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Lacaze P, Marquina C, Tiller J, Riaz M, Sturm A, Nelson M, Ference B, Pang J, Watts G, Nicholls S, Zoungas S, Liew D, McNeil J, Ademi Z. Population Genomic Screening of Young Adults for Familial Hypercholesterolaemia: A Cost-Effectiveness Analysis. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ademi Z, Marquina C, Lacaze P, Tiller J, Riaz M, Sturm AC, Nelson M, Ference BA, Pang J, Watts GF, Nicholls SJ, Zoungas S, Liew D, McNeil J. Population genomic screening of all young adults in Australia to detect familial hypercholesterolemia: a cost-effectiveness analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Heterozygous familial hypercholesterolemia (FH) is a highly-penetrant, autosomal dominant monogenic disorder that causes elevated plasma low-density cholesterol (LDL-C) levels and risk of premature coronary heart disease (CHD). To date, the cost-effectiveness of the emerging strategy of genomic screening of adult populations for FH has not been investigated.
Purpose
To assess the impact and cost-effectiveness of offering population genomic screening to all young adults in Australia to detect heterozygous familial hypercholesterolemia (FH).
Methods
We designed a decision analysis model to compare the current standard of care for heterozygous FH diagnosis in Australia (opportunistic cholesterol screening and genetic cascade testing) with population genomic screening of adults aged 18–40 years to detect pathogenic variants in the LDLR/APOB/PCSK9 genes. The model captured morbidity/mortality due to coronary heart disease (CHD) over a lifetime horizon, from a healthcare perspective. Risk of CHD, treatment effects, prevalence, and healthcare costs were estimated from published studies. Outcomes included quality adjusted life years (QALYs), costs and incremental cost-effectiveness ratio (ICER), discounted 5% annually. Sensitivity analyses were undertaken to explore the impact of key input parameters on the robustness of the model. The model structure was designed to be transferable to countries with different healthcare systems.
Results
Over the lifetime of the population (4,167,768 men; 4,129,961 women), the model estimated a gain of 62,722 years of life lived and 73,959 QALYs due to CHD prevention. Population genomic screening for FH would be cost-effective from a healthcare perspective if the cost per test was ≤AU$300 (∼US$233) which would yield an ICER AU$28,000 cost-saving.
Conclusion
Based on our model, offering population genomic screening to all young adults to detect FH could be cost-effective in the Australian healthcare system, at testing costs that are currently feasible.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): This work was supported by the Australian National Heart Foundation and Monash University Faculty of Medicine, Nursing and Health Sciences Results from scenario analysesResults from Monte Carlo simulations
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Affiliation(s)
- Z Ademi
- Monash University, Melbourne, Australia
| | | | - P Lacaze
- Monash University, Melbourne, Australia
| | - J Tiller
- Monash University, Melbourne, Australia
| | - M Riaz
- Monash University, Melbourne, Australia
| | - A C Sturm
- Genomic Medicine Institute, Geisinger, United States of America
| | - M Nelson
- Monash University, Melbourne, Australia
| | - B A Ference
- University of Cambridge, Cambridge, United Kingdom
| | - J Pang
- The University of Western Australia, Perth, Australia
| | - G F Watts
- The University of Western Australia, Perth, Australia
| | | | - S Zoungas
- Monash University, Melbourne, Australia
| | - D Liew
- Monash University, Melbourne, Australia
| | - J McNeil
- Monash University, Melbourne, Australia
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Ademi Z, Norman R, Pang J, Liew D, Zoungas S, Sijbrands E, Ference B, Wiegman A, Watts G. Health economic evaluation of screening and treating children with familial hypercholesterolemia early in life: many happy returns on investment? Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
There are no studies that have specifically investigated the cost-effectiveness of cascade screening of children for heterozygous familial hypercholesterolemia (FH) and treatment of affected individuals with statins to prevent coronary heart disease (CHD).
Purpose
This study explores the cost-effectiveness of this strategy from the perspective of the Australian public healthcare system.
Methods
A lifetime Markov model with four health states (Alive without CHD, Alive with CHD, Dead from fatal CHD, and Dead from other causes) was developed to simulate the progression of ten- year-old children screened for FH and treated immediately with statins if found to have FH. The underlying prevalence of FH in this target population was assumed to be 56.8%, and the sensitivity and specificity of testing was 100%. The comparator was usual care, which assumed that subjects started statins spontaneously at a later point or when they experienced a cardiovascular event. The effect of reducing low-density lipoprotein cholesterol (LDL-C) on the risk of a first event at each age assumed that risk was proportional to total lifetime exposure and was implemented using Mendelian randomisation analysis data. Cost and other outcome data were sourced from published sources. Outcome of interests were costs in Australian dollars (AUD), life years gained (LYG) and quality-adjusted life years (QALYs) gained, as well as incremental cost-effectiveness ratios (ICERs) of costs per LYG and per QALY gained. All future costs and outcomes were discounted by 5% annually.
Results
Undiscounted results showed that compared with usual care, cascade screening of ten year-old children for FH and initiation of treatment of affected individuals saved 7.77 LYG and 7.53 QALYs per person over a lifetime. With 5% annual discounting, there were 0.97 LYG and 1.07 QALYs gained per person, at an additional cost of $3,244. These equated to ICERs of $3334 per LYG and $3023 per QALY gained. The equivalent ICERs in USD would be $5089 per LYG gained and $4615 per QALY gained. Sensitivity analysis showed the results to be robust.
Conclusions
Compared to usual care, cascade screening of ten year old children for FH and treating affected individuals is likely to be highly cost-effective.
Table 1. Granular cost and benefit data
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- Z Ademi
- Monash Centre of Cardiovascular Research & Education in Therapeutics, Melbourne, Australia
| | - R Norman
- Curtin University, Perth, Australia
| | - J Pang
- The University of Western Australia, Perth, Australia
| | - D Liew
- Monash Centre of Cardiovascular Research & Education in Therapeutics, Melbourne, Australia
| | - S Zoungas
- Monash University, Melbourne, Australia
| | - E Sijbrands
- Erasmus University Medical Centre, Rotterdam, Netherlands (The)
| | - B.A Ference
- University of Cambridge, Cambridge, United Kingdom
| | - A Wiegman
- Amsterdam University Medical Center, Amsterdam, Netherlands (The)
| | - G Watts
- The University of Western Australia, Perth, Australia
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Savira F, Wang B, Kompa A, Ademi Z, Owen A, Tonkin A, Zoungas S, Liew D, Zomer E. Cost-effectiveness of dapagliflozin in chronic heart failure: an analysis from the Australian healthcare perspective. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial demonstrated that dapagliflozin reduced heart failure hospitalisations and mortality in patients with established heart failure, regardless of diabetic status.
Purpose
To assess the cost-effectiveness of dapagliflozin in addition to standard care versus standard care alone in patients with chronic heart failure, from the perspective of the Australian public healthcare system.
Methods
A Markov model populated with 1000 hypothetical individuals was constructed based on the DAPA-HF trial to assess the clinical outcomes and costs of patients with established heart failure and reduced ejection fraction over a lifetime time horizon. The model consisted of three health states: “Alive and event-free”, “Alive after non-fatal hospitalisation for heart failure” or “Dead”. Costs and utilities were estimated from published sources. Outcomes of interest were the incremental cost-effectiveness ratios (ICERs) in terms of cost per quality-adjusted life year (QALY) gained and cost per year of life saved (YoLS). All outcomes were discounted at a rate of 5% annually.
Results
Over a lifetime analysis, addition of dapagliflozin to standard care in patients with chronic heart failure prevented 88 acute heart failure hospitalisations (including readmission), and saved 416 (discounted) years of life and 288 (discounted) QALYs, at an additional cost of A$3,692,440 or €2,263,204 (discounted). This resulted in ICERs of A$8,875 (€5,439) per YoLS and A$12,482 (€7,650) per QALY gained, well below the Australian arbitrary willingness-to-pay threshold of A$50,000 (€30,645).
Conclusion
From the Australian public healthcare perspective, dapagliflozin is cost-effective when used as an adjunct therapy to standard care compared to standard care alone for the treatment of chronic heart failure with reduced ejection fraction.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- F Savira
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | - B.H Wang
- Baker Heart and Diabetes Institute, Biomarker Discovery Laboratory, Melbourne, Australia
| | - A.R Kompa
- St Vincent's Hospital, Department of Medicine, Melbourne, Australia
| | - Z Ademi
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | - A Owen
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | - A Tonkin
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | - S Zoungas
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | - D Liew
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | - E Zomer
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
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Szwarcbard N, Villani M, Earnest A, Flack J, Andrikopoulos S, Wischer N, Soldatos G, Gasevic D, Zoungas S. The association of smoking status with glycemic control, metabolic profile and diabetic complications- Results of the Australian National Diabetes Audit (ANDA). J Diabetes Complications 2020; 34:107626. [PMID: 32527672 DOI: 10.1016/j.jdiacomp.2020.107626] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tobacco smoking and diabetes mellitus contribute significantly to the overall health burden and mortality of Australians. We aimed to assess the relationship of smoking with glycemic control, metabolic profile and complications in Australian patients living with diabetes. METHODS We analysed the 2011-2017 biennial Australian National Diabetes Audit cross-sectional data. Patients were classified as current, past or never smokers. Linear (or quantile) and logistic regression models were used to assess for associations. RESULTS Data from 15,352 patients were analysed, including 72.2% with type 2 diabetes. Current smokers comprised 13.5% of the study population. Current and past smokers had a median HbA1c that was 0.49% and 0.14% higher than never smokers, respectively, as well as higher triglyceride and lower HDL levels (all p values < .0001). Compared to never smokers, current smokers had higher odds of severe hypoglycemia and current and past smokers had higher odds of myocardial infarction, stroke, peripheral vascular disease, lower limb amputation, erectile dysfunction and peripheral neuropathy (all p values ≤.001), with no significant change over time. CONCLUSION When compared to never smokers, current and past smokers had poorer glycemic and lipid control and higher odds of macrovascular and microvascular complications. Despite this, current smoking remains prevalent among Australians with diabetes.
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Affiliation(s)
- N Szwarcbard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - M Villani
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia; Research and Evaluation, Ambulance Victoria, Blackburn, VIC 3130, Australia
| | - A Earnest
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - J Flack
- Department of Diabetes and Endocrinology, Bankstown-Lidcombe Hospital, Bankstown, NSW 2200, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW,Australia; School of Medicine, Western Sydney University, Sydney, NSW,Australia
| | - S Andrikopoulos
- Department of Medicine, University of Melbourne, Parkville, VIC 3010, Australia; Australian Diabetes Society, Sydney, NSW 2000, Australia
| | - N Wischer
- National Association of Diabetes Centres, Sydney, NSW, 2000, Australia
| | - G Soldatos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia; Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC,Australia, 3168
| | - D Gasevic
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia; Usher Institute, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom
| | - S Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia; Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC,Australia, 3168.
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Middleton TL, Constantino MI, Molyneaux L, D'Souza M, Twigg SM, Wu T, Yue DK, Zoungas S, Wong J. Young-onset type 2 diabetes and younger current age: increased susceptibility to retinopathy in contrast to other complications. Diabet Med 2020; 37:991-999. [PMID: 31968129 PMCID: PMC7317898 DOI: 10.1111/dme.14238] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Type 2 diabetes diagnosed during youth and early adulthood is aggressive and associated with a high burden of vascular complications. The increase in complications is often attributed to long disease duration and poor metabolic control. Whether people with young-onset type 2 diabetes are inherently more susceptible to long-term complications than those diagnosed in later adulthood is unclear. METHODS Prospective data from 3322 individuals, diagnosed between the age of 15 and 70 years and collected 10-25 years after diabetes diagnosis, were analysed. The cross-sectional associations between age at diagnosis and microvascular and macrovascular complications were analysed using logistic regression models, adjusted for duration of diabetes exposure and metabolic risk factors including blood pressure, cholesterol and updated mean HbA1c . RESULTS The prevalence of retinopathy was highest in those with young-onset type 2 diabetes (diagnosed at age 15 to <40 years). After 10-15 years' diabetes duration, the adjusted odds ratio for retinopathy in this population was 2.8 (95% CI 1.9-4.1; reference group those diagnosed at 60 to <70 years of age). The odds of retinopathy remained higher in people with young-onset type 2 diabetes after longer durations of diabetes exposure; the odds decreased with increasing age at diagnosis. This pattern was not observed in models of other complications: after 10-15 years' diabetes exposure, the adjusted odds ratios for albuminuria, peripheral neuropathy and macrovascular disease in people with young-onset type 2 diabetes were 0.5 (95% CI 0.4-0.8), 0.7 (95% CI 0.5-1.1) and 0.2 (95% CI 0.1-0.3), respectively. CONCLUSION After accounting for disease duration and other important confounders, people with type 2 diabetes diagnosed in youth and early adulthood (or with a younger current age) appeared to be inherently more susceptible to retinopathy. For other complications, adjusted risk appears highest in the oldest age of diagnosis group. These data have screening and treatment target implications.
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Affiliation(s)
- T. L. Middleton
- Diabetes CentreRoyal Prince Alfred HospitalSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - M. I. Constantino
- Diabetes CentreRoyal Prince Alfred HospitalSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - L. Molyneaux
- Diabetes CentreRoyal Prince Alfred HospitalSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - M. D'Souza
- Sydney Local Health District Clinical Research CentreCamperdownNSWAustralia
| | - S. M. Twigg
- Diabetes CentreRoyal Prince Alfred HospitalSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - T. Wu
- Diabetes CentreRoyal Prince Alfred HospitalSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - D. K. Yue
- Diabetes CentreRoyal Prince Alfred HospitalSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
| | - S. Zoungas
- School of Public Health and Preventative MedicineMonash UniversityPrahanVic.Australia
- Diabetes and Vascular Medicine UnitMonash HealthClaytonVic.Australia
- George Institute for Global HealthCamperdownNSWAustralia
| | - J. Wong
- Diabetes CentreRoyal Prince Alfred HospitalSydneyNSWAustralia
- Faculty of Medicine and HealthUniversity of SydneySydneyNSWAustralia
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Savira F, Wang B, Kompa A, Ademi Z, Owen A, Zoungas S, Tonkin A, Liew D, Zomer E. 176 The Cost-Effectiveness of Dapagliflozin for Chronic Heart Failure in Australia. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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8
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Gupta Y, Kapoor D, Josyula LK, Praveen D, Naheed A, Desai AK, Pathmeswaran A, de Silva HA, Lombard CB, Shamsul Alam D, Prabhakaran D, Teede HJ, Billot L, Bhatla N, Joshi R, Zoungas S, Jan S, Patel A, Tandon N. A lifestyle intervention programme for the prevention of Type 2 diabetes mellitus among South Asian women with gestational diabetes mellitus [LIVING study]: protocol for a randomized trial. Diabet Med 2019; 36:243-251. [PMID: 30368898 DOI: 10.1111/dme.13850] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2018] [Indexed: 01/05/2023]
Abstract
AIM This study aims to determine whether a resource- and culturally appropriate lifestyle intervention programme in South Asian countries, provided to women with gestational diabetes (GDM) after childbirth, will reduce the incidence of worsening of glycaemic status in a manner that is affordable, acceptable and scalable. METHODS Women with GDM (diagnosed by oral glucose tolerance test using the International Association of the Diabetes and Pregnancy Study Groups criteria) will be recruited from 16 hospitals in India, Sri Lanka and Bangladesh. Participants will undergo a repeat oral glucose tolerance test at 6 ± 3 months postpartum and those without Type 2 diabetes, a total sample size of 1414, will be randomly allocated to the intervention or usual care. The intervention will consist of four group sessions, 84 SMS or voice messages and review phone calls over the first year. Participants requiring intensification of the intervention will receive two additional individual sessions over the latter half of the first year. Median follow-up will be 2 years. The primary outcome is the proportion of women with a change in glycaemic category, using the American Diabetes Association criteria: (i) normal glucose tolerance to impaired fasting glucose, or impaired glucose tolerance, or Type 2 diabetes; or (ii) impaired fasting glucose or impaired glucose tolerance to Type 2 diabetes. Process evaluation will explore barriers and facilitators of implementation of the intervention in each local context, while trial-based and modelled economic evaluations will assess cost-effectiveness. DISCUSSION The study will generate important new evidence about a potential strategy to address the long-term sequelae of GDM, a major and growing problem among women in South Asia. (Clinical Trials Registry of India No: CTRI/2017/06/008744; Sri Lanka Clinical Trials Registry No: SLCTR/2017/001; and ClinicalTrials.gov Identifier No: NCT03305939).
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Affiliation(s)
- Y Gupta
- Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - D Kapoor
- Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - L K Josyula
- The George Institute for Global Health, Hyderabad, India
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - D Praveen
- The George Institute for Global Health, Hyderabad, India
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - A Naheed
- Initiative for Noncommunicable Diseases, Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - A K Desai
- Department of Medicine, Goa Medical College and Hospital, Bambolim, Goa, India
| | - A Pathmeswaran
- Department ofPublic Health, University of Kelaniya, Ragama, Sri Lanka
| | - H A de Silva
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - C B Lombard
- Department of Nutrition and Dietetics, Monash University, Melbourne, Australia
| | - D Shamsul Alam
- Faculty of Health, School of Kinesiology and Health Science, York University, Toronto, Canada
| | | | - H J Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - L Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - N Bhatla
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - R Joshi
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - S Zoungas
- Division of Metabolism, Ageing and Genomics, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - S Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - A Patel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - N Tandon
- Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Abell SK, Boyle JA, Earnest A, England P, Nankervis A, Ranasinha S, Soldatos G, Wallace EM, Zoungas S, J Teede H. Impact of different glycaemic treatment targets on pregnancy outcomes in gestational diabetes. Diabet Med 2019; 36:177-183. [PMID: 30102812 DOI: 10.1111/dme.13799] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2018] [Indexed: 11/27/2022]
Abstract
AIM With no current randomized trials, we explored the impact of tight compared with standard treatment targets on pregnancy outcomes in gestational diabetes mellitus (GDM). METHODS This cohort study of singleton births ≥ 28 weeks' gestation was conducted at two major Australian maternity services (2009-2013). Standardized maternal, neonatal and birth outcomes were examined using routine healthcare data and compared for women with GDM at Service One (n = 2885) and Service Two (n = 1887). Services applied different treatment targets: Service One (standard targets, reference group) fasting < 5.5 mmol/l, 2-h postprandial < 7.0 mmol/l; Service Two (tight targets) fasting < 5.0 mmol/l, 2-h postprandial < 6.7 mmol/l. Multivariable regression with propensity score adjustment was used to examine associations between targets and outcomes. RESULTS GDM prevalence and insulin use were 7.9% and 31% at Service One, and 5.7% and 46% at Service Two. There were no differences in primary outcomes: birthweight > 90th centile [adjusted odds ratio (OR) 1.06, 95% confidence interval (CI) 0.87-1.30] and < 10th centile (OR 0.84, 95% CI 0.70-1.01), or secondary outcomes gestational hypertension, pre-eclampsia, shoulder dystocia or a perinatal composite. Service Two with tight targets had increased induction of labour (OR 3.63, 95% CI 3.17-4.16), elective Caesarean section (OR 1.75, 95% CI 1.37-2.23) and Apgar scores < 7 at 5 min (OR 1.54, 95% CI 1.05-2.25), decreased hypoglycaemia (OR 0.76, 95% CI 0.61-0.94]), jaundice (OR 0.47, 95% CI 0.35-0.63) and respiratory distress (OR 0.68, 95% CI 0.47-0.98). CONCLUSIONS Tight GDM treatment targets were associated with greater insulin use and no difference in primary birthweight outcomes. The service with tight targets had higher obstetric intervention, lower rates of reported hypoglycaemia, jaundice, respiratory distress and lower Apgar scores. High-quality interventional data are required before tight treatment targets can be implemented.
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Affiliation(s)
- S K Abell
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Vic., Australia
| | - J A Boyle
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Monash Women's Services, Monash Health, Melbourne, Vic., Australia
| | - A Earnest
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - P England
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, Melbourne, Vic., Australia
| | - A Nankervis
- Diabetes Unit, Royal Women's Hospital, Melbourne, Vic., Australia
| | - S Ranasinha
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - G Soldatos
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Vic., Australia
| | - E M Wallace
- Monash Women's Services, Monash Health, Melbourne, Vic., Australia
- The Ritchie Centre, Department of Obstetrics and Gynaecology, Monash University, Melbourne, Vic., Australia
| | - S Zoungas
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Vic., Australia
| | - H J Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Vic., Australia
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10
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Nanayakkara N, Pease AJ, Ranasinha S, Wischer N, Andrikopoulos S, de Courten B, Zoungas S. Younger people with Type 2 diabetes have poorer self-care practices compared with older people: results from the Australian National Diabetes Audit. Diabet Med 2018; 35:1087-1095. [PMID: 29729055 DOI: 10.1111/dme.13660] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2018] [Indexed: 11/26/2022]
Abstract
AIM This cross-sectional study compares the self-care practices of younger and older people with Type 2 diabetes. METHODS Data were analysed from the Australian National Diabetes Audit (ANDA) including 2552 adults with Type 2 diabetes from Australian Diabetes Centres. Pre-specified demographic and clinical variables were obtained. Self-care variables (physical activity, following dietary recommendations, medication adherence and monitoring blood glucose levels) were compared in people ≤ 64 and > 64 years of age. RESULTS Mean age (± sd) of participants was 63 ± 13 years overall, 53 ± 9 years for the younger group and 73 ± 6 years for the older group. A greater proportion of younger people had HbA1c levels > 53 mmol/mol (> 7.0%) (76% vs. 68%), reported difficulty following dietary recommendations (50% vs. 32%) and forgetting medications (37% vs. 22%) compared with older people (all P-values <0.001). A smaller proportion of younger compared with older people reported monitoring their blood glucose levels as often as recommended (60% vs. 70%, P < 0.001). Similar proportions of people aged ≤ 64 and > 64 years required insulin therapy (59% vs. 57%, P = 0.200). Younger age was associated with a twofold increase in the odds of not following the recommended self-care practices after adjustment for gender, smoking, insulin therapy, depression and allied health attendance (all P < 0.001). CONCLUSIONS Despite shorter diabetes duration, younger age was associated with worse glycaemic control and poorer diabetes self-care practices among people with Type 2 diabetes. Targeted strategies are required to optimize diabetes self-care practices and thereby glycaemic control.
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Affiliation(s)
- N Nanayakkara
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia
| | - A J Pease
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia
| | - S Ranasinha
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - N Wischer
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- National Association Diabetes Centres, Sydney, Australia
| | - S Andrikopoulos
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- National Association Diabetes Centres, Sydney, Australia
| | - B de Courten
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia
| | - S Zoungas
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia
- The George Institute for Global Health, Camperdown, New South Wales, Australia
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Abstract
AIM To examine the current treatment guidelines for the emergency management of hypoglycaemia and the evidence underpinning recommendations. METHODS International diabetes agencies were searched for hypoglycaemia treatment guidelines. Guidelines were assessed using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument. An electronic database search was conducted for evidence regarding emergency treatment of hypoglycaemia in adults, and relevant articles were critically appraised. RESULTS Of the international diabetes agencies, six sets of guidelines were deemed relevant and of sufficient detail for appraisal by AGREE II. The evidence search returned 2649 articles, of which 17 pertaining to the emergency management of hypoglycaemia were included. High-quality evidence for the management of hypoglycaemia was lacking, limiting treatment recommendations. In general, guidelines and studies were somewhat concordant and recommended 15-20 g of oral glucose or sucrose, repeated after 10-15 min for treatment of the responsive adult, and 10% intravenous dextrose or 1 mg intramuscular glucagon for treatment of the unresponsive adult. No evidence was found for other treatment approaches. CONCLUSION Evidence for the emergency treatment of hypoglycaemia in adults is limited, is often low grade and mostly pre-dates contemporary management of diabetes. Guideline recommendations are limited by the lack of randomized trials. Further high-quality studies are required to inform the optimum management of this frequently occurring emergency condition.
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Affiliation(s)
- M Villani
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University in partnership with Monash Health, Clayton, VIC, Australia
| | - B de Courten
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University in partnership with Monash Health, Clayton, VIC, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC, Australia
| | - S Zoungas
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University in partnership with Monash Health, Clayton, VIC, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC, Australia
- The George Institute for Global Health, Camperdown, NSW, Australia
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12
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Blomster JI, Zoungas S, Woodward M, Neal B, Harrap S, Poulter N, Marre M, Williams B, Chalmers J, Hillis GS. The impact of level of education on vascular events and mortality in patients with type 2 diabetes mellitus: Results from the ADVANCE study. Diabetes Res Clin Pract 2017; 127:212-217. [PMID: 28395214 DOI: 10.1016/j.diabres.2017.03.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 03/16/2017] [Indexed: 11/29/2022]
Abstract
AIMS The relationship between educational level and the risk of all-cause mortality is well established, whereas the association with vascular events in individuals with type 2 diabetes is not well described. Any association may reflect a link with common cardiovascular or lifestyle-based risk factors. METHODS The relationships between the highest level of educational attainment and major cardiovascular events, microvascular complications and all-cause mortality were explored in a cohort of 11,140 individuals with type 2 diabetes. Completion of formal education before the age of 16 was categorized as a low level of education. Regional differences between Asia, East Europe and Established Market Economies were also assessed. RESULTS During a median of 5years of follow up, 1031 (9%) patients died, 1147 (10%) experienced a major cardiovascular event and 1136 (10%) a microvascular event. After adjustment for baseline characteristics and risk factors, individuals with lower education had an increased risk of cardiovascular events (hazard ratio (HR) 1.31, 95% CI 1.16-1.48, p<0.0001), microvascular events (HR 1.23, 95% CI 1.08-1.39, p=0.0013) and all-cause mortality (HR 1.34, 95% CI 1.18-1.52, p<0.0001). In regional analyses the increased risk of studied outcomes associated with lower education was weakest in Established Market Economies and strongest in East Europe. CONCLUSIONS A low level of education is associated with an increased risk of vascular events and death in patients with type 2 diabetes, independently of common lifestyle associated cardiovascular risk factors. The effect size varies between geographical regions.
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Affiliation(s)
- J I Blomster
- The George Institute for Global Health, University of Sydney, Sydney, Australia; University of Turku, Turku, Finland.
| | - S Zoungas
- The George Institute for Global Health, University of Sydney, Sydney, Australia; School of Public Health, Monash University, Melbourne, Australia
| | - M Woodward
- The George Institute for Global Health, University of Sydney, Sydney, Australia; Department of Epidemiology, Johns Hopkins University, Baltimore, USA; The George Institute for Global Health, University of Oxford, UK
| | - B Neal
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - S Harrap
- Department of Physiology, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
| | - N Poulter
- Imperial College London and Hammersmith Hospital, London, UK
| | - M Marre
- Service d'Endocrinologie Diabétologie Nutrition, Groupe Hospitalier Bichat-Claude Bernard, Paris, France
| | - B Williams
- University College London and the National Institute for Health Research UCL Hospitals Biomedical Research Centre, London, UK
| | - J Chalmers
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - G S Hillis
- The George Institute for Global Health, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Australia
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13
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Lo C, Teede H, Fulcher G, Gallagher M, Kerr PG, Ranasinha S, Russell G, Walker R, Zoungas S. Gaps and barriers in health-care provision for co-morbid diabetes and chronic kidney disease: a cross-sectional study. BMC Nephrol 2017; 18:80. [PMID: 28245800 PMCID: PMC5331625 DOI: 10.1186/s12882-017-0493-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 02/21/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Patients with diabetes and chronic kidney disease (CKD) are a complex subset of the growing number of patients with diabetes, due to multi-morbidity. Gaps between recommended and received care for diabetes and chronic kidney disease (CKD) are evident despite promulgation of guidelines. Here, we document gaps in tertiary health-care, and the commonest patient-reported barriers to health-care, before exploring the association between these gaps and barriers. METHODS This cross-sectional study recruited patients with diabetes and CKD (eGFR < 60 mL/min/1.73 m2) across 4 large hospitals. For each patient, questionnaires were completed examining clinical data, recommended care, and patient-reported barriers limiting health-care. Descriptive statistics, subgroup analyses by CKD stage and hospital, and analyses examining the relationship between health-care gaps and barriers were performed. RESULTS 308 patients, of mean age 66.9 (SD 11.0) years, and mostly male (69.5%) and having type 2 diabetes (88.0%), participated. 49.1% had stage 3, 24.7% stage 4 and 26.3% stage 5 CKD. Gaps between recommended versus received care were evident: 31.9% of patients had an HbA1c ≥ 8%, and 39.3% had a measured blood pressure ≥ 140/90 mmHg. The commonest barriers were poor continuity of care (49.3%), inadequate understanding/education about CKD (43.5%), and feeling unwell (42.6%). However, barriers associated with a failure to receive items of recommended care were inadequate support from family and friends, conflicting advice from and poor communication amongst specialists, the effect of co-morbidities on self-management and feeling unmotivated (all p < 0.05). CONCLUSIONS Barriers to health-care varied across CKD stages and hospitals. Barriers associated with a deviation from recommended care were different for different items of care, suggesting that specific interventions targeting each item of care are required.
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Affiliation(s)
- C. Lo
- Diabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria Australia
| | - H. Teede
- Diabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria Australia
| | - G. Fulcher
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales Australia
| | - M. Gallagher
- Department of Nephrology, Concord Hospital, Concord, New South Wales Australia
- The George Institute for Global Health, Sydney, New South Wales Australia
| | - P. G. Kerr
- Department of Nephrology, Monash Health, Clayton, Victoria Australia
| | - S. Ranasinha
- Diabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria Australia
| | - G. Russell
- School of Primary Health Care, Monash University, Notting Hill, Victoria Australia
| | - R. Walker
- Department of Renal Medicine, Alfred Health, Prahran, Victoria Australia
| | - S. Zoungas
- Diabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales Australia
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14
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Abell SK, Zoungas S, Teede HJ. Caution in clinical interpretation of population level administrative data. BJOG 2016; 124:814. [PMID: 27726274 DOI: 10.1111/1471-0528.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S K Abell
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic., Australia.,Monash Diabetes, Monash Health, Clayton, Vic., Australia
| | - S Zoungas
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic., Australia.,Monash Diabetes, Monash Health, Clayton, Vic., Australia
| | - H J Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic., Australia.,Monash Diabetes, Monash Health, Clayton, Vic., Australia
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15
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Woodward M, Hirakawa Y, Kengne AP, Matthews DR, Zoungas S, Patel A, Poulter N, Grobbee R, Cooper M, Jardine M, Chalmers J. Prediction of 10-year vascular risk in patients with diabetes: the AD-ON risk score. Diabetes Obes Metab 2016; 18:289-94. [PMID: 26661693 DOI: 10.1111/dom.12614] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 11/11/2015] [Accepted: 11/30/2015] [Indexed: 11/30/2022]
Abstract
AIMS To formulate a combined cardiovascular risk score in diabetes that could be useful both to physicians and healthcare funders. METHODS Data were derived from the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation Observational (ADVANCE-ON) study, a randomized controlled trial (mean duration 5 years) with a post-randomization follow-up (mean 4.9 years), that included 11 140 high-risk patients with diabetes. The outcome analysed was the occurrence of either fatal or non-fatal macrovascular or renal disease. A Cox regression model was used to determine weightings in the risk score. The resultant score was recalibrated to each of three major global regions, as covered by the ADVANCE-ON study. RESULTS Over a median of 9.9 years, 1145 patients experienced at least one component of the combined outcome event. The resultant score, the AD-ON risk score, incorporated 13 demographic or clinical variables. Its discrimination was modest [c-statistic = 0.668 (95% confidence interval 0.651, 0.685)] but its calibration was excellent (predicted and observed risks coincided well, within disparate global regions). In terms of the integrated discrimination improvement index, its performance was marginally superior, over a 10-year risk horizon, to existing risk scores in clinical use, from a restricted version of the same data, for macrovascular and renal disease separately. CONCLUSIONS The AD-ON risk score has advantages over the existing vascular risk scores in diabetes that used data from the original ADVANCE trial, which treat macrovascular and renal diseases separately. These advantages include its simplicity of use and global application.
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Affiliation(s)
- M Woodward
- George Institute for Global Health, University of Sydney, Sydney, Australia
- George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Y Hirakawa
- George Institute for Global Health, University of Sydney, Sydney, Australia
| | - A-P Kengne
- George Institute for Global Health, University of Sydney, Sydney, Australia
- Non-Communicable Diseases Research Unit, South African Medical Research Council, University of Cape Town, Cape Town, South Africa
| | - D R Matthews
- Oxford Centre for Diabetes, Endocrinology Metabolism, University of Oxford, Oxford, UK
| | - S Zoungas
- George Institute for Global Health, University of Sydney, Sydney, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Australia
| | - A Patel
- George Institute for Global Health, University of Sydney, Sydney, Australia
| | - N Poulter
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - R Grobbee
- Julius Global Health, the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Cooper
- The Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - M Jardine
- George Institute for Global Health, University of Sydney, Sydney, Australia
| | - J Chalmers
- George Institute for Global Health, University of Sydney, Sydney, Australia
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16
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Ranasinha S, Joham AE, Norman RJ, Shaw JE, Zoungas S, Boyle J, Moran L, Teede HJ. The association between Polycystic Ovary Syndrome (PCOS) and metabolic syndrome: a statistical modelling approach. Clin Endocrinol (Oxf) 2015; 83:879-87. [PMID: 26052744 DOI: 10.1111/cen.12830] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/14/2015] [Accepted: 06/01/2015] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) affects 12-21% of women. Women with PCOS exhibit clustering of metabolic features. We applied rigorous statistical methods to further understand the interplay between PCOS and metabolic features including insulin resistance, obesity and androgen status. DESIGN Retrospective cross-sectional analysis. PATIENTS Women with PCOS attending reproductive endocrine clinics in South Australia for the treatment of PCOS (n = 172). Women without PCOS (controls) in the same Australian region (n = 335) from the Australian Diabetes, Obesity and Lifestyle Study (AusDiab), a national population-based study (age- and BMI-matched within one standard deviation of the PCOS cohort). MEASUREMENTS The factor structure for metabolic syndrome for women with PCOS and control groups was examined, specifically, the contribution of individual factors to metabolic syndrome and the association of hyperandrogenism with other metabolic factors. RESULTS Women with PCOS demonstrated clustering of metabolic features that was not observed in the control group. Metabolic syndrome in the PCOS cohort was strongly represented by obesity (standardized factor loading = 0·95, P < 0·001) and insulin resistance factors (loading = 0·92, P < 0·001) and moderately by blood pressure (loading = 0·62, P < 0·001) and lipid factors (loading = 0·67, P = 0·002). On further analysis, the insulin resistance factor strongly correlated with the obesity (r = 0·70, P < 0·001) and lipid factors (r = 0·68, P < 0·001) and moderately with the blood pressure factor (loading = 0·43, P = 0·002). The hyperandrogenism factor was moderately correlated with the insulin resistance factor (r = 0·38, P < 0·003), but did not correlate with any other metabolic factors. CONCLUSIONS PCOS women are more likely to display metabolic clustering in comparison with age- and BMI-matched control women. Obesity and insulin resistance, but not androgens, are independently and most strongly associated with metabolic syndrome in PCOS.
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Affiliation(s)
- S Ranasinha
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
| | - A E Joham
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Vic, Australia
| | - R J Norman
- Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, North Adelaide, SA, Australia
| | - J E Shaw
- Baker IDI Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - S Zoungas
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Vic, Australia
| | - J Boyle
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
| | - L Moran
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
- Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, North Adelaide, SA, Australia
| | - H J Teede
- Women's Reproductive Health Research, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Vic, Australia
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van Dieren S, Kengne AP, Chalmers J, Beulens JWJ, Davis TME, Fulcher G, Heller SR, Patel A, Colagiuri S, Hamet P, Mancia G, Marre M, Neal B, Williams B, Peelen LM, van der Schouw YT, Woodward M, Zoungas S. Intensification of medication and glycaemic control among patients with type 2 diabetes - the ADVANCE trial. Diabetes Obes Metab 2014; 16:426-32. [PMID: 24251579 DOI: 10.1111/dom.12238] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/02/2013] [Accepted: 11/02/2013] [Indexed: 02/04/2023]
Abstract
AIMS The aim of this study was to assess associations between patient characteristics, intensification of blood glucose-lowering treatment through oral glucose-lowering therapy and/or insulin and effective glycaemic control in type 2 diabetes. METHODS 11 140 patients from the Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) trial who were randomized to intensive glucose control or standard glucose control and followed up for a median of 5 years were categorized into two groups: effective glycaemic control [haemoglobin A1c (HbA1c) ≤ 7.0% or a proportionate reduction in HbA1c over 10%] or ineffective glycaemic control (HbA1c > 7.0% and a proportionate reduction in HbA1c less than or equal to 10%). Therapeutic intensification was defined as addition of an oral glucose-lowering agent or commencement of insulin. Pooled logistic regression models examined the associations between patient factors, intensification and effective glycaemic control. RESULTS A total of 7768 patients (69.7%), including 3198 in the standard treatment group achieved effective glycaemic control. Compared to patients with ineffective control, patients with effective glycaemic control had shorter duration of diabetes and lower HbA1c at baseline and at the time of treatment intensification. Treatment intensification with addition of an oral agent or commencement of insulin was associated with a 107% [odds ratio, OR: 2.07 (95% confidence interval, CI: 1.95-2.20)] and 152% [OR: 2.52 (95% CI: 2.30-2.77)] greater chance of achieving effective glycaemic control, respectively. These associations were robust after adjustment for several baseline characteristics and not modified by the number of oral medications taken at the time of treatment intensification. CONCLUSIONS Effective glycaemic control was associated with treatment intensification at lower HbA1c levels at all stages of the disease course and in both arms of the ADVANCE trial.
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Affiliation(s)
- S van Dieren
- The George Institute for Global Health, University of Sydney, Sydney, Australia; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Zoungas S, Curtis AJ, McNeil JJ, Tonkin AM. Treatment of dyslipidemia and cardiovascular outcomes: the journey so far--is this the end for statins? Clin Pharmacol Ther 2014; 96:192-205. [PMID: 24727468 DOI: 10.1038/clpt.2014.86] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 04/07/2014] [Indexed: 01/28/2023]
Abstract
Dyslipidemia is common and is associated with the highest population-attributable risk for cardiovascular disease. Of various cardiovascular preventive therapies, the evidence from randomized controlled trials supporting the importance of aggressive lipid lowering is the most robust, particularly for statins. Despite the use of proven therapies, cardiovascular disease event rates remain relatively high, underpinning the development of novel therapies. In addition to testing new drugs to reduce low-density-lipoprotein cholesterol, there has been a major focus on treatments that can favorably influence high-density-lipoprotein cholesterol and triglyceride levels. This review provides an overview of the important relationship between lipids and cardiovascular disease, the lipid-modifying therapeutic approaches to reducing cardiovascular disease, new guidelines and recommendations, and the challenges ahead for the treatment of dyslipidemia, particularly whether statins will remain at the forefront of recommended therapies.
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Affiliation(s)
- S Zoungas
- 1] School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia [2] The George Institute for Global Health, Sydney, Australia
| | - A J Curtis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - J J McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - A M Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Joham AE, Ranasinha S, Zoungas S, Moran L, Teede HJ. Gestational diabetes and type 2 diabetes in reproductive-aged women with polycystic ovary syndrome. J Clin Endocrinol Metab 2014; 99:E447-52. [PMID: 24081730 DOI: 10.1210/jc.2013-2007] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
CONTEXT Polycystic ovary syndrome (PCOS) affects 6%-21% of women. PCOS has been associated with an increased risk of dysglycemia including gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM). OBJECTIVE The objective of the study was to assess the prevalence of dysglycemia and the impact of obesity in young reproductive-aged women with and without PCOS in a community-based cohort. DESIGN This was a cross-sectional analysis of data from a large longitudinal study (the Australian Longitudinal Study on Women's Health). SETTING The setting for the study was the general community. PARTICIPANTS Women were randomly selected from the national health insurance database. Standardized data collection occurred at five survey time points (years 1996, 2000, 2003, 2006, and 2009). Data from survey 4 (2006, n = 9145, 62% of original cohort aged 18-23 y) were examined for this study. MAIN OUTCOME MEASURES Self-reported PCOS, GDM, and T2DM were measured. RESULTS In women aged 28-33 years, PCOS prevalence was 5.8% [95% confidence interval (CI) 5.3%-6.4%]. The prevalence of GDM (in women reporting prior pregnancy) and T2DM was 11.2% and 5.1% in women with PCOS and 3.8% and 0.3% in women without PCOS, respectively (P for both < .001). PCOS was associated with an increased odds of GDM and T2DM. After adjusting for age, body mass index, hypertension, smoking, and demographic factors, the odds of GDM (odds ratio 2.1, 95% CI 1.1-3.9, P = .02) and T2DM (odds ratio 8.8, 95% CI 3.9-20.1, P < .001) remained increased in women reporting PCOS. CONCLUSIONS In a large community-based cohort of reproductive-aged women, PCOS was independently associated with a higher risk of GDM and T2DM, independent of body mass index. Aggressive screening, prevention, and management of dysglycemia is clearly warranted in women with PCOS.
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Affiliation(s)
- A E Joham
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, (A.E.J., S.R., S.Z., L.M., H.J.T.), Monash University, and Southern Health, Clayton, Victoria 3168, Australia; and The Robinson Institute (L.M.), University of Adelaide, North Adelaide, SA 5006, Australia
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Joham AE, Boyle JA, Ranasinha S, Zoungas S, Teede HJ. Contraception use and pregnancy outcomes in women with polycystic ovary syndrome: data from the Australian Longitudinal Study on Women's Health. Hum Reprod 2014; 29:802-8. [DOI: 10.1093/humrep/deu020] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Blomster JI, Chow CK, Zoungas S, Woodward M, Patel A, Poulter NR, Marre M, Harrap S, Chalmers J, Hillis GS. The influence of physical activity on vascular complications and mortality in patients with type 2 diabetes mellitus. Diabetes Obes Metab 2013; 15:1008-12. [PMID: 23675676 DOI: 10.1111/dom.12122] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/24/2013] [Accepted: 04/23/2013] [Indexed: 11/30/2022]
Abstract
AIMS There is limited evidence regarding the association between physical activity and vascular complications, particularly microvascular disease, in patients with type 2 diabetes. METHODS From the 11 140 patients in the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron modified release Controlled Evaluation) trial, the effect of physical activity, categorized as none, mild, moderate or vigorous, and the number of sessions within a week, was examined in multivariable regression models adjusted for potential confounders. The study end-points were major cardiovascular events, microvascular complications and all-cause mortality. RESULTS Forty-six percent of participants reported undertaking moderate to vigorous physical activity for >15 min at least once in the previous week. During a median of 5 years of follow-up, 1031 patients died, 1147 experienced a major cardiovascular event and 1136 a microvascular event. Compared to patients who undertook no or mild physical activity, those reporting moderate to vigorous activity had a decreased risk of cardiovascular events (HR: 0.78, 95% CI: 0.69-0.88, p < 0.0001), microvascular events (HR: 0.85, 95% CI: 0.76-0.96, p = 0.010) and all-cause mortality (HR: 0.83, 95% CI: 0.73-0.94, p = 0.0044). CONCLUSIONS Moderate to vigorous, but not mild, physical activity is associated with a reduced incidence of cardiovascular events, microvascular complications and all-cause mortality in patients with type 2 diabetes.
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Affiliation(s)
- J I Blomster
- The George Institute for Global Health and University of Sydney, Sydney, Australia; University of Turku, Turku, Finland
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Zaman MJ, Patel A, Chalmers J, Woodward M, Clarke P, Li Q, Zoungas S. The effects of patient characteristics and geographical region on hospitalization in patients with type 2 diabetes. Diabet Med 2013; 30:918-25. [PMID: 23534416 DOI: 10.1111/dme.12181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 11/30/2022]
Abstract
AIMS The ADVANCE trial recruited participants from 20 countries worldwide. We analyse here regional variations and causes of hospitalization for people with Type 2 diabetes from Asia, Established Market Economies and Eastern Europe. METHODS A cohort analysis examining the effects of region on causes of first hospitalization, and the association of participant characteristics on all-cause first hospitalization across regions, using multivariable (adjusted for clinical, physiological, behavioural and socio-demographic factors) Cox models. RESULTS Of 11 140 individuals (6407 men), all-cause hospitalization rates were highest in Established Market Economies, followed by Eastern Europe then Asia. Eastern Europe had rates of hospitalization for diabetic causes four times greater than Established Market Economies [multivariable-adjusted hazard ratio 4.02 (95% CI 2.86-5.63)]. There were no significant regional variations in hospitalization rates for cardiovascular disease (P = 0.534), but much lower rates for musculoskeletal and non-specific causes in Eastern Europe [multivariable-adjusted hazard ratio 0.44 (95% CI 0.32-0.60) and 0.19 (95% CI 0.12-0.29)] and Asia [hazard ratio 0.21 (95% CI 0.16-0.29) and 0.09 (95% CI 0.06-0.14)] compared with Established Market Economies. In all regions, participants hospitalized for any cause were more likely to be older, male, hypertensive, smokers, have higher glycated haemoglobin and a history of macrovascular or macrovascular disease. CONCLUSIONS Across three markedly different regions of the world, regional rates and causes of hospitalization varied widely in patients with Type 2 diabetes. Adjustment for a range of patient characteristics did not explain these regional differences in hospitalization, which appear to be attributable to health system factors.
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Affiliation(s)
- M J Zaman
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
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Moran L, Ranasinha S, Zoungas S, McNaughton S, Brown W, Teede H. The contribution of diet, physical activity and sedentary behaviour to body mass index in women with and without polycystic ovary syndrome. Hum Reprod 2013; 28:2276-83. [DOI: 10.1093/humrep/det256] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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van Dieren S, Czernichow S, Chalmers J, Kengne AP, de Galan BE, Poulter N, Woodward M, Beulens JWJ, Grobbee DE, van der Schouw YT, Zoungas S. Weight changes and their predictors amongst 11 140 patients with type 2 diabetes in the ADVANCE trial. Diabetes Obes Metab 2012; 14:464-9. [PMID: 22226008 DOI: 10.1111/j.1463-1326.2012.01556.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To determine the baseline characteristics and glucose-lowering therapies associated with weight change among patients with type 2 diabetes. METHODS Eleven thousand one hundred and forty participants in the ADVANCE trial were randomly assigned to an intensive [aiming for a haemoglobin A1c (HbA1c) ≤6.5%] or a standard blood glucose-control strategy. Weight was measured at baseline and every 6 months over a median follow-up of 5 years. Multivariable linear regression and linear-mixed effect models were used to examine predictors of weight change. RESULTS The mean difference in weight between the intensive and standard glucose-control arm during follow-up was 0.75 kg (95% CI: 0.56-0.94), p-value <0.001. The mean weight decreased by 0.70 kg (95% CI: 0.53-0.87), p < 0.001 by the end of follow-up in the standard arm but remained stable in the intensive arm, with a non-significant gain of 0.16 kg (95% CI: -0.02 to 0.34), p = 0.075. Baseline factors associated with weight gain were younger age, higher HbA1c, Caucasian ethnicity and number of glucose-lowering medications. Treatment combinations including insulin [3.22 kg (95% CI: 2.92-3.52)] and thiazolidinediones [3.06 kg (95% CI: 2.69-3.43)] were associated with the greatest weight gain while treatment combinations including sulphonylureas were associated with less weight gain [0.71 kg (95%CI: 0.39-1.03)]. CONCLUSIONS Intensive glucose-control regimens are not necessarily associated with substantial weight gain. Patient characteristic associated with weight change were age, ethnicity, smoking and HbA1c. The main treatment strategies predicting weight gain were the use of insulin and thiazolidinediones.
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Affiliation(s)
- S van Dieren
- The George Institute for Global Health, University of Sydney, Sydney, Australia
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Hillis GS, Woodward M, Rodgers A, Chow CK, Li Q, Zoungas S, Patel A, Webster R, Batty GD, Ninomiya T, Mancia G, Poulter NR, Chalmers J. Resting heart rate and the risk of death and cardiovascular complications in patients with type 2 diabetes mellitus. Diabetologia 2012; 55:1283-90. [PMID: 22286552 PMCID: PMC4170780 DOI: 10.1007/s00125-012-2471-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 01/09/2012] [Indexed: 02/02/2023]
Abstract
AIMS/HYPOTHESIS An association between resting heart rate and mortality has been described in the general population and in patients with cardiovascular disease. There are, however, few data exploring this relationship in patients with type 2 diabetes mellitus. The current study addresses this issue. METHODS The relationship between baseline resting heart rate and all-cause mortality, cardiovascular death and major cardiovascular events (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke) was examined in 11,140 patients who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) Study. RESULTS A higher resting heart rate was associated with a significantly increased risk of all-cause mortality (fully adjusted HR 1.15 per 10 bpm [95% CI 1.08, 1.21], p<0.001), cardiovascular death and major cardiovascular outcomes without adjustment and after adjusting for age and sex and multiple covariates. The increased risk associated with a higher baseline resting heart rate was most obvious in patients with previous macrovascular complications (fully adjusted HR for death 1.79 for upper [mean 91 bpm] vs lowest [mean 58 bpm] fifth of resting heart rate in this subgroup [95% CI 1.28, 2.50], p = .001). CONCLUSIONS/INTERPRETATION Among patients with type 2 diabetes, a higher resting heart rate is associated with an increased risk of death and cardiovascular complications. It remains unclear whether a higher heart rate directly mediates the increased risk or is a marker for other factors that determine a poor outcome.
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Affiliation(s)
- G S Hillis
- The George Institute for Global Health, King George V Building, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.
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Zoungas S, Chalmers J, Ninomiya T, Li Q, Cooper ME, Colagiuri S, Fulcher G, de Galan BE, Harrap S, Hamet P, Heller S, MacMahon S, Marre M, Poulter N, Travert F, Patel A, Neal B, Woodward M. Association of HbA1c levels with vascular complications and death in patients with type 2 diabetes: evidence of glycaemic thresholds. Diabetologia 2012; 55:636-43. [PMID: 22186981 DOI: 10.1007/s00125-011-2404-1] [Citation(s) in RCA: 211] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 11/04/2011] [Indexed: 01/14/2023]
Abstract
AIMS/HYPOTHESIS There is conflicting evidence regarding appropriate glycaemic targets for patients with type 2 diabetes. Here, we investigate the relationship between HbA(1c) and the risks of vascular complications and death in such patients. METHODS Eleven thousand one hundred and forty patients were randomised to intensive or standard glucose control in the Action in Diabetes and Vascular disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Glycaemic exposure was assessed as the mean of HbA(1c) measurements during follow-up and prior to the first event. Adjusted risks for each HbA(1c) decile were estimated using Cox models. Possible differences in the association between HbA(1c) and risks at different levels of HbA(1c) were explored using linear spline models. RESULTS There was a non-linear relationship between mean HbA(1c) during follow-up and the risks of macrovascular events, microvascular events and death. Within the range of HbA(1c) studied (5.5-10.5%), there was evidence of 'thresholds', such that below HbA(1c) levels of 7.0% for macrovascular events and death, and 6.5% for microvascular events, there was no significant change in risks (all p > 0.8). Above these thresholds, the risks increased significantly: every 1% higher HbA(1c) level was associated with a 38% higher risk of a macrovascular event, a 40% higher risk of a microvascular event and a 38% higher risk of death (all p < 0.0001). CONCLUSIONS/INTERPRETATION In patients with type 2 diabetes, HbA(1c) levels were associated with lower risks of macrovascular events and death down to a threshold of 7.0% and microvascular events down to a threshold of 6.5%. There was no evidence of lower risks below these levels but neither was there clear evidence of harm.
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Affiliation(s)
- S Zoungas
- The George Institute for Global Health, PO Box M201, Missenden Road, Camperdown, NSW 2050, Sydney, NSW, Australia.
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Batty GD, Li Q, Huxley R, Zoungas S, Taylor BA, Neal B, de Galan B, Woodward M, Harrap SB, Colagiuri S, Patel A, Chalmers J. Oral disease in relation to future risk of dementia and cognitive decline: prospective cohort study based on the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) trial. Eur Psychiatry 2011; 28:49-52. [PMID: 21964484 DOI: 10.1016/j.eurpsy.2011.07.005] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 07/11/2011] [Accepted: 07/16/2011] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE Examine the association of oral disease with future dementia/cognitive decline in a cohort of people with type 2 diabetes. METHODS A total of 11,140 men and women aged 55-88 years at study induction with type 2 diabetes participated in a baseline medical examination when they reported the number of natural teeth and days of bleeding gums. Dementia and cognitive decline were ascertained periodically during a 5-year follow-up. RESULTS Relative to the group with the greatest number of teeth (more than or equal to 22), having no teeth was associated with the highest risk of both dementia (hazard ratio; 95% confidence interval: 1.48; 1.24, 1.78) and cognitive decline (1.39; 1.21, 1.59). Number of days of bleeding gums was unrelated to these outcomes. CONCLUSIONS Tooth loss was associated with an increased risk of both dementia and cognitive decline.
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Affiliation(s)
- G-D Batty
- Department of Epidemiology and Public Health, University College of London, Torrington Place, London, UK.
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Stefansdottir G, Zoungas S, Chalmers J, Kengne AP, Knol MJ, Leufkens HGM, Patel A, Woodward M, Grobbee DE, De Bruin ML. Intensive glucose control and risk of cancer in patients with type 2 diabetes. Diabetologia 2011; 54:1608-14. [PMID: 21509444 DOI: 10.1007/s00125-011-2104-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 02/08/2011] [Indexed: 12/28/2022]
Abstract
AIMS/HYPOTHESIS Type 2 diabetes has been associated with an increased risk of cancer. This study examines the effect of more vs less intensive glucose control on the risk of cancer in patients with type 2 diabetes. METHODS All 11,140 participants from the Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE) trial (ClinicalTrials.gov NCT00145925) were studied. Cancer incidence and cancer mortality was compared in groups randomised to intensive or standard glucose control. Information on events during follow-up was obtained from serious adverse event reports and death certificates. HRs (95% CI) were calculated for all cancers, all solid cancers, cancer deaths and site-specific cancers. RESULTS After a median follow-up of 5 years, 363 and 337 cancer events were reported in the intensive and standard control groups, respectively (incidence 1.39/100 person-years [PY] and 1.28/100 PY; HR 1.08 [95% CI 0.93-1.26]). The incidences of all solid cancers and cancer deaths were 1.25/100 PY and 0.55/100 PY in the intensive group and 1.15/100 PY and 0.63/100 PY in the standard group (HR 1.09[95% CI 0.93–1.27] for solid cancers, and 0.88 [0.71–1.10] for cancer death) [corrected].Across all the major organ systems studied, no significant differences in the cancer incidences were observed in the intensive and standard control groups. CONCLUSIONS/INTERPRETATIONS More intensive glucose control achieved with a regimen that included greater use of gliclazide, insulin, metformin and other agents, did not affect the risk of cancer events or death in patients with type 2 diabetes.
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Affiliation(s)
- G Stefansdottir
- Julius Centre for Health Sciences and Primary Care, University Medical Centre (UMC), Utrecht, the Netherlands
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Ben-Shlomo Y, Spears M, Boustred C, May M, Anderson S, Boutouyrie P, Cameron J, Chen C, Cockcroft J, Cruickshank K, Hwang S, Lakatta E, Laurent S, Maldonado J, McEniery C, Mitchell G, Najjar S, Newman A, Ohishi M, Pannier B, Pereira T, Shokawa T, Sutton-Tyrell K, Webb D, Willum-Hansen T, Zoungas S, Wilkinson I. 1.3 PROGNOSTIC VALUE OF CAROTID-FEMORAL PULSE WAVE VELOCITY FOR CARDIOVASCULAR EVENTS: AN IPD META-ANALYSIS OF PROSPECTIVE OBSERVATIONAL DATA FROM 14 STUDIES INCLUDING 16,358 SUBJECTS. Artery Res 2011. [DOI: 10.1016/j.artres.2011.10.209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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Morton J, Li Q, Celermajer D, Chalmers J, Zoungas S, Patel A, Ng M. HDL Cholesterol is a Risk Factor for Diabetic Nephropathy But Not Retinopathy—Results From the ADVANCE Study. Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.05.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Li Q, Chalmers J, Czernichow S, Neal B, Taylor BA, Zoungas S, Poulter N, Woodward M, Patel A, de Galan B, Batty GD. Oral disease and subsequent cardiovascular disease in people with type 2 diabetes: a prospective cohort study based on the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) trial. Diabetologia 2010; 53:2320-7. [PMID: 20700576 PMCID: PMC4170775 DOI: 10.1007/s00125-010-1862-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 07/06/2010] [Indexed: 01/04/2023]
Abstract
AIMS/HYPOTHESIS While there are plausible biological mechanisms linking oral health with cardiovascular disease (CVD) and mortality rates, no study, to our knowledge, has examined this association in a representative population of people with type 2 diabetes. METHODS We used the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) study, a large, detailed, randomised controlled trial among a general population of individuals with type 2 diabetes. For the purposes of the present analyses, data from the trial are used within a prospective cohort study design. A total of 10,958 men and women, aged 55 to 88 years and with type 2 diabetes, participated in a baseline medical examination, during which they counted their number of natural teeth and reported the number of days that their gums had bled over the preceding year. Study members were followed up for mortality and morbidity over 5 years. RESULTS After controlling for a range of potential confounding factors, the group with no teeth had a markedly increased risk of death due to all causes (HR 1.48, 95% CI 1.24-1.78), CVD (1.35, 1.05-1.74) and non-CVD (1.64, 1.26-2.13), relative to the group with the most teeth (≥22 teeth). Frequency of bleeding gums was not associated with any of the outcomes of interest. There was no suggestion that treatment group or sex modified these relationships. CONCLUSIONS/INTERPRETATION In people with type 2 diabetes, oral disease, as indexed by fewer teeth, was related to an increased risk of death from all causes and of death due to CVD and non-CVD.
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Affiliation(s)
- Q Li
- The George Institute for International Health, Sydney, NSW, Australia
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Zoungas S, Chalmers J, Kengne AP, Pillai A, Billot L, de Galan B, Marre M, Neal B, Harrap S, Poulter N, Patel A. The efficacy of lowering glycated haemoglobin with a gliclazide modified release-based intensive glucose lowering regimen in the ADVANCE trial. Diabetes Res Clin Pract 2010; 89:126-33. [PMID: 20541825 DOI: 10.1016/j.diabres.2010.05.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 05/12/2010] [Accepted: 05/17/2010] [Indexed: 12/18/2022]
Abstract
The aim of these analyses was to examine the efficacy of the intensive gliclazide MR-based glucose lowering regimen used in the ADVANCE trial in lowering the level of glycated haemoglobin (HbA1c). All 11,140 randomised patients were included in analyses of treatment efficacy. Treatment efficacy was also examined in subgroups defined by baseline characteristics and treatments. At the end of 5 years follow-up, the mean HbA1c was reduced from 7.5% at baseline to 6.5% in those on intensive glucose control and to 7.3% in those on standard glucose control. With intensive glucose lowering greater proportions achieved HbA1c levels of < or =7.0%, < or =6.5% and < or =6.0%. With intensive glucose lowering substantial reductions in HbA1c were observed across subgroups defined by baseline age, sex, duration of diabetes, BMI, HbA1c or treatment regimen (p<0.0001). The main independent predictors of reduction in HbA1c during follow-up were baseline HbA1c, duration of diabetes and BMI. There was no weight gain in the intensive glucose control group and severe hypoglycaemia was uncommon, though more frequent than in the standard control group. Intensive glucose control with a gliclazide MR-based regimen was well tolerated and consistently effective in lowering HbA1c across a broad range of patient with type 2 diabetes.
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Affiliation(s)
- S Zoungas
- The George Institute For International Health, University of Sydney, Sydney, Australia; School of Public Health, Monash University, Melbourne, Australia
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Kengne AP, Patel A, Colagiuri S, Heller S, Hamet P, Marre M, Pan CY, Zoungas S, Grobbee DE, Neal B, Chalmers J, Woodward M. The Framingham and UK Prospective Diabetes Study (UKPDS) risk equations do not reliably estimate the probability of cardiovascular events in a large ethnically diverse sample of patients with diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE) Study. Diabetologia 2010; 53:821-31. [PMID: 20157695 DOI: 10.1007/s00125-010-1681-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Accepted: 01/14/2010] [Indexed: 02/04/2023]
Abstract
AIMS/HYPOTHESIS Available multivariable equations for cardiovascular risk assessment in people with diabetes have been derived either from the general population or from populations with diabetes. Their utility and comparative performance in a contemporary group of patients with type 2 diabetes are not well established. The aim of this study was to evaluate the performance of the Framingham and UK Prospective Diabetes Study (UKPDS) risk equations in participants who took part in the Action in Diabetes and Vascular disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE) trial. METHODS The 4-year risks of cardiovascular disease (CVD) and its constituents were estimated using two published Framingham and the UKPDS risk equations in 7,502 individuals with type 2 diabetes without prior known CVD at their enrolment in the trial. RESULTS The risk of major CVD was overestimated by 170% (95% CI 146-195%) and 202% (176-231%) using the two Framingham equations. The risk of major coronary heart disease was overestimated by 198% (162-238%) with the UKPDS, and by 146% (117-179%) and 289% (243-341%) with the two different Framingham equations, respectively. The risks of stroke events were also overestimated with the UKPDS and one of the Framingham equations. The ability of these equations to rank risk among ADVANCE participants was modest, with c-statistics ranging from 0.57 to 0.71. Results stratified by sex, treatment allocation and ethnicity were broadly similar. CONCLUSIONS/INTERPRETATION Application of the Framingham and UKPDS risk equations to a contemporary treated group of patients with established type 2 diabetes is likely to substantially overestimate cardiovascular risk.
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Affiliation(s)
- A P Kengne
- The George Institute for International Health, University of Sydney, PO Box M201, Level 10 KGV Building, RPAH, Missenden Road, Camperdown, Sydney, NSW 2050, Australia.
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Moran LJ, Meyer C, Hutchison SK, Zoungas S, Teede HJ. Novel inflammatory markers in overweight women with and without polycystic ovary syndrome and following pharmacological intervention. J Endocrinol Invest 2010; 33:258-65. [PMID: 19834313 DOI: 10.1007/bf03345790] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is associated with reproductive and metabolic abnormalities. AIM The aim of this study was to assess novel inflammatory markers [adipokines leptin, adiponectin, and leptinadiponectin ratio (L/A)] in overweight women with and without PCOS and to examine alterations in these markers [aldosterone, leptin, adiponectin, and L/A] with pharmacological interventions modulating insulin resistance (IR) in PCOS. MATERIALS/SUBJECTS AND METHODS Overweight age, and body mass index (BMI)-matched women with (no.=80) or without PCOS (no.=27) were assessed cross-sectionally. Subjects with PCOS were then randomised to 6 months metformin (1 g b.d, no.=26) or oral contraceptive pill (OCP) (35 g ethinyl estradiol/2 mg cytoproterone acetate, no.=30). Outcome measures were leptin, adiponectin, L/A, aldosterone, highly sensitive C-reactive protein, lipid profile, IR, and androgen levels. RESULTS Leptin levels were lower (156.4+/-85.9 vs 208.5+/-105.2 ng/ml, p=0.015) while adiponectin and L/A were not different between women with and without PCOS. Following intervention, IR increased for the OCP and decreased for metformin, however leptin and aldosterone decreased equivalently with the OCP and metformin with no difference between each treatment (p=0.583 and p=0.801, respectively). There was no change in adiponectin or L/A with the OCP or metformin. On multiple regression, the only baseline predictor of leptin was BMI (r(2)=0.485, p<0.001) and the strongest predictor of change in leptin was change in weight (r(2)=0.402, p<0.001). CONCLUSIONS Alterations in leptin between women with and without PCOS and following pharmacological interventions are primarily related to adiposity and not IR. Aldosterone was reduced equivalently with metformin and the OCP despite differential effects on IR.
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Affiliation(s)
- L J Moran
- The Jean Hailes Foundation for Women's Health, Monash Institute of Health Services Research, Monash University, Clayton, Victoria 3168, Australia.
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Zoungas S, Lui M, Kerr PG, Teede HJ, McNeil JJ, McGrath BP, Polkinghorne KR. Advanced chronic kidney disease, cardiovascular events and the effect of diabetes: data from the Atherosclerosis and Folic Acid Supplementation Trial. Intern Med J 2010; 41:825-32. [DOI: 10.1111/j.1445-5994.2010.02226.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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de Galan BE, Zoungas S, Chalmers J, Anderson C, Dufouil C, Pillai A, Cooper M, Grobbee DE, Hackett M, Hamet P, Heller SR, Lisheng L, MacMahon S, Mancia G, Neal B, Pan CY, Patel A, Poulter N, Travert F, Woodward M. Cognitive function and risks of cardiovascular disease and hypoglycaemia in patients with type 2 diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Diabetologia 2009; 52:2328-2336. [PMID: 19688336 DOI: 10.1007/s00125-009-1484-7] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 07/13/2009] [Indexed: 12/20/2022]
Abstract
AIMS/HYPOTHESIS The relationship between cognitive function, cardiovascular disease and premature death is not well established in patients with type 2 diabetes. We assessed the effects of cognitive function in 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Furthermore, we tested whether level of cognitive function altered the beneficial effects of the BP-lowering and glycaemic-control regimens in the trial. METHODS Cognitive function was assessed using the Mini Mental State Examination at baseline, and defined by scores 28-30 ('normal', n = 8,689), 24-27 ('mild dysfunction', n = 2,231) and <24 ('severe dysfunction', n = 212). Risks of major cardiovascular events, death and hypoglycaemia and interactions with treatment were assessed using Cox proportional hazards analysis. RESULTS Relative to normal function, both mild and severe cognitive dysfunction significantly increased the multiple-adjusted risks of major cardiovascular events (HR 1.27, 95% CI 1.11-1.46 and 1.42, 95% CI 1.01-1.99; both p < 0.05), cardiovascular death (1.41, 95% CI 1.16-1.71 and 1.56, 95% CI 0.99-2.46; both p <or= 0.05) and all-cause death (1.33, 95% CI 1.16-1.54 and 1.50, 95% CI 1.06-2.12; both p < 0.03). Severe, but not mild, cognitive dysfunction increased the risk of severe hypoglycaemia (HR 2.10, 95% CI 1.14-3.87; p = 0.018). There was no evidence of heterogeneity of treatment effects on cardiovascular outcomes in subgroups defined by cognitive function at baseline. CONCLUSIONS/INTERPRETATION Cognitive dysfunction is an independent predictor of clinical outcomes in patients with type 2 diabetes, but does not modify the effects of BP lowering or glucose control on the risks of major cardiovascular events. TRIAL REGISTRATION ClinicalTrials.gov NCT00145925.
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Affiliation(s)
- B E de Galan
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
- Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - S Zoungas
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia.
- Monash University, Melbourne, VIC, Australia.
| | - J Chalmers
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
| | - C Anderson
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
| | - C Dufouil
- INSERM U708, Paris, France
- UPMC University of Paris, Paris, France
| | - A Pillai
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
| | - M Cooper
- Baker IDI Heart Research Institute, Melbourne, VIC, Australia
| | - D E Grobbee
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - M Hackett
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
| | - P Hamet
- Centre Hospitalier de l'Université de Montreal and Université de Montreal, Montreal, QC, Canada
| | - S R Heller
- University of Sheffield and Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, UK
| | - L Lisheng
- Chinese Hypertension League Institute, Beijing, China
| | - S MacMahon
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
| | - G Mancia
- University of Milan-Bicocca and San Gerardo Hospital, Milan, Italy
| | - B Neal
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
| | - C Y Pan
- Chinese People's Liberation Army General Hospital, Beijing, China
| | - A Patel
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
| | - N Poulter
- Imperial College and St Mary's Hospital, London, UK
| | - F Travert
- UPMC University of Paris, Paris, France
| | - M Woodward
- The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia
- Mount Sinai School of Medicine, New York, NY, USA
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Teede HJ, Liang YL, Kotsopoulos D, Zoungas S, Craven R, McGrath BP. Placebo-controlled trial of transdermal estrogen therapy alone in postmenopausal women: effects on arterial compliance and endothelial function. Climacteric 2009. [DOI: 10.1080/cmt.5.2.160.169] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Polycystic ovary syndrome is the most common endocrinopathy of reproductive aged women affecting 6-10% of the population. Traditionally considered a reproductive disorder manifesting as chronic anovulation, infertility, and hyperandrogenism, management has primarily focused on short-term reproductive outcomes. Recently, however, significant metabolic aspects in conjunction with longer-term health sequealae of PCOS have been recognized. The metabolic features are primarily related to underlying insulin resistance (IR), which is now understood to play an important role in both the pathogenesis and long-term sequelae of PCOS.
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Affiliation(s)
- H J Teede
- Jean Hailes Research Group, Monash University Institute of Health Services Research and Diabetes Unit Southern Health, Melbourne, Australia.
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Teede HJ, Hutchison S, Zoungas S, Meyer C. Insulin resistance, the metabolic syndrome, diabetes, and cardiovascular disease risk in women with PCOS. Endocrine 2006; 30:45-53. [PMID: 17185791 DOI: 10.1385/endo:30:1:45] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2005] [Revised: 11/30/1999] [Accepted: 12/11/2005] [Indexed: 11/11/2022]
Abstract
Polycystic ovary syndrome is the most common endocrinopathy of reproductive aged women affecting 6-10% of the population. Traditionally considered a reproductive disorder manifesting as chronic anovulation, infertility, and hyperandrogenism, management has primarily focused on short-term reproductive outcomes. Recently, however, significant metabolic aspects in conjunction with longer-term health sequealae of PCOS have been recognized. The metabolic features are primarily related to underlying insulin resistance (IR), which is now understood to play an important role in both the pathogenesis and long-term sequelae of PCOS.
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Affiliation(s)
- H J Teede
- Jean Hailes Research Group, Monash University Institute of Health Services Research and Diabetes Unit Southern Health, Melbourne, Australia.
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Polkinghorne KR, Zoungas S, Branley P, Villanueva E, McNeil JJ, Atkins RC, McGrath BP, Kerr PG. Randomized, placebo-controlled trial of intramuscular vitamin B12for the treatment of hyperhomocysteinaemia in dialysis patients. Intern Med J 2003; 33:489-94. [PMID: 14656250 DOI: 10.1046/j.1445-5994.2003.00420.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Plasma homocysteine is elevated in patients with end-stage renal disease (ESRD) and is a risk factor for cardiovascular disease. Folic acid has been shown to partially reduce homocysteine levels in dialysis patients. It is not known whether vitamin B12 reduces homocysteine independent of folic acid in patients who are not vitamin B12 deficient. AIM To determine whether 1 mg vitamin B12 lowers homocysteine in stable, chronic, haemodialysis patients independent of folic acid. METHODS Twenty-eight haemodialysis patients were randomized to receive three doses of 1 mg vitamin B12 or 1 mL saline placebo in a double-blind fashion at 1-month intervals. Fasting plasma total homocysteine, folic acid, red-cell folate, vitamin B12 and haemoglobin levels were determined prior to each dose and 4 weeks after the final injection. The study was powered to detect a 30% reduction in homocysteine over the 3 months. RESULTS Both the two groups were well matched with respect to total homocysteine levels, folic acid, red-cell folate and vitamin B12 levels. Serum vitamin B12 levels were significantly higher in the treatment group compared to placebo (217.7 pmol/L; 95% confidence interval (CI) 103.0-332.5; P < 0.001) at the end of the trial but homocysteine levels were not significantly different (3.08 micromol/L; 95% CI -4.44-10.61; P= 0.406). CONCLUSIONS The administration of intramuscular vitamin B12 over a 3-month period does not result in any reduction of plasma homocysteine levels in haemo-dialysis patients independent of folate status, however reductions of <30% cannot be excluded by the present study. High-dose folic acid remains the treatment of choice in reducing homocysteine, but whether this results in a reduction in cardiovascular events remains to be determined.
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Affiliation(s)
- K R Polkinghorne
- Department of Nephrology, Monash Medical Centre and Monash University, Melbourne, Victoria, Australia.
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Teede HJ, Liang YL, Kotsopoulos D, Zoungas S, Craven R, McGrath BP. Placebo-controlled trial of transdermal estrogen therapy alone in postmenopausal women: effects on arterial compliance and endothelial function. Climacteric 2002; 5:160-9. [PMID: 12051112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND The cardiovascular effects of hormone replacement therapy (HRT) are controversial. Improvement in vascular function, potentially mediated, at least in part, via improvements in lipid profiles, is a proposed mechanism of estrogen action; however, there are few controlled human trials. We have studied the effects of HRT, independent of changes in lipid profile, with transdermal estrogen therapy, focusing on blood pressure, lipid profiles and vascular function, encompassing both biomechanical arterial properties (systemic arterial compliance and pulse wave velocity) and endothelial function (flow-mediated vasodilatation). METHODS In this 2-year, double-blind, placebo-controlled, cross-over study, 34 healthy postmenopausal women were randomized to transdermal estrogen alone (Menorest, 50 micrograms) or placebo. After withdrawals, 25 women completed measurements at baseline, 6 weeks, 6 months and 12 months during both treatment phases. RESULTS Transdermal estrogen did not improve blood pressure, lipid profiles or arterial function, compared with placebo. CONCLUSION From this randomized, controlled trial, it appears that transdermal estrogen alone, in healthy postmenopausal women, does not improve lipid profiles or a spectrum of indices of arterial function, compared with placebo. These results would suggest that there might not be a beneficial effect of transdermal HRT on the vasculature in postmenopausal women.
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Affiliation(s)
- H J Teede
- Department of Medicine, Monash University, Dandenong Hospital, Dandenong, Australia
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McGrath B, Zoungas S, McNeil J, Branley P, Kerr P. THE ATHEROSCLEROSIS AND FOLIC ACID SUPPLEMENTATION TRIAL IN CRF (ASFAST): RATIONALE, DESIGN AND BASELINE RESULTS. Nephrology (Carlton) 2002. [DOI: 10.1046/j.1440-1797.2002.00007-1-65.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Teede HJ, Liang YL, Kotsopoulos D, Zoungas S, Cravent R, McGrath BP. A placebo-controlled trial of long-term oral combined continuous hormone replacement therapy in postmenopausal women: effects on arterial compliance and endothelial function. Clin Endocrinol (Oxf) 2001; 55:673-82. [PMID: 11894980 DOI: 10.1046/j.1365-2265.2001.01382.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To study the effects of long-term combined continuous oral hormone replacement therapy (HRT) on vascular function in healthy postmenopausal women. BACKGROUND The cardiovascular effects of HRT are controversial. Improvement in vascular function is a proposed mechanism of oestrogen action but there are no long-term controlled human trials in this area. In this study, we examined the effects of HRT on lipid profiles and vascular function, encompassing both biomechanical arterial properties [systemic arterial compliance (SAC) and pulse wave velocity (PWV)] and endothelial function [flow-mediated vasodilation (FMD)]. METHODS In this 2-year, double-blind, placebo-controlled study, 59 healthy postmenopausal women were randomized to oral combined continuous oestrogen and progesterone [Kliogest, oestradiol (2 mg), norethisterone (1 mg)] or placebo, with end-points measured at baseline, 6 weeks and after 6,12 and 24 months of treatment. RESULTS Oral combined HRT reduced lipoprotein a [Lp(a)], although other lipid benefits were not observed. There were no significant changes in SAC, PWV or FMD with oral combined HRT, compared to placebo. CONCLUSION In this long-term, randomized placebo-controlled trial, oral continuous HRT with combined oestradiol and norethisterone in healthy postmenopausal women did not improve a spectrum of indices of arterial function compared to placebo. These results suggest that HRT might not be of cardiovascular benefit in postmenopausal women.
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Affiliation(s)
- H J Teede
- Department of Medicine, Monash University, Dandenong Hospital, Victoria, Australia.
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Zoungas S, Ristevski S, Lightfoot P, Liang YL, Branley P, Shiel LM, Kerr P, Atkins R, McNeil JJ, McGrath BP. Carotid artery intima-medial thickness is increased in chronic renal failure. Clin Exp Pharmacol Physiol 2000; 27:639-41. [PMID: 10901397 DOI: 10.1046/j.1440-1681.2000.03301.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
1. Chronic renal failure (CRF) is associated with rapidly progressive atherosclerotic vascular disease. In the present study, carotid arterial intima-medial thickness (IMT) was assessed in a large cohort of patients with CRF and matched controls and related to risk factors. 2. A total of 159 subjects with CRF (serum creatinine > or =0.40 mmol/L) aged > 50 years (mean (+/-SD) 63.8+/-7.7 years) and 159 healthy controls matched for age, sex and smoking status were studied. 3. The IMT was determined using B-mode ultrasound measurements of the far wall of both common carotid arteries and presented as the mean IMT. Fasting plasma homocysteine (tHcy) was measured in the CRF group. 4. Intima-medial thickness was significantly greater in CRF patients than controls (0.89+/-0.17 vs 0.73+/-0.13 mm, respectively) after matching for age, sex and smoking status. Heart rate and pulse pressure were also significantly increased. The tHcy was increased two-fold in the CRF group (27.7+/-11.3 micromol/L; normal < 13.0 micromol/L) and did not correlate with carotid IMT. 5. Compared with controls after adjusting for traditional risk factors, patients with CRF exhibit significantly increased IMT.
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Affiliation(s)
- S Zoungas
- Department of Medicine, Monash University, Clayton, Victoria, Australia.
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