugs), previous treatment with rapid-acting insulins, hypoglycaemia and the Charlson co-morbidity score. Furthermore, adjustment was carried out for baseline microvascular complications when analysing macrovascular outcomes and vice versa.

RESULTS

Overall, the risk of combined macrovascular outcomes was 15% lower for insulin aspart users (p = 0.01). For insulin aspart there was also a decreased risk incident stroke [HR: 0.58; 95% confidence interval (CI): 0.45-0.74], myocardial infarction (HR: 0.69; 95% CI: 0.54-0.88) and peripheral vascular disease (HR: 0.80; 95% CI: 0.69-0.93). For microvascular complications (retinopathy, neuropathy and nephropathy), no significant differences were observed (HR: 0.96; 95% CI: 0.87-1.06).

CONCLUSION

Use of the rapid-acting insulin analogue aspart was associated with a reduced incidence of macrovascular outcomes in type 2 diabetes in general practices. It is important to confirm this finding in a randomized controlled trial.

Addition of either pioglitazone or a sulfonylurea in type 2 diabetic patients inadequately controlled with metformin alone: impact on cardiovascular events. A randomized controlled trial

BACKGROUND AND AIMS

Metformin is the first-line therapy in type 2 diabetes. In patients inadequately controlled with metformin, the addition of a sulfonylurea or pioglitazone are equally plausible options to improve glycemic control. However, these drugs have profound differences in their mechanism of action, side effects, and impact on cardiovascular risk factors. A formal comparison of these two therapies in terms of cardiovascular morbidity and mortality is lacking. The TOSCA.IT study was designed to explore the effects of adding pioglitazone or a sulfonylurea on cardiovascular events in type 2 diabetic patients inadequately controlled with metformin.

METHODS

Multicentre, randomized, open label, parallel group trial of 48 month duration. Type 2 diabetic subjects, 50-75 years, BMI 20-45 Kg/m(2), on secondary failure to metformin monotherapy will be randomized to add-on a sulfonylurea or pioglitazone. The primary efficacy outcome is a composite endpoint of all-cause mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned coronary revascularization. Principal secondary outcome is a composite ischemic endpoint of sudden death, fatal and non-fatal myocardial infarction and stroke, endovascular or surgical intervention on the coronary, leg or carotid arteries, major amputations. Side effects, quality of life and economic costs will also be evaluated. Efficacy, safety, tolerability, and study conduct will be monitored by an independent Data Safety Monitoring Board. End points will be adjudicated by an independent external committee.

CONCLUSIONS

TOSCA.IT is the first on-going study investigating the head-to-head comparison of adding a sulfonylurea or pioglitazone to existing metformin treatment in terms of hard cardiovascular outcomes.

REGISTRATION

Clinicaltrials.gov ID NCT00700856.

[Update on diabetic macroangiopathy]

Current findings from the literature on the multifactorial genesis of macroangiopathy of diabetes mellitus (DM) were compiled using the PubMed database. The primary aim was to find an explanation for the morphological, immunohistochemical and molecular characteristics of this form of atherosclerosis. The roles of advanced glycation end products (AGE), defective signal transduction and imbalance of matrix metalloproteinases in the increased progression of atherosclerosis in coronary and cerebral arteries as well as peripheral vascular disease are discussed. The restricted formation of collateral arteries (arteriogenesis) in diabetic patients with postischemic lesions is also a focus of attention. The increased level of prothrombotic factors and the role of diabetic neuropathy in DM are also taken into account. Therapeutic influences of AGE-RAGE (receptor of AGE) interactions on the vascular wall and the effects of endothelial progenitor cells in the repair of diabetic vascular lesions are additionally highlighted.

Incidence of complications and mortality in a type 2 diabetes patient cohort study followed up from diagnosis in a primary healthcare centre

AIMS

To determine the microvascular and macrovascular complications and mortality incidence rates and to identify the related factors in patients recently diagnosed with type 2 diabetes between 1991 and 2000 and followed until 2006.

METHODS

Retrospective longitudinal study in a primary healthcare center. Patients without any measure of glycaemia in the 3 years previous to diabetes diagnosis were excluded. Annual incidence rates for microvascular and macrovascular complications and mortality were estimated. Analysis of KaplanMeier survival curves and Cox proportional risk models by gender were done.

RESULTS

Of 469 patients [mean age: 60.4 (SD 10.7) years, 53.9% women], 80 died principally of tumoral (38.7%) and cardiovascular (30%) causes. The mean follow-up period was 8.81 years. (SD 3.21). The complication rates per 1000 patients/year (95% CI) were: microvascular complications 29.11 (22.97-36.38), macrovascular complications 24.10 (19.05-30.08) and mortality 19.23 (15.25-23.93), all of those being significantly greater in males except for cerebrovascular disease. Complications and mortality were associated with age, HbA1c, HDL-cholesterol, blood pressure and smoking with a different significance for each gender. HbA1c was related to microvascular complications in both sexes and to macrovascular complications only in women.

CONCLUSION

The annual rates for death and complications in a Mediterranean type 2 diabetic patient cohort followed from diagnosis were lower than those published in Anglo-Saxon countries. Males showed higher death and complication rates except in terms of cerebrovascular disease. Predictors of complication and death were different depending on gender. In terms of mortality, unlike in other studies, only one-third of the deaths were for cardiovascular causes.

Sustained reduction in major amputations in diabetic patients: 628 amputations in 461 patients in a defined population over a 20-year period

BACKGROUND AND PURPOSE

With an ageing population and an increasing incidence of diabetes, reduction of the number of diabetes-related amputations becomes increasingly difficult to achieve and maintain. There is controversy in this respect regarding the degree of success. We started a multidisciplinary treatment program for diabetic foot ulcers in 1982, and have now assessed incidence rates of amputations from 1982 through 2001.

METHODS

In a defined population, gradually increasing from 199,000 to 234,000, all diabetes-related amputations of the lower extremity from toe to hip were recorded from January 1, 1982 to December 31, 2001, using several sources of information.

RESULTS

The incidence of major amputations decreased by 0.57 from 16 (11-22) to 6.8 (6.1-7.5) per 100,000 inhabitants between the first and last 4-year period. The most substantial decrease was seen in patients aged 80 years and older. The fraction of amputations with a final level at or below the ankle (n = 240) increased from 0.23 in the first 4-year period to 0.31, 0.49, 0.47, and 0.49 in the following 4-year periods. The overall fraction of re-amputation was 0.34 in the first 4- year period and 0.27, 0.21, 0.32, and 0.21 in the following 4-year periods. The fraction of amputations in diabetic patients that were channeled through the footcare team prior to amputation increased from 0.51 in the first 4- year period to 0.83, 0.86, 0.90, and 0.90 in the following 4-year periods.

INTERPRETATION

Our findings indicate that a substantial decrease in the incidence of major lower extremity amputations in diabetic patients has been achieved and maintained.

Prevalence and incidence of chronic complications and mortality in a cohort of type 2 diabetic patients in Spain

AIMS

To evaluate the prevalence, incidence of micro- and macrovascular complications, final events, and mortality in type 2 diabetic patients, followed over a period of 10 years in Spain.

METHODS

Prospective, population-based cohort study. 317 type 2 diabetic patients treated at a Primary Care Centre, followed for 10 years. Variables were described by means of ratios, mean values and standard deviation. The chi(2) test was used to compare ratios and the Student's t test to compare mean values.

RESULTS

Mean age in women (61%) was 61.2 years; men 66.7 years. With regard to the prevalence of complications, the following was observed: an increase in nephropathy (12%), in retinopathy (6.2%) and in neuropathy (2.1%), a decrease in ischemic cardiomyopathy (-6.2%), an increase in peripheral vascular disease (5.6%). Cerebrovascular event and diabetic foot remaining unchanged. The highest incidence rates (1000 subjects/year) were: nephropathy 43, neuropathy 39 and ischemic cardiomyopathy 32. The prevalence of cardiovascular risk factors increased over the follow-up; being high blood pressure the most noticeable (30%). Overall mortality was 28/1000 subjects/year, being cardiovascular disease the main cause (31.2%).

CONCLUSIONS

Our study determines the prevalence and incidence of chronic complications and risk factors in Spain.

Risk of myocardial infarction in men and women with type 2 diabetes in the UK: a cohort study using the General Practice Research Database

AIMS/HYPOTHESIS

Our primary aim was to establish reliable and generalisable estimates of the risk of myocardial infarction (MI) for men and women with type 2 diabetes in the UK compared with people without diabetes. Our secondary aim was to investigate how the MI risk associated with diabetes differs between men and women.

METHODS

A cohort study using the General Practice Research Database (1992-1999) was carried out, selecting 40,727 patients with type 2 diabetes and 194,913 age and sex-matched patients without diabetes. Rates of MI in men and women with and without diabetes were derived, as were hazard ratios for MI adjusted for known risk factors.

RESULTS

The rate of MI in men with type 2 diabetes was 19.74 (95% CI 18.83-20.69) per 1,000 person-years compared with 16.18 (95% CI 15.33-17.08) per 1,000 person-years in women with type 2 diabetes. The overall adjusted relative risk of MI in diabetes versus no diabetes was 2.13 (95% CI 2.01-2.26) in men and 2.95 (95% CI 2.75-3.17) in women and decreased with age in both sexes. Women with type 2 diabetes aged 35 to 54 years were at almost five times the risk of MI compared with women of the same age without diabetes (HR 4.86 [95% CI 2.78-8.51]).

CONCLUSIONS/INTERPRETATION

This study has demonstrated that women with type 2 diabetes are at a much greater relative risk of MI than men even when adjusted for risk factors.

Relation of central adiposity and body mass index to the development of diabetes in the Diabetes Prevention Program

BACKGROUND

Greater central adiposity is related to the risk of diabetes.

OBJECTIVE

We aimed to test the hypothesis that central adiposity measured by computed tomography (CT) is a better predictor of the risk of diabetes than is body mass index (BMI), waist circumference (WC), waist/hip ratio (WHR), or waist/height ratio.

DESIGN

Visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) were measured at the L2-3 and L4-5 disc spaces in 1106 of the 3234 participants in the Diabetes Prevention Program. Sex-specific proportional hazards models were used to evaluate the association between VAT and SAT at both cuts, BMI, and other measures of central adiposity as predictors of the development of diabetes.

RESULTS

Men had more VAT than did women. White subjects had more VAT at both cuts than did other ethnic groups. The ratio of VAT to SAT was lowest in African Americans of both sexes. Among men in the placebo group, VAT at both cuts, WC, BMI, waist/height ratio, and WHR predicted diabetes (hazard ratio: 1.79-1.44 per 1 SD of variable). Among women in the lifestyle group, VAT at both cuts predicted diabetes as well as did BMI, and L2-3 was a significantly better predictor than was WC or WHR. SAT did not predict diabetes. None of the body fat measurements predicted diabetes in the metformin group.

CONCLUSIONS

In the placebo and lifestyle groups, VAT at both cuts, WHR, and WC predicted diabetes. No measure predicted diabetes in the metformin group. CT provided no important advantage over these simple measures. SAT did not predict diabetes.

Re-amputation occurrence in the diabetic population in South Wales, UK

The incidence of re-amputation following lower extremity amputations (LEA) among the diabetic patients referred to the Artificial Limb and Appliance Centers (ALAC) in South Wales, UK, was investigated. Manual and electronic data-gathering systems were used to extract the medical records of 473 people with various causes of LEA referred to the ALAC in South Wales during 2001-2003. The data included demographic information, causes of amputation and occurrence of various levels of re-amputation. Two hundred and five subjects with diabetes underwent 316 amputations, 44 were foot amputations and 272 major amputations on the ipsilateral and contra-lateral sides. Of the diabetic patients, 45.9% with single LEA underwent re-amputations with 22% incidence of contra-lateral LEA within 2 years. In comparison, 15% underwent re-amputations in the non diabetic dysvascular patients. Ipsilateral re-amputations occurred much earlier (average 21 weeks) compared with the contra-lateral amputations which took an average of 82 weeks following the first amputation. Nearly half of the diabetic patients with single LEA referred for rehabilitation underwent re-amputations within 2 years; out of which 22% of the patients underwent contra-lateral LEA. Although the progression of level of amputations does not follow a particular pattern, re-amputation on the contra-lateral side occurred almost four times later than that on the ipsilateral side.

Overview of epidemiologic studies of diabetic retinopathy

Diabetic retinopathy has been an important cause of blindness in young and middle age adults in the United States. Epidemiologic studies have quantitated the risk and have described potentially causal factors associated with many ocular complications of diabetes and other facets of this disease. A review of recent advances in diagnosis, treatment, temporal trends, and health care for diabetic retinopathy was conducted. Since the early 1980's, there have been studies of the variability of diabetic retinopathy in populations around the world and subpopulations in the United States which have demonstrated the high prevalences and incidences of this condition. Observational studies and clinical trials have documented the importance of glycemic and blood pressure control in the development and progression of this disease. There are some differences in the importance of confounders in different populations. Epidemiologic data have helped understand the importance of health care and health education in prevention and treatment of this condition. Observational studies have documented the importance of this disease on quality of life. Although there have been advances in understanding the distribution, causes, and severity of diabetic retinopathy, this is ever changing and requires continued monitoring. This is important because the increasing burden of diabetes will place a greater burden on the population and the medical care systems that will be caring for them.

Approaches to prevention of cardiovascular complications and events in diabetes mellitus

Diabetes mellitus affects about 8% of the adult population. The estimated number of patients with diabetes, presently about 170 million people, is expected to increase by 50-70% within the next 25 years. Diabetes is an important component of the complex of 'common' cardiovascular risk factors, and is responsible for acceleration and worsening of atherothrombosis. Major cardiovascular events cause about 80% of the total mortality in diabetic patients. Diabetes also induces peculiar microangiopathic changes leading to diabetic nephropathy conducive to end-stage renal failure, and to diabetic retinopathy that may progress to vision loss and blindness. In terms of major cardiovascular events, coronary heart disease and ischaemic stroke are the main causes of morbidity and mortality in diabetic patients. Peripheral arterial disease frequently occurs, and is more likely to be conducive to critical limb ischaemia and amputation than in the absence of diabetes. Although there are a number of differences in the pathogenesis and clinical features of diabetic macroangiopathy and microangiopathy, these two entities often coexist and induce mutually worsening effects. Endothelial injury, dysfunction and damage are common starting points for both conditions. Causes of endothelial injury can be distinguished into those 'common' to nondiabetic atherothrombosis, such as hypertension, dyslipidaemia, smoking, hypercoagulability and platelet activation; and those more specific and in some cases 'unique' to diabetes and directly related to the metabolic derangement of the disease, such as (i) desulfation of glycosaminoglycans (GAGs) of the vascular matrix; (ii) formation of advanced glycation end-products (AGE) and their endothelial receptors (RAGE); (iii) oxidative and reductive stress; (iv) decline in nitric oxide production; (v) activation of the renin-angiotensin aldosterone system (RAAS); and (vi) endothelial inflammation caused by glucose, insulin, insulin precursors and AGE/RAGE. Prevention of major cardiovascular events with the antithrombotic agent aspirin (acetylsalicylic acid) is widely recommended, but reportedly underutilised in patients with diabetes. However, some data suggest that aspirin may be less effective than expected in preventing cardiovascular events and especially mortality in patients with diabetes, as well as in slowing progression of retinopathy. In contrast, a recent study found picotamide, a direct thromboxane inhibitor, to be superior to aspirin in diabetic patients. Clopidogrel was either equivalent or less active in diabetic versus nondiabetic patients, depending upon different clinical settings.Recent studies have shown that some GAG compounds are able to reduce micro- and macroalbuminuria in diabetic nephropathy, and hard exudates in diabetic retinopathy, but it is as yet unknown whether these agents also influence the natural history of microvascular complications of diabetes. Lifestyle changes and physical exercise are also essential in preventing cardiovascular events in diabetic patients. Available data on the control of the metabolic state and the main risk factors show that careful adjustment of blood sugar and glycated haemoglobin is more effective in counteracting microvascular damage than in preventing major cardiovascular events. The latter objective requires a more comprehensive approach to the whole constellation of risk factors both specific for diabetes and common to atherothrombosis. This approach includes lifestyle modifications, such as dietary changes and smoking cessation and the use of HMG-CoA reductase inhibitors (statins), which are able to correct the lipid status and to prevent major cardiovascular events independently of the baseline lipidaemic or cardiovascular status. Tight control of hypertension is essential to reduce not only major cardiovascular events but also microvascular complications. Among antihypertensive measures, blockade of the RAAS by means of ACE inhibitors or angiotensin II receptor antagonists recently emerged as a potentially polyvalent approach, not only for treating hypertension and reducing cardiovascular events, but also to prevent or reduce albuminuria, counteract diabetic nephropathy and lower the occurrence of new type 2 diabetes in individuals at risk.

Therapy Insight: peripheral arterial disease and diabetes—from pathogenesis to treatment guidelines

The increased risk of atherothrombotic events present in all patients with peripheral arterial disease (PAD) is amplified with concomitant diabetes. Moreover, diabetes is associated with increased PAD severity. This Review summarizes atherothrombosis and PAD in patients with diabetes, and American College of Cardiology and American Heart Association guidelines for management of patients with PAD. Patients with PAD and diabetes require optimal limb care and aggressive cardiovascular risk reduction. An LDL cholesterol level of less than 1.8 mmol/l (<70 mg/dl) is the therapeutic goal in these patients, and this target should be pursued using an aggressive statin regimen. Fibrate therapy can also be indicated. beta-blockers and angiotensin-converting-enzyme inhibitors reduce cardiovascular events in high-risk patient populations, and these agents are recommended for use in patients with both diabetes and PAD. Blood pressure of less than 130/80 mmHg should be achieved, and glycated hemoglobin should be reduced to below 7%. Patients should also receive indefinite antiplatelet therapy with aspirin or clopidogrel. For patients with claudication, a supervised exercise program and cilostazol therapy to improve PAD symptoms and walking distance form the main noninvasive components of therapy. Revascularization can also be indicated in carefully selected patients with claudication. For patients with critical limb ischemia, diagnostic testing by a vascular specialist will determine whether revascularization or amputation is feasible.

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

AIMS/HYPOTHESIS

Risk estimates for stroke in patients with diabetes vary. We sought to obtain reliable risk estimates for stroke and the association with diabetes, comorbidity and lifestyle in a large cohort of type 2 diabetic patients in the UK.

MATERIALS AND METHODS

Using the General Practice Research Database, we identified all patients who had type 2 diabetes and were aged 35 to 89 years on 1 January 1992. We also identified five comparison subjects without diabetes and of the same age and sex. Hazard ratios (HRs) for stroke between January 1992 and October 1999 were calculated, and the association with age, sex, body mass index, smoking, hypertension, atrial fibrillation and duration of diabetes was investigated.

RESULTS

The absolute rate of stroke was 11.91 per 1,000 person-years (95% CI 11.41-12.43) in people with diabetes (n = 41,799) and 5.55 per 1,000 person-years (95% CI 5.40-5.70) in the comparison group (n = 202,733). The age-adjusted HR for stroke in type 2 diabetic compared with non-diabetic subjects was 2.19 (95% CI 2.09-2.32) overall, 2.08 (95% CI 1.94-2.24) in men and 2.32 (95% CI 2.16-2.49) in women. The increase in risk attributable to diabetes was highest among young women (HR 8.18; 95% CI 4.31-15.51) and decreased with age. No investigated comorbidity or lifestyle characteristic emerged as a major contributor to risk of stroke.

CONCLUSIONS/INTERPRETATION

This study provides risk estimates for stroke for an unselected population from UK general practice. Patients with type 2 diabetes were at an increased risk of stroke, which decreased with age and was higher in women. Additional risk factors for stroke in type 2 diabetic patients included duration of diabetes, smoking, obesity, atrial fibrillation and hypertension.

Diabetic erectile dysfunction--an indicator of generalised endothelial function per se?

Erectile dysfunction (ED) affects up to 70% of men with diabetes. However, the pathophysiology of ED in diabetes remains uncertain with both neuronal and vascular factors cited. We examined whether ED is an indicator of generalized endothelial dysfunction. A unique group of diabetic patients free from established conventional cardiac risk factors were investigated. Forearm bloodflow responses to nitroprusside and acetylcholine on 11 diabetic men with ED and 11 potent diabetic men were measured by venous plethysmography. Patient characteristics between the impotent and potent patients were similar except for Hba1c which was higher in the group with ED (8.35% vs. 7.03%: p = 0.003). Both groups showed increases in FBF to incremental infusions of nitroprusside and acetylcholine but the area under curve (AUC) were similar in the ED and the non-ED groups (p = 0.16 and p = 0.17, respectively). We demonstrated that ED in patients with type 2 diabetes is not associated with additional generalized endothelial dysfunction.

Diabetes information systems: a rapidly emerging support for diabetes surveillance and care

BACKGROUND

With the rapid advances in information technology in the last decade, various diabetes information systems have evolved in different parts of the world. Availability of new technologies and information systems for monitoring and treating diabetes is critical to achieving recommended metabolic control, including glycosylated hemoglobin levels. The first step is to develop a registry, including a patient identifier that can link multiple data sources, which can then serve as a springboard to electronic mechanisms for practitioners to gain information on performance and results.

OBJECTIVE

The aim is to review the provisions for diabetes surveillance in different parts of the world. This is a systematic review of national and regional information systems for diabetes surveillance.

LITERATURE REVIEW

A comprehensive review was undertaken using Medline literature review, internet search using the Google search engine, and e-mail consultation with opinion leaders. TOPICS REVIEW: National/regional-level diabetes surveillance systems in Europe, the United States, Australia/New Zealand, and Asia have been reviewed. State-of-the-art diabetes information systems linking multiple data sources, with extensive audit and feedback capabilities, have also been looked at.

RESULTS

National/regional-level audit databases have been tabulated. Diabetes information systems linking multiple data sources have been described. Most of the developed countries have now implemented systems such as diabetes registers and audits for diabetes surveillance in at least some regions, if not nationally. Developing nations are beginning to recognize the need for chronic disease management.

CONCLUSIONS

With the advancements in information technology, the diabetes registers have the potential to rise beyond their traditional functions with dynamic data integration, decision support, and data access, as demonstrated by some diabetes information systems. With the rapid pace of development in electronic health records and health information systems, countries that are beginning to build their health information technology infrastructure could benefit from planning and funding along these lines.

Hospital admissions in diabetic and non-diabetic patients: a case-control study

AIM

To examine differences in morbidity and rates of hospital admission between diabetes patients and patients without diabetes in New Zealand.

METHODS

A 1,123 and 11,325 patients with Types 1 and 2 diabetes in the Southlink Health diabetes register were identified. Types 1 and 2 diabetes patients were matched with non-diabetic patients drawn from primary care patient registers. Hospital admission rates for diabetic complications and general medical conditions, length of stay in hospital, patients readmitted, deaths in hospital and hospital procedures were analyzed for the 3-year period from 2000 to 2002.

RESULTS

Diabetes patients were more likely to be admitted to hospital for any reason than patients without diabetes (odds ratio (OR) 2.55, 95% confidence interval (CI) 2.13-3.04, p<0.001 for Type 1 patients; OR 1.40, CI 1.33-1.48, p<0.001 for Type 2 patients). A 46% (770) of all admissions for Type 1 patients were due to complications arising from diabetes and 33% (4685) for Type 2 patients. Major complications included ischaemic heart disease, heart failure, cataracts and conditions specific to diabetes.

CONCLUSIONS

Increasing prevalence of diabetes will increase demand for hospital services overall, and particularly for inpatient care related to macroangiopathy, ophthalmic and renal problems and peripheral circulatory disorders.

Mortality in people with type 2 diabetes in the UK

AIMS

Under-reporting of diabetes on death certificates contributes to the unreliable estimates of mortality as a result of diabetes. The influence of obesity on mortality in Type 2 diabetes is not well documented. We aimed to study mortality from diabetes and the influence of obesity on mortality in Type 2 diabetes in a large cohort selected from the General Practice Research Database (GPRD). Methods A cohort of 44 230 patients aged 35-89 years in 1992 with Type 2 diabetes was identified. A comparison group matched by year of birth and sex with no record of diabetes at any time was identified (219 797). Hazards ratios (HRs) for all-cause mortality during the period January 1992 to October 1999 were calculated using the Cox Proportional Hazards Model. The effects of body mass index (BMI), smoking and duration of diabetes on all-cause mortality amongst people with diabetes was assessed (n = 28 725). Results The HR for all-cause mortality in Type 2 diabetes compared with no diabetes was 1.93 (95% CI 1.89-1.97), in men 1.77 (1.72-1.83) and in women 2.13 (2.06-2.20). The HR decreased with increasing age. In the multivariate analysis in diabetes only, the HR for all-cause mortality amongst smokers was 1.50 (1.41-1.61). Using BMI 20-24 kg/m(2) as the reference range, for those with a BMI 35-54 kg/m(2) the HR was 1.43 (1.28-1.59) and for those with a BMI 15-19 kg/m(2) the HR was 1.38 (1.18-1.61).

CONCLUSIONS

Patients with Type 2 diabetes have almost double the mortality rate compared with those without. The relative risk decreases with age. In people with Type 2 diabetes, obesity and smoking both contribute to the risk of all-cause mortality, supporting doctrines to stop smoking and lose weight.

Prevalence of inadequate glycemic control among patients with type 2 diabetes in the United Kingdom general practice research database: A series of retrospective analyses of data from 1998 through 2002

BACKGROUND

Since the mid-1990s, the development of new oral antidiabetic agents (OAs) and treatment guidelines have created an opportunity to improve glycemic control in patients with type 2 diabetes.

OBJECTIVES

This study aimed to assess the prevalence of good and inadequate glycemic control across a 5-year period among patients with diabetes in the United Kingdom. It also investigated the factors associated with achieving glycemic targets.

METHODS

This was a retrospective, cross-sectional analysis of data from the General Practice Research Database. Three limits were used to assess glycosylated hemoglobin (HbA1c): 6.5%, 7.0%, or 7.5%. Values above the cutoffs indicated inadequate control of HbA1c; those at or below the cutoffs indicated good control. The study evaluated clinical and pharmacy data from the years 1998 to 2002 for patients with type 2 diabetes, > or =2 years of follow-up, and > or =2 HbA1c measurements during the first year. Five independent cross-sectional analyses were conducted, grouping data by year. Statistical significance was determined by Student t and chi2 tests.

RESULTS

Data were analyzed for 10,663 patients aged 17 to 98 years. The number of total eligible type 2 diabetes patients increased over the course of the study period: 5674 patients in 1998, 6553 in 1999, 7314 in 2000, 7323 in 2001, and 6192 in 2002. Overall, the study population had a mean (SD) age of 66 (11.0) years, was 53% male (3033/5674), and had a body mass index of 29 kg/m(2). Seventy-six percent of patients had HbA1c >7.0% and 37% were taking > or =2 oral agents. In 1998 and 2002, 79% (4482/5674) and 76% (4732/6192) of patients, respectively, had inadequate glycemic control, defined as HbA1c >7.0%. When defined as HbA1c >7.5%, 69% (3923/5674) and 62% (3814/6192) of patients, respectively, had inadequate control. Finally, when defined as HbA1c >6.5%, 88% (5011/5674) of patients in both 1998 and 2002 had inadequate control. Compared with patients with good disease control (HbA1c < or =7.0%), patients with inadequate control were approximately 2 years younger (P < 0.001) and had been prescribed more OAs: 41% received > or =2 OAs in 1998 and 52% in 2002, compared with 23% and 34% (both, P = 0.001), respectively, of patients with good glycemic control (P < 0.02). Sex, number of diabetes complications, and number of comorbidities did not differ between groups (P = NS).

CONCLUSIONS

Despite the introduction of new OAs and treatment guidelines, the prevalence of inadequate glycemic control remains high (>60%) in patients with type 2 diabetes in the United Kingdom. Regardless of the HbA1c cutoff, patients with inadequate control were younger and received prescriptions for more OAs than patients with good control.

Diabetes mellitus in individuals with spinal cord injury or disorder

BACKGROUND/OBJECTIVE

To examine diabetes prevalence, care, complications, and characteristics of veterans with a spinal cord injury or disorder (SCI/D).

METHODS

A national survey of veterans with an SCI/D was conducted using Behavioral Risk Factor Surveillance System (BRFSS) survey questions. Data were compared with national Centers for Disease Control and Prevention BRFSS data for veteran and nonveteran general populations.

RESULTS

Overall prevalence of diabetes in individuals with an SCI/D was 20% (3 times higher than in the general population). Veterans with an SCI/D and veterans, in general, had a higher prevalence of diabetes across all age groups; however, those with an SCI/D who were 45 to 59 years of age had a higher prevalence than other veterans. One fourth of the persons with an SCI/D and diabetes reported that diabetes affected their eyes or that they had retinopathy (25%), and 41% had foot sores that took more than 4 weeks to heal. More veterans, both with (63%) and without an SCI/D (60%), took a class on how to manage their diabetes than the general population (50%). Veterans with an SCI/D and diabetes were more likely to report other chronic conditions and poorer quality of life than those without diabetes.

CONCLUSIONS

Diabetes prevalence is greater among veterans with an SCI/D compared with the civilian population, but is similar to that of other veterans, although it may occur at a younger age in those with an SCI/D. Veterans with an SCI/D and diabetes reported more comorbidities, more slow-healing foot sores, and poorer quality of life than those without diabetes. Efforts to prevent diabetes and to provide early intervention in persons with SCI/D are needed.

Evidence-based management of peripheral vascular disease

Peripheral vascular disease (PVD) is very prevalent in the United States and is part of a global vascular problem. PVD patients have a heightened inflammatory state and are at high risk of death from acute cardiovascular problems rather than from progression of PVD. Modifiable risk factors for PVD include smoking, hypertension, diabetes, hyperlipidemia, elevated high sensitivity C-reactive protein, obesity, and the metabolic syndrome. Symptomatic treatment of claudication includes smoking cessation, exercise, cilostazol, statins, and revascularization with percutaneous or surgical therapy. Antithrombotic therapy with aspirin or clopidogrel is important to reduce cardiovascular events but does not affect symptoms of claudication. Patients with rest limb ischemia or ulceration should be revascularized to minimize the chance of limb loss. Percutaneous revascularization is not without significant complications, however, and future research needs to focus on inflammation, thrombosis, and restenosis in the PVD patient. Finally, new devices that tackle difficult lesions, drug-eluting stents, and pharmacologic agents that reduce global atherosclerosis are on the horizon and are likely to become critical components in the management of the PVD patient.