Health burden in type 2 diabetes and prediabetes in The Maastricht Study

Mortality in type 2 diabetes, is determined not only by classical complications, but also by comorbidities, and is linked to hyperglycaemia and apparent even in prediabetes. We aimed to comprehensively investigate, in a population-based cohort, health burden defined as the presence of comorbidities in addition to classical complications and cardiometabolic risk factors, in not only type 2 diabetes but also prediabetes. Such population-based study has not been performed previously. Extensive phenotyping was performed in 3,410 participants of the population-based Maastricht Study (15.0% prediabetes and 28.6% type 2 diabetes) to assess presence of 17 comorbidities, six classical complications, and ten cardiometabolic risk factors. These were added up into individual and combined sum scores and categorized. Group differences were studied with multinomial regression analyses adjusted for age and sex. Individuals with type 2 diabetes and prediabetes, as compared to normal glucose metabolism (NGM), had greater comorbidities, classical complications, cardiometabolic risk factors and combined sum scores (comorbidities sum score ≥ 3: frequencies (95% CI) 61.5% (57.6;65.4) and 41.2% (36.5;45.9) vs. 25.4% (23.5;27.4), p-trend < 0.001; classical complications ≥ 2 (26.6% (23.1;30.1; P < 0.001 vs. NGM) and 10.1% (7.8;12.7; P = 0.065 vs NGM) vs. 8.0% (6.9;9.3)); cardiometabolic risk factors ≥ 6 (39.7% (35.9;43.4) and 28.5% (24.5;32.6) vs. 14.0% (12.5;15.6); p-trend < 0.001); combined ≥ 8 (66.6% (62.7;70.5) and 48.4% (43.7;53.1) vs. 26.0%(24.1;28.0), p-trend < 0.001). Type 2 diabetes and prediabetes health burden was comparable to respectively 32 and 14 years of ageing. Our population-based study shows, independently of age and sex, a considerable health burden in both type 2 diabetes and prediabetes, which to a substantial extent can be attributed to comorbidities in addition to classical complications and cardiometabolic risk factors. Our findings emphasize the necessity of comorbidities' awareness in (pre)diabetes and for determining the exact role of hyperglycaemia in the occurrence of comorbidities.

Adalimumab successful in sarcoidosis patients with refractory chronic non-infectious uveitis

INTRODUCTION

Adalimumab, a humanized monoclonal antibody targeted against TNF-α, has proved to be successful in the treatment of uveitis. Another anti-TNF-α agent, i.e., infliximab, has been reported of benefit in the treatment of refractory sarcoidosis. The aim of this prospective case series was to evaluate the effect of adalimumab on intraocular inflammatory signs and other relevant clinical manifestations (lung function, serological inflammatory parameters, and fatigue) of sarcoidosis.

METHODS

Sarcoidosis patients with refractory posterior uveitis (n = 26, 17 females, 41 eyes in total) were systematically followed for 12 months after initiation of adalimumab 40 mg sc once a week. Inclusion criteria were non-responsiveness to prednisone and methotrexate (MTX) or intolerance to these drugs. Adjunctive therapy with prednisone and MTX was tapered during treatment with adalimumab. Localization and improvement, stabilization or deterioration of intraocular inflammatory signs was scored. Pulmonary function- and laboratory testing were performed and Fatigue Assessment Scale was completed. Results at baseline, 6 months, and 12 months were compared.

RESULTS

Choroidal involvement resolved in 10/15 patients, five had partial improvement; vasculitis resolved in 1/1 patient; papillitis resolved in 7/8 patients, one had partial response; macular edema resolved in 5/8 patients, three had partial response; vitreous cleared completely in 5/5 patients. Overall outcome regarding intraocular inflammatory signs showed improvement in 22 patients (85%) and stabilization in four patients (15%). At 12 months, no recurrences were reported in those successfully treated. Laboratory parameters of inflammatory activity (C-reactive protein; serum angiotensin-converting enzyme and soluble interleukin-2 Receptor) improved (p < 0.01). Moreover, fatigue improved in 14/21 (67%) of the patients suffering from fatigue and the diffusion capacity for carbon monoxide (DLCO) improved in 7/8 (88%) of patients with a decreased DLCO (p < 0.01). The dosage of both prednisone and MTX could be tapered down significantly (p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

Adalimumab appeared successful in sarcoidosis patients with refractory chronic non-infectious uveitis showing improvement in intraocular inflammatory signs as well as in other relevant clinical indicators of disease activity. Future randomized studies are needed to determine the optimal dosage, dose interval and duration of therapy in refractory multisystemic sarcoidosis.

Physical load in daily life and low back problems in the general population-The MORGEN study

BACKGROUND

We studied the contribution of physical load in daily activities, including activities in work, housekeeping, and leisure time, to the burden of low back problems (LBP) in the population.

METHODS

Logistic regression models were used to calculate the association between physical load and several LBP parameters as assessed by questionnaire in a cross-sectional study on 22,415 randomly selected men and women in The Netherlands, controlling for well-known LBP determinants. The population attributable risk (PAR) percentage was estimated with the elimination method using the logistic model.

RESULTS

Half of the population reported LBP during the past year and 19% chronic LBP. Activities characterized by an awkward posture, by the same posture for a long time, or by often bending and rotating the trunk increased the risk for LBP, with ORs between 1.1 and 1.6. More than 13% of the 1-year prevalence of LBP could be contributed to these activities. This PAR was higher for those belonging to the working population, for women, and for the more severe LBP parameters.

CONCLUSION

Because LBP present such a large public health problem, the estimated potential impact of eliminating (the unhealthy effect of) physical load is substantial. To assess the real health gain, more insight is necessary into the causality of the relationship and into effective preventive measures.

Prevalence and consequences of low back problems in The Netherlands, working vs non-working population, the MORGEN-Study. Monitoring Project on Risk Factors for Chronic Disease

OBJECTIVE

To study the burden of illness of low back problems--prevalence and consequences--in the working and the non-working population.

METHODS

Data from the Monitoring Project on Risk factors for Chronic Diseases, the MORGEN-study, were used. This project provided data on a probability sample of the general population aged 20-59 y in the Netherlands. Cross-sectional questionnaire data on 6317 men (24% non-working) and 7505 women (47% non-working) gathered over the period 1993-1995 were analysed.

RESULTS

The 12 month period prevalence of low back problems for the working and non-working population was 44.4% and 45.8% for men, and 48.2% and 55.0% for women. Larger differences were found for chronic low back problems, and activity limitation and use of health services due to low back problems. More than one-third of those who were disabled were so because of low back problems. When those unable to work because of disability (work disabled) were excluded, the prevalence and consequences of low back pain were still higher in the non-working group in comparison with the working population. Most of the non-working women were housewives and this group was both large in size and had a high prevalence of low back problems.

CONCLUSIONS

Among the men studied, more than a quarter of the total burden of low back problems in those aged 20-59 y were found in the non-working population, among women this was 50%. Both research on causes and determinants of low back pain and the development of preventive actions--now being extensively focused on the working population--should also be translated to the non-working population.

['Public health status and perspectives' 1997. VI. Effects of health care]

The aim of this study was to investigate whether more health improvement might be attained with existing medical interventions. The interventions for ten diseases were studied to assess their efficacy (effect in ideal, experimental situation), their effectiveness (effect in daily practice) and the discrepancy between the efficacy and effectiveness. In addition, the causes of unexpectedly low effectiveness were studied. Interventions with proven efficacy were identified for all ten diseases. The effectiveness was less often studied. Existing health care registrations could provide information on the effectiveness for only three diseases (tuberculosis, colorectal tumours, and acute myocardial infarction). Causes of unexpectedly low effectiveness were observed in several of the five phases of the process of care: contacting the health care system, diagnosing the disease, prescribing the appropriate intervention, executing the intervention and patient compliance.

The prevalence of low back pain and associations with body fatness, fat distribution and height

OBJECTIVES

To examine the associations of low back pain symptoms with waist circumference, height, waist to hip ratio and body mass index, and to test the interactions between (1) waist circumference and height, and (2) waist to hip ratio and body mass index.

SETTING

Cross-sectional study set in The Netherlands of a random sample of 5887 men and 7018 women aged 20-60 y.

RESULTS

The prevalences of low back pain in men and women in the past 12 months were 46% and 52%, of whom 17% and 21% had low back pain for a total of 12 or more weeks, and 13% and 18% had symptoms suggestive of intervertebral disc herniation. After adjustments for age, smoking and education, more women in the highest tertile of waist circumference reported low back pain in the past 12 months (odds ratio = 1.2, 95% confidence interval: 1.1-1.4), low back pain for a total of 12 or more weeks (odds ratio = 1.5, 95% confidence interval: 1.3-1.8), and intervertebral disc herniation symptoms (odds ratio = 1.3, 95% confidence interval: 1.1-1.6) than women in the lowest waist tertile. Corresponding values of low back pain symptoms for women with high body mass index or high waist to hip ratio were similar to those with high waist. There were no significant differences between men in different tertiles of waist, waist to hip ratio or body mass index reporting low back pain symptoms. Tallest subjects did not report low back pain symptoms more often than shortest subjects. There was no significant interactions between waist and height or between waist to hip ratio and body mass index on low back pain symptoms.

CONCLUSIONS

Women who are overweight or with a large waist have a significantly increased likelihood of low back pain. There are no significant interactions between waist and height, or waist to hip ratio and body mass index on low back pain symptoms.

Classification criteria: methodological considerations and results from a 12 year following study in the general population

In a 12 year followup study on knee osteoarthritis (OA) in the general population, several methodological aspects of the development and choice of classification criteria were studied. It cannot be assumed that the American College of Rheumatology (ACR) criteria sets developed in a clinical setting with comparable sensitivity and specificity will give comparable results in the general population. Moreover, validity needs to be studied in the general population to show whether there is consistency of research findings in the study of the prevalence and the relationship with putative risk factors. We found that the clinical criteria sets, with or without laboratory criteria in a traditional format, do not give results consistent with the other sets of ACR criteria. Kellgren and Lawrence's criteria were shown to predict the presence of future OA according to the other sets of ACR criteria.

Insulin-like growth factor-1: a prognostic factor of knee osteoarthritis

During a population survey in 1975-1978 persons with radiological osteoarthritis (ROA) of the knee were identified. After 12 years a follow-up study was conducted to study the effect of circulating insulin-like growth factor-1 (IGF-1) on cartilage loss, osteophyte growth and overall progression in 141 persons with confirmed ROA of the knee. The outcome measures were scored by comparing the radiographs taken at baseline and at follow-up. Insulin-like growth factor-1 was measured by radioimmunoassay in serum taken at follow-up and in 79% of the baseline sera. After adjusting for age, gender and body mass index at baseline, IGF-1 concentration at follow-up was related to osteophyte growth and overall progression. The adjusted odds ratio of the highest vs the lowest tertile was 2.96 (95% CI: 1.15-7.60) for osteophyte growth and 2.58 (1.01-6.60) for overall progression. No clear relationship was found with cartilage loss. These results were confirmed when baseline IGF-1 was studied. We conclude that the circulating IGF-1 concentration has an effect on the course of knee OA by influencing osteophyte formation but a preventive effect on cartilage loss could not be shown.

High blood pressure and the incidence of non-insulin dependent diabetes mellitus: findings in a 11.5 year follow-up study in The Netherlands

To examine the contribution of cardiovascular risk factors to the development of non-insulin dependent diabetes mellitus, a prospective follow-up study was performed of a cohort, initially examined in a population survey on cardiovascular risk factors. The survey was conducted from 1975 to 1978 in the Netherlands among 5700 men and women aged 20 to 65. In 1988 a questionnaire on the prevalence of chronic diseases, including diabetes mellitus, was sent to all living participants of the initial survey. The general practitioners of the persons who indicated to have diabetes mellitus were asked to confirm the diagnosis. Diabetes mellitus was defined as current use of oral hypoglycemic drugs or insulin. After exclusion of the prevalent cases at the initial survey, 65 incident confirmed cases remained. All others responding to the questionnaire served as controls. The incidence of diabetes mellitus was associated with body mass index, use of diuretics, systolic and diastolic blood pressure. After adjustment for age and body mass index systolic and diastolic blood pressure were still associated with the incidence of non-insulin dependent diabetes mellitus in men; relative risks 1.28 (95% confidence interval 1.06-1.54) and 1.40 (95% CI 1.06-1.85) per 10 mmHg respectively. For women, only the relative risk associated with the use of diuretics remained statistically significant (2.26, 95% CI 1.04-4.90). This probably reflects the risk of (treated) hypertension: adjusted for blood pressure, the relative risk lost statistical significance. These findings suggest that elevated blood pressure is a risk for the development of non-insulin dependent diabetes mellitus (NIDDM). This supports the view that NIDDM and hypertension may have a similar origin.

A 12 year follow up study in the general population on prognostic factors of cartilage loss in osteoarthritis of the knee

The natural history and prognostic factors of cartilage loss in osteoarthritis of the knee were studied in subjects from a general population survey on rheumatic diseases in 1975-8. Baseline data were collected by questionnaire, physical examination, and weightbearing anteroposterior knee radiographs. Follow up of the subjects aged 46-68 years with radiological osteoarthritis grade 2-4 (Kellgren) took place in 1988-9. Cartilage loss was assessed by two observers who scored the change in joint space width between two radiographs. Thirty four per cent had cartilage loss. Prognostic factors and adjusted odds ratios (ORs) (95% confidence intervals) were: body mass index OR = 11.1 (3.3 to 37.3) fourth v first quartile; body weight OR = 7.9 (2.6 to 24.0) third v first tertile; age OR = 3.8 (1.1 to 13.4) > 60 v < or = 49 years; Heberden's nodes OR = 6.0 (1.5 to 23.1); clinical diagnosis of generalised osteoarthritis OR = 3.3 (1.3 to 8.3); and previous bow legs or knock knees OR = 5.1 (1.1 to 23.1). The relation of age with cartilage loss was also confounded by the presence of Heberden's nodes or a diagnosis of generalised osteoarthritis. There was no statistically significant relation for gender, meniscectomy, injury, uric acid concentration, chondrocalcinosis, smoking, and occupation related factors, except possibly standing.

Natural menopause, oophorectomy, hysterectomy and the risk of osteoarthritis of the dip joints

The purpose of this study was to determine whether postmenopausal women have an increased risk of developing radiological osteoarthritis (ROA), bony enlargement or Heberden's nodes of the distal interphalangeal (DIP) joints. Secondly, the effects of the duration of the postmenopausal period, age at menopause or duration of the fertile period on the occurrence of DIP-OA were studied. Data from a population survey were used and 143 postmenopausal women with a natural menopause, 53 with a hysterectomy and 75 with a hysterectomy and bilateral oophorectomy were compared with 374 premenopausal women. There was no significant association of these postmenopausal states with ROA, bony swelling or Heberden's nodes. Age adjusted odds ratios and 95% confidence intervals were 1.14 (0.68-1.91), 1.30 (0.72-2.35), 1.92 (0.77-4.76), respectively for the women with a natural menopause. After adjusting for age there was a positive relationship of Heberden's nodes with age at menopause and duration of the fertile period for women with a natural menopause.

The associations of neck pain with radiological abnormalities of the cervical spine and personality traits in a general population

Degenerative changes are considered to be a common cause of neck pain. In addition to this cause, personality traits could contribute to the complaint of neck pain. We investigated the associations of neck pain with personality traits, disc degeneration and osteoarthritis (OA) on radiographs of the cervical spine in a general population of 5,440 men and women between 20 and 65 years of age. Disc degeneration was associated with neck pain in the men but not in the women. OA of the facet joints was not related to neck pain, either in the men or the women, but the personality traits, neuroticism and injuredness, were. Among those with severe disc degeneration or OA of the cervical spine, neuroticism was a strong independent determinant of pain. Our findings show that neuroticism is a more powerful determinant of neck pain than radiological signs of disc degeneration or OA in the general population.

Do clinical findings associate with radiographic osteoarthritis of the knee?

From a population survey of 2865 subjects, test characteristics of a number of clinical findings relating to knee osteoarthritis were calculated against the standard of radiographic diagnosis. The clinical findings included from the history were age, gender, current pain in the knee, swollen knee, pain in both hands, morning stiffness, osteoarthritis in any joint, pain or stiffness, or both, in knees or hips when rising from seated position, and pain in knees or hips while climbing stairs; and from the physical examination: Quetelet's index, Heberden's nodes, bony enlargement, palpable effusion, soft tissue swelling, limitation of knee function, pain with knee flexion, bony tenderness and, finally, the latex fixation test. Of 18 clinical variables, all but Heberden's nodes, palpable knee effusion, pain in both hands, and latex fixation test showed a significant association after adjustment for age. Neither one single variable nor a combination could predict radiographic osteoarthritis of the knee with reasonable accuracy and thus be applicable in clinical practice. The x ray film, therefore, keeps its place in the diagnosis of knee osteoarthritis in general practice as well as in epidemiological research.