Prevalence of diabetic retinopathy and diabetic macular edema in a primary care-based teleophthalmology program for American Indians and Alaskan Natives

Prevalence and associated factors of proliferative diabetic retinopathy among adult diabetic patients in Northwest Ethiopia, 2023: A cross-sectional multicenter study

BACKGROUND

Proliferative diabetic retinopathy is one of the advanced complications of diabetic retinopathy. If left untreated, almost all eyes could lose a significant portion of their vision within four months. There is limited evidence regarding the magnitude of proliferative diabetic retinopathy and associated factors in the study setting and also in Ethiopia.

PURPOSE

To determine the magnitude and associated factors of proliferative diabetic retinopathy among adult diabetic patients attending Specialized Comprehensive Hospital-Diabetic Care Clinics in Northwest Ethiopia, 2023.

METHODS

A multicenter, hospital-based, cross-sectional study was conducted on 1219 adult diabetic patients selected by systematic random sampling technique. Data were collected through an in-person interview and physical examination. The Statistical Package for Social Science Version 20 was used to analyze the data. Logistic regression methods were used to test the association between predisposing factors and proliferative diabetic retinopathy. The adjusted odds ratio with a 95% confidence interval was used to determine the strength of association.

RESULTS

The prevalence of proliferative diabetic retinopathy was 3.1% (95% CI: 2.10%-4.10%). Hypertension (AOR = 4.35 (95% CI: 1.87-10.12)), peripheral neuropathy (AOR = 3.87 (95% CI: 1.57-9.54)), nephropathy (AOR = 2.58 (95% CI: 1.13-5.87)), ≥10 years duration of diabetes mellitus (AOR = 5.30 (95% CI: 2.32-12.14)), insulin use (AOR = 3.07 (95% CI: 1.08-8.68)), and poor adherence to diabetes mellitus medications (AOR = 3.77 (95% CI: 1.64-8.64)) were confirmed to have statistically significant association with proliferative diabetic retinopathy.

CONCLUSION

The prevalence of proliferative diabetic retinopathy among adult diabetic patients in the diabetes clinic was higher than the global study. Hypertension, peripheral neuropathy, nephropathy, ≥10 year's duration of diabetic mellitus, insulin use and poor adherence to diabetes mellitus medications were among the factors significantly associated with proliferative diabetic retinopathy.

Sight-threatening diabetic retinopathy and its predictors among patients with diabetes visiting Adare General Hospital in Southern Ethiopia: a hospital-based cross-sectional study

OBJECTIVE

The study aimed to determine the prevalence of sight-threatening diabetic retinopathy and its predictors among patients with diabetes attending Adare General Hospital in Southern Ethiopia.

DESIGN

A hospital-based cross-sectional study was conducted using a systematic random sampling method.

SETTING

The study was conducted at the diabetic clinic of Adare General Hospital in Sidama region, Southern Ethiopia.

PARTICIPANTS

The study included 391 patients with diabetes aged ≥18 years who had attended the diabetic clinic of Adare General Hospital in Southern Ethiopia.

MAIN OUTCOME MEASURES

Data were collected using questionnaires completed by an interviewer, a review of medical records and eye examinations.

RESULT

The study included 391 patients with diabetes with a median age of 49 years. The prevalence of sight-threatening diabetic retinopathy was 10.7% (95% CI: 7.7% to 14%). Rural dwellers (adjusted OR (AOR)=2.17, 95% CI: 1.05 to 4.46), duration of diabetes ≥6 years (AOR=2.43, 95% CI: 1.06 to 5.57), poor glycaemic control (AOR=2.80, 95% CI: 1.03 to 7.64), low physical activity (AOR=2.85, 95% CI: 1.01 to 8.05), hypertension (AOR=3.25, 95% CI: 1.48 to 7.15) and diabetic peripheral neuropathy (AOR=3.32, 95% CI: 1.18 to 9.33) were significantly associated with sight-threatening diabetic retinopathy.

CONCLUSION

This study showed a high prevalence of sight-threatening diabetic retinopathy. Sight-threatening diabetic retinopathy was significantly associated with modified factors such as glycaemic control, hypertension, physical activity and diabetic peripheral neuropathy. Therefore, all patients with diabetes were recommended to maintain normal blood glucose, avoid hypertension, exercise regularly and have regular eye examinations.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A Review of the Prevalence of Ophthalmologic Diseases in Native American Populations

PURPOSE

Compared with the general population in North America, Native American/American Indian and Alaska Native (AI/AN) populations experience a disparate prevalence of eye diseases. Visual impairment is a barrier to communication, interferes with academic and social success, and decreases overall quality of life. The prevalence of ocular pathology could serve as an indicator of health and social disparities. Therefore, the objective of this research was to perform a thorough review comparing the prevalence of common ophthalmological pathologies between AI/AN and non-AI/AN individuals in North America.

DESIGN

Retrospective, cross-sectional study.

METHODS

A total of 57 articles were retrieved and reviewed, and 14 met the criteria outlined for inclusion. These articles were retrieved from PubMed, MEDLINE, and ISI Web of Knowledge. Only studies that were peer reviewed in the last 25 years and reported on the prevalence of eye diseases in AI/AN compared with a non-AI/AN population met criteria.

RESULTS

Rates of retinopathy, cataracts, visual impairment, and blindness were clearly higher for AI/AN compared with non-AI/AN counterparts. Although rates of macular degeneration and glaucoma were similar between AI/AN and non-AI/AN populations, the treatment rates were lower and associated with poorer outcomes in AI/AN individuals.

CONCLUSIONS

There are considerable inequities in the prevalence and treatment rates of ophthalmologic conditions in AI/AN individuals. A likely explanation is the barrier of lack of access to adequate health and eye care. Because of substantial underinsurance and geographic variability, attention needs to be brought to expanding eye care access to AI/AN communities. The results are subject to the availability of appropriate technology, health literacy, and language.

Serum apolipoprotein A1 and B are associated with 6-month persistent and incident diabetic macular oedema in type 2 diabetes

AIMS

To investigate the associations of baseline apolipoprotein A1 (ApoA1) and B (ApoB) levels with persistent and incident diabetic macular oedema (DMO) after 6 months of follow-up.

METHODS

This is a prospective cohort study of patients aged ≥30 years with untreated diabetic retinopathy. Examinations, fundus photography and spectral domain optical coherence tomography (SD-OCT) were assessed at baseline, 1, 3 and 6 months. Serum lipids and apolipoproteins were analysed at a pathology laboratory. DMO was confirmed using SD-OCT, classified as (1) incident DMO, (2) persistent DMO and (3) regressed DMO. Eye-specific data were used, controlling for covariates and cluster effect.

RESULTS

We recruited 53 patients but only 38 completed the study [(62 eyes), 20 eyes (32.3%) with DMO]. Higher quartile of ApoA1 was associated with lower risk of persistent/incident DMO (p for trend 0.02), while higher ApoB/A1 was associated with higher risk of persistent/incident DMO (p for trend 0.02). Every 10 mg/dL increase in ApoA1 levels was associated with lower risk of persistent/incident DMO (OR 0.69; 95% CI 0.49 to 0.92; p value 0.016), whereas every 0.2 increase in ApoB/A1 was significantly associated with higher risk of persistent/incident DMO (OR 1.4; 95% CI 1.1 to 1.9; p value 0.013) at the end of the study.

CONCLUSION

Individuals with diabetes with higher ApoA1 had lower risk of persistent/incident DMO and those with higher ApoB/A1 had higher risk of persistent/incident DMO at the end of 6 months. These suggest that serum ApoA1 and ApoB/A1 levels may be important risk factors for DMO and could be predictive of persistent/incident DMO despite anti-vascular endothelial growth factor treatment.

Evaluating the Efficacy of Teleophthalmology in Delivering Ophthalmic Care to Underserved Populations: A Literature Review

Technological advancement has brought commendable changes in medicine, advancing diagnosis, treatment, and interventions. Telemedicine has been adopted by various subspecialties including ophthalmology. Over the years, teleophthalmology has been implemented in various countries, and continuous progress is being made in this area. In underserved populations, due to socioeconomic factors, there is little or no access to healthcare facilities, and people are at higher risk of eye diseases and vision impairment. Transportation is the major hurdle for these people in obtaining access to eye care in the main hospitals. There is a dire need for accessible eye care for such populations, and teleophthalmology is the ray of hope for providing eye care facilities to underserved people. Numerous studies have reported the advantages of teleophthalmology for rural populations such as being cost-effective, timesaving, reliable, efficient, and satisfactory for patients. Although it is being practiced in urban populations, for rural populations, its benefits amplify. However, there are certain obstacles as well, such as the cost of equipment, lack of steady electricity and internet supply in rural areas, and the attitude of people in certain regions toward acceptance of teleophthalmology. In this review, we have discussed in detail eye health in rural populations, teleophthalmology, and its effectiveness in rural populations of different countries.

Scoping review of telehealth use by Indigenous populations from Australia, Canada, New Zealand, and the United States

INTRODUCTION

Telehealth has the potential to address health disparities experienced by Indigenous people, especially in remote areas. This scoping review aims to map and characterize the existing evidence on telehealth use by Indigenous people and explore the key concepts for effective use, cultural safety, and building therapeutic relationships.

METHODS

A search for published and gray literature, written in English, and published between 2000 and 2022 was completed in 17 electronic databases. Two reviewers independently screened retrieved records for eligibility. For included articles, data were extracted, categorized, and analyzed. Synthesis of findings was performed narratively.

RESULTS

A total of 321 studies were included. The most popular type of telehealth used was mHealth (44%), and the most common health focuses of the telehealth interventions were mental health (26%) and diabetes/diabetic retinopathy (13%). Frequently described barriers to effective telehealth use included concerns about privacy/confidentiality and limited internet availability; meanwhile, telehealth-usage facilitators included cultural relevance and community engagement. Although working in collaboration with Indigenous communities was the most frequently reported way to achieve cultural safety, 40% of the studies did not report Indigenous involvement. Finally, difficulty to establish trusting therapeutic relationships was a major concern raised about telehealth, and evidence suggests that having the first visit-in-person is a potential way to address this issue.

CONCLUSION

This comprehensive review identified critical factors to guide the development of culturally-informed telehealth services to meet the needs of Indigenous people and to achieve equitable access and positive health outcomes.

Incidence and Progression of Diabetic Retinopathy in American Indian and Alaska Native Individuals Served by the Indian Health Service, 2015-2019

Importance

Estimates of diabetic retinopathy (DR) incidence and progression in American Indian and Alaska Native individuals are based on data from before 1992 and may not be informative for strategizing resources and practice patterns.

Objective

To examine incidence and progression of DR in American Indian and Alaska Native individuals.

Design, Setting, and Participants

This was a retrospective cohort study conducted from January 1, 2015, to December 31, 2019, and included adults with diabetes and no evidence of DR or mild nonproliferative DR (NPDR) in 2015 who were reexamined at least 1 time during the 2016 to 2019 period. The study setting was the Indian Health Service (IHS) teleophthalmology program for diabetic eye disease.

Exposure

Development of new DR or worsening of mild NPDR in American Indian and Alaska Native individuals with diabetes.

Main Outcomes and Measures

Outcomes were any increase in DR, 2 or more (2+) step increases, and overall change in DR severity. Patients were evaluated with nonmydriatic ultra-widefield imaging (UWFI) or nonmydriatic fundus photography (NMFP). Standard risk factors were included.

Results

The total cohort of 8374 individuals had a mean (SD) age of 53.2 (12.2) years and a mean (SD) hemoglobin A1c level of 8.3% (2.2%) in 2015, and 4775 were female (57.0%). Of patients with no DR in 2015, 18.0% (1280 of 7097) had mild NPDR or worse in 2016 to 2019, and 0.1% (10 of 7097) had PDR. The incidence rate from no DR to any DR was 69.6 cases per 1000 person-years at risk. A total of 6.2% of participants (441 of 7097) progressed from no DR to moderate NPDR or worse (ie, 2+ step increase; 24.0 cases per 1000 person-years at risk). Of patients with mild NPDR in 2015, 27.2% (347 of 1277) progressed to moderate NPDR or worse in 2016 to 2019, and 2.3% (30 of 1277) progressed to severe NPDR or worse (ie, 2+ step progression). Incidence and progression were associated with expected risk factors and evaluation with UWFI.

Conclusions and Relevance

In this cohort study, the estimates of DR incidence and progression were lower than those previously reported for American Indian and Alaska Native individuals. The results suggest extending the time between DR re-evaluations for certain patients in this population, if follow-up compliance and visual acuity outcomes are not jeopardized.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Prevalence of Diabetic Eye Diseases in American Indians and Alaska Natives (AI/AN) as Identified by the Indian Health Service's National Teleophthalmology Program Using Ultrawide Field Imaging (UWFI)

PURPOSE

Estimates of diabetic eye disease in American Indian and Alaska Natives (AI/AN) vary over time, region, and methods. This article reports recent prevalence of diabetic retinopathy (DR) and diabetic macular edema (DME) in AI/AN served by the Indian Health Services' (IHS) teleophthalmology program, as identified using ultrawide field imaging (UWFI).

METHODS

This was a retrospective analysis of 2016-2019 clinical data (n = 53,900). UWF images were acquired by certified imagers using a validated protocol, and graded by licensed, certified optometrists supervised by an ophthalmologist. Graders evaluated the extent/severity of retinal lesions in comparison to standard photographs. DR lesions predominantly in any peripheral field were considered "predominantly peripheral lesions" (PPL). The analyses calculated prevalence of any DR, any DME, DR and DME severity, sight-threatening disease, and PPL.

RESULTS

Patients averaged 56 years of age with a 68 mmol/mol A1c and 55% had had diabetes for 5+ years. Prevalence of any DR, any DME, and sight-threatening disease was 28.6%, 3.0%, and 3.0%. In patients with mild nonproliferative DR, PPL was seen in 25.3%. PPL suggested a more severe level of DR in 8.7% of patients. DR increased with age. DME decreased with age. Males and patients in the Nashville IHS area had more diabetic eye disease.

CONCLUSION

AI/AN have a high burden of diabetes and its complications. The IHS is resource-constrained, making accurate disease estimates necessary for resource allocation and budget justifications to Congress. These data update the estimates of diabetic eye disease in Indian Country and suggest that UWFI identifies early DR.

Social Determinants of Health and Impact on Screening, Prevalence, and Management of Diabetic Retinopathy in Adults: A Narrative Review

Diabetic retinal disease (DRD) is the leading cause of blindness among working-aged individuals with diabetes. In the United States, underserved and minority populations are disproportionately affected by diabetic retinopathy and other diabetes-related health outcomes. In this narrative review, we describe racial disparities in the prevalence and screening of diabetic retinopathy, as well as the wide-range of disparities associated with social determinants of health (SDOH), which include socioeconomic status, geography, health-care access, and education.

Epidemiology of Treated Diabetes Ocular Complications in France 2008-2018-The LANDSCAPE French Nationwide Study

AIM

LANDSCAPE aimed to estimate the annual incidence and prevalence of treated diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) between 2008 and 2018.

METHODS

This French nationwide observational study used data from the French National Health Insurance Databases covering 99% of the French population. Data about healthcare consumption were used to identify adults treated with anti-VEGFs or dexamethasone implants (for DME) and with pan-retinal photocoagulation (for PDR). All French patients newly treated between 2008 and 2018 were included. Incidence and prevalence of treated DME and PDR were estimated for the age-matched general population and the population with diabetes in France. Sociodemographic characteristics and medical history were described in both populations.

RESULTS

We identified 53,584 treated DME patients and 127,273 treated PDR patients between 2008 and 2018, and 11,901 DME and 11,996 PDR new incident patients in 2018. The treated DME incidence in 2018 was 2.5 per 10,000 in the general population and 37.3 per 10,000 in the population with diabetes. Prevalence in 2018 was 9.5 and 143.7 per 10,000 in the respective populations. Treated PDR incidence in 2018 was 2.3 per 10,000 in the general population and 31.2 per 10,000 in the population with diabetes. Prevalence in 2018 was 19.9 and 270.3 per 10,000 in the respective populations. Incidence and prevalence were not age-dependent. Incidence of treated PDR incidence was relatively stable from 2008-2018. Incidence of treated DME incidence rose from 2012-2018, probably due to widening access to newly available treatments, such as anti-VEGFs.

CONCLUSIONS

We provide exhaustive nationwide data on the incidence and prevalence of treated diabetic ocular complications in France over a 10-year period.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Screening of Diabetic Retinopathy Using Teleophthalmology to Complement Human Resources for Eye Health: A Systematic Review and Meta-Analysis

Diabetic retinopathy is a vascular disease of the retina that affects patients with uncontrolled diabetes. Untreated diabetic retinopathy (DR) can eventually lead to blindness. To date, diabetic retinopathy is the third leading cause of vision loss in the working class globally. Frequent retinal screening for all diabetic people is an effective method of preventing diabetic retinopathy blindness. This has relied on the use of ophthalmologists, but due to scarce resources, such as a shortage of human resources for eye health, this has denied many patients quality eye health care in a resource-limited setting. The recent advances on the use of teleophthalmology are promising to close this gap. This study aimed to map available evidence on the use of teleophthalmology in the screening of DR globally and to explore how this can be used to complement short-staffed eye clinics, especially in resource-constrained contexts. Studies were sourced from Google Scholar, PubMed, Science Direct, and EBSCO host. The final study selection was presented using a PRISMA chart. The mixed method appraisal tool was used to assess the quality of the nine studies included. The random effect model was used to estimate pooled prevalence estimates. Levels of heterogeneity were evaluated using Cochran's Q statistic and I2. Of nine included studies, eight were from high-income countries. The screening was performed at the primary healthcare level in eight of nine included studies. Only one study used a mydriatic agent, and the commonly used fundus camera was the non-mydriatic fundus camera. The overall estimated pooled prevalence of DR was 29 (95%CI: 10-34). Teleophthalmology at the primary health care level showed that early intervention in diabetic retinopathy reduced avoidable blindness and ensured remote access to eye health professionals, thus alleviating the burden on them.

Advancing Diabetes Prevention and Control in American Indians and Alaska Natives

As with many Indigenous populations globally, American Indians and Alaska Natives (AI/ANs) experience high rates of type 2 diabetes. Prevention efforts, ongoing medical care, patient self-management education, and support to prevent and reduce the risk of long-term complications must be developed to limit the impact of diabetes on individuals, families, and communities. Diabetes prevention and control require both individual- and community-level efforts as well as policies that attempt to mitigate contributing adverse socioeconomic factors. Congressional funding since 1998 continues to address the epidemic of diabetes in AI/AN groups with the Special Diabetes Program for Indians (SDPI), which has resulted in significant outcomes and key lessons that can inform new efforts to prevent diabetes in other populations and communities. The purpose of this review is to understand the context behind the epidemic of diabetes in AI/ANs, review the impact of the SDPI on prevention and control of diabetes as well as the translation of these strategies into clinical practice and their influence on health practice, and identify lessons learned for future efforts to address this ongoing challenge for AI/AN and other communities suffering from type 2 diabetes.

Sources of bias in artificial intelligence that perpetuate healthcare disparities-A global review

BACKGROUND

While artificial intelligence (AI) offers possibilities of advanced clinical prediction and decision-making in healthcare, models trained on relatively homogeneous datasets, and populations poorly-representative of underlying diversity, limits generalisability and risks biased AI-based decisions. Here, we describe the landscape of AI in clinical medicine to delineate population and data-source disparities.

METHODS

We performed a scoping review of clinical papers published in PubMed in 2019 using AI techniques. We assessed differences in dataset country source, clinical specialty, and author nationality, sex, and expertise. A manually tagged subsample of PubMed articles was used to train a model, leveraging transfer-learning techniques (building upon an existing BioBERT model) to predict eligibility for inclusion (original, human, clinical AI literature). Of all eligible articles, database country source and clinical specialty were manually labelled. A BioBERT-based model predicted first/last author expertise. Author nationality was determined using corresponding affiliated institution information using Entrez Direct. And first/last author sex was evaluated using the Gendarize.io API.

RESULTS

Our search yielded 30,576 articles, of which 7,314 (23.9%) were eligible for further analysis. Most databases came from the US (40.8%) and China (13.7%). Radiology was the most represented clinical specialty (40.4%), followed by pathology (9.1%). Authors were primarily from either China (24.0%) or the US (18.4%). First and last authors were predominately data experts (i.e., statisticians) (59.6% and 53.9% respectively) rather than clinicians. And the majority of first/last authors were male (74.1%).

INTERPRETATION

U.S. and Chinese datasets and authors were disproportionately overrepresented in clinical AI, and almost all of the top 10 databases and author nationalities were from high income countries (HICs). AI techniques were most commonly employed for image-rich specialties, and authors were predominantly male, with non-clinical backgrounds. Development of technological infrastructure in data-poor regions, and diligence in external validation and model re-calibration prior to clinical implementation in the short-term, are crucial in ensuring clinical AI is meaningful for broader populations, and to avoid perpetuating global health inequity.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Prevalence of the Burden of Diseases Causing Visual Impairment and Blindness in South Africa in the Period 2010-2020: A Systematic Scoping Review and Meta-Analysis

The prevalence of visual impairment (VI) continues to rise, despite efforts to reduce it. The burden of disease negatively impacts the quality of life, education opportunities, and other developments in various communities. Henceforth, this study aimed to determine and quantify the major causes of VI in South Africa, to ensure accurate interventions in addressing them and to reduce the burden of ocular disease in that context. A systematic scoping review was conducted to map evidence on VI and ocular diseases, using the PRISMA-P guidelines. English studies were searched for on PubMed, Google Scholar, and EBSCOhost using various search terms. The eligible articles underwent screening and ultimately data extraction to identify major causes of VI in South Africa. A meta-analysis further resulted in pooled prevalence estimates (PPE) using the Inverse Variance Heterogeneity (IVhet) model. Of the 13,527 studies screened at three levels, 10 studies met the inclusion criteria for the final review; however, 9 studies were eligible for quality assessment performed by two independent reviewers. The quality index for the included studies was 71.1%. The prevalence of VI was 2% for blindness and 12% for moderate and severe visual impairment (MSVI). Pooled prevalence identified uncorrected refractive error (URE) (43%), cataract (28%), glaucoma (7%), and diabetic retinopathy (4%) as major causes of MSVI. The leading causes of blindness were untreated cataracts (54%), glaucoma (17%), and diabetic retinopathy (57%). Ocular diseases causing VI are avoidable and similar to those of low-to-middle income countries. MSVI were caused by URE, cataract, glaucoma, and diabetic retinopathy. Blindness was mainly caused by cataracts, glaucoma, and diabetic retinopathy. A strategic plan to manage these conditions would largely reduce the burden of VI in the country. Early screenings and interventions to maximize care at primary health levels would decrease the burden of avoidable blindness in the country significantly.

Assessing Eye Health and Eye Care Needs Among North American Native Individuals

IMPORTANCE

There are few population-level studies on ophthalmic conditions and services among North American Native individuals.

OBJECTIVE

To evaluate whether disparities in ophthalmic conditions and services exist between North American Native individuals and non-Hispanic White individuals in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used 100% Medicare fee-for-service (MFFS) enrollment data from the Vision and Eye Health Surveillance System (VEHSS) to examine ophthalmic conditions and service use in North American Native individuals and non-Hispanic White individuals in the US. In this study North American Native individuals included those who identified as American Indian, Native Alaskan, Native Hawaiian, and Pacific Islander. Data were analyzed from August 2020 to April 2021.

INTERVENTIONS

Claims and sociodemographic characteristics were extracted and means computed for categories of ophthalmic conditions and select ophthalmic services. Ophthalmic conditions and services were defined in the VEHSS using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Logistic regression was used to model differences between age-adjusted mean ophthalmic condition and service claim rates among North American Native individuals and non-Hispanic White individuals for each age cohort. Matching ophthalmic condition claim rates and ophthalmic service claim rates was performed to examine disparities by racial group.

MAIN OUTCOMES AND MEASURES

Mean age-adjusted claim rates for ophthalmic conditions and services among North American Native individuals vs non-Hispanic White individuals per 100 persons.

RESULTS

Claims were identified for 177 100 Native American Native individuals and 24 438 000 non-Hispanic White individuals. In 16 of 17 ophthalmic condition categories and 6 of 9 service categories, North American Native individuals had significantly different claim rates from non-Hispanic White individuals. There were higher ophthalmic condition claim rates but lower service claim rates for North American Native individuals (vs non-Hispanic White individuals) for refractive errors (ophthalmic condition, 17.2 vs 11.1; service, 48.3 vs 49.6, respectively; P < .001); blindness and low vision (ophthalmic condition, 1.48 vs 0.75: service, 19.2 vs 20.1, respectively; P < .001); injury, burns, and surgical complications (ophthalmic condition, 1.8 vs 1.7; service, 19.2 vs 20.1, respectively; P < .001); and orbital and external disease (ophthalmic condition, 15.7 vs 13.3; service, 48.3 vs 49.6, respectively; P < .001). For diabetic eye diseases, North American Native individuals had higher ophthalmic condition claim rates (5.22 vs 2.20) but no difference in service claim rates (14.4 vs 14.8; P = .26) compared with non-Hispanic White individuals.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, North American Native individuals had higher prevalence of ophthalmic conditions but no corresponding increase in services (treatment for most ophthalmic conditions) compared with non-Hispanic White individuals. These results suggest worse eye health and higher unmet eyecare needs for North American Native individuals with MFFS coverage compared with non-Hispanic White individuals with MFFS coverage.

Epidemiology of Type 2 Diabetes in Indigenous Communities in the United States

PURPOSE OF REVIEW

The present review focuses on the epidemiology of type 2 diabetes (T2D) in Indigenous communities in the continental United States (U.S.)-including disease prevention and management-and discusses special considerations in conducting research with Indigenous communities.

RECENT FINDINGS

Previous studies have reported the disparately high prevalence of diabetes, especially T2D, among Indigenous peoples in the U.S. The high prevalence and incidence of early-onset T2D in Indigenous youth relative to that of all youth in the U.S. population pose challenges to the prevention of complications of diabetes. Behavioral, dietary, lifestyle, and genetic factors associated with T2D in Indigenous communities are often investigated. More limited is the discussion of the historical and ongoing consequences of colonization and displacement that impact the aforementioned risk factors. Future research is necessary to assess community-specific needs with respect to diabetes prevention and management across the diversity of Indigenous communities in the U.S.

Prevalence of Diabetic Retinopathy and Risk Factors among Diabetic Patients at University of Gondar Tertiary Eye Care and Training Center, North-West Ethiopia

PURPOSE:

Diabetic retinopathy (DR) is one of the most serious complications of diabetes mellitus (DM). It is the most common cause of blindness among the working age group in the developed world and the fifth leading cause of global blindness. In Sub-Saharan Africa, 2.8% of all blindness is caused by DR. Studies addressing the prevalence of DR and associated factors are scarce in Ethiopia. The objective of this study was to determine the Prevalence and associated factors of DR development among DM patients attending University of Gondar, Tertiary Eye Care and Training center.

METHODS:

A cross-sectional study was carried out from March 2019 to February 2020 involving all consecutive diabetes patients who visited the center during the study period. Data were collected using a semi-structured questionnaire and data extraction check list and entered into SPSS version 20 and analyzed. Univariate and multivariable logistic regression analysis were done to identify predictors of DR. Statistical significance was determined with 95% confidence interval (CI) using odds ratio and P < 0.05.

RESULTS:

A total of 225 DM patients with a mean age of 55.4 ± 13.5 years were studied, of whom 95 (42.2%) had DR. Duration of diabetes ≥6 years (AOR = 2.91: 95% CI; 1.01–8.35) and baseline age < 60 years (AOR = 3.2: 95% CI; 1.19–8.63) were significantly associated with DR. DR was significantly associated with the form of therapy. Those on insulin (P = 0.025) and oral hypoglycemic agents (OHA) with insulin combination (P = 0.014) had statistically significantly associated with the development of DR. Patients with systolic blood pressure of <140 mmHg were 3.6 times (AOR = 0.28: 95% CI: 0.09–0.82) less likely to have DR. A majority of patients had nonproliferative DR without diabetic macular edema (DME) (34.2%). DME and proliferative DR were seen in 5.7% and 3.6% of the patients, respectively. Vision threatening DR (VTDR) was seen in 10.7% of patients. There was a significant association between age <60 years and VTDR (AOR = 4.19: 95% CI; 1.23–14.35).

CONCLUSION:

The prevalence of DR among our study patients was very high. Longer duration of diabetes, higher systolic blood pressure, baseline age <60 years, use of insulin alone, and use of combination of insulin with OHA were independently associated with DR. Health education, early screening, and treatment are recommended.

Multi-level Diabetes Prevention and Treatment Interventions for Native People in the USA and Canada: a Scoping Review

PURPOSE OF REVIEW

This scoping literature review seeks to answer the question "What is known in the existing literature about multi-level diabetes prevention and treatment interventions for Native people living in the United States and Canada?"

RECENT FINDINGS

Multi-level interventions to prevent and/or treat chronic diseases, such as diabetes, promise to help individuals who experience health disparities related to social determinants of health. As described by the socio-ecological model, such interventions mobilize support through a combination of individual, interpersonal, organizational, community, and policy levels of activity. This review revealed little literature about multi-level diabetes prevention and/or treatment programs for US and Canada-based Native peoples. Ten interventions were identified; all focused on diabetes prevention; eight were specific to youth. Multi-level intervention design elements were largely individual-, school-, and community-based. Only three interventions included environmental or policy-level components.

A Systematic Review of Current Teleophthalmology Services in New Zealand Compared to the Four Comparable Countries of the United Kingdom, Australia, United States of America (USA) and Canada

Background

Over 700,000 New Zealanders (NZ), particularly elderly and Māori, live without timely access to specialist ophthalmology services. Teleophthalmology is a widely recognised tool that can assist in overcoming resource and distance barriers. Teleophthalmology gained unprecedented traction in NZ during the COVID-19 pandemic and subsequent lockdown. However, its provision is still limited and there are equity issues. The aim of this study was to conduct a systematic review identifying, describing and contrasting teleophthalmology services in NZ with the comparable countries of Australia, USA, Canada and the United Kingdom.

Methods

The electronic databases Embase, PubMed, Web of Science, Google Scholar and Google were systemically searched using the keywords: telemedicine, ophthalmology, tele-ophthalmology/teleophthalmology. The searches were filtered to the countries above, with no time constraints. An integrative approach was used to synthesise findings.

Results

One hundred and thirty-two studies were identified describing 90 discrete teleophthalmology services. Articles spanned from 1997 to 2020. Models were categorised into general eye care (n=21; 16%); emergency/trauma (n=6; 4.5%); school screening (n=25; 19%); artificial intelligence (AI) (n=23; 18%); and disease-specific models of care (MOC) (n=57; 43%). The most common diseases addressed were diabetic retinopathy (n=23; 17%); retinopathy of prematurity (n=9; 7%); and glaucoma (n=8; 6%). Programs were mainly centred in the US (n=72; 54.5%), followed by the UK (n=29; 22%), then Canada (n=16; 12%), Australia (n=13; 10%), with the fewest identified in NZ (n=3; 2%). Models generally involved an ophthalmologist consultative service, remote supervision and triaging. Most models involved local clinicians transmitting fed-forward or live images.

Conclusion

Teleophthalmology will likely play a crucial role in the future of eye care. COVID-19 has offered a unique opportunity to observe the use of teleophthalmology services globally. Feed-forward and, increasingly, live-based teleophthalmology services have demonstrated feasibility and cost-effectiveness in similar countries internationally. New Zealand’s teleophthalmology services, however, are currently limited. Investing in strategic partnerships and technology at a national level can advance health equities in ophthalmic care.

Global and Regional Prevalence of Diabetic Retinopathy; A Comprehensive Systematic Review and Meta-analysis

PURPOSE

We conducted a systematic search to estimate DR prevalence in different age and gender groups, and to evaluate the determinants of heterogeneity in its prevalence.

METHODS

A systematic and comprehensive search from inception to August 10, 2020, was done in international databases, including Scopus, PubMed, Web of Science, Embase, and other data sources without any restriction to find cross-sectional studies related to the prevalence of DR.

RESULTS

Of 6399 studies, 90 articles with a sample size of 563460 individuals and 204189 diabetic patients were analyzed. The estimated pooled prevalence of DR in the diabetic population in general; in female and in male was 28.41% (95% CI: 25.98 to 30.84); 25.93% (95% CI: 23.54 to 28.31) and 28.95% (95% CI: 26.57 to 31.32); respectively and the prevalence of DR showed no inter-gender difference. The heterogeneity of the pooled prevalence according to I² was 99% (p < .001). According to the meta-regression results, the variables of WHO region (Coefficient of AMRO vs SEARO: 15.56; p: 0.002), age (Coefficient of above 60 years vs below 40 year: 18.67; p: 0.001), type of DR (Coefficient: 19.01; p < .001), and publication year (Coefficient: -0.60; p: 0.001) had a significant correlation with heterogeneity.

CONCLUSION

One third of diabetic patients suffered from DR, mostly NPDR. DR increased markedly after the age of 60 years, which could be due to the longer duration of diabetes. Age, WHO region, type of DR, and publication year affected the heterogeneity in the prevalence of DR.

Genetics of Diabetic Retinopathy, a Leading Cause of Irreversible Blindness in the Industrialized World

Diabetic retinopathy (DR) is a chronic complication of diabetes and a leading cause of blindness in the industrialized world. Traditional risk factors, such as glycemic control and duration of diabetes, are unable to explain why some individuals remain protected while others progress to a more severe form of the disease. Differences are also observed in DR heritability as well as the response to anti-vascular endothelial growth factor (VEGF) treatment. This review discusses various aspects of genetics in DR to shed light on DR pathogenesis and treatment. First, we discuss the global burden of DR followed by a discussion on disease pathogenesis as well as the role genetics plays in the prevalence and progression of DR. Subsequently, we provide a review of studies related to DR’s genetic contribution, such as candidate gene studies, linkage studies, and genome-wide association studies (GWAS) as well as other clinical and meta-analysis studies that have identified putative candidate genes. With the advent of newer cutting-edge technologies, identifying the genetic components in DR has played an important role in understanding DR incidence, progression, and response to treatment, thereby developing newer therapeutic targets and therapies.

Associations with sight-threatening diabetic macular oedema among Indigenous adults with type 2 diabetes attending an Indigenous primary care clinic in remote Australia: a Centre of Research Excellence in Diabetic Retinopathy and Telehealth Eye and Associated Medical Services Network study

Objective

To identify factors associated with sight-threatening diabetic macular oedema (STDM) in Indigenous Australians attending an Indigenous primary care clinic in remote Australia.

Methods and analysis

A cross-sectional study design of retinopathy screening data and routinely-collected clinical data among 236 adult Indigenous participants with type 2 diabetes (35.6% men) set in one Indigenous primary care clinic in remote Australia. The primary outcome variable was STDM assessed from retinal images.

Results

Age (median (range)) was 48 (21–86) years, and known diabetes duration (median (range)) was 8.0 (0–24) years. Prevalence of STDM was high (14.8%) and similar in men and women. STDM was associated with longer diabetes duration (11.7 vs 7.9 years, respectively; p<0.001) and markers of renal impairment: abnormal estimated Glomerular Filtration Rate (eGFR) (62.9 vs 38.3%, respectively; p=0.007), severe macroalbuminuria (>300 mg/mmol) (20.6 vs 5.7%, respectively; p=0.014) and chronic kidney disease (25.7 vs 12.2%, respectively; p=0.035). Some clinical factors differed by sex: anaemia was more prevalent in women. A higher proportion of men were smokers, prescribed statins and had increased albuminuria. Men had higher blood pressure, but lower glycated Haemoglobin A1c (HbA1c) levels and body mass index, than women.

Conclusion

STDM prevalence was high and similar in men and women. Markers of renal impairment and longer diabetes duration were associated with STDM in this Indigenous primary care population. Embedded teleretinal screening, known diabetes duration-based risk stratification and targeted interventions may lower the prevalence of STDM in remote Indigenous primary care services.

Trial registration number

Australia and New Zealand Clinical Trials Register: ACTRN 12616000370404.

Eye care delivery models to improve access to eye care for Indigenous peoples in high-income countries: a scoping review

Purpose

Globally, there are ~370 million Indigenous peoples. Indigenous peoples typically experience worse health compared with non-Indigenous people, including higher rates of avoidable vision impairment. Much of this gap in eye health can be attributed to barriers that impede access to eye care services. We conducted a scoping review to identify and summarise service delivery models designed to improve access to eye care for Indigenous peoples in high-income countries.

Methods

Searches were conducted on MEDLINE, Embase and Global Health in January 2019 and updated in July 2020. All study designs were eligible if they described a model of eye care service delivery aimed at populations with over 50% Indigenous peoples. Two reviewers independently screened titles, abstracts and full-text articles and completed data charting. We extracted data on publication details, study context, service delivery interventions, outcomes and evaluations, engagement with Indigenous peoples and access dimensions targeted. We summarised findings descriptively following thematic analysis.

Results

We screened 2604 abstracts and 67 studies fulfilled our eligibility criteria. Studies were focused on Indigenous peoples in Australia (n=45), USA (n=11), Canada (n=7), New Zealand (n=2), Taiwan (n=1) and Greenland (n=1). The main disease focus was diabetic retinopathy (n=30, 45%), followed by ‘all eye care’ (n=16, 24%). Most studies focused on targeted interventions to increase availability of services. Fewer than one-third of studies reported involving Indigenous communities when designing the service. 41 studies reflected on whether the model improved access, but none undertook rigorous evaluation or quantitative assessment.

Conclusions

The geographical and clinical scope of service delivery models to improve access to eye care for Indigenous peoples in high-income countries is narrow, with most studies focused on Australia and services for diabetic retinopathy. More and better engagement with Indigenous communities is required to design and implement accessible eye care services.

The Role of Telemedicine, In-Home Testing and Artificial Intelligence to Alleviate an Increasingly Burdened Healthcare System: Diabetic Retinopathy

In the presence of the ever-increasing incidence of diabetes mellitus (DM), the prevalence of diabetic eye disease (DED) is also growing. Despite many improvements in diabetic care, DM remains a leading cause of visual impairment in working-age patients. So far, prevention has been the best way to protect vision. The sooner we diagnose DED, the more effective the treatment is. Thus, diabetic retinopathy (DR) screening, especially with imaging techniques, is a method of choice for vision protection. To alleviate the burden of diabetic patients who need ophthalmic care, telemedicine and in-home testing are used, supported by artificial intelligence (AI) algorithms. This is why we decided to evaluate current image teleophthalmology methods used for DR screening. We searched the PubMed platform for papers published over the last 5 years (2015–2020) using the following key words: telemedicine in diabetic retinopathy screening, diabetic retinopathy screening, automated diabetic retinopathy screening, artificial intelligence in diabetic retinopathy screening, smartphone diabetic retinopathy testing. We have included 118 original articles meeting the above criteria, discussing imaging diabetic retinopathy screening methods. We have found that fundus cameras, stable or mobile, are most commonly used for retinal photography, with portable fundus cameras also relatively common. Other possibilities involve the use of ultra-wide-field (UWF) imaging and even optical coherence tomography (OCT) devices for DR screening. Also, the role of smartphones is increasingly recognized in the field. Retinal fundus images are assessed by humans instantly or remotely, while AI algorithms seem to be useful tools facilitating retinal image assessment. The common use of smartphones and availability of relatively cheap, easy-to-use adapters for retinal photographs augmented by AI algorithms make it possible for eye fundus photographs to be taken by non-specialists and in non-medical setting. This opens the way for in-home testing conducted on a much larger scale in the future. In conclusion, based on current DR screening techniques, we can suggest that the future practice of eye care specialists will be widely supported by AI algorithms, and this way will be more effective.

Discovery and validation of hsa_circ_0001953 as a potential biomarker for proliferative diabetic retinopathy in human blood

PURPOSE

This study aimed to determine whether circular RNAs (circRNAs) in whole blood could be served as novel non-invasive biomarkers for proliferative diabetic retinopathy (PDR).

METHODS

This retrospective cross-sectional study comprised 34 healthy participants, 34 PDR patients and 34 non-proliferative DR (NPDR) patients. High-throughput whole transcriptome sequencing was performed to explore the expression profile of circRNAs in the whole blood, and the candidate circRNAs were validated by quantitative real-time polymerase chain reaction (qRT-PCR). Receiver operating characteristic (ROC) analysis evaluated the ability of these candidate circRNAs in discriminating PDR patients from NPDR patients and healthy subjects. Finally, the networks of circRNA-miRNA-mRNA based on the candidate circRNAs were constructed.

RESULTS

Using sequencing and qRT-PCR, hsa_circ_0001953 was found to be elevated in PDR patients in contrast with the other two groups. Statistical analysis showed that the expression levels of hsa_circ_0001953 in PDR patients were positively related to the duration of diabetes and HbAc1. Receiver operating characteristic (ROC) curve analysis revealed that hsa_circ_0001953 was associated with a high diagnostic accuracy in discriminating PDR patients from NPDR patients and healthy controls, resulting in an area under the curve (AUC) of 0.87 and 0.92, respectively. The circRNA-miRNA-target gene networks for hsa_circ_0001953 showed that hsa_circ_0001953 could interact with dozens of miRNAs and some targeted mRNAs have been potentially involved in the pathogenesis of diabetes.

CONCLUSION

The present findings indicate that hsa_circ_0001953 in the whole blood may serve as a novel diagnostic biomarker and potential therapeutic target for PDR.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Digital health technology for Indigenous older adults: A scoping review

BACKGROUND

Telehealth implementation is a great solution for Indigenous older adults (OAs) due to the rise of chronic disease and other age-related health disorders. Telehealth is a promising option to increase quality of life, decrease healthcare costs, and offer more independent living.

OBJECTIVES

This scoping review investigated existing telehealth solutions that have been implemented to serve Indigenous OAs.

METHODS

A structured search strategy was performed on 6 electronic databases: Ovid Medline, Ovid PsycINFO, Ovid Embase, EBSCOhost, Scopus and Cochrane. Studies were included in the review if they contained information on telehealth technologies for Indigenous OAs (aged 65 years and older). Grey literature was also explored in ProQuest Theses and Dissertations, ERIC, Google Advanced and various government websites from Canada, Australia/New Zealand and the USA.

RESULTS

Twenty six articles were included and reviewed by two assessors. Analysis of the results from five countries revealed eight different types of telehealth solutions for Indigenous OAs. No documented telerehabilitation technologies were available to OAs in Indigenous Communities. Analysis of a broad range of Indigenous OAs with different chronic diseases revealed that they are seeking telehealth technologies for ease of access to health care, increased health equity and cost-effectiveness. Results revealed various advantages of telehealth for Indigenous OAs and barriers for implementing such technologies in Indigenous communities.

CONCLUSION

The use of telehealth technologies among OAs is expected to rise, but effective implementation will be successful only if the patient's acceptance and culture are kept at the forefront, and if healthcare services are provided by telehealth-trained healthcare professionals.

The Association between Social Determinants of Health and Self-Reported Diabetic Retinopathy: An Exploratory Analysis

One-third of Americans with diabetes will develop diabetic retinopathy (DR), the leading cause of blindness in working-age Americans. Social determinants of health (SDOHs) are conditions in a person’s environment that may impact health. The objective of this study was to determine whether there is an association between SDOHs and DR in patients with type II diabetes. This cross-section study used data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). This study included people with self-reported diabetes in the US in 2018 (n = 60,703). Exposure variables included homeownership, marital status, income, health care coverage, completed level of education, and urban vs. rural environment. The outcome variable was DR. Logistic regression analysis were applied to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Alaskan Native/Native American (OR 2.11; 95% CI: 1.14–3.90), out of work (OR 2.82; 95% CI: 1.62–4.92), unable to work (OR 2.14; 95% CI: 1.57–2.91), did not graduate high school (OR 1.91; 95% CI: 1.30–2.79), only graduated high school (OR 1.43; 95% CI 1.08–1.97), or only attended college or technical school without graduating (OR 1.42; 95% CI: 1.09–1.86) were SDOHs associated with DR in patients with diabetes. Health care providers should identify these possible SDOHs affecting their diabetic patients.

Sight-threatening Diabetic Retinopathy and Associated Risk Factors Among Adult Diabetes Patients at Debre Tabor General Hospital, Northwest Ethiopia

BACKGROUND

People with diabetes have an increased risk of developing sight-threatening conditions. Sight threatening diabetic retinopathy (STDR) is an advanced microvascular of complication of diabetes on the eye. It remains one of the leading causes of preventable blindness among working age adults around the world. There is a paucity of evidence on the prevalence of STDR and its associated factors in Ethiopia, particularly in the study area. Therefore, the aim of our study was to determine the prevalence of STDR and its associated factors among adult diabetes patients at Debre Tabor General Hospital (DTGH), Northwest Ethiopia.

MATERIALS AND METHODS

An institution-based cross-sectional study was conducted on 306 diabetes patients at Debre Tabor General Hospital with systematic random sampling technique. Semi-structured questionnaire, document review and physical examination were applied to collect the data. Binary and multivariable logistic regression model were used to identify associated factors for STDR.

RESULTS

The majority of the participants 163 (53.3%) were type 1 diabetes (T1DM) and the mean age of T1 and T2 DM participants was 34.5 (12.8) and 58.7 (10.7) years respectively. The prevalence of STDR was 15.3% (95%CI: 9.6%-20.9%) and 11.9% (6.6-17.5) in T1DM and T2DM, respectively. Low family monthly income (adjusted odds ratio (AOR)=4.4, 95%CI: 1.05-18.40) among T2DM, longer duration of diabetes (AOR=10.9, 95%CI: 2.94-40.4) among T1DM (AOR=3.54, 95CI: 1.06-11.8) among T2DM and poor glycemic control (AOR=3.93, 95%CI: 1.06-14.5) and hypertension (AOR=5.86, 95%CI: 1.20-28.6) among T1DM and BMI (AOR=4.79, 95%CI: 1.35-17.00) among T2DM were significantly associated with STDR.

CONCLUSION AND RECOMMENDATION

The prevalence of STDR was high. Low family monthly income, longer duration of diabetes, poor glycemic control, hypertension and obesity were positively associated with STDR. Early screening of STDR and improving diabetes self management in all diabetes patients were recommended.

The Indian Health Service Primary Care-Based Teleophthalmology Program for Diabetic Eye Disease Surveillance and Management

Background: Historically, fewer than half of American Indians and Alaska Natives (AI/AN) with diabetes received the annual diabetic retinopathy (DR) examination that is considered the minimum standard of care; this rate is similar to that of the general United States (U.S.) population with diabetes. Solution: The Indian Health Service-Joslin Vision Network (IHS-JVN) Teleophthalmology Program in 2000 to increase compliance with DR standards of care among AI/AN through validated, primary care-based telemedicine. The IHS-JVN provides remote diagnosis of DR severity, with a report including management recommendations that is returned to the patient's primary care provider. The program conforms with the American Telemedicine Association (ATA) Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy. Outcomes: The IHS-JVN has been expanding incrementally since the first patients were recruited in 2000; this expansion coincides with large improvements in the annual DR examination rates reported as part of local, regional, and national regulatory compliance under the Government Performance and Results Act (GPRA). Currently, with 99 clinical implementations in 23 states, IHS-JVN is the largest primary care-based ATA validation category three telemedicine program in the U.S. Summary: This article describes the program's workflow, imaging and reading technologies, diagnostic protocols, reports to providers, training, quality assurance processes, and geographical distribution. In addition to its clinical use, the program has been utilized in research on utilization of diabetic eye care, cost-effectiveness, technology development, and DR epidemiology of the AI/AN population. Potential next steps for this program are discussed.

Systemic Disease and Ocular Comorbidity Analysis of Geographically Isolated Federally Recognized American Indian Tribes of the Intermountain West

BACKGROUND

The American Indian Navajo and Goshute peoples are underserved patient populations residing in the Four Corners area of the United States and Ibupah, Utah, respectively.

METHODS

We conducted a cross-sectional study of epidemiological factors and lipid biomarkers that may be associated with type II diabetes, hypertension and retinal manifestations in tribal and non-tribal members in the study areas (n = 146 participants). We performed multivariate analyses to determine which, if any, risk factors were unique at the tribal level. Fundus photos and epidemiological data through standardized questionnaires were collected. Blood samples were collected to analyze lipid biomarkers. Univariate analyses were conducted and statistically significant factors at p < 0.10 were entered into a multivariate regression.

RESULTS

Of 51 participants for whom phenotyping was available, from the Four Corners region, 31 had type II diabetes (DM), 26 had hypertension and 6 had diabetic retinopathy (DR). Of the 64 participants from Ibupah with phenotyping available, 20 had diabetes, 19 had hypertension and 6 had DR. Navajo participants were less likely to have any type of retinopathy as compared to Goshute participants (odds ratio (OR) = 0.059; 95% confidence interval (CI) = 0.016-0.223; p < 0.001). Associations were found between diabetes and hypertension in both populations. Older age was associated with hypertension in the Four Corners, and the Navajo that reside there on the reservation, but not within the Goshute and Ibupah populations. Combining both the Ibupah, Utah and Four Corners study populations, being American Indian (p = 0.022), residing in the Four Corners (p = 0.027) and having hypertension (p < 0.001) increased the risk of DM. DM (p < 0.001) and age (p = 0.002) were significantly associated with hypertension in both populations examined. When retinopathy was evaluated for both populations combined, hypertension (p = 0.037) and living in Ibupah (p < 0.001) were associated with greater risk of retinopathy. When combining both American Indian populations from the Four Corners and Ibupah, those with hypertension were more likely to have DM (p < 0.001). No lipid biomarkers were found to be significantly associated with any disease state.

CONCLUSIONS

We found different comorbid factors with retinal disease outcome between the two tribes that reside within the Intermountain West. This is indicated by the association of tribe and with the type of retinopathy outcome when we combined the populations of American Indians. Overall, the Navajo peoples and the Four Corners had a higher prevalence of chronic disease that included diabetes and hypertension than the Goshutes and Ibupah. To the best of our knowledge, this is the first study to conduct an analysis for disease outcomes exclusively including the Navajo and Goshute tribe of the Intermountain West.

Sustained Lower Incidence of Diabetes-Related End-Stage Kidney Disease Among American Indians and Alaska Natives, Blacks, and Hispanics in the U.S., 2000-2016

OBJECTIVE

Diabetes-related end-stage kidney disease (ESKD-D) disproportionately affects U.S. racial/ethnic minority populations compared with whites. However, from 1996 to 2013, ESKD-D incidence among American Indians and Alaska Natives (AIANs) and blacks declined. We assessed recent ESKD-D incidence data to determine whether trends by race/ethnicity have changed since 2013.

RESEARCH DESIGN AND METHODS

United States Renal Data System data from 2000 to 2016 were used to determine the number of whites, blacks, AIANs, Asians, and Hispanics aged ≥18 years with newly treated ESKD-D (with diabetes listed as primary cause). Using census population estimates as denominators, annual ESKD-D incidence rates were calculated and age adjusted to the 2000 U.S. standard population. Joinpoint regression was used to analyze trends and estimate an average annual percent change (AAPC) in incidence rates.

RESULTS

For adults overall, from 2000 to 2016, age-adjusted ESKD-D incidence rates decreased by 53% for AIANs (66.7-31.2 per 100,000, AAPC -4.5%, P < 0.001), by 33% for Hispanics (50.0-33.3, -2.1%, P < 0.001), and by 20% for blacks (56.2-44.7, -1.6%, P < 0.001). However, during the study period, age-adjusted ESKD-D incidence rates did not change significantly for Asians and increased by 10% for whites (15.4-17.0, 0.6%, P = 0.01). In 2016, ESKD-D incidence rates in AIANs, Hispanics, and blacks were ∼2.0-2.5 times higher than whites.

CONCLUSIONS

ESKD-D incidence declined for AIANs, Hispanics, and blacks and increased for whites. Continued efforts might be considered to reverse the trend in whites and sustain and lower ESKD-D incidence in the other populations.

Diabetic Retinopathy Screening Using a Gold Nanoparticle-Based Paper Strip Assay for the At-Home Detection of the Urinary Biomarker 8-Hydroxy-2'-Deoxyguanosine

PURPOSE

We sought to assess a smartphone-based, gold nanoparticle-based colorimetric lateral flow immunoassay paper sensor for quantifying urine 8-hydroxy-2'-deoxyguanosine (8-OHdG) as a biomarker for diabetic retinopathy (DR) screening.

METHODS

Paper strips incorporate gold nanoparticle-8-OHdG antibody conjugates that produce color changes that are proportional to urine 8-OHdG and that are discernible on a smartphone camera photograph. Paper strip accuracy, precision, and stability studies were performed with 8-OHdG solutions of varying concentrations. Urine was collected from 97 patients with diabetes who were receiving DR screening examinations, including 7-field fundus photographs. DR was graded by standard methods as either low risk (no or mild DR) or high risk (moderate or severe DR). Paper sensor assays were performed on urine samples from patients and 8-OHdG values were correlated with DR grades. The differences in 8-OHdG values between the low- and high-risk groups were analyzed for outliers to identify the threshold 8-OHdG value that would minimize false-negative results.

RESULTS

Lateral flow immunoassay paper strips quantitatively measure 8-OHdG and were found to be accurate, precise, and stable. Average urine 8-OHdG concentrations in study patients were 22 ± 10 ng/mg of creatinine in the low-risk group and 55 ± 11 ng/mg of creatinine in the high-risk group. Screening cutoff values of 8-OHdG >50 ng/mg of creatinine or urine creatinine >1.5 mg minimized screen failures, with 91% sensitivity and 81% specificity.

CONCLUSIONS

Urinary 8-OHdG is a useful biomarker to screen DR. Quantitative 8-OHdG detection with the lateral flow immunoassay paper sensor and smartphone camera demonstrates its potential in DR screening. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Prevalence of diagnosed diabetes in American Indian and Alaska Native adults, 2006-2017

INTRODUCTION

The objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian Health Service (IHS) active clinical population.

RESEARCH DESIGN AND METHODS

Data were extracted from the IHS National Data Warehouse for AI/AN adults for each fiscal year from 2006 (n=729 470) through 2017 (n=1 034 814). The prevalence of diagnosed diabetes for each year and the annual percentage change were estimated for adults overall, as well as by sex, age group, and geographic region.

RESULTS

After increasing significantly from 2006 to 2013, diabetes prevalence for AI/AN adults in the IHS active clinical population decreased significantly from 2013 to 2017. Prevalence was 14.4% (95% CI 13.9% to 15.0%) in 2006; 15.4% (95% CI 14.8% to 16.0%) in 2013; and 14.6% (95% CI 14.1% to 15.2%) in 2017. Trends for men and women were similar to the overall population, as were those for all age groups. For all geographic regions, prevalence either decreased significantly or leveled off in recent years.

CONCLUSIONS

Diabetes prevalence in AI/AN adults in the IHS active clinical population has decreased significantly since 2013. While these results cannot be generalized to all AI/AN adults in the USA, this study documents the first known decrease in diabetes prevalence for AI/AN people.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Comparison of Coronary Heart Disease and Stroke in Association with Diabetic Retinopathy in Adults with Diabetes Using a National Survey

OBJECTIVE

Diabetic retinopathy (DR) was reported to have higher prevalence of coronary heart disease (CHD) and stroke compared with people without DR. However, whether DR had similar effects on CHD and stroke in US adults with diabetes was not well known. This study was to compare the association between DR, CHD and stroke in US adults with diabetes using the 2015 Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

Respondents with diabetes aged over 18 years and undergone a fundus examination over the past 2 years were included in this study. DR, CHD and stroke were self-reported. A weighted hierarchical logistic regression was used to examine the association of DR with CHD and stroke.

RESULTS

A total of 21,049 respondents with diabetes aged over 18 years having undergone a fundus examination over the past 2 years were included in the analysis. There were 4690 people reported having CHD, accounting for the weighted prevalence 22.1%. The weighted prevalence of stroke was 9.6%. There was 28.3% of CHD people who had DR which was higher than that in people without CHD. Differences in weighted frequency distributions of gender, age category (over 45 years or not), current smoking, hypercholesterolemia, hypertension and insulin treatment were significantly different between the CHD and without CHD groups (p<0.001). Similar results were found in people with stroke. Logistic analysis showed that DR was related to CHD and stroke (crude OR =1.876, 2.263, respectively, p all <0.001). After adjusting other variables, these associations persisted (Adjusted OR=1.632 (95% CI=1.625-1.639), 1.846 (95% CI=1.836-1.856), respectively, p all<0.001).

CONCLUSION

The BRFSS 2015 data indicated that DR was not only associated with CHD but also associated with stroke in US adults with diabetes, independently of other risk factor. DR might be more strongly associated with stroke than with CHD.

Ongoing challenges in access to diabetes care among the indigenous population: perspectives of individuals living in rural Guatemala

Background

Indigenous persons living in Latin America suffer from a higher prevalence of type 2 diabetes compared to their non-indigenous counterparts. This difference has been attributed to a wide range of factors. Future interventions could be influenced by a deeper understanding of the challenges that impact care in rural regions and in other low-income settings.

Methods

This study was conducted using a modified grounded theory approach. Extended observations and fifteen interviews were performed with adult male and female residents of three rural Mayan towns in Sololá Department, Guatemala using purposive sampling. Questions focused on the perceptions of individuals living with type 2 diabetes and their caregivers regarding disease and treatment.

Results

Across interviews the most common themes that emerged included mistreatment by healthcare providers, mental health comorbidity, and medication affordability. These perceptions were in part influenced by indigeneity, poverty, and/or gender.

Conclusions

Both structural and cultural barriers continue to impact diabetes care for indigenous communities in rural Guatemala. The interviews in this study suggest that indigenous people experience mistrust in the health care system, unreliable access to care, and mental health comorbidity in the context of type 2 diabetes care. These experiences are shaped by the complex relationship among poverty, gender, and indigeneity in this region. Targeted interventions that are conscious of these factors may increase their chances of success when attempting to address similar health disparities in comparable populations.

IDF Diabetes Atlas: A review of studies utilising retinal photography on the global prevalence of diabetes related retinopathy between 2015 and 2018

AIMS

The purpose of this study is to assess the prevalence of diabetic retinopathy (DR) world-wide from articles published since 2015 where the assessment of the presence and severity of DR was based on retinal images.

METHODS

A total of 4 databases were searched for the MESH terms diabetic retinopathy and prevalence. Of 112 publications 32 studies were included and individual data pooled for analysis. The presence of any DR or diabetic macular edema (DME) was recorded and severity as mild, moderate or severe non-proliferative DR (NPDR), proliferative DR (PDR) and DME and/or clinically significant macular edema (CSME). The level of severity of DR reported refer to persons with diabetes and not individual eyes.

RESULTS

The global prevalence of DR and DME, for the period 2015 to 2019 were 27.0% for any DR comprising of 25.2%, NPDR, 1.4% PDR and 4.6% DME. The lowest prevalence was in Europe at 20.6% and South East Asia at 12.5% and highest in Africa at 33.8%, Middle East and North Africa 33.8%, and the Western Pacific region at 36.2%.

CONCLUSIONS

This study illustrated difficulties in deriving a meaningful global prevalence rate for DR and DME due to the lack of uniformity in defining the study populations, methodological differences, retinal image capture and grading criteria. Therefore, international consensus is required using a minimal data set for future studies.

New imaging systems in diabetic retinopathy

Various imaging modalities are of significant utility in the screening, grading, treatment, and follow-up of the different stages of diabetic retinopathy (DR) and diabetic macular edema. Color stereographic photography, fluorescein angiography, and optical coherence tomography (OCT) have been the gold standard for DR imaging for years. Besides these tools, newer technologies are gaining validation and popularity, such as fundus autofluorescence and OCT angiography. Furthermore, widefield retinography and ultra-widefield retinography have been introduced for a more comprehensive evaluation of the medium-far and very-far retinal peripheries, which is crucial for the assessment of the diverse manifestations of the disease. The aim of this review is to illustrate the recent advancements of the imaging systems for diagnosing DR, with a focus on the newest and noninvasive diagnostic tools.

The diagnostic accuracy of an intelligent and automated fundus disease image assessment system with lesion quantitative function (SmartEye) in diabetic patients

BACKGROUND

With the diabetes mellitus (DM) prevalence increasing annually, the human grading of retinal images to evaluate DR has posed a substantial burden worldwide. SmartEye is a recently developed fundus image processing and analysis system with lesion quantification function for DR screening. It is sensitive to the lesion area and can automatically identify the lesion position and size. We reported the diabetic retinopathy (DR) grading results of SmartEye versus ophthalmologists in analyzing images captured with non-mydriatic fundus cameras in community healthcare centers, as well as DR lesion quantitative analysis results on different disease stages.

METHODS

This is a cross-sectional study. All the fundus images were collected from the Shanghai Diabetic Eye Study in Diabetics (SDES) program from Apr 2016 to Aug 2017. 19,904 fundus images were acquired from 6013 diabetic patients. The grading results of ophthalmologists and SmartEye are compared. Lesion quantification of several images at different DR stages is also presented.

RESULTS

The sensitivity for diagnosing no DR, mild NPDR (non-proliferative diabetic retinopathy), moderate NPDR, severe NPDR, PDR (proliferative diabetic retinopathy) are 86.19, 83.18, 88.64, 89.59, and 85.02%. The specificity are 63.07, 70.96, 64.16, 70.38, and 74.79%, respectively. The AUC are PDR, 0.80 (0.79, 0.81); severe NPDR, 0.80 (0.79, 0.80); moderate NPDR, 0.77 (0.76, 0.77); and mild NPDR, 0.78 (0.77, 0.79). Lesion quantification results showed that the total hemorrhage area, maximum hemorrhage area, total exudation area, and maximum exudation area increase with DR severity.

CONCLUSIONS

SmartEye has a high diagnostic accuracy in DR screening program using non-mydriatic fundus cameras. SmartEye quantitative analysis may be an innovative and promising method of DR diagnosis and grading.

Genetic Epidemiologic Analysis of Hypertensive Retinopathy in an Underrepresented and Rare Federally Recognized Native American Population of the Intermountain West

Understanding disease risk is challenging in multifactorial conditions as it can differ by environment, ethnicity and race. The Confederated Tribes of the Goshute Reservation are one of the most isolated populations in the United States. Retinal changes are a reliable indicator for systemic disease. We conducted a cross-sectional study to identify correlations between genetic data and epidemiological risk factors for blinding retinal disease in this tribe. As part of the "Supporting Prediction and Prevention Blindness Project (SPBPP)" in the Native American Population of the Intermountain West, we found that hypertensive retinopathy was the most prevalent retinal disease. We found that forty-two percent of the Goshute population was affected. Blood samples, fundus photos and intraocular pressure were obtained for all participants. In addition, a standardized questionnaire was administered. DNA and total cholesterol, HDL, LDL, VLDL, triglycerides and HbA1c were also evaluated. Our study interrogated genetic variants from the PAGE study (ARMS2 rs10490924, CFH rs800292, rs1061170) and additional studies that looked at previously associated genetic variants with retinal disease associated with cardiovascular disease. We conducted univariate and multivariate logistic regression in Stata v15.0. We found an association between hypertriglyceridemia and HTR (adjp = .05) within the Goshute population. To the best of our knowledge, this is the first study to demonstrate the prevalence of hypertensive retinopathy in a Native American population. Moreover, our study is the first to demonstrate an independently predictive relationship between hypertriglyceridemia and hypertensive retinopathy in an American Indian population. This study furthers our knowledge about prevalent blinding eye disease within the most geographically isolated federally recognized native United States American tribe, for which nothing has been published with respect to any disease. Although, this study furthers our understanding about the prevalence of genetic epidemiological risk factors within this population, it has greater implications for the screening of blinding diseases in underserved populations in general. This study can inform public health on planning and delivering of quality, accessible and relevant care to this population.

Use of graded Semmes Weinstein monofilament testing for ascertaining peripheral neuropathy in people with and without diabetes

AIMS

To assess peripheral neuropathy (PN) using graded Semmes Weinstein monofilaments (SWMs) and determine factors associated with PN among adult volunteers with and without diabetes.

METHODS

Adult volunteers were assessed for distal sensory PN using three graded SWMs. Four PN levels were defined: 0 (no PN; felt all three filaments), 1 (subclinical PN; insensate to 1-g filament), 2 (insensate to 10-g), or 3 (insensate to 75-g). Levels 2-3 were considered clinical PN. Associations with PN were determined using ordinal logistic regression.

RESULTS

In 1564 subjects (median age 41.9 years, 50.1% women), PN was subclinical or worse in 68.9% and clinical in 11.2%. Age-sex-race-adjusted prevalence of clinical PN was greater in people with diabetes (15.3%) than without (6.1%; P < 0.001). Associated factors included older age, male sex, greater BMI, greater heart rate, lower mean arterial pressure, and family history of diabetes or cardiovascular diseases. Higher PN levels associated with worse albuminuria and retinopathy. Only older age and male sex associated with PN both in people with and without diabetes.

CONCLUSIONS

PN is common in our sample, notably in those without diabetes, although diabetes greatly increases its risk. Using graded SWMs may have a prognostic value as it permits the identification of subclinical PN.

Eye Care Utilization Among Insured People With Diabetes in the U.S., 2010-2014

OBJECTIVE

Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults, and although screening with eye exams is effective, screening rates are low. We evaluated eye exam visits over a 5-year period in a large population of insured patients 10-64 years of age with diabetes.

RESEARCH DESIGN AND METHODS

We used claims data from IBM Watson Health to identify patients with diabetes and continuous insurance coverage from 2010 to 2014. Diabetes and DR were defined using ICD-9 Clinical Modification codes. We calculated eye exam visit frequency by diabetes type over a 5-year period and estimated period prevalence and cumulative incidence of DR among those receiving an eye exam.

RESULTS

Among the 298,383 insured patients with type 2 diabetes and no diagnosed DR, almost half had no eye exam visits over the 5-year period and only 15.3% met the American Diabetes Association (ADA) recommendations for annual or biennial eye exams. For the 2,949 patients with type 1 diabetes, one-third had no eye exam visits and 26.3% met ADA recommendations. The 5-year period prevalence and cumulative incidence of DR were 24.4% and 15.8%, respectively, for patients with type 2 diabetes and 54.0% and 33.4% for patients with type 1 diabetes.

CONCLUSIONS

The frequency of eye exams was alarmingly low, adding to the abundant literature that systemic changes in health care may be needed to detect and prevent vision-threatening eye disease among people with diabetes.

Associations of renal function with diabetic retinopathy and visual impairment in type 2 diabetes: A multicenter nationwide cross-sectional study

BACKGROUND

Diabetic retinopathy (DR) separately has been noted as a major public health problem worldwide as well. Currently, many studies have demonstrated an association between diabetic nephropathy and DR in type 1 diabetes mellitus (T1DM) patients, but this association is less strong in T2DM. The evidence for an association between renal function and DR and visual impairment among T2DM patients is limited, particularly in the Asian population.

AIM

To assess the association between glomerular filtration rate (GFR) and DR, severe DR, and severe visual impairment among T2DM patients in Thailand.

METHODS

We conducted a nationwide cross-sectional study based on the DM/HT study of the Medical Research Network of the Consortium of Thai Medical Schools. This study evaluated adult T2DM patients from 831 public hospitals in Thailand in the year 2013. GFR was categorized into ≥ 90, 60-89, 30-59 and < 30 mL/min/1.73 m². The association between GFR and DR, severe DR, and severe visual impairment were assessed using multivariate logistic regression.

RESULTS

A total of 13192 T2DM patients with available GFR were included in the analysis. The mean GFR was 66.9 ± 25.8 mL/min/1.73 m². The prevalence of DR, proliferative DR, diabetic macular edema, and severe visual impairment were 12.4%, 1.8%, 0.2%, and 2.1%, respectively. Patients with GFR of 60-89, 30-59 and < 30 mL/min/1.73 m² were significantly associated with increased DR and severe DR when compared with patients with GFR of ≥ 90 mL/min/1.73 m². In addition, increased severe visual impairment was associated with GFR 30-59 and < 30 mL/min/1.73 m².

CONCLUSION

Decreased GFR was independently associated with increased DR, severe DR, and severe visual impairment. GFR should be monitored in diabetic patients for DR awareness and prevention.