A few diabetes papers of interest

i. Burden of Diabetic Foot Ulcers for Medicare and Private Insurers.

Some observations from the paper (my bold):

According to the American Diabetes Association, the annual cost of diabetes, which affects 22.3 million people in the U.S., was $245 billion in 2012: $176 billion in excess health care expenditures and $69 billion in reduced workforce productivity (1). While much of the excess health care cost is attributable to treatment of diabetes itself, a substantial amount of the cost differential arises via treatment of chronic complications such as those related to the heart, kidneys, and nervous system (1).

One common complication of diabetes is the development of foot ulcers. Historically, foot ulcers have been estimated to affect 1–4% of patients with diabetes annually (2,3) and as many as 25% of the patients with diabetes over their lifetimes (2). More recently, Margolis et al. (3) have estimated that the annual incidence of foot ulcers among patients with diabetes may be as high as 6%. Treatment of diabetic foot ulcers (DFUs) includes conventional wound management (e.g., debridement, moist dressings, and offloading areas of high pressure or friction) as well as more sophisticated treatments such as bioengineered cellular technologies and hyperbaric oxygen therapy (HBO) (4).

DFUs often require extensive healing time and are associated with increased risk for infections and other sequelae that can result in severe and costly outcomes (4). […] DFU patients have a low survival prognosis, with a 3-year cumulative mortality rate of 28% (6) and rates among amputated patients approaching 50% (7).”

“While DFU patients can require substantial amounts of resource use, little is known about the burden of DFUs imposed on the U.S. health care system and payers. In fact, we are aware of only two studies to date that have estimated the incremental medical resource use and costs of DFU beyond that of diabetes alone (6,8). Neither of these analyses, however, accounted for the many underlying differences between DFU and non-DFU patient populations, such as disproportionate presence of costly underlying comorbid conditions among DFU patients […] Other existing literature on the burden of DFUs in the U.S. calculated the overall health care costs (as opposed to incremental) without reference to a non-DFU control population (911). As a result of the variety of data and methodologies used, it is not surprising that the burden of DFUs reported in the literature is wide-ranging, with the average per-patient costs, for example, ranging from $4,595 per episode (9) to over $35,000 annually for all services (6).

The objective of this study was to expand and improve on previous research to provide a more robust, current estimate of incremental clinical and economic burden of DFUs. To do so, this analysis examined the differences in medical resource use and costs between patients with DFUs during a recent time period (January 2007–September 2011) and a matched control population with diabetes but without DFUs, using administrative claims records from nationally representative databases for Medicare and privately insured populations. […] [Our] criteria resulted in a final analytic sample of 231,438 Medicare patients, with 29,681 (12.8%) identified as DFU patients and the remaining 201,757 comprising the potential control population of non-DFU diabetic patients. For private insurance, 119,018 patients met the sample selection criteria, with 5,681 (4.8%) DFU patients and 113,337 potential controls (Fig. 1).”

Prior to matching, DFU patients were statistically different from the non-DFU control population on nearly every dimension examined during the 12-month preindex period. […] The matching process resulted in the identification of 27,878 pairs of DFU and control patients for Medicare and 4,536 pairs for private insurance that were very similar with regards to preindex patient characteristics […] [I]mportantly, the matched DFU and control groups had comparable health care costs during the 12 months prior to the index date (Medicare, $17,744 DFU and controls; private insurance, $14,761 DFU vs. $14,766 controls). […] Despite having matched the groups to ensure similar patient characteristics, DFU patients used significantly (P < 0.0001) more medical resources during the 12-month follow-up period than did the matched controls […]. Among matched Medicare patients, DFU patients had 138.2% more days hospitalized, 85.4% more days of home health care, 40.6% more ED visits, and 35.1% more outpatient/physician office visits. The results were similar for the privately insured DFU patients, who had 173.5% more days hospitalized, 230.0% more days of home health care, 109.0% more ED visits, and 42.5% more outpatient/physician office visits than matched controls. […] The rate of lower limb amputations was 3.8% among matched Medicare DFU patients and 5.0% among matched privately insured DFU patients. In contrast, observed lower limb amputation rates among diabetic patients without foot ulcer were only 0.04% in Medicare and 0.02% in private insurance.”

Increased medical resource utilization resulted in DFU patients having approximately twice the costs as the matched non-DFU controls […], with annual incremental per-patient medical costs ranging from $11,710 for Medicare ($28,031 vs. $16,320; P < 0.0001) to $15,890 for private insurance ($26,881 vs. $10,991; P < 0.0001). All places of service (i.e., inpatient, ED, outpatient/physician office, home health care, and other) contributed approximately equally to the cost differential among Medicare patients. For the privately insured, however, increased inpatient costs ($17,061 vs. $6,501; P < 0.0001) were responsible for nearly two-thirds of the overall cost differential, […] resulting in total incremental direct health care (i.e., medical + prescription drug) costs of $16,883 ($31,419 vs. $14,536; P < 0.0001). Substantial proportions of the incremental medical costs were attributable to claims with DFU-related diagnoses or procedures for both Medicare (45.1%) and privately insured samples (60.3%).”

“Of the 4,536 matched pairs of privately insured patients, work-loss information was available for 575 DFU patients and 857 controls. DFU patients had $3,259 in excess work-loss costs ($6,311 vs. $3,052; P < 0.0001) compared with matched controls, with disability and absenteeism comprising $1,670 and $1,589 of the overall differential, respectively […] The results indicate that compared with diabetic patients without foot ulcers, DFU patients miss more days of work due to medical-related absenteeism and to disability, imposing additional burden on employers.”

“These estimates indicate that DFU imposes substantial burden on payers beyond that required to treat diabetes itself. For example, prior research has estimated annual per-patient incremental health care expenditures for patients with diabetes (versus those without diabetes) of approximately $7,900 (1). The estimates of this analysis suggest that the presence of DFU further compounds these incremental treatment costs by adding $11,710 to $16,883 per patient. Stated differently, the results indicate that the excess health care costs of DFU are approximately twice that attributable to treatment of diabetes itself, and that the presence of DFU approximately triples the excess cost differential versus a population of patients without diabetes.

“Using estimates of the total U.S. diabetes population (22.3 million) (1) and the midpoint (3.5%) of annual DFU incidence estimates (1–6%) (2,3), the results of this analysis suggest an annual incremental payer burden of DFU ranging from $9.1 billion (22.3 million patients with diabetes × 3.5% DFU incidence × $11,710 Medicare cost differential) to $13.2 billion (22.3 million patients with diabetes × 3.5% DFU incidence × $16,883 private insurance cost differential). These estimates, moreover, likely understate the actual burden of DFU because the incremental costs referenced in this calculation do not include excess work-loss costs described above, prescription drug costs for Medicare patients, out-of-pocket costs paid by the patient, costs borne by supplemental insurers, and other (non-work loss) indirect costs such as those associated with premature mortality, reduced quality of life, and informal caregiving.”

ii. Contributors to Mortality in High-Risk Diabetic Patients in the Diabetes Heart Study.

“Rates of cardiovascular disease (CVD) are two- to fourfold greater in individuals with type 2 diabetes compared with nondiabetic individuals, and up to 65% of all-cause mortality among individuals with type 2 diabetes is attributed to CVD (1,2). However, the risk profile is not uniform for all individuals affected by diabetes (35). Coronary artery calcified plaque (CAC), determined using computed tomography, is a measure of CVD burden (6,7). CAC scores have been shown to be an independent predictor of CVD outcomes and mortality in population-based studies (810) and a powerful predictor of all-cause and CVD mortality in individuals affected by type 2 diabetes (4,1115).

In the Diabetes Heart Study (DHS), individuals with CAC >1,000 were found to have greater than 6-fold (16) and 11-fold (17) increased risk for all-cause mortality and CVD mortality, respectively, after 7 years of follow-up. With this high risk for adverse outcomes, it is noteworthy that >50% of the DHS sample with CAC >1,000 have lived with this CVD burden for (now) an average of over 12 years. This suggests that outcomes vary in the type 2 diabetic patient population, even among individuals with the highest risk. This study examined the subset of DHS participants with CAC >1,000 and evaluated whether differences in a range of clinical factors and measurements, including modifiable CVD risk factors, provided further insights into risk for mortality.”

“This investigation focused on 371 high-risk participants (from 260 families) […] The goal of this analysis was to identify clinical and other characteristics that influence risk for all-cause mortality in high-risk (baseline CAC >1,000) DHS participants. […] a predominance of traditional CVD risk factors, including older age, male sex, elevated BMI, and high rates of dyslipidemia and hypertension, was evident in this high-risk subgroup (Table 1). These participants were followed for 8.2 ± 3.0 years (mean ± SD), over which time 41% died. […] a number of indices continued to significantly predict outcome following adjustment for other CVD risk factors (including age, sex, and medication use) […]. Higher cholesterol and LDL concentrations were associated with an increased risk (∼1.3-fold) for mortality […] Slightly larger increases in risk for mortality were observed with changes in kidney function (1.3- to 1.4-fold) and elevated CRP (∼1.4-fold) […] use of cholesterol-lowering medication was less common among the deceased participants; those reporting no use of cholesterol-lowering medication at baseline were at a 1.4-fold increased risk of mortality […] these results confirm that, even among this high-risk group, heterogeneity in known CVD risk factors and associations with adverse outcomes are still observed and support their ongoing consideration as useful tools for individual risk assessment. Finally, the data presented here suggest that use of cholesterol-lowering medication was strongly associated with protection, supporting the known beneficial effects of cholesterol management on CVD risk (28,29). […] data suggest that cholesterol-lowering medications may be used less than recommended and need to be more aggressively targeted as a critical modifiable risk factor.”

iii. Neurological Consequences of Diabetic Ketoacidosis at Initial Presentation of Type 1 Diabetes in a Prospective Cohort Study of Children.

“Patients aged 6–18 years with and without DKA at diagnosis were studied at four time points: <48 h, 5 days, 28 days, and 6 months postdiagnosis. Patients underwent magnetic resonance imaging (MRI) and spectroscopy with cognitive assessment at each time point. Relationships between clinical characteristics at presentation and MRI and neurologic outcomes were examined using multiple linear regression, repeated-measures, and ANCOVA analyses.”

“With DKA, cerebral white matter showed the greatest alterations with increased total white matter volume and higher mean diffusivity in the frontal, temporal, and parietal white matter. Total white matter volume decreased over the first 6 months. For gray matter in DKA patients, total volume was lower at baseline and increased over 6 months. […] Of note, although changes in total and regional brain volumes over the first 5 days resolved, they were associated with poorer delayed memory recall and poorer sustained and divided attention at 6 months. Age at time of presentation and pH level were predictors of neuroimaging and functional outcomes.

CONCLUSIONS DKA at type 1 diabetes diagnosis results in morphologic and functional brain changes. These changes are associated with adverse neurocognitive outcomes in the medium term.”

“This study highlights the common nature of transient focal cerebral edema and associated impaired mental state at presentation with new-onset type 1 diabetes in children. We demonstrate that alterations occur most markedly in cerebral white matter, particularly in the frontal lobes, and are most prominent in the youngest children with the most dramatic acidemia. […] early brain changes were associated with persisting alterations in attention and memory 6 months later. Children with DKA did not differ in age, sex, SES, premorbid need for school assistance/remediation, or postdiagnosis clinical trajectory. Earlier diagnosis of type 1 diabetes in children may avoid the complication of DKA and the neurological consequences documented in this study and is worthy of a major public health initiative.”

“In relation to clinical risk factors, the degree of acidosis and younger age appeared to be the greatest risk factors for alterations in cerebral structure. […] cerebral volume changes in the frontal, temporal, and parietal regions in the first week after diagnosis were associated with lower attention and memory scores 6 months later, suggesting that functional information processing difficulties persist after resolution of tissue water increases in cerebral white matter. These findings have not been reported to date but are consistent with the growing concern over academic performance in children with diabetes (2). […] Brain injury should no longer be considered a rare complication of DKA. This study has shown that it is both frequent and persistent.” (my bold)

iv. Antihypertensive Treatment and Resistant Hypertension in Patients With Type 1 Diabetes by Stages of Diabetic Nephropathy.

“High blood pressure (BP) is a risk factor for coronary artery disease, heart failure, and stroke, as well as for chronic kidney disease. Furthermore, hypertension has been estimated to affect ∼30% of patients with type 1 diabetes (1,2) and both parallels and precedes the worsening of kidney disease in these patients (35). […] Despite strong evidence that intensive treatment of elevated BP reduces the risk of cardiovascular disease and microvascular complications, as well as improves the prognosis of patients with diabetic nephropathy (especially with the use of ACE inhibitors [ACEIs] and angiotensin II antagonists [angiotensin receptor blockers, ARBs]) (1,911), treatment targets and recommendations seem difficult to meet in clinical practice (1215). This suggests that the patients might either show poor adherence to the treatment and lifestyle changes or have a suboptimal drug regimen. It is evident that most patients with hypertension might require multiple-drug therapy to reach treatment goals (16). However, certain subgroups of the patients have been considered to have resistant hypertension (RH). RH is defined as office BP that remains above target even after using a minimum of three antihypertensive drugs at maximal tolerated doses, from different classes, one of which is a diuretic. Also, patients with controlled BP using four or more antihypertensive drugs are considered resistant to treatment (17).”

“The true prevalence of RH is unknown, but clinical trials suggest a share between 10 and 30% of the hypertensive patients in the general population (18). […] Only a few studies have considered BP control and treatment in patients with type 1 diabetes (2,15,22). Typically these studies have been limited to a small number of participants, which has not allowed stratifying of the patients according to the nephropathy status. The rate of RH is therefore unknown in patients with type 1 diabetes in general and with respect to different stages of diabetic nephropathy. Therefore, we estimated to what extent patients with type 1 diabetes meet the BP targets proposed by the ADA guidelines. We also evaluated the use of antihypertensive medication and the prevalence of RH in the patients stratified by stage of diabetic nephropathy.”

“[A]ll adult patients with type 1 diabetes from >80 hospitals and primary healthcare centers across Finland were asked to participate. Type 1 diabetes was defined by age at onset of diabetes <40 years, C-peptide ≤0.3 nmol/L, and insulin treatment initiated within 1 year of diagnosis, if C-peptide was not measured. […] we used two different ADA BP targets: <130/85 mmHg, which was the target until 2000 (6), and <130/80 mmHg, which was the target between 2001 and 2012 (7). Patients were divided into groups based on whether their BP had reached the target or not and whether the antihypertensive drug was in use or not. […] uncontrolled hypertension was defined as failure to achieve target BP, based on these two different ADA guidelines, despite use of antihypertensive medication. RH was defined as failure to achieve the goal BP (<130/85 mmHg) even after using a minimum of three antihypertensive drugs, from different classes, one of which was a diuretic. […] On the basis of eGFR (mL/min/1.73 m2) level, patients were classified into five groups according to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines: stage 1 eGFR ≥90, stage 2 eGFR 60–89, stage 3 eGFR 30–59, stage 4 eGFR 15–29, and stage 5 eGFR <15. Patients who were on dialysis were classified into stage 5. […] A total of 3,678 patients with complete data on systolic and diastolic BP and nephropathy status were identified from the FinnDiane database. […] The mean age was 38.0 ± 12.0 and mean duration of diabetes 22.1 ± 12.3 years.  […] The patients with advanced diabetic nephropathy had higher BP, worse dyslipidemia, poorer glycemic control, and more insulin resistance and macrovascular complications. BMI values were lower in the dialysis patients, probably due to renal cachexia.”

“Of all patients, 60.9% did not reach the BP target <130/85 mmHg, and the proportion was 70.3% with the target of <130/80 mmHg. […] The patients who were not on target had higher age and longer duration of diabetes and were more likely to be men. They also had poorer glycemic and lipid control as well as more micro- and macrovascular complications. […] Based on the BP target <130/85 mmHg, more than half of the patients in the normoalbuminuria group did not reach the BP target, and the share increased along with the worsening of nephropathy; two-thirds of the patients in the microalbuminuria group and fourfifths in the macroalbuminuria group were not on target, while even 90% of the dialysis and kidney transplant patients did not reach the target (Fig. 1A). Based on the stricter BP target of <130/80 mmHg, the numbers were obviously worse, but the trend was the same (Fig. 1B).”

“About 37% of the FinnDiane patients had antihypertensive treatment […] Whereas 14.1% of the patients with normal AER [Albumin Excretion Rate] had antihypertensive treatment, the proportions were 60.5% in the microalbuminuric, 90.3% in the macroalbuminuric, 88.6% in the dialysis, and 91.2% in the kidney transplant patients. However, in all groups, only a minority of the patients had BP values on target with the antihypertensive drug treatment they were prescribed […] The mean numbers of antihypertensive drugs varied within the nephropathy groups between those who had BP on target and those who did not […]. However, only in the micro- (P = 0.02) and macroalbuminuria (P = 0.003) groups were the mean numbers of the drugs higher if the BP was not on target, compared with those who had reached the targets. Notably, among the patients with normoalbuminuria who had not reached the BP target, 58% and, of the patients with microalbuminuria, 61% were taking only one antihypertensive drug. In contrast, more than half of the dialysis and 40% of the macroalbuminuric and transplanted patients, who had not reached the targets, had at least three drugs in their regimen. Moreover, one-fifth of the dialysis, 15% of the macroalbuminuric, and 10% of the transplanted patients had at least four antihypertensive drugs in use without reaching the target (Table 2). Almost all patients treated with antihypertensive drugs in the normo-, micro-, and macroalbuminuria groups (76% of normo-, 93% of micro-, and 89% of macrolbuminuric patients) had ACEIs or ARBs in the regimen. The proportions were lower in the ESRD groups: 42% of the dialysis and 29% of the transplanted patients were taking these drugs.”

“In general, the prevalence of RH was 7.9% for all patients with type 1 diabetes (n = 3,678) and 21.2% for the antihypertensive drug–treated patients (n = 1,370). The proportion was higher in men than in women (10.0 vs. 5.7%, P < 0.0001) […] When the patients were stratified by nephropathy status, the figures changed; in the normoalbuminuria group, the prevalence of RH was 1.2% of all and 8.7% of the drug treated patients. The corresponding numbers were 4.7 and 7.8% for the microalbuminuric patients, 28.1 and 31.2% for the macroalbuminuric patients, 36.6 and 41.3% for the patients on dialysis, and 26.3 and 28.8% for the kidney-transplanted patients, respectively […] The prevalence of RH also increased along with the worsening of renal function. The share was 1.4% for all and 7.4% for drug-treated patients at KDOQI stage 1. The corresponding numbers were 3.8 and 10.0% for the patients at stage 2, 26.6 and 30.0% for the patients at stage 3, 54.8 and 56.0% for the patients at stage 4, and 48.0 and 52.1% for those at stage 5, when kidney transplantation patients were excluded. […] In a multivariate logistic regression analysis, higher age, lower eGFR, higher waist-to-hip ratio, higher triglycerides, as well as microalbuminuria and macroalbuminuria, when normoalbuminuria was the reference category, were independently associated with RH […] A separate analysis also showed that dietary sodium intake, based on urinary sodium excretion rate, was independently associated with RH.”

“The current study shows that the prevalence of RH in patients with type 1 diabetes increases alongside the worsening of diabetic nephropathy. Whereas less than one-tenth of the antihypertensive drug–treated patients with normo- or microalbuminuria met the criteria for RH, the proportions were substantially higher among the patients with overt nephropathy: one-third of the patients with macroalbuminuria or a transplanted kidney and even 40% of the patients on dialysis. […] the prevalence of RH for the drug-treated patients was even higher (56%) in patients at the predialysis stage (eGFR 15–29). The findings are consistent with other studies that have demonstrated that chronic kidney disease is a strong predictor of failure to achieve BP targets despite the use of three or more different types of antihypertensive drugs in the general hypertensive population (26).”

“The prevalence of RH was 21.2% of the patients treated with antihypertensive drugs. Previous studies have indicated a prevalence of RH of 13% among patients being treated for hypertension (1921,27). […] the prevalence [of RH] seems to be […] higher among the drug-treated type 1 diabetic patients. These figures can only partly be explained by the use of a lower treatment target for BP, as recommended for patients with diabetes (6), since even when we used the BP target recommended for hypertensive patients (<140/90 mmHg), our data still showed a higher prevalence of RH (17%).”

“The study also confirmed previous findings that a large number of patients with type 1 diabetes do not achieve the recommended BP targets. Although the prevalence of RH increased with the severity of diabetic nephropathy, our data also suggest that patients with normo- and microalbuminuria might have a suboptimal drug regimen, since the majority of those who had not reached the BP target were taking only one antihypertensive drug. […] There is therefore an urgent need to improve antihypertensive treatment, not only in patients with overt nephropathy but also in those who have elevated BP without complications or early signs of renal disease. Moreover, further emphasis should be placed on the transplanted patients, since it is well known that hypertension affects both graft and patient survival negatively (30).” (my bold)

v. Association of Autoimmunity to Autonomic Nervous Structures With Nerve Function in Patients With Type 1 Diabetes: A 16-Year Prospective Study.

“Neuropathy is a chronic complication that includes a number of distinct syndromes and autonomic dysfunctions and contributes to increase morbidity and mortality in the diabetic population. In particular, cardiovascular autonomic neuropathy (CAN) is an independent risk factor for mortality in type 1 diabetes and is associated with poor prognosis and poor quality of life (13). Cardiovascular (CV) autonomic regulation rests upon a balance between sympathetic and parasympathetic innervation of the heart and blood vessels controlling heart rate and vascular dynamics. CAN encompasses several clinical manifestations, from resting tachycardia to fatal arrhythmia and silent myocardial infarction (4).

The mechanisms responsible for altered neural function in diabetes are not fully understood, and it is assumed that multiple mutually perpetuating pathogenic mechanisms may concur. These include dysmetabolic injury, neurovascular insufficiency, deficiency of neurotrophic growth factors and essential fatty acids, advanced glycosylation products (5,6), and autoimmune damage. Independent cross-sectional and prospective (713) studies identified circulating autoantibodies to autonomic nervous structures and hypothesized that immune determinants may be involved in autonomic nerve damage in type 1 diabetes. […] However, demonstration of a cause–effect relationship between antibodies (Ab) and diabetic autonomic neuropathy awaits confirmation.”

“We report on a 16-year follow-up study specifically designed to prospectively examine a cohort of patients with type 1 diabetes and aimed at assessing whether the presence of circulating Ab to autonomic nervous structures is associated with increased risk and predictive value of developing CAN. This, in turn, would be highly suggestive of the involvement of autoimmune mechanisms in the pathogenesis of this complication.”

“The present prospective study, conducted in young patients without established autonomic neuropathy at recruitment and followed for over 16 years until adulthood, strongly indicates that a cause–effect relationship may exist between auto-Ab to autonomic nervous tissues and development of diabetic autonomic neuropathy. Incipient or established CAN (22) reached a prevalence of 68% among the Ab-positive patients, significantly higher compared with the Ab-negative patients. […] Logistic regression analysis indicates that auto-Ab carry an almost 15-fold increased RR of developing an abnormal DB [deep breathing] test over 16 years and an almost sixfold increase of developing at least one abnormal CV [cardiovascular] test, independent of other variables. […] Circulating Ab to autonomic structures are associated with the development of autonomic dysfunction in young diabetic patients independent of glycemic control. […] autoimmune mechanisms targeting sympathetic and parasympathetic structures may play a primary etiologic role in the development and progression of autonomic dysfunction in type 1 diabetes in the long term. […] positivity for auto-Ab had a high positive predictive value for the later development of autonomic neuropathy.”

“Diabetic autonomic neuropathy, possibly the least recognized and most overlooked of diabetes complications, has increasingly gained attention as an independent predictor of silent myocardial ischemia and mortality, as consistently indicated by several cross-sectional studies (2,3,33). The pooled prevalence rate risk for silent ischemia is estimated at 1.96 by meta-analysis studies (5). In this report, established CAN (22) was detected in nearly 20% of young adult patients with acceptable metabolic control, after over approximately 23 years of diabetes duration, against 12% of patients of the same cohort with subtle asymptomatic autonomic dysfunction (one abnormal CV test) a decade earlier, in line with other studies in type 1 diabetes (2,24). Approximately 30% of the patients developed signs of peripheral somatic neuropathy not associated with autonomic dysfunction. This discrepancy suggests the participation of pathogenic mechanisms different from metabolic control and a distinct clinical course, as indicated by the DCCT study, where hyperglycemia had a less robust relationship with autonomic than somatic neuropathy (6).”

“Furthermore, this study shows that autonomic neuropathy, together with female sex and the occurrence of severe hypoglycemia, is a major determinant for poor quality of life in patients with type 1 diabetes. This is in agreement with previous reports (35) and linked to such invalidating symptoms as orthostatic hypotension and chronic diarrhea. […] In conclusion, the current study provides persuasive evidence for a primary pathogenic role of autoimmunity in the development of autonomic diabetic neuropathy. However, the mechanisms through which auto-Ab impair their target organ function, whether through classical complement action, proapoptotic effects of complement, enhanced antigen presentation, or channelopathy (26,39,40), remain to be elucidated.” (my bold)

vi. Body Composition Is the Main Determinant for the Difference in Type 2 Diabetes Pathophysiology Between Japanese and Caucasians.

“According to current understanding, the pathophysiology of type 2 diabetes is different in Japanese compared with Caucasians in the sense that Japanese are unable to compensate insulin resistance with increased insulin secretion to the same extent as Caucasians. Prediabetes and early stage diabetes in Japanese are characterized by reduced β-cell function combined with lower degree of insulin resistance compared with Caucasians (810). In a prospective, cross-sectional study of individuals with normal glucose tolerance (NGT) and impaired glucose tolerance (IGT), it was demonstrated that Japanese in Japan were more insulin sensitive than Mexican Americans in the U.S. and Arabs in Israel (11). The three populations also differed with regards to β-cell response, whereas the disposition index — a measure of insulin secretion relative to insulin resistance — was similar across ethnicities for NGT and IGT participants. These studies suggest that profound differences in type 2 diabetes pathophysiology exist between different populations. However, few attempts have been made to establish the underlying demographic or lifestyle-related factors such as body composition, physical fitness, and physical activity leading to these differences.”

“The current study aimed at comparing Japanese and Caucasians at various glucose tolerance states, with respect to 1) insulin sensitivity and β-cell response and 2) the role of demographic, genetic, and lifestyle-related factors as underlying predictors for possible ethnic differences in insulin sensitivity and β-cell response. […] In our study, glucose profiles from OGTTs [oral glucose tolerance tests] were similar in Japanese and Caucasians, whereas insulin and C-peptide responses were lower in Japanese participants compared with Caucasians. In line with these observations, measures of β-cell response were generally lower in Japanese, who simultaneously had higher insulin sensitivity. Moreover, β-cell response relative to the degree of insulin resistance as measured by disposition indices was virtually identical in the two populations. […] We […] confirmed the existence of differences in insulin sensitivity and β-cell response between Japanese and Caucasians and showed for the first time that a major part of these differences can be explained by differences in body composition […]. On the basis of these results, we propose a similar pathophysiology of type 2 diabetes in Caucasians and Japanese with respect to insulin sensitivity and β-cell function.”


October 12, 2017 Posted by | Cardiology, Diabetes, Epidemiology, Health Economics, Medicine, Nephrology, Neurology, Pharmacology, Studies | Leave a comment

Diabetes and the Brain (V)

I have blogged this book in some detail in the past, but I never really finished my intended coverage of the book. This post is an attempt to rectify this.

Below I have added some quotes and observations from some of the chapters I have not covered in my previous posts about the book. I bolded some key observations along the way.

A substantial number of studies have assessed the effect of type 2 diabetes on cognitive functioning with psychometric tests. The majority of these studies reported subtle decrements in individuals with type 2 diabetes relative to non-diabetic controls (2, 4). […] the majority of studies in patients with type 2 diabetes reported moderate reductions in neuropsychological test performance, mainly in memory, information-processing speed, and mental flexibility, a pattern that is also observed in aging-related cognitive decline. […] the observed cognitive decrements are relatively subtle and rather non-specific. […] All in all, disturbances in glucose and insulin metabolism and associated vascular risk factors are associated with modest reductions in cognitive performance in “pre-diabetic stages.” Consequently, it may well be that the cognitive decrements that can be observed in patients with type 2 diabetes also start to develop before the actual onset of the diabetes. […] Because the different vascular and metabolic risk factors that are clustered in the metabolic syndrome are strongly interrelated, the contribution of each of the individual factor will be difficult to assess.” 

“Aging-related changes on brain imaging include vascular lesions and focal and global atrophy. Vascular lesions include (silent) brain infarcts and white-matter hyperintensities (WMHs). WMHs are common in the general population and their prevalence increases with age, approaching 100% by the age of 85 (69). The prevalence of lacunar infarcts also increases with age, up to 5% for symptomatic infarcts and 30% for silent infarcts by the age of 80 (70). In normal aging, the brain gradually reduces in size, which becomes particularly evident after the age of 70 (71). This loss of brain volume is global […] age-related changes of the brain […] are often relatively more pronounced in older patients with type 2 […] A recent systematic review showed that patients with diabetes have a 2-fold increased risk of (silent) infarcts compared to non-diabetic persons (75). The relationship between type 2 diabetes and WMHs is subject to debate. […] there are now clear indications that diabetes is a risk factor for WMH progression (82). […] The presence of the APOE ε4 allele is a risk factor for the development of Alzheimer’s disease (99). Patients with type 2 diabetes who carry the APOE ε4 allele appeared to have a 2-fold increased risk of dementia compared to persons with either of these risk factors in isolation (100, 101).”

In adults with type 1 diabetes the occurrence of microvascular complications is associated with reduced cognitive performance (137) and accelerated cognitive decline (138). Moreover, type 1 diabetes is associated with decreased white-matter volume of the brain and diminished cognitive performance in particular in patients with retinopathy (139). Microvascular complications are also thought to play a role in the development of cognitive decline in patients with type 2 diabetes, but studies that have specifically examined this association are scarce. […] Currently there are no established specific treatment measures to prevent or ameliorate cognitive impairments in patients with diabetes.”

“Clinicians should be aware of the fact that cognitive decrements are relatively more common among patients with diabetes. […] it is important to note that cognitive complaints as spontaneously expressed by the patient are often a poor indicator of the severity of cognitive decrements. People with moderate disturbances may express marked complaints, while people with marked disturbances of cognition often do not complain at all. […] Diabetes is generally associated with relatively mild impairments, mainly in attention, memory, information-processing speed, and executive function. Rapid cognitive decline or severe cognitive impairment, especially in persons under the age of 60 is indicative of other underlying pathology. Potentially treatable causes of cognitive decline such as depression should be excluded. People who are depressed often present with complaints of concentration or memory.”

“Insulin resistance increases with age, and the organism maintains normal glucose levels as long as it can produce enough insulin (hyperinsulinemia). Some individuals are less capable than others to mount sustained hyperinsulinemia and will develop glucose intolerance and T2D (23). Other individuals with insulin resistance will maintain normal glucose levels at the expense of hyperinsulinemia but their pancreas will eventually “burn out,” will not be able to sustain hyperinsulinemia, and will develop glucose intolerance and diabetes (23). Others will continue having insulin resistance, may have or not have glucose intolerance, will not develop diabetes, but will have hyperinsulinemia and suffer its consequences. […] Elevations of adiposity result in insulin resistance, causing the pancreas to increase insulin to abnormal levels to sustain normal glucose, and if and when the pancreas can no longer sustain hyperinsulinemia, glucose intolerance and diabetes will ensue. However, the overlap between these processes is not complete (26). Not all persons with higher adiposity will develop insulin resistance and hyperinsulinemia, but most will. Not all persons with insulin resistance and hyperinsulinemia will develop glucose intolerance and diabetes, and this depends on genetic and other susceptibility factors that are not completely understood (25, 26). Some adults develop diabetes without going through insulin resistance and hyperinsulinemia, but it is thought that most will. The susceptibility to adiposity, that is, the risk of developing the above-described sequence in response to adiposity, varies by gender (4) and particularly by ethnicity. […] Chinese and Southeast Asians are more susceptible than Europeans to developing insulin resistance with comparable increases of adiposity (2).”

There is very strong evidence that adiposity, hyperinsulinemia, and T2D are related to cognitive impairment syndromes, whether AD [Alzheimer’s Disease], VD [Vascular Dementia], or MCI [Mild Cognitive Impairment], and whether the main mechanism is cerebrovascular disease or non-vascular mechanisms. However, more evidence is needed to establish causation. If the relation between these conditions and dementia were to be causal, the public health implications are enormous. […] Diabetes mellitus affects about 20% of adults older than 65 years of age […] two-thirds of the adult population in the United States are overweight or obese, and the short-term trend is for this to worsen. These trends are also being observed worldwide. […] We estimated that in New York City the presence of diabetes or hyperinsulinemia in elderly people could account for 39% of cases of AD (78).”

Psychiatric illnesses in general may be more common among persons with diabetes than in community-based samples, specifically affective and anxiety-related disorders (4). Persons with diabetes are twice as likely to have depression as non-diabetic persons (5). A review of 20 studies on the comorbidity of depression and diabetes found that the average prevalence was about 15%, and ranged from 8.5 to 40%, three times the rate of depressive disorders found in the general adult population of the United States (4–7). The rates of clinically significant depressive symptoms among persons with diabetes are even higher – ranging from 21.8 to 60.0% (8). Recent studies have indicated that persons with type II diabetes, accompanied by either major or minor depression, have significantly higher mortality rates than non-depressed persons with diabetes (9–10) […] A recent meta-analysis reported that patients with type 2 diabetes have a 2-fold increased risk of depression compared to non-diabetic persons (142). The prevalence of major depressive disorder in patients with type 2 diabetes was estimated at 11% and depressive symptoms were observed in 31% of the patients.” (As should be obvious from the above quotes the range of estimates vary a lot here, but the estimates tend to be high – US.)

Depression is an important risk factor for cardiovascular disease (Glassman, Maj & Sartorius is a decent book on these topics), and diabetes is also an established risk factor. Might this not lead to a hypothesis that diabetics who are depressed may do particularly poorly, with higher mortality rates and so on? Yes. …and it seems that this is also what people tend to find when they look at this stuff:

Persons with diabetes and depressive symptoms have mortality rates nearly twice as high as persons with diabetes and no depressive symptomatology (9). Persons with co-occurring medical illness and depression also have higher health care utilization leading to higher direct and indirect health care costs (12–13) […]. A meta-analysis of the relationship between depression and diabetes (types I and II) indicated that an increase in the number of depressive symptoms is associated with an increase in the severity and number of diabetic complications, including retinopathy, neuropathy, and nephropathy (15–17). Compared to persons with either diabetes or depression alone, individuals with co-occurring diabetes and depression have shown poorer adherence to dietary and physical activity recommendations, decreased adherence to hypoglycemic medication regimens, higher health care costs, increases in HgbA1c levels, poorer glycemic control, higher rates of retinopathy, and macrovascular complications such as stroke and myocardial infarction, higher ambulatory care use, and use of prescriptions (14, 18–22). Diabetes and depressive symptoms have been shown to have strong independent effects on physical functioning, and individuals experiencing either of these conditions will have worse functional outcomes than those with neither or only one condition (19–20). Nearly all of diabetes management is conducted by the patient and those with co-occurring depression may have poorer outcomes and increased risk of complications due to less adherence to glucose, diet, and medication regimens […] There is some evidence that treatment of depression with antidepressant and/or cognitive-behavioral therapies can improve glycemic control and glucose regulation without any change in the treatment for diabetes (27, 28) […] One important finding is [also] that treatment of depression seems to be able to halt atrophy of the hippocampus and may even lead to stimulation of neurogenesis of hippocampal cells (86).”

Diabetic neuropathy is a severe, disabling chronic condition that affects a significant number of individuals with diabetes. Long considered a disease of the peripheral nervous system, there is mounting evidence of central nervous system involvement. Recent advances in neuroimaging methods have led to a better understanding and refinement of how diabetic neuropathy affects the central nervous system. […] spinal cord atrophy is an early process being present not only in established-DPN [diabetic peripheral neuropathy] but also even in subjects with relatively modest impairments of nerve function (subclinical-DPN) […] findings […] show that the neuropathic process in diabetes is not confined to the peripheral nerve and does involve the spinal cord. Worryingly, this occurs early in the neuropathic process. Even at the early DPN stage, extensive and perhaps even irreversible damage may have occurred. […] it is likely that the insult of diabetes is generalised, concomitantly affecting the PNS and CNS. […] It is noteworthy that a variety of therapeutic interventions specifically targeted at peripheral nerve damage in DPN have thus far been ineffective, and it is possible that this may in part be due to inadequate appreciation of the full extent of CNS involvement in DPN.

Interestingly, if the CNS is also involved in the pathogenesis of (‘human’) diabetic neuropathy it may have some relevance to the complaint that some methods of diabetes-induction in animal models cause (secondary) damage to central structures in animal models – a complaint which I’ve previously made a note of e.g. in the context of my coverage of Horowitz & Samson’s book. The relevance of this depends quite a bit on whether it’s the same central structures that are affected in the animal models and in humans. It probably isn’t. These guys also discuss this stuff in some detail, though I won’t go into too much detail here. Some observations on related topics are however worth including here:

“Several studies examining behavioral learning have shown progressive deficits in diabetic rodents, whereas simple avoidance tasks are preserved. Impaired spatial learning and memory as assessed by the Morris water maze paradigm occur progressively in both the spontaneously diabetic BB/Worrat and STZ-induced diabetic rodents (1, 11, 12, 22, 41, 42). The cognitive components reflected by impaired Morris water maze performances involve problem-solving, enhanced attention and storage, and retrieval of information (43). […] Observations regarding cognition and plasticity in models characterized by hyperglycemia and insulin deficiency (i.e., alloxan or STZ-diabetes, BB/Wor rats, NOD-mice), often referred to as models of type 1 diabetes, are quite consistent. With respect to clinical relevance, it should be noted that the level of glycemia in these models markedly exceeds that observed in patients. Moreover, changes in cognition as observed in these models are much more rapid and severe than in adult patients with type 1 diabetes […], even if the relatively shorter lifespan of rodents is taken into account. […] In my view these models of “type 1 diabetes” may help to understand the pathophysiology of the effects of severe chronic hyperglycemia–hypoinsulinemia on the brain, but mimic the impact of type 1 diabetes on the brain in humans only to a limited extent.”

“Abnormalities in cognition and plasticity have also been noted in the majority of models characterized by insulin resistance, hyperinsulinemia, and (modest) hyperglycemia (e.g., Zucker fa/fa rat, Diabetic Zucker rat, db/db mouse, GK rat, OLETF rat), often referred to as models of type 2 diabetes. With regard to clinical relevance, it is important to note that although the endocrinological features of these models do mimic certain aspects of type 2 diabetes, the genetic defect that underlies each of them is not the primary defect encountered in humans with type 2 diabetes. Some of the genetic abnormalities that lead to a “diabetic phenotype” may also have a direct impact on the brain. […] some studies using these models report abnormalities in cognition and plasticity, even in the absence of hyperglycemia […] In addition, in the majority of available models insulin resistance and associated metabolic abnormalities develop at a relatively early age. Although this is practical for research purposes it needs to be acknowledged that type 2 diabetes is typically a disease of older age in humans. […] It is therefore still too early to determine the clinical significance of the available models in understanding the impact of type 2 diabetes on the brain. Further efforts into the development of a valid model are warranted.”

[A] key problem in clinical studies is the complexity and multifactorial nature of cerebral complications in relation to diabetes. Metabolic factors in patients (e.g., glucose levels, insulin levels, insulin sensitivity) are strongly interrelated and related to other factors that may affect the brain (e.g., blood pressure, lipids, inflammation, oxidative stress). Derangements in these factors in the periphery and the brain may be dissociated, for example, through the role of the blood–brain barrier, or adaptations of transport across this barrier, or through differences in receptor functions and post-receptor signaling cascades in the periphery and the brain. The different forms of treatments that patients receive add to the complexity. A key contribution of animal studies may be to single out individual components and study them in isolation or in combination with a limited number of other factors in a controlled fashion.

October 9, 2017 Posted by | Books, Cardiology, Diabetes, Epidemiology, Medicine, Neurology, Pharmacology | Leave a comment

Type 1 Diabetes Mellitus and Cardiovascular Disease

“Despite the known higher risk of cardiovascular disease (CVD) in individuals with type 1 diabetes mellitus (T1DM), the pathophysiology underlying the relationship between cardiovascular events, CVD risk factors, and T1DM is not well understood. […] The present review will focus on the importance of CVD in patients with T1DM. We will summarize recent observations of potential differences in the pathophysiology of T1DM compared with T2DM, particularly with regard to atherosclerosis. We will explore the implications of these concepts for treatment of CVD risk factors in patients with T1DM. […] The statement will identify gaps in knowledge about T1DM and CVD and will conclude with a summary of areas in which research is needed.”

The above quote is from this paper: Type 1 Diabetes Mellitus and Cardiovascular Disease: A Scientific Statement From the American Heart Association and American Diabetes Association.

I originally intended to cover this one in one of my regular diabetes posts, but I decided in the end that there was simply too much stuff to cover here for it to make sense not to devote an entire post to it. I have quoted extensively from the paper/statement below and I also decided to bold a few of the observations I found particularly important/noteworthy(/worth pointing out to people reading along?).

“T1DM has strong human leukocyte antigen associations to the DQA, DQB, and DRB alleles (2). One or more autoantibodies, including islet cell, insulin, glutamic acid decarboxylase 65 (GAD65), zinc transporter 8 (3), and tyrosine phosphatase IA-2β and IA-2β antibodies, can be detected in 85–90% of individuals on presentation. The rate of β-cell destruction varies, generally occurring more rapidly at younger ages. However, T1DM can also present in adults, some of whom can have enough residual β-cell function to avoid dependence on insulin until many years later. When autoantibodies are present, this is referred to as latent autoimmune diabetes of adulthood. Infrequently, T1DM can present without evidence of autoimmunity but with intermittent episodes of ketoacidosis; between episodes, the need for insulin treatment can come and go. This type of DM, called idiopathic diabetes (1) or T1DM type B, occurs more often in those of African and Asian ancestry (4). Because of the increasing prevalence of obesity in the United States, there are also obese individuals with T1DM, particularly children. Evidence of insulin resistance (such as acanthosis nigricans); fasting insulin, glucose, and C-peptide levels; and the presence of islet cell, insulin, glutamic acid decarboxylase, and phosphatase autoantibodies can help differentiate between T1DM and T2DM, although both insulin resistance and insulin insufficiency can be present in the same patient (5), and rarely, T2DM can present at an advanced stage with low C-peptide levels and minimal islet cell function.”

Overall, CVD events are more common and occur earlier in patients with T1DM than in nondiabetic populations; women with T1DM are more likely to have a CVD event than are healthy women. CVD prevalence rates in T1DM vary substantially based on duration of DM, age of cohort, and sex, as well as possibly by race/ethnicity (8,11,12). The Pittsburgh Epidemiology of Diabetes Complications (EDC) study demonstrated that the incidence of major coronary artery disease (CAD) events in young adults (aged 28–38 years) with T1DM was 0.98% per year and surpassed 3% per year after age 55 years, which makes it the leading cause of death in that population (13). By contrast, incident first CVD in the nondiabetic population ranges from 0.1% in 35- to 44-year-olds to 7.4% in adults aged 85–94 years (14). An increased risk of CVD has been reported in other studies, with the age-adjusted relative risk (RR) for CVD in T1DM being ≈10 times that of the general population (1517). One of the most robust analyses of CVD risk in this disease derives from the large UK General Practice Research Database (GPRD), comprising data from >7,400 patients with T1DM with a mean ± SD age of 33 ± 14.5 years and a mean DM duration of 15 ± 12 years (8). CVD events in the UK GPRD study occurred on average 10 to 15 years earlier than in matched nondiabetic control subjects.”

“When types of CVD are reported separately, CHD [coronary heart disease] predominates […] The published cumulative incidence of CHD ranges between 2.1% (18) and 19% (19), with most studies reporting cumulative incidences of ≈15% over ≈15 years of follow-up (2022). […] Although stroke is less common than CHD in T1DM, it is another important CVD end point. Reported incidence rates vary but are relatively low. […] the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) reported an incidence rate of 5.9% over 20 years (≈0.3%) (21); and the European Diabetes (EURODIAB) Study reported a 0.74% incidence of cerebrovascular disease per year (18). These incidence rates are for the most part higher than those reported in the general population […] PAD [peripheral artery disease] is another important vascular complication of T1DM […] The rate of nontraumatic amputation in T1DM is high, occurring at 0.4–7.2% per year (28). By 65 years of age, the cumulative probability of lower-extremity amputation in a Swedish administrative database was 11% for women with T1DM and 20.7% for men (10). In this Swedish population, the rate of lower-extremity amputation among those with T1DM was nearly 86-fold that of the general population.

“Abnormal vascular findings associated with atherosclerosis are also seen in patients with T1DM. Coronary artery calcification (CAC) burden, an accepted noninvasive assessment of atherosclerosis and a predictor of CVD events in the general population, is greater in people with T1DM than in nondiabetic healthy control subjects […] With regard to subclinical carotid disease, both carotid intima-media thickness (cIMT) and plaque are increased in children, adolescents, and adults with T1DM […] compared with age- and sex-matched healthy control subjects […] Endothelial function is altered even at a very early stage of T1DM […] Taken together, these data suggest that preclinical CVD can be seen more frequently and to a greater extent in patients with T1DM, even at an early age. Some data suggest that its presence may portend CVD events; however, how these subclinical markers function as end points is not clear.”

“Neuropathy in T1DM can lead to abnormalities in the response of the coronary vasculature to sympathetic stimulation, which may manifest clinically as resting tachycardia or bradycardia, exercise intolerance, orthostatic hypotension, loss of the nocturnal decline in BP, or silent myocardial ischemia on cardiac testing. These abnormalities can lead to delayed presentation of CVD. An early indicator of cardiac autonomic neuropathy is reduced heart rate variability […] Estimates of the prevalence of cardiac autonomic neuropathy in T1DM vary widely […] Cardiac neuropathy may affect as many as ≈40% of individuals with T1DM (45).”

CVD events occur much earlier in patients with T1DM than in the general population, often after 2 decades of T1DM, which in some patients may be by age 30 years. Thus, in the EDC study, CVD was the leading cause of death in T1DM patients after 20 years of disease duration, at rates of >3% per year (13). Rates of CVD this high fall into the National Cholesterol Education Program’s high-risk category and merit intensive CVD prevention efforts (48). […] CVD events are not generally expected to occur during childhood, even in the setting of T1DM; however, the atherosclerotic process begins during childhood. Children and adolescents with T1DM have subclinical CVD abnormalities even within the first decade of DM diagnosis according to a number of different methodologies”.

Rates of CVD are lower in premenopausal women than in men […much lower: “Cardiovascular disease develops 7 to 10 years later in women than in men” – US]. In T1DM, these differences are erased. In the United Kingdom, CVD affects men and women with T1DM equally at <40 years of age (23), although after age 40 years, men are affected more than women (51). Similar findings on CVD mortality rates were reported in a large Norwegian T1DM cohort study (52) and in the Allegheny County (PA) T1DM Registry (13), which reported the relative impact of CVD compared with the general population was much higher for women than for men (standardized mortality ratio [SMR] 13.2 versus 5.0 for total mortality and 24.7 versus 8.8 for CVD mortality, women versus men). […] Overall, T1DM appears to eliminate most of the female sex protection seen in the nondiabetic population.”

“The data on atherosclerosis in T1DM are limited. A small angiographic study compared 32 individuals with T1DM to 31 nondiabetic patients matched for age and symptoms (71). That study found atherosclerosis in the setting of T1DM was characterized by more severe (tighter) stenoses, more extensive involvement (multiple vessels), and more distal coronary findings than in patients without DM. A quantitative coronary angiographic study in T1DM suggested more severe, distal disease and an overall increased burden compared with nondiabetic patients (up to fourfold higher) (72).”

“In the general population, inflammation is a central pathological process of atherosclerosis (79). Limited pathology data suggest that inflammation is more prominent in patients with DM than in nondiabetic control subjects (70), and those with T1DM in particular are affected. […] Knowledge of the clinical role of inflammatory markers in T1DM and CVD prediction and management is in its infancy, but early data suggest a relationship with preclinical atherosclerosis. […] Studies showed C-reactive protein is elevated within the first year of diagnosis of T1DM (80), and interleukin-6 and fibrinogen levels are high in individuals with an average disease duration of 2 years (81), independent of adiposity and glycemia (82). Other inflammatory markers such as soluble interleukin-2 receptor (83) and CD40 ligand (84,85) are higher in patients with T1DM than in nondiabetic subjects. Inflammation is evident in youth, even soon after the diagnosis of T1DM. […] The mechanisms by which inflammation operates in T1DM are likely multiple but may include hyperglycemia and hypoglycemia, excess adiposity or altered body fat distribution, thrombosis, and adipokines. Several recent studies have demonstrated a relationship between acute hypoglycemia and indexes of systemic inflammation […] These studies suggest that acute hypoglycemia in T1DM produces complex vascular effects involved in the activation of proinflammatory, prothrombotic, and proatherogenic mechanisms. […] Fibrinogen, a prothrombotic acute phase reactant, is increased in T1DM and is associated with premature CVD (109), and it may be important in vessel thrombosis at later stages of CVD.”

“Genetic polymorphisms appear to influence the progression and prognosis of CVD in T1DM […] Like fibrinogen, haptoglobin is an acute phase protein that inhibits hemoglobin-induced oxidative tissue damage by binding to free hemoglobin (110). […] In humans, there are 2 classes of alleles at the haptoglobin locus, giving rise to 3 possible genotypes: haptoglobin 1-1, haptoglobin 2-1, and haptoglobin 2-2. […] In T1DM, there is an independent twofold increased incidence of CAD in haptoglobin 2-2 carriers compared with those with the haptoglobin 1-1 genotype (117); the 2-1 genotype is associated with an intermediate effect of increased CVD risk. More recently, an independent association was reported in T1DM between the haptoglobin 2-2 genotype and early progression to end-stage renal disease (ESRD) (118). In the CACTI study group, the presence of the haptoglobin 2-2 genotype also doubled the risk of CAC [coronary artery calcification] in patients free from CAC at baseline, after adjustment for traditional CVD risk factors (119). […] At present, genetic testing for polymorphisms in T1DM [however] has no clear clinical utility in CVD prediction or management.”

“Dysglycemia is often conceived of as a vasculopathic process. Preclinical atherosclerosis and epidemiological studies generally support this relationship. Clinical trial data from the DCCT supplied definitive findings strongly in favor of beneficial effects of better glycemic control on CVD outcomes. Glycemia is associated with preclinical atherosclerosis in studies that include tests of endothelial function, arterial stiffness, cIMT, autonomic neuropathy, and left ventricular (LV) function in T1DM […] LV mass and function improve with better glycemic control (126,135,136). Epidemiological evidence generally supports the relationship between hyperglycemia and clinical CHD events in T1DM. […] A large Swedish database review recently reported a reasonably strong association between HbA1c and CAD in T1DM (HR, 1.3 per 1% HbA1c increase) (141). […] findings support the recommendation that early optimal glycemic control in T1DM will have long-term benefits for CVD reduction.”

“Obesity is a known independent risk factor for CVD in nondiabetic populations, but the impact of obesity in T1DM has not been fully established. Traditionally, T1DM was a condition of lean individuals, yet the prevalence of overweight and obesity in T1DM has increased significantly […] This is related to epidemiological shifts in the population overall, tighter glucose control leading to less glucosuria, more frequent/greater caloric intake to fend off real and perceived hypoglycemia, and the specific effects of intensive DM therapy, which has been shown to increase the prevalence of obesity (152). Indeed, several clinical trials, including the DCCT, demonstrate that intensive insulin therapy can lead to excessive weight gain in a subset of patients with T1DM (152). […] No systematic evaluation has been conducted to assess whether improving insulin sensitization lowers rates of CVD. Ironically, the better glycemic control associated with insulin therapy may lead to weight gain, with a superimposed insulin resistance, which may be approached by giving higher doses of insulin. However, some evidence from the EDC study suggests that weight gain in the presence of improved glycemic control is associated with an improved CVD risk profile (162). […] Although T1DM is characteristically a disease of absolute insulin deficiency (154), insulin resistance appears to contribute to CHD risk in patients with T1DM. For example, having a family history of T2DM, which suggests a genetic predisposition for insulin resistance, has been associated with an increased CVD risk in patients with T1DM (155).”

“In general, the lipid levels of adults with well-controlled T1DM are similar to those of individuals without DM […] Worse glycemic control, higher weight (164), and more insulin resistance as measured by euglycemic clamp (165) are associated with a more atherogenic cholesterol distribution in men and women with T1DM […] Studies in pediatric and young adult populations suggest higher lipid values than in youth without T1DM, with glycemic control being a significant contributor (148). […] Most studies show that as is true for the general population, dyslipidemia is a risk factor for CVD in T1DM. Qualitative differences in lipid and lipoprotein fractions are being investigated to determine whether abnormal lipid function may contribute to this. The HDL-C fraction has been of particular interest because the metabolism of HDL-C in T1DM may be altered because of abnormal lipoprotein lipase and hepatic lipase activities related to exogenously administered insulin […] Additionally, as noted earlier, the less efficient handling of heme by the haptoglobin 2-2 genotype in patients with T1DM leaves these complexes less capable of being removed by macrophages, which allows them to associate with HDL, which renders it less functional (116). […] Conventionally, pharmacotherapy is used more aggressively for patients with T1DM and lipid disorders than for nondiabetic patients; however, recommendations for treatment are mostly extrapolated from interventional trials in adults with T2DM, in which rates of CVD events are equivalent to those in secondary prevention populations. Whether this is appropriate for T1DM is not clear […] Awareness of CVD risk and screening for hypercholesterolemia in T1DM have increased over time, yet recent data indicate that control is suboptimal, particularly in younger patients who have not yet developed long-term complications and might therefore benefit from prevention efforts (173). Adults with T1DM who have abnormal lipids and additional risk factors for CVD (e.g., hypertension, obesity, or smoking) who have not developed CVD should be treated with statins. Adults with CVD and T1DM should also be treated with statins, regardless of whether they have additional risk factors.”

“Diabetic kidney disease (DKD) is a complication of T1DM that is strongly linked to CVD. DKD can present as microalbuminuria or macroalbuminuria, impaired GFR, or both. These represent separate but complementary manifestations of DKD and are often, but not necessarily, sequential in their presentation. […] the risk of all-cause mortality increased with the severity of DKD, from microalbuminuria to macroalbuminuria to ESRD. […] Microalbuminuria is likely an indicator of diffuse vascular injury. […] Microalbuminuria is highly correlated with CVD (49,180182). In the Steno Diabetes Center (Gentofte, Denmark) cohort, T1DM patients with isolated microalbuminuria had a 4.2-fold increased risk of CVD (49,180). In the EDC study, microalbuminuria was associated with mortality risk, with an SMR of 6.4. In the FinnDiane study, mortality risk was also increased with microalbuminuria (SMR, 2.8). […] A recent review summarized these data. In patients with T1DM and microalbuminuria, there was an RR of all-cause mortality of 1.8 (95% CI, 1.5–2.1) that was unaffected by adjustment for confounders (183). Similar RRs were found for mortality from CVD (1.9; 95% CI, 1.3–2.9), CHD (2.1; 95% CI, 1.2–3.5), and aggregate CVD mortality (2.0; 95% CI, 1.5–2.6).”

“Macroalbuminuria represents more substantial kidney damage and is also associated with CVD. Mechanisms may be more closely related to functional consequences of kidney disease, such as higher LDL-C and lower HDL-C. Prospective data from Finland indicate the RR for CVD is ≈10 times greater in patients with macroalbuminuria than in those without macroalbuminuria (184). Historically, in the [Danish] Steno cohort, patients with T1DM and macroalbuminuria had a 37-fold increased risk of CVD mortality compared with the general population (49,180); however, a more recent report from EURODIAB suggests a much lower RR (8.7; 95% CI, 4.03–19.0) (185). […] In general, impaired GFR is a risk factor for CVD, independent of albuminuria […] ESRD [end-stage renal disease, US], the extreme form of impaired GFR, is associated with the greatest risk of CVD of all varieties of DKD. In the EDC study, ESRD was associated with an SMR for total mortality of 29.8, whereas in the FinnDiane study, it was 18.3. It is now clear that GFR loss and the development of eGFR <60 mL · min−1 · 1.73 m−2 can occur without previous manifestation of microalbuminuria or macroalbuminuria (177,178). In T1DM, the precise incidence, pathological basis, and prognosis of this phenotype remain incompletely described.”

“Prevention of DKD remains challenging. Although microalbuminuria and macroalbuminuria are attractive therapeutic targets for CVD prevention, there are no specific interventions directed at the kidney that prevent DKD. Inhibition of the renin-angiotensin-aldosterone system is an attractive option but has not been demonstrated to prevent DKD before it is clinically apparent. […] In contrast to prevention efforts, treatment of DKD with agents that inhibit the renin-angiotensin-aldosterone system is effective. […] angiotensin-converting enzyme (ACE) inhibitors reduce the progression of DKD and death in T1DM (200). Thus, once DKD develops, treatment is recommended to prevent progression and to reduce or minimize other CVD risk factors, which has a positive effect on CVD risk. All patients with T1DM and hypertension or albuminuria should be treated with an ACE inhibitor. If an ACE inhibitor is not tolerated, an angiotensin II receptor blocker (ARB) is likely to have similar efficacy, although this has not been studied specifically in patients with T1DM. Optimal dosing for ACE inhibitors or ARBs in the setting of DKD is not well defined; titration may be guided by BP, albuminuria, serum potassium, and creatinine. Combination therapy of ACE and ARB blockade cannot be specifically recommended at this time.”

“Hypertension is more common in patients with T1DM and is a powerful risk factor for CVD, regardless of whether an individual has DKD. In the CACTI [Coronary Artery Calcification in Type 1 Diabetes] study, hypertension was much more common in patients with T1DM than in age- and sex-matched control subjects (43% versus 15%, P < 0.001); in fact, only 42% of all T1DM patients met the Joint National Commission 7 goal (BP <130/80 mmHg) (201). Hypertension also affects youth with T1DM. The SEARCH trial of youth aged 3–17 years with T1DM (n = 3,691) found the prevalence of elevated BP was 5.9% […] Abnormalities in BP can stem from DKD or obesity. Hyperglycemia may also contribute to hypertension over the long term. In the DCCT/EDIC cohort, higher HbA1c was strongly associated with increased risk of hypertension, and intensive DM therapy reduced the long-term risk of hypertension by 24% (203). […] There are few published trials about the ideal pharmacotherapeutic agent(s) for hypertension in T1DM.”

“Smoking is a major risk factor for CVD, particularly PAD (213); however, there is little information on the prevalence or effects of smoking in T1DM. […] The added CVD risk of smoking may be particularly important in patients with DM, who are already vulnerable. In patients with T1DM, cigarette smoking [has been shown to increase] the risk of DM nephropathy, retinopathy, and neuropathy (214,215) […] Smoking increases CVD risk factors in T1DM via deterioration in glucose metabolism, lipids, and endothelial function (216). Unfortunately, smoking cessation can result in weight gain, which may deter smokers with DM from quitting (217). […] Smoking cessation should be strongly recommended to all patients with T1DM as part of an overall strategy to lower CVD, in particular PAD.”

“CVD risk factors are more common in children with T1DM than in the general pediatric population (218). Population-based studies estimate that 14–45% of children with T1DM have ≥2 CVD risk factors (219221). As with nondiabetic children, the prevalence of CVD risk factors increases with age (221). […] The American Academy of Pediatrics, the American Heart Association, and the ADA recognize patients with DM, and particularly T1DM, as being in a higher-risk group who should receive more aggressive risk factor screening and treatment than nondiabetic children […] The available data suggest many children and adolescents with T1DM do not receive the recommended treatment for their dyslipidemia and hypertension (220,222).”

“There are no CVD risk-prediction algorithms for patients with T1DM in widespread use. […] Use of the Framingham Heart Study and UK Prospective Diabetes Study (UKPDS) algorithms in the EDC study population did not provide good predictive results, which suggests that neither general or T2DM risk algorithms are sufficient for risk prediction in T1DM (235). On the basis of these findings, a model has been developed with the use of EDC cohort data (236) that incorporates measures outside the Framingham construct (white blood cell count, albuminuria, DM duration). Although this algorithm was validated in the EURODIAB Study cohort (237), it has not been widely adopted, and diagnostic and therapeutic decisions are often based on global CVD risk-estimation methods (i.e., Framingham risk score or T2DM-specific UKPDS risk engine []). Other options for CVD risk prediction in patients with T1DM include the ADA risk-assessment tool ( and the Atherosclerosis Risk in Communities (ARIC) risk predictor (, but again, accuracy for T1DM is not clear.”

September 25, 2017 Posted by | Cardiology, Diabetes, Epidemiology, Genetics, Medicine, Nephrology, Neurology, Pharmacology, Studies | Leave a comment

A few diabetes papers of interest

i. Glycated Hemoglobin and All-Cause and Cause-Specific Mortality in Singaporean Chinese Without Diagnosed Diabetes: The Singapore Chinese Health Study.

“Previous studies have reported that elevated levels of HbA1c below the diabetes threshold (<6.5%) are associated with an increased risk for cardiovascular morbidity and mortality (312). Yet, this research base is not comprehensive, and data from Chinese populations are scant, especially in those without diabetes. This gap in the literature is important since Southeast Asian populations are experiencing epidemic rates of type 2 diabetes and related comorbidities with a substantial global health impact (1316).

Overall, there are few cohort studies that have examined the etiologic association between HbA1c levels and all-cause and cause-specific mortality. There is even lesser insight on the nature of the relationship between HbA1c and significant clinical outcomes in Southeast Asian populations. Therefore, we examined the association between HbA1c and all-cause and cause-specific mortality in the Singapore Chinese Health Study (SCHS).”

“The design of the SCHS has been previously summarized (17). Briefly, the cohort was drawn from men and women, aged 45–74 years, who belonged to one of the major dialect groups (Hokkien or Cantonese) of Chinese in Singapore. […] Between April 1993 and December 1998, 63,257 individuals completed an in-person interview that included questions on usual diet, demographics, height and weight, use of tobacco, usual physical activity, menstrual and reproductive history (women only), medical history including history of diabetes diagnosis by a physician, and family history of cancer. […] At the follow-up interview (F1), which occurred in 1999–2004, subjects were asked to update their baseline interview information. […] The study population derived from 28,346 participants of the total 54,243 who were alive and participated at F1, who provided consent at F1 to collect subsequent blood samples (a consent rate of ∼65%). The participants for this study were a random selection of individuals from the full study population who did not report a history of diabetes or CVD at the baseline or follow-up interview and reported no history of cancer.”

“During 74,890 person-years of follow-up, there were 888 total deaths, of which 249 were due to CVD, 388 were due to cancer, and 169 were recorded as respiratory mortality. […] There was a positive association between HbA1c and age, BMI, and prevalence of self-reported hypertension, while an inverse association was observed between educational attainment and HbA1c. […] The crude mortality rate was 1,186 deaths per 100,000 person-years. The age- and sex-standardized mortality rates for all-cause, CVD, and cerebrovascular each showed a J-shaped pattern according to HbA1c level. The CHD and cancer mortality rates were higher for HbA1c ≥6.5% (≥48 mmol/mol) and otherwise displayed no apparent pattern. […] There was no association between any level of HbA1c and respiratory causes of death.”

“Chinese men and women with no history of cancer, reported diabetes, or CVD with an HbA1c level ≥6.5% (≥48 mmol/mol) were at a significant increased risk of mortality during follow-up relative to their peers with an HbA1c of 5.4–5.6% (36–38 mmol/mol). No other range of HbA1c was significantly associated with risk of mortality during follow-up, and in secondary analyses, when the HbA1c level ≥6.5% (≥48 mmol/mol) was divided into four categories, this increased risk was observed in all four categories; thus, these data represent a clear threshold association between HbA1c and mortality in this population. These results are consistent with previous prospective cohort studies identifying chronically high HbA1c, outside of diabetes, to be associated with increased risk for all-cause and CVD-related mortality (312,22).”

“Hyperglycemia is a known risk factor for CVD, not limited to individuals with diabetes. This may be in part due to the vascular damage caused by oxidative stress in periods of hypo- and hyperglycemia (23,24). For individuals with impaired fasting glucose and impaired glucose tolerance, increased oxidative stress and endothelial dysfunction are present before the onset of diabetes (25). The association between chronically high levels of HbA1c and development of and death from cancer is not as well defined (9,2630). Abnormal metabolism may play a role in cancer development and death. This is important, considering cancer is the leading cause of death in Singapore for adults 15–59 years of age (31). Increased risk for cancer mortality was found in individuals with impaired glucose tolerance (30). […] Hyperinsulinemia and IGF-I are associated with increased cancer risk, possibly through mitogenic effects and tumor formation (27,28,37). This is the basis for the insulin-cancer hypothesis. Simply put, chronic levels of hyperinsulinemia reduce the production of IGF binding proteins 1 and 2. The absence of these proteins results in excess bioactive IGF-I, supporting tumor development (38). Chronic hyperglycemia, indicating high levels of insulin and IGF-I, may explain inhibition of cell apoptosis, increased cell proliferation, and increased cancer risk (39).”

ii. The Cross-sectional and Longitudinal Associations of Diabetic Retinopathy With Cognitive Function and Brain MRI Findings: The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial.

“Brain imaging studies suggest that type 2 diabetes–related microvascular disease may affect the central nervous system in addition to its effects on other organs, such as the eye and kidney. Histopathological evidence indicates that microvascular disease in the brain can lead to white matter lesions (WMLs) visible with MRI of the brain (1), and risk for them is often increased by type 2 diabetes (26). Type 2 diabetes also has recently been associated with lower brain volume, particularly gray matter volume (79).

The association between diabetic retinopathy and changes in brain tissue is of particular interest because retinal and cerebral small vessels have similar anatomy, physiology, and embryology (10). […] the preponderance of evidence suggests diabetic retinopathy is associated with increased WML burden (3,1214), although variation exists. While cross-sectional studies support a correlation between diabetic retinopathy and WMLs (2,3,6,15), diabetic retinopathy and brain atrophy (16), diabetic retinopathy and psychomotor speed (17,18), and psychomotor speed and WMLs (5,19,20), longitudinal evidence demonstrating the assumed sequence of disease development, for example, vascular damage of eye and brain followed by cognitive decline, is lacking.

Using Action to Control Cardiovascular Risk in Diabetes (ACCORD) data, in which a subset of participants received longitudinal measurements of diabetic retinopathy, cognition, and MRI variables, we analyzed the 1) cross-sectional associations between diabetic retinopathy and evidence of brain microvascular disease and 2) determined whether baseline presence or severity of diabetic retinopathy predicts 20- or 40-month changes in cognitive performance or brain microvascular disease.”

“The ACCORD trial (21) was a multicenter randomized trial examining the effects of intensive glycemic control, blood pressure, and lipids on cardiovascular disease events. The 10,251 ACCORD participants were aged 40–79 years, had poorly controlled type 2 diabetes (HbA1c > 7.5% [58.5 mmol/mol]), and had or were at high risk for cardiovascular disease. […] The ACCORD-Eye sample comprised 3,472 participants who did not report previous vitrectomy or photocoagulation surgery for proliferative diabetic retinopathy at baseline […] ACCORD-MIND included a subset of 2,977 ACCORD participants who completed a 30-min cognitive testing battery, 614 of whom also had useable scans from the MRI substudy (23,24). […] ACCORD-MIND had visits at three time points: baseline, 20 months, and 40 months. MRI of the brain was completed at baseline and the 40-month time point.”

“Baseline diabetic retinopathy was associated with more rapid 40-month declines in DSST and MMSE [Mini-Mental State Examination] when adjusting for demographics and lifestyle factors in model 1 […]. Moreover, increasing severity of diabetic retinopathy was associated with increased amounts of decline in DSST [Digit Symbol Substitution Test] performance (−1.30, −1.76, and −2.81 for no, mild, and moderate/severe NPDR, respectively; P = 0.003) […Be careful about how to interpret that p-value – see below, US] . The associations remained virtually unchanged after further adjusting for vascular and diabetes risk factors, depression, and visual acuity using model 2.”

“This longitudinal study provides new evidence that diabetic retinopathy is associated with future cognitive decline in persons with type 2 diabetes and confirms the finding from the Edinburgh Type 2 Diabetes Study derived from cross-sectional data that lifetime cognitive decline is associated with diabetic retinopathy (32). We found that the presence of diabetic retinopathy, independent of visual acuity, predicts greater declines in global cognitive function measured with the MMSE and that the magnitude of decline in processing speed measured with the DSST increased with increasing severity of baseline diabetic retinopathy. The association with psychomotor speed is consistent with prior cross-sectional findings in community-based samples of middle-aged (18) and older adults (17), as well as prospective studies of a community-based sample of middle-aged adults (33) and patients with type 1 diabetes (34) showing that retinopathy with different etiologies predicted a subsequent decline in psychomotor speed. This study extends these findings to patients with type 2 diabetes.”

“we tested a number of different associations but did not correct P values for multiple testing” [Aargh!, US.]

iii. Incidence of Remission in Adults With Type 2 Diabetes: The Diabetes & Aging Study.

(Note to self before moving on to the paper: these people identified type 1 diabetes by self-report or diabetes onset at <30 years of age, treated with insulin only and never treated with oral agents).

“It is widely believed that type 2 diabetes is a chronic progressive condition, which at best can be controlled, but never cured (1), and that once treatment with glucose-lowering medication is initiated, it is required indefinitely and is intensified over time (2,3). However, a growing body of evidence from clinical trials and case-control studies (46) has reported the remission of type 2 diabetes in certain populations, most notably individuals who received bariatric surgery. […] Despite the clinical relevance and importance of remission, little is known about the incidence of remission in community settings (11,12). Studies to date have focused largely on remission after gastric bypass or relied on data from clinical trials, which have limited generalizability. Therefore, we conducted a retrospective cohort study to describe the incidence rates and variables associated with remission among adults with type 2 diabetes who received usual care, excluding bariatric surgery, in a large, ethnically diverse population. […] 122,781 individuals met our study criteria, yielding 709,005 person-years of total follow-up time.”

“Our definitions of remission were based on the 2009 ADA consensus statement (10). “Partial remission” of diabetes was defined as having two or more consecutive subdiabetic HbA1c measurements, all of which were in the range of 5.7–6.4% [39–46 mmol/mol] over a period of at least 12 months. “Complete remission” was defined as having two or more consecutive normoglycemic HbA1c measurements, all of which were <5.7% [<39 mmol/mol] over a period of at least 12 months. “Prolonged remission” was defined as having two or more consecutive normoglycemic HbA1c measurements, all of which were <5.7% [<39 mmol/mol] over a period of at least 60 months. Each definition of remission requires the absence of pharmacologic treatment during the defined observation period.”

“The average age of participants was 62 years, 47.1% were female, and 51.6% were nonwhite […]. The mean (SD) interval between HbA1c tests in the remission group was 256 days (139 days). The mean interval (SD) between HbA1c tests among patients not in the remission group was 212 days (118 days). The median time since the diagnosis of diabetes in our cohort was 5.9 years, and the average baseline HbA1c level was 7.4% [57 mmol/mol]. The 18,684 individuals (15.2%) in the subset with new-onset diabetes, defined as ≤2 years since diagnosis, were younger, were more likely to have their diabetes controlled by diet, and had fewer comorbidities […] The incidence densities of partial, complete, and prolonged remission in the full cohort were 2.8 (95% CI 2.6–2.9), 0.24 (95% CI 0.20–0.28), and 0.04 (95% CI 0.01–0.06) cases per 1,000 person-years, respectively […] The 7-year cumulative incidences of partial, complete, and prolonged remission were 1.5% (95% CI 1.4–1.5%), 0.14% (95% CI 0.12–0.16%), and 0.01% (95% CI 0.003–0.02%), respectively. The 7-year cumulative incidence of any remission decreased with longer time since diagnosis from a high of 4.6% (95% CI 4.3–4.9%) for individuals diagnosed with diabetes in the past 2 years to a low of 0.4% (95% CI 0.3–0.5%) in those diagnosed >10 years ago. The 7-year cumulative incidence of any remission was much lower for individuals using insulin (0.05%; 95% CI 0.03–0.1%) or oral agents (0.3%; 95% CI 0.2–0.3%) at baseline compared with diabetes patients not using medication at baseline (12%; 95% CI 12–13%).”

“In this large cohort of insured adults with type 2 diabetes not treated with bariatric surgery, we found that 1.5% of individuals with recent evidence of clinical diabetes achieved at least partial remission over a 7-year period. If these results were generalized to the 25.6 million U.S. adults living with type 2 diabetes in 2010 (25), they would suggest that 384,000 adults could experience remission over the next 7 years. However, the rate of prolonged remission was extremely rare (0.007%), translating into only 1,800 adults in the U.S. experiencing remission lasting at least 5 years. To provide context, 1.7% of the cohort died, while only 0.8% experienced any level of remission, during the calendar year 2006. Thus, the chances of dying were higher than the chances of any remission. […] Although remission of type 2 diabetes is uncommon, it does occur in patients who have not undergone surgical interventions. […] Our analysis shows that remission is rare and variable. The likelihood of remission is more common among individuals with early-onset diabetes and those not treated with glucose-lowering medications at the point of diabetes diagnosis. Although rare, remission can also occur in individuals with more severe diabetes and those previously treated with insulin.”

iv. Blood pressure control for diabetic retinopathy (Cochrane review).

“Diabetic retinopathy is a common complication of diabetes and a leading cause of visual impairment and blindness. Research has established the importance of blood glucose control to prevent development and progression of the ocular complications of diabetes. Simultaneous blood pressure control has been advocated for the same purpose, but findings reported from individual studies have supported varying conclusions regarding the ocular benefit of interventions on blood pressure. […] The primary aim of this review was to summarize the existing evidence regarding the effect of interventions to control or reduce blood pressure levels among diabetics on incidence and progression of diabetic retinopathy, preservation of visual acuity, adverse events, quality of life, and costs. A secondary aim was to compare classes of anti-hypertensive medications with respect to the same outcomes.”

“We included 15 RCTs, conducted primarily in North America and Europe, that had enrolled 4157 type 1 and 9512 type 2 diabetic participants, ranging from 16 to 2130 participants in individual trials. […] Study designs, populations, interventions, and lengths of follow-up (range one to nine years) varied among the included trials. Overall, the quality of the evidence for individual outcomes was low to moderate.”

“The evidence from these trials supported a benefit of more intensive blood pressure control intervention with respect to 4- to 5-year incidence of diabetic retinopathy (estimated risk ratio (RR) 0.80; 95% confidence interval (CI) 0.71 to 0.92) and the combined outcome of incidence and progression (estimated RR 0.78; 95% CI 0.63 to 0.97). The available evidence provided less support for a benefit with respect to 4- to 5-year progression of diabetic retinopathy (point estimate was closer to 1 than point estimates for incidence and combined incidence and progression, and the CI overlapped 1; estimated RR 0.88; 95% CI 0.73 to 1.05). The available evidence regarding progression to proliferative diabetic retinopathy or clinically significant macular edema or moderate to severe loss of best-corrected visual acuity did not support a benefit of intervention on blood pressure: estimated RRs and 95% CIs 0.95 (0.83 to 1.09) and 1.06 (0.85 to 1.33), respectively, after 4 to 5 years of follow-up. Findings within subgroups of trial participants (type 1 and type 2 diabetics; participants with normal blood pressure levels at baseline and those with elevated levels) were similar to overall findings.”

“The available evidence supports a beneficial effect of intervention to reduce blood pressure with respect to preventing diabetic retinopathy for up to 4 to 5 years. However, the lack of evidence to support such intervention to slow progression of diabetic retinopathy or to prevent other outcomes considered in this review, along with the relatively modest support for the beneficial effect on incidence, weakens the conclusion regarding an overall benefit of intervening on blood pressure solely to prevent diabetic retinopathy.”

v. Early Atherosclerosis Relates to Urinary Albumin Excretion and Cardiovascular Risk Factors in Adolescents With Type 1 Diabetes: Adolescent Type 1 Diabetes cardio-renal Intervention Trial (AdDIT).

“Children with type 1 diabetes are at greatly increased risk for the development of both renal and cardiovascular disease in later life (1,2). Evidence is accumulating that these two complications may have a common pathophysiology, with endothelial dysfunction a key early event.

Microalbuminuria is a recognized marker of endothelial damage (3) and predicts progression to proteinuria and diabetic nephropathy, as well as to atherosclerosis (4) and increased cardiovascular risk (5). It is, however, rare in adolescents with type 1 diabetes who more often have higher urinary albumin excretion rates within the normal range, which are associated with later progression to microalbuminuria and proteinuria (6).”

“The Adolescent Type 1 Diabetes cardio-renal Intervention Trial (AdDIT) (10) is designed to examine the impact of minor differences in albumin excretion in adolescents on the initiation and progression of cardiovascular and renal disease. The primary cardiovascular end point in AdDIT is carotid intima-media thickness (cIMT). Subclinical atherosclerosis can be detected noninvasively using high-resolution ultrasound to measure the intima-media thickness (IMT) of the carotid arteries, which predicts cardiovascular morbidity and mortality (11,12). […] The primary aim of this study was to examine the relationship of increased urinary albumin excretion and cardiovascular risk factors in adolescents with type 1 diabetes with structural arterial wall changes. We hypothesized that even minor increases in albumin excretion would be associated with early atherosclerosis but that this would be detectable only in the abdominal aorta. […] A total of 406 adolescents, aged 10–16 years, with type 1 diabetes for more than 1 year, recruited in five centers across Australia, were enrolled in this cross-sectional study”.

“Structural changes in the aorta and carotid arteries could be detected in >50% of adolescents with type 1 diabetes […] The difference in aIMT [aortic intima-media thickness] between type 1 diabetic patients and age- and sex-matched control subjects was equivalent to that seen with a 5- to 6-year age increase in the type 1 diabetic patients. […] Aortic IMT was […] able to better differentiate adolescents with type 1 diabetes from control subjects than was carotid wall changes. Aortic IMT enabled detection of the very early wall changes that are present with even small differences in urinary albumin excretion. This not only supports the concept of early intervention but provides a link between renal and cardiovascular disease.

The independent relationship between aIMT and urinary albumin excretion extends our knowledge of the pathogenesis of cardiovascular and renal disease in type 1 diabetes by showing that the first signs of the development of cardiovascular disease and diabetic nephropathy are related. The concept that microalbuminuria is a marker of a generalized endothelial damage, as well as a marker of renal disease, has been recognized for >20 years (3,20,21). Endothelial dysfunction is the first critical step in the development of atherosclerosis (22). Early rises in urinary albumin excretion precede the development of microalbuminuria and proteinuria (23). It follows that the first structural changes of atherosclerosis could relate to the first biochemical changes of diabetic nephropathy. To our knowledge, this is the first study to provide evidence of this.”

“In conclusion, atherosclerosis is detectable from early adolescence in type 1 diabetes. Its early independent associations are male sex, age, systolic blood pressure, LDL cholesterol, and, importantly, urinary albumin excretion. […] Early rises in urinary albumin excretion during adolescence not only are important for determining risk of progression to microalbuminuria and diabetic nephropathy but also may alert the clinician to increased risk of cardiovascular disease.”

vi. Impact of Islet Autoimmunity on the Progressive β-Cell Functional Decline in Type 2 Diabetes.

“Historically, type 2 diabetes (T2D) has not been considered to be immune mediated. However, many notable discoveries in recent years have provided evidence to support the concept of immune system involvement in T2D pathophysiology (15). Immune cells have been identified in the pancreases of phenotypic T2D patients (35). Moreover, treatment with interleukin-1 receptor agonist improves β-cell function in T2D patients (68). These studies suggest that β-cell damage/destruction mediated by the immune system may be a component of T2D pathophysiology.

Although the β-cell damage and destruction in autoimmune diabetes is most likely T-cell mediated (T), immune markers of autoimmune diabetes have primarily centered on the presence of circulating autoantibodies (Abs) to various islet antigens (915). Abs commonly positive in type 1 diabetes (T1D), especially GAD antibody (GADA) and islet cell Abs (ICA), have been shown to be more common in patients with T2D than in nondiabetic control populations, and the presence of multiple islet Abs, such as GADA, ICA, and tyrosine phosphatase-2 (insulinoma-associated protein 2 [IA-2]), have been demonstrated to be associated with an earlier need for insulin treatment in adult T2D patients (14,1620).”

“In this study, we observed development of islet autoimmunity, measured by islet Abs and islet-specific T-cell responses, in 61% of the phenotypic T2D patients. We also observed a significant association between positive islet-reactive T-cell responses and a more rapid decline in β-cell function as assessed by FCP and glucagon-SCP responses. […] The results of this pilot study led us to hypothesize that islet autoimmunity is present or will develop in a large portion of phenotypic T2D patients and that the development of islet autoimmunity is associated with a more rapid decline in β-cell function. Moreover, the prevalence of islet autoimmunity in most previous studies is grossly underestimated because these studies have not tested for islet-reactive T cells in T2D patients but have based the presence of autoimmunity on antibody testing alone […] The results of this pilot study suggest important changes to our understanding of T2D pathogenesis by demonstrating that the prevalence of islet autoimmune development is not only more prevalent in T2D patients than previously estimated but may also play an important role in β-cell dysfunction in the T2D disease process.”

September 18, 2017 Posted by | Cancer/oncology, Cardiology, Diabetes, Epidemiology, Immunology, Medicine, Nephrology, Neurology, Ophthalmology, Studies | Leave a comment

A few diabetes papers of interest

i. Impact of Parental Socioeconomic Status on Excess Mortality in a Population-Based Cohort of Subjects With Childhood-Onset Type 1 Diabetes.

“Numerous reports have shown that individuals with lower SES during childhood have increased morbidity and all-cause mortality at all ages (10–14). Although recent epidemiological studies have shown that all-cause mortality in patients with T1D increases with lower SES in the individuals themselves (15,16), the association between parental SES and mortality among patients with childhood-onset T1D has not been reported to the best of our knowledge. Our hypothesis was that low parental SES additionally increases mortality in subjects with childhood-onset T1D. In this study, we used large population-based Swedish databases to 1) explore in a population-based study how parental SES affects mortality in a patient with childhood-onset T1D, 2) describe and compare how the effect differs among various age-at-death strata, and 3) assess whether the adult patient’s own SES affects mortality independently of parental SES.”

“The Swedish Childhood Diabetes Registry (SCDR) is a dynamic population-based cohort reporting incident cases of T1D since 1 July 1977, which to date has collected >16,000 prospective cases. […] All patients recorded in the SCDR from 1 January 1978 to 31 December 2008 were followed until death or 31 December 2010. The cohort was subjected to crude analyses and stratified analyses by age-at-death groups (0–17, 18–24, and ≥25 years). Time at risk was calculated from date of birth until death or 31 December 2010. Kaplan-Meier analyses and log-rank tests were performed to compare the effect of low maternal educational level, low paternal educational level, and family income support (any/none). Cox regression analyses were performed to estimate and compare the hazard ratios (HRs) for the socioeconomic variables and to adjust for the potential confounding variables age at onset and sex.”

“The study included 14,647 patients with childhood-onset T1D. A total of 238 deaths (male 154, female 84) occurred in 349,762 person-years at risk. The majority of mortalities occurred among the oldest age-group (≥25 years of age), and most of the deceased subjects had onset of T1D at the ages of 10–14.99 years […]. Mean follow-up was 23.9 years and maximum 46.5 years. The overall standardized mortality ratio up to the age of 47 years was 2.3 (95% CI 1.35–3.63); for females, it was 2.6 (1.28–4.66) and for males, 2.1 (1.27–3.49). […] Analyses on the effect of low maternal educational level showed an increased mortality for male patients (HR 1.43 [95% CI 1.01–2.04], P = 0.048) and a nonsignificant increased mortality for female patients (1.21 [0.722–2.018], P = 0.472). Paternal educational level had no significant effect on mortality […] Having parents who ever received income support was associated with an increased risk of death in both males (HR 1.89 [95% CI 1.36–2.64], P < 0.001) and females (2.30 [1.43–3.67], P = 0.001) […] Excluding the 10% of patients with the highest accumulated income support to parents during follow-up showed that having parents who ever received income support still was a risk factor for mortality.”

“A Cox model including maternal educational level together with parental income support, adjusting for age at onset and sex, showed that having parents who received income support was associated with a doubled mortality risk (HR 1.96 [95% CI 1.49–2.58], P < 0.001) […] In a Cox model including the adult patient’s own SES, having parents who received income support was still an independent risk factor in the younger age-at-death group (18–24 years). Among those who died at age ≥25 years of age, the patient’s own SES was a stronger predictor for mortality (HR 2.46 [95% CI 1.54–3.93], P < 0.001)”

“Despite a well-developed health-care system in Sweden, overall mortality up to the age of 47 years is doubled in both males and females with childhood-onset T1D. These results are in accordance with previous Swedish studies and reports from other comparable countries […] Previous studies indicated that low SES during childhood is associated with low glycemic control and diabetes-related morbidity in patients with T1D (8,9), and the current study implies that mortality in adulthood is also affected by parental SES. […] The findings, when stratified by age-at-death group, show that adult patients’ own need of income support independently predicted mortality in those who died at ≥25 years of age, whereas among those who died in the younger age-group (18–24 years), parental requirement of income support was still a strong independent risk factor. None of the present SES measures seem to predict mortality in the ages 0–17 years perhaps due to low numbers and, thus, power.”

ii. Exercise Training Improves but Does Not Normalize Left Ventricular Systolic and Diastolic Function in Adolescents With Type 1 Diabetes.

“Adults and adolescents with type 1 diabetes have reduced exercise capacity (810), which increases their risk for cardiovascular morbidity and mortality (11). The causes for this reduced exercise capacity are unclear. However, recent studies have shown that adolescents with type 1 diabetes have lower stroke volume during exercise, which has been attributed to alterations in left ventricular function (9,10). Reduced left ventricular compliance resulting in an inability to fill the left ventricle appropriately during exercise has been shown to contribute to the lower stroke volume during exercise in both adults and adolescents with type 1 diabetes (12).

Exercise training is recommended as part of the management of type 1 diabetes. However, the effects of exercise training on left ventricular function at rest and during exercise in adolescents with type 1 diabetes have not been investigated. In particular, it is unclear whether exercise training improves cardiac hemodynamics during exercise in adolescents with diabetes. Therefore, we aimed to assess left ventricular volumes at rest and during exercise in a group of adolescents with type 1 diabetes compared with adolescents without diabetes before and after a 20-week exercise-training program. We hypothesized that exercise training would improve exercise capacity and exercise stroke volume in adolescents with diabetes.”

RESEARCH DESIGN AND METHODS Fifty-three adolescents with type 1 diabetes (aged 15.6 years) were divided into two groups: exercise training (n = 38) and nontraining (n = 15). Twenty-two healthy adolescents without diabetes (aged 16.7 years) were included and, with the 38 participants with type 1 diabetes, participated in a 20-week exercise-training intervention. Assessments included VO2max and body composition. Left ventricular parameters were obtained at rest and during acute exercise using MRI.

RESULTS Exercise training improved aerobic capacity (10%) and stroke volume (6%) in both trained groups, but the increase in the group with type 1 diabetes remained lower than trained control subjects. […]

CONCLUSIONS These data demonstrate that in adolescents, the impairment in left ventricular function seen with type 1 diabetes can be improved, although not normalized, with regular intense physical activity. Importantly, diastolic dysfunction, a common mechanism causing heart failure in older subjects with diabetes, appears to be partially reversible in this age group.”

“This study confirms that aerobic capacity is reduced in [diabetic] adolescents and that this, at least in part, can be attributed to impaired left ventricular function and a blunted cardiac response to exercise (9). Importantly, although an aerobic exercise-training program improved the aerobic capacity and cardiac function in adolescents with type 1 diabetes, it did not normalize them to the levels seen in the training group without diabetes. Both left ventricular filling and contractility improved after exercise training in adolescents with diabetes, suggesting that aerobic fitness may prevent or delay the well-described impairment in left ventricular function in diabetes (9,10).

The increase in peak aerobic capacity (∼12%) seen in this study was consistent with previous exercise interventions in adults and adolescents with diabetes (14). However, the baseline peak aerobic capacity was lower in the participants with diabetes and improved with training to a level similar to the baseline observed in the participants without diabetes; therefore, trained adolescents with diabetes remained less fit than equally trained adolescents without diabetes. This suggests there are persistent differences in the cardiovascular function in adolescents with diabetes that are not overcome by exercise training.”

“Although regular exercise potentially could improve HbA1c, the majority of studies have failed to show this (3134). Exercise training improved aerobic capacity in this study without affecting glucose control in the participants with diabetes, suggesting that the effects of glycemic status and exercise training may work independently to improve aerobic capacity.”


iii. Change in Medical Spending Attributable to Diabetes: National Data From 1987 to 2011.

“Diabetes care has changed substantially in the past 2 decades. We examined the change in medical spending and use related to diabetes between 1987 and 2011. […] Using the 1987 National Medical Expenditure Survey and the Medical Expenditure Panel Surveys in 2000–2001 and 2010–2011, we compared per person medical expenditures and uses among adults ≥18 years of age with or without diabetes at the three time points. Types of medical services included inpatient care, emergency room (ER) visits, outpatient visits, prescription drugs, and others. We also examined the changes in unit cost, defined by the expenditure per encounter for medical services.”

RESULTS The excess medical spending attributed to diabetes was $2,588 (95% CI, $2,265 to $3,104), $4,205 ($3,746 to $4,920), and $5,378 ($5,129 to $5,688) per person, respectively, in 1987, 2000–2001, and 2010–2011. Of the $2,790 increase, prescription medication accounted for 55%; inpatient visits accounted for 24%; outpatient visits accounted for 15%; and ER visits and other medical spending accounted for 6%. The growth in prescription medication spending was due to the increase in both the volume of use and unit cost, whereas the increase in outpatient expenditure was almost entirely driven by more visits. In contrast, the increase in inpatient and ER expenditures was caused by the rise of unit costs. […] The increase was observed across all components of medical spending, with the greatest absolute increase in the spending on prescription medications ($1,528 increase), followed by inpatient visits ($680 increase) and outpatient visits ($430 increase). The absolute change in the spending on ER and other medical services use was relatively small. In relative terms, the spending on ER visits grew more than five times, faster than that of prescription medication and other medical components. […] Among the total annual diabetes-attributable medical spending, the spending on inpatient and outpatient visits dropped from 40% and 23% to 31% and 19%, respectively, between 1987 and 2011, whereas spending on prescription medication increased from 27% to 41%.”

“The unit costs rose universally in all five measures of medical care in adults with and without diabetes. For each hospital admission, diabetes patients spent significantly more than persons without diabetes. The gap increased from $1,028 to $1,605 per hospital admission between 1987 and 2001, and dropped slightly to $1,360 per hospital admission in 2011. Diabetes patients also had higher spending per ER visit and per purchase of prescription medications.”

“From 1999 to 2011, national data suggest that growth in the use and price of prescription medications in the general population is 2.6% and 3.6% per year, respectively; and the growth has decelerated in recent years (22). Our analysis suggests that the growth rates in the use and prices of prescription medications for diabetes patients are considerably higher. The higher rate of growth is likely, in part, due to the growing emphasis on achieving glycemic targets, the use of newer medications, and the use of multidrug treatment strategies in modern diabetes care practice (23,24). In addition, the growth of medication spending is fueled by the rising prices per drug, particularly the drugs that are newly introduced in the market. For example, the prices for newer drug classes such as glitazones, dipeptidyl peptidase-4 inhibitors, and incretins have been 8 to 10 times those of sulfonylureas and 5 to 7 times those of metformin (9).”

“Between 1987 and 2011, medical spending increased both in persons with and in persons without diabetes; and the increase was substantially greater among persons with diabetes. As a result, the medical spending associated with diabetes nearly doubled. The growth was primarily driven by the spending in prescription medications. Further studies are needed to assess the cost-effectiveness of increased spending on drugs.”

iv. Determinants of Adherence to Diabetes Medications: Findings From a Large Pharmacy Claims Database.

“Adults with type 2 diabetes are often prescribed multiple medications to treat hyperglycemia, diabetes-associated conditions such as hypertension and dyslipidemia, and other comorbidities. Medication adherence is an important determinant of outcomes in patients with chronic diseases. For those with diabetes, adherence to medications is associated with better control of intermediate risk factors (14), lower odds of hospitalization (3,57), lower health care costs (5,79), and lower mortality (3,7). Estimates of rates of adherence to diabetes medications vary widely depending on the population studied and how adherence is defined. One review found that adherence to oral antidiabetic agents ranged from 36 to 93% across studies and that adherence to insulin was ∼63% (10).”

“Using a large pharmacy claims database, we assessed determinants of adherence to oral antidiabetic medications in >200,000 U.S. adults with type 2 diabetes. […] We selected a cohort of members treated for diabetes with noninsulin medications (oral agents or GLP-1 agonists) in the second half of 2010 who had continuous prescription benefits eligibility through 2011. Each patient was followed for 12 months from their index diabetes claim date identified during the 6-month targeting period. From each patient’s prescription history, we collected the date the prescription was filled, how many days the supply would last, the National Drug Code number, and the drug name. […] Given the difficulty in assessing insulin adherence with measures such as medication possession ratio (MPR), we excluded patients using insulin when defining the cohort.”

“We looked at a wide range of variables […] Predictor variables were defined a priori and grouped into three categories: 1) patient factors including age, sex, education, income, region, past exposure to therapy (new to diabetes therapy vs. continuing therapy), and concurrent chronic conditions; 2) prescription factors including refill channel (retail vs. mail order), total pill burden per day, and out of pocket costs; and 3) prescriber factors including age, sex, and specialty. […] Our primary outcome of interest was adherence to noninsulin antidiabetic medications. To assess adherence, we calculated an MPR for each patient. The ratio captures how often patients refill their medications and is a standard metric that is consistent with the National Quality Forum’s measure of adherence to medications for chronic conditions. MPR was defined as the proportion of days a patient had a supply of medication during a calendar year or equivalent period. We considered patients to be adherent if their MPR was 0.8 or higher, implying that they had their medication supplies for at least 80% of the days. An MPR of 0.8 or above is a well-recognized index of adherence (11,12). Studies have suggested that patients with chronic diseases need to achieve at least 80% adherence to derive the full benefits of their medications (13). […] [W]e [also] determined whether a patient was persistent, that is whether they had not discontinued or had at least a 45-day gap in their targeted therapy.”

“Previous exposure to diabetes therapy had a significant impact on adherence. Patients new to therapy were 61% less likely to be adherent to their diabetes medication. There was also a clear age effect. Patients 25–44 years of age were 49% less likely to be adherent when compared with patients 45–64 years of age. Patients aged 65–74 years were 27% more likely to be adherent, and those aged 75 years and above were 41% more likely to be adherent when compared with the 45–64 year age-group. Men were significantly more likely to be adherent than women […I dislike the use of the word ‘significant’ in such contexts; there is a difference in the level of adherence, but it is not large in absolute terms; the male vs female OR is 1.14 (CI 1.12-1.16) – US]. Education level and household income were both associated with adherence. The higher the estimated academic achievement, the more likely the patient was to be adherent. Patients completing graduate school were 41% more likely to be adherent when compared with patients with a high school equivalent education. Patients with an annual income >$60,000 were also more likely to be adherent when compared with patients with a household income <$30,000.”

“The largest effect size was observed for patients obtaining their prescription antidiabetic medications by mail. Patients using the mail channel were more than twice as likely to be adherent to their antidiabetic medications when compared with patients filling their prescriptions at retail pharmacies. Total daily pill burden was positively associated with antidiabetic medication adherence. For each additional pill a patient took per day, adherence to antidiabetic medications increased by 22%. Patient out-of-pocket costs were negatively associated with adherence. For each additional $15 in out-of-pocket costs per month, diabetes medication adherence decreased by 11%. […] We found few meaningful differences in patient adherence according to prescriber factors.”

“In our study, characteristics that suggest a “healthier” patient (being younger, new to diabetes therapy, and taking few other medications) were all associated with lower odds of adherence to antidiabetic medications. This suggests that acceptance of a chronic illness diagnosis and the potential consequences may be an important, but perhaps overlooked, determinant of medication-taking behavior. […] Our findings regarding income and costs are important reminders that prescribers should consider the impact of medication costs on patients with diabetes. Out-of-pocket costs are an important determinant of adherence to statins (26) and a self-reported cause of underuse of medications in one in seven insured patients with diabetes (27). Lower income has previously been shown to be associated with poor adherence to diabetes medications (15) and a self-reported cause of cost-related medication underuse (27).”

v. The Effect of Alcohol Consumption on Insulin Sensitivity and Glycemic Status: A Systematic Review and Meta-analysis of Intervention Studies.

“Moderate alcohol consumption, compared with abstaining and heavy drinking, is related to a reduced risk of type 2 diabetes (1,2). Although the risk is reduced with moderate alcohol consumption in both men and women, the association may differ for men and women. In a meta-analysis, consumption of 24 g alcohol/day reduced the risk of type 2 diabetes by 40% among women, whereas consumption of 22 g alcohol/day reduced the risk by 13% among men (1).

The association of alcohol consumption with type 2 diabetes may be explained by increased insulin sensitivity, anti-inflammatory effects, or effects of adiponectin (3). Several intervention studies have examined the effect of moderate alcohol consumption on these potential underlying pathways. A meta-analysis of intervention studies by Brien et al. (4) showed that alcohol consumption significantly increased adiponectin levels but did not affect inflammatory factors. Unfortunately, the effect of alcohol consumption on insulin sensitivity has not been summarized quantitatively. A review of cross-sectional studies by Hulthe and Fagerberg (5) suggested a positive association between moderate alcohol consumption and insulin sensitivity, although the three intervention studies included in their review did not show an effect (68). Several other intervention studies also reported inconsistent results (9,10). Consequently, consensus is lacking about the effect of moderate alcohol consumption on insulin sensitivity. Therefore, we aimed to conduct a systematic review and meta-analysis of intervention studies investigating the effect of alcohol consumption on insulin sensitivity and other relevant glycemic measures.”

“22 articles met criteria for inclusion in the qualitative synthesis. […] Of the 22 studies, 15 used a crossover design and 7 a parallel design. The intervention duration of the studies ranged from 2 to 12 weeks […] Of the 22 studies, 2 were excluded from the meta-analysis because they did not include an alcohol-free control group (14,19), and 4 were excluded because they did not have a randomized design […] Overall, 14 studies were included in the meta-analysis”

“A random-effects model was used because heterogeneity was present (P < 0.01, I2 = 91%). […] For HbA1c, a random-effects model was used because the I2 statistic indicated evidence for some heterogeneity (I2 = 30%).” [Cough, you’re not supposed to make these decisions that way, coughUS. This is not the first time I’ve seen this approach applied, and I don’t like it; it’s bad practice to allow the results of (frequently under-powered) heterogeneity tests to influence model selection decisions. As Bohrenstein and Hedges point out in their book, “A report should state the computational model used in the analysis and explain why this model was selected. A common mistake is to use the fixed-effect model on the basis that there is no evidence of heterogeneity. As [already] explained […], the decision to use one model or the other should depend on the nature of the studies, and not on the significance of this test”]

“This meta-analysis shows that moderate alcohol consumption did not affect estimates of insulin sensitivity or fasting glucose levels, but it decreased fasting insulin concentrations and HbA1c. Sex-stratified analysis suggested that moderate alcohol consumption may improve insulin sensitivity and decrease fasting insulin concentrations in women but not in men. The meta-regression suggested no influence of dosage and duration on the results. However, the number of studies may have been too low to detect influences by dosage and duration. […] The primary finding that alcohol consumption does not influence insulin sensitivity concords with the intervention studies included in the review of Hulthe and Fagerberg (5). This is in contrast with observational studies suggesting a significant association between moderate alcohol consumption and improved insulin sensitivity (34,35). […] We observed lower levels of HbA1c in subjects consuming moderate amounts of alcohol compared with abstainers. This has also been shown in several observational studies (39,43,44). Alcohol may decrease HbA1c by suppressing the acute rise in blood glucose after a meal and increasing the early insulin response (45). This would result in lower glucose concentrations over time and, thus, lower HbA1c concentrations. Unfortunately, the underlying mechanism of glycemic control by alcohol is not clearly understood.”

vi. Predictors of Lower-Extremity Amputation in Patients With an Infected Diabetic Foot Ulcer.

“Infection is a frequent complication of diabetic foot ulcers, with up to 58% of ulcers being infected at initial presentation at a diabetic foot clinic, increasing to 82% in patients hospitalized for a diabetic foot ulcer (1). These diabetic foot infections (DFIs) are associated with poor clinical outcomes for the patient and high costs for both the patient and the health care system (2). Patients with a DFI have a 50-fold increased risk of hospitalization and 150-fold increased risk of lower-extremity amputation compared with patients with diabetes and no foot infection (3). Among patients with a DFI, ∼5% will undergo a major amputation and 20–30% a minor amputation, with the presence of peripheral arterial disease (PAD) greatly increasing amputation risk (46).”

“As infection of a diabetic foot wound heralds a poor outcome, early diagnosis and treatment are important. Unfortunately, systemic signs of inflammation such as fever and leukocytosis are often absent even with a serious foot infection (10,11). As local signs and symptoms of infection are also often diminished, because of concomitant peripheral neuropathy and ischemia (12), diagnosing and defining resolution of infection can be difficult.”

“The system developed by the International Working Group on the Diabetic Foot (IWGDF) and the Infectious Diseases Society of America (IDSA) provides criteria for the diagnosis of infection of ulcers and classifies it into three categories: mild, moderate, or severe. The system was validated in three relatively small cohorts of patients […] The European Study Group on Diabetes and the Lower Extremity (Eurodiale) prospectively studied a large cohort of patients with a diabetic foot ulcer (17), enabling us to determine the prognostic value of the IWGDF system for clinically relevant lower-extremity amputations. […] We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries. […] Among these patients, 159 (28%) underwent an amputation. […] Patients were followed monthly until healing of the foot ulcer(s), major amputation, or death — up to a maximum of 1 year.”

“One hundred and ninety-nine patients had a grade 2 (mild) infection, 338 a grade 3 (moderate), and 38 a grade 4 (severe). Amputations were performed on 159 (28%) patients (126 minor and 33 major) within the year of follow-up; 103 patients (18%) underwent amputations proximal to and including the hallux. […] The independent predictors of any amputation were as follows: periwound edema, HR 2.01 (95% CI 1.33–3.03); foul smell, HR 1.74 (1.17–2.57); purulent and nonpurulent exudate, HR 1.67 (1.17–2.37) and 1.49 (1.02–2.18), respectively; deep ulcer, HR 3.49 (1.84–6.60); positive probe-to-bone test, HR 6.78 (3.79–12.15); pretibial edema, HR 1.53 (1.02–2.31); fever, HR 2.00 (1.15–3.48); elevated CRP levels but less than three times the upper limit of normal, HR 2.74 (1.40–5.34); and elevated CRP levels more than three times the upper limit, HR 3.84 (2.07–7.12). […] In comparison with mild infection, the presence of a moderate infection increased the hazard for any amputation by a factor of 2.15 (95% CI 1.25–3.71) and 3.01 (1.51–6.01) for amputations excluding the lesser toes. For severe infection, the hazard for any amputation increased by a factor of 4.12 (1.99–8.51) and for amputations excluding the lesser toes by a factor of 5.40 (2.20–13.26). Larger ulcer size and presence of PAD were also independent predictors of both any amputation and amputations excluding the lesser toes, with HRs between 1.81 and 3 (and 95% CIs between 1.05 and 6.6).”

“Previously published studies that have aimed to identify independent risk factors for lower-extremity amputation in patients with a DFI have noted an association with older age (5,22), the presence of fever (5), elevated acute-phase reactants (5,22,23), higher HbA1c levels (24), and renal insufficiency (5,22).”

“The new risk scores we developed for any amputation, and amputations excluding the lesser toes had higher prognostic capability, based on the area under the ROC curve (0.80 and 0.78, respectively), than the IWGDF system (0.67) […] which is currently the only one in use for infected diabetic foot ulcers. […] these Eurodiale scores were developed based on the available data of our cohort, and they will need to be validated in other populations before any firm conclusions can be drawn. The advantage of these newly developed scores is that they are easier for clinicians to perform […] These newly developed risk scores can be readily used in daily clinical practice without the necessity of obtaining additional laboratory testing.”

September 12, 2017 Posted by | Cardiology, Diabetes, Economics, Epidemiology, Health Economics, Infectious disease, Medicine, Microbiology, Statistics | Leave a comment

Infectious Disease Surveillance (III)

I have added some more observations from the book below.

“Zoonotic diseases are infections transmitted between animals and humans […]. A recent survey identified more than 1,400 species of human disease–causing agents, over half (58%) of which were zoonotic [2]. Moreover, nearly three-quarters (73%) of infectious diseases considered to be emerging or reemerging were zoonotic [2]. […] In many countries there is minimal surveillance for live animal imports or imported wildlife products. Minimal surveillance prevents the identification of wildlife trade–related health risks to the public, agricultural industry, and native wildlife [36] and has led to outbreaks of zoonotic diseases […] Southeast Asia [is] a hotspot for emerging zoonotic diseases because of rapid population growth, high population density, and high biodiversity […] influenza virus in particular is of zoonotic importance as multiple human infections have resulted from animal exposure [77–79].”

“[R]abies is an important cause of death in many countries, particularly in Africa and Asia [85]. Rabies is still underreported throughout the developing world, and 100-fold underreporting of human rabies is estimated for most of Africa [44]. Reasons for underreporting include lack of public health personnel, difficulties in identifying suspect animals, and limited laboratory capacity for rabies testing. […] Brucellosis […] is transmissible to humans primarily through consumption of unpasteurized milk or dairy products […] Brucella is classified as a category B bioterrorism agent [90] because of its potential for aerosolization [I should perhaps here mention that the book coverage does overlaps a bit with that of Fong & Alibek’s book – which I covered here – but that I decided against covering those topics in much detail here – US] […] The key to preventing brucellosis in humans is to control or eliminate infections in animals [91–93]; therefore, veterinarians are crucial to the identification, prevention, and control of brucellosis [89]. […] Since 1954 [there has been] an ongoing eradication program involving surveillance testing of cattle at slaughter, testing at livestock markets, and whole-herd testing on the farm [in the US] […] Except for endemic brucellosis in wildlife in the Greater Yellowstone Area, all 50 states and territories in the United States are free of bovine brucellosis [94].”

“Because of its high mortality rate in humans in the absence of early treatment, Y. pestis is viewed as one of the most pathogenic human bacteria [101]. In the United States, plague is most often found in the Southwest where it is transmitted by fleas and maintained in rodent populations [102]. Deer mice and voles typically serve as maintenance hosts [and] these animals are often resistant to plague [102]. In contrast, in amplifying host species such as prairie dogs, ground squirrels, chipmunks, and wood rats, plague spreads rapidly and results in high mortality [103]. […] Human infections with Y. pestis can result in bubonic, pneumonic, or septicemic plague, depending on the route of exposure. Bubonic plague is most common; however, pneumonic plague poses a more serious public health risk since it can be easily transmitted person-to-person through inhalation of aerosolized bacteria […] Septicemic plague is characterized by bloodstream infection with Y. pestis and can occur secondary to pneumonic or bubonic forms of infection or as a primary infection [6,60].
Plague outbreaks are often correlated with animal die-offs in the area [104], and rodent control near human residences is important to prevent disease [103]. […] household pets can be an important route of plague transmission and flea control in dogs and cats is an important prevention measure [105]. Plague surveillance involves monitoring three populations for infection: vectors (e.g., fleas), humans, and rodents [106]. In the past 20 years, the numbers of human cases of plague reported in the United States have varied from 1 to 17 cases per year [90]. […]
Since rodent species are the main reservoirs of the bacteria, these animals can be used for sentinel surveillance to provide an early warning of the public health risk to humans [106]. […] Rodent die-offs can often be an early indicator of a plague outbreak”.

“Zoonotic disease surveillance is crucial for protection of human and animal health. An integrated, sustainable system that collects data on incidence of disease in both animals and humans is necessary to ensure prompt detection of zoonotic disease outbreaks and a timely and focused response [34]. Currently, surveillance systems for animals and humans [operate] largely independently [34]. This results in an inability to rapidly detect zoonotic diseases, particularly novel emerging diseases, that are detected in the human population only after an outbreak occurs [109]. While most industrialized countries have robust disease surveillance systems, many developing countries currently lack the resources to conduct both ongoing and real-time surveillance [34,43].”

“Acute hepatitis of any cause has similar, usually indistinguishable, signs and symptoms. Acute illness is associated with fever, fatigue, nausea, abdominal pain, followed by signs of liver dysfunction, including jaundice, light to clay-colored stool, dark urine, and easy bruising. The jaundice, dark urine, and abnormal stool are because of the diminished capacity of the inflamed liver to handle the metabolism of bilirubin, which is a breakdown product of hemoglobin released as red blood cells are normally replaced. In severe hepatitis that is associated with fulminant liver disease, the liver’s capacity to produce clotting factors and to clear potential toxic metabolic products is severely impaired, with resultant bleeding and hepatic encephalopathy. […] An effective vaccine to prevent hepatitis A has been available for more than 15 years, and incidence rates of hepatitis A are dropping wherever it is used in routine childhood immunization programs. […] Currently, hepatitis A vaccine is part of the U.S. childhood immunization schedule recommended by the Advisory Committee on Immunization Practices (ACIP) [31].”

Chronic hepatitis — persistent and ongoing inflammation that can result from chronic infection — usually has minimal to no signs or symptoms […] Hepatitis B and C viruses cause acute hepatitis as well as chronic hepatitis. The acute component is often not recognized as an episode of acute hepatitis, and the chronic infection may have little or no symptoms for many years. With hepatitis B, clearance of infection is age related, as is presentation with symptoms. Over 90% of infants exposed to HBV develop chronic infection, while <1% have symptoms; 5–10% of adults develop chronic infection, but 50% or more have symptoms associated with acute infection. Among those who acquire hepatitis C, 15–45% clear the infection; the remainder have lifelong infection unless treated specifically for hepatitis C.”

“[D]ata are only received on individuals accessing care. Asymptomatic acute infection and poor or unavailable measurements for high risk populations […] have resulted in questionable estimates of the prevalence and incidence of hepatitis B and C. Further, a lack of understanding of the different types of viral hepatitis by many medical providers [18] has led to many undiagnosed individuals living with chronic infection, who are not captured in disease surveillance systems. […] Evaluation of acute HBV and HCV surveillance has demonstrated a lack of sensitivity for identifying acute infection in injection drug users; it is likely that most cases in this population go undetected, even if they receive medical care [36]. […] Best practices for conducting surveillance for chronic hepatitis B and C are not well established. […] The role of health departments in responding to infectious diseases is typically responding to acute disease. Response to chronic HBV infection is targeted to prevention of transmission to contacts of those infected, especially in high risk situations. Because of the high risk of vertical transmission and likely development of chronic disease in exposed newborns, identification and case management of HBV-infected pregnant women and their infants is a high priority. […] For a number of reasons, states do not conduct uniform surveillance for chronic hepatitis C. There is not agreement as to the utility of surveillance for chronic HCV infection, as it is a measurement of prevalent rather than incident cases.”

“Among all nationally notifiable diseases, three STDs (chlamydia, gonorrhea, and syphilis) are consistently in the top five most commonly reported diseases annually. These three STDs made up more than 86% of all reported diseases in the United States in 2010 [2]. […] The true burden of STDs is likely to be higher, as most infections are asymptomatic [4] and are never diagnosed or reported. A synthesis of a variety of data sources estimated that in 2008 there were over 100 million prevalent STDs and nearly 20 million incident STDs in the United States [5]. […] Nationally, 72% of all reported STDs are among persons aged 15–24 years [3], and it is estimated that 1 in 4 females aged 14–19 has an STD [7]. […] In 2011, the rates of chlamydia, gonorrhea, and primary and secondary syphilis among African-­Americans were, respectively, 7.5, 16.9, and 6.7 times the rates among whites [3]. Additionally, men who have sex with men (MSM) are disproportionately infected with STDs. […] several analyses have shown risk ratios above 100 for the associations between being an MSM and having syphilis or HIV [9,10]. […] Many STDs can be transmitted congenitally during pregnancy or birth. In 2008, over 400,000 neonatal deaths and stillbirths were associated with syphilis worldwide […] untreated chlamydia and gonorrhea can cause ophthalmia neonatorum in newborns, which can result in blindness [13]. The medical and societal costs for STDs are high. […] One estimate in 2008 put national costs at $15.6 billion [15].”

“A significant challenge in STD surveillance is that the term “STD” encompasses a variety of infections. Currently, there are over 35 pathogens that can be transmitted sexually, including bacteria […] protozoa […] and ectoparasites […]. Some infections can cause clinical syndromes shortly after exposure, whereas others result in no symptoms or have a long latency period. Some STDs can be easily diagnosed using self-collected swabs, while others require a sample of blood or a physical examination by a clinician. Consequently, no one particular surveillance strategy works for all STDs. […] The asymptomatic nature of most STDs limits inferences from case­-based surveillance, since in order to be counted in this system an infection must be diagnosed and reported. Additionally, many infections never result in disease. For example, an estimated 90% of human papillomavirus (HPV) infections resolve on their own without sequelae [24]. As such, simply counting infections may not be appropriate, and sequelae must also be monitored. […] Strategies for STD surveillance include case reporting; sentinel surveillance; opportunistic surveillance, including use of administrative data and positivity in screened populations; and population-­based studies […] the choice of strategy depends on the type of STD and the population of interest.”

“Determining which diseases and conditions should be included in mandatory case reporting requires balancing the benefits to the public health system (e.g., utility of the data) with the costs and burdens of case reporting. While many epidemiologists and public health practitioners follow the mantra “the more data, the better,” the costs (in both dollars and human resources) of developing and maintaining a robust case­-based reporting system can be large. Case­-based surveillance has been mandated for chlamydia, gonorrhea, syphilis, and chancroid nationally; but expansion of state­-initiated mandatory reporting for other STDs is controversial.”

August 18, 2017 Posted by | Books, Epidemiology, Immunology, Infectious disease, Medicine | Leave a comment

Type 1 Diabetes Is Associated With an Increased Risk of Fracture Across the Life Span

Type 1 Diabetes Is Associated With an Increased Risk of Fracture Across the Life Span: A Population-Based Cohort Study Using The Health Improvement Network (THIN).

I originally intended to include this paper in a standard diabetes post like this one, but the post gradually got more and more unwieldy as I added more stuff and so in the end I decided – like in this case – that it might be a better idea to just devote an entire post to the paper and then postpone my coverage of some of the other papers included in the post.

I’ve talked about this stuff before, but I’m almost certain the results of this paper were not included in Czernik and Fowlkes’ book as this paper was published at almost exactly the same time as was the book. It provides further support of some of the observations included in C&F’s publication. This is a very large and important study in the context of the relationship between type 1 diabetes and skeletal health. I have quoted extensively from the paper below, and also added some observations of my own along the way in order to provide a little bit of context where it might be needed:

“There is an emerging awareness that diabetes adversely affects skeletal health and that type 1 diabetes affects the skeleton more severely than type 2 diabetes (5). Studies in humans and animal models have identified a number of skeletal abnormalities associated with type 1 diabetes, including deficits in bone mineral density (BMD) (6,7) and bone structure (8), decreased markers of bone formation (9,10), and variable alterations in markers of bone resorption (10,11).

Previous studies and two large meta-analyses reported that type 1 diabetes is associated with an increased risk of fracture (1219). However, most of these studies were conducted in older adults and focused on hip fractures. Importantly, most affected individuals develop type 1 diabetes in childhood, before the attainment of peak bone mass, and therefore may be at increased risk of fracture throughout their life span. Moreover, because hip fractures are rare in children and young adults, studies limited to this outcome may underestimate the overall fracture burden in type 1 diabetes.

We used The Health Improvement Network (THIN) database to conduct a population-based cohort study to determine whether type 1 diabetes is associated with increased fracture incidence, to delineate age and sex effects on fracture risk, and to determine whether fracture site distribution is altered in participants with type 1 diabetes compared with participants without diabetes. […] 30,394 participants aged 0–89 years with type 1 diabetes were compared with 303,872 randomly selected age-, sex-, and practice-matched participants without diabetes. Cox regression analysis was used to determine hazard ratios (HRs) for incident fracture in participants with type 1 diabetes. […] A total of 334,266 participants, median age 34 years, were monitored for 1.9 million person-years. HR were lowest in males and females age <20 years, with HR 1.14 (95% CI 1.01–1.29) and 1.35 (95% CI 1.12–1.63), respectively. Risk was highest in men 60–69 years (HR 2.18 [95% CI 1.79–2.65]), and in women 40–49 years (HR 2.03 [95% CI 1.73–2.39]). Lower extremity fractures comprised a higher proportion of incident fractures in participants with versus those without type 1 diabetes (31.1% vs. 25.1% in males, 39.3% vs. 32% in females; P < 0.001). Secondary analyses for incident hip fractures identified the highest HR of 5.64 (95% CI 3.55–8.97) in men 60–69 years and the highest HR of 5.63 (95% CI 2.25–14.11) in women 30–39 years.”

“Conditions identified by diagnosis codes as covariates of interest were hypothyroidism, hyperthyroidism, adrenal insufficiency, celiac disease, inflammatory bowel disease, vitamin D deficiency, fracture before the start of the follow-up period, diabetic retinopathy, and diabetic neuropathy. All variables, with the exception of prior fracture, were treated as time-varying covariates. […] Multivariable Cox regression analysis was used to assess confounding by covariates of interest. Final models were stratified by age category (<20, 20–29, 30–39, 40–49, 50–59, 60–69, and ≥70 years) after age was found to be a significant predictor of fracture and to violate the assumption of proportionality of hazards […] Within each age stratum, models were again assessed for proportionality of hazards and further stratified where appropriate.”

A brief note on a few of those covariates. Some of them are obvious, other perhaps less so. Retinopathy is probably included mainly due to the associated vision issues, rather than some sort of direct pathophysiological linkage between the conditions; vision problems may increase the risk of falls, particularly in the elderly, and falls increase the fracture risk (they note this later on in the paper). Neuropathy could in my opinion affect risk in multiple ways, not only through an increased fall risk, but either way it certainly makes a lot of sense to include that variable if it’s available. Thyroid disorders can cause bone problems, and the incidence of thyroid disorders is elevated in type 1 – to the extent that e.g. the Oxford Handbook of Clinical Medicine recommends screening people with diabetes mellitus for abnormalities in thyroid function on the annual review. Both Addison‘s (adrenal insufficiency) and thyroid disorders in type 1 diabetics may be specific components of a more systemic autoimmune disease (relevant link here, see the last paragraph), by some termed autoimmune polyendocrine syndromes. When you treat people with Addison’s you give them glucocorticoids, and this treatment can have deleterious effects on bone density especially in the long run – they note in the paper that exposure to corticosteroids is a significant fracture predictor in their models, which is not surprising. In one of the chapters included in Horowitz & Samson‘s book (again, I hope to cover it in more detail later…) the authors note that the combination of coeliac disease and diabetes may lead to protein malabsorption (among other things), which can obviously affect bone health, and they also observe e.g. that common lab abnormalities found in patients with coeliac include “low levels of haemoglobin, albumin, calcium, potassium, magnesium and iron” and furthermore that “extra-intestinal symptoms [include] muscle cramps, bone pain due to osteoporotic fractures or osteomalacia” – coeliac is obviously relevant here, especially as the condition is much more common in type 1 diabetics than in non-diabetics (“The prevalence of coeliac disease in type 1 diabetic children varies from 1.0% to 3.5%, which is at least 15 times higher than the prevalence among children without diabetes” – also an observation from H&S’s book, chapter 5).

Moving on…

“During the study period, incident fractures occurred in 2,615 participants (8.6%) with type 1 diabetes compared with 18,624 participants (6.1%) without diabetes. […] The incidence in males was greatest in the 10- to 20-year age bracket, at 297.2 and 261.3 fractures per 10,000 person-years in participants with and without type 1 diabetes, respectively. The fracture incidence in women was greatest in the 80- to 90-year age bracket, at 549.1 and 333.9 fractures per 10,000 person-years in participants with and without type 1 diabetes, respectively.”

It’s important to note that the first percentages reported above (8.6% vs 6.1%) may be slightly misleading as the follow-up periods for the two groups were dissimilar; type 1s in the study were on average followed for a shorter amount of time than were the controls (4.7 years vs 3.89 years), meaning that raw incident fracture risk estimates like these cannot be translated directly into person-year estimates. The risk differential is thus at least slightly higher than these percentages would suggest. A good view of how the person-year risk difference evolves as a function of age/time are displayed in the paper’s figure 2.

“Hip fractures alone comprised 5.5% and 11.6% of all fractures in males and females with type 1 diabetes, compared with 4.1% and 8.6% in males and females without diabetes (P = 0.04 for males and P = 0.001 for females). Participants with type 1 diabetes with a lower extremity fracture were more likely to have retinopathy (30% vs. 22.5%, P < 0.001) and neuropathy (5.4% vs. 2.9%, P = 0.001) compared with those with fractures at other sites. The median average HbA1c did not differ between the two groups.”

I’ll reiterate this because it’s important: They care about lower-extremity fractures because some of those kinds of fractures, especially hip fractures, have a really poor prognosis. It’s not that it’s annoying and you’ll need a cast; I’ve seen estimates suggesting that roughly one-third of diabetics who sustain a hip fracture die within a year; a prognosis like that is much worse than many cancers. A few relevant observations from Czernik and Fowlkes:

“Together, [studies conducted during the last 15 years on type 1 diabetics] demonstrate an unequivocally increased fracture risk at the hip [compared to non-diabetic controls], with most demonstrating a six to ninefold increase in relative risk. […] type I DM patients have hip fractures at a younger age on average, with a mean of 43 for women and 41 for men in one study. Almost 7 % of people with type I DM can be expected to have sustained a hip fracture by age 65 [7] […] Patients with DM and hip fracture are at a higher risk of mortality than patients without DM, with 1-year rates as high as 32 % vs. 13 % of nondiabetic patients”.

Back to the paper:

“Incident hip fracture risk was increased in all age categories for female participants with type 1 diabetes, and in age categories >30 years in men. […] Type 1 diabetes remained significantly associated with fracture after adjustment for covariates in all previously significant sex and age strata, with the exception of women aged 40–49. […] Each 1% (11 mmol/mol) greater average HbA1c level was associated with a 5% greater risk of incident fracture in males and an 11% greater risk of fracture in females. Diabetic neuropathy was a significant risk factor for incident fracture in males (HR 1.33; 95% CI 1.03–1.72) and females (HR 1.52; 95% CI 1.19–1.92); however, diabetic retinopathy was significant only in males (HR 1.13; 95% CI 1.01–1.28). […] The presence of celiac disease was associated with an increased risk of fractures in females, with an HR of 1.8 (95% CI 1.18–2.76), but not in males. A higher BMI was protective against fracture. Smoking was a risk factor for fracture in males in the 13,763 participants with type 1 diabetes with smoking and BMI data available for analysis.”

The Hba1c-link was interesting to me because the relationships between glycemic control and fracture risk has in other contexts been somewhat unclear; one problem is that Hba1c levels in the lower ranges increase the risk of hypoglycemic episodes, and such episodes may increase the risk of fractures, so even if chronic hyperglycemia is bad for bone health if you don’t have access e.g. to event-level/-rate data on hypoglycemic episodes confounding may be an issue causing a (very plausible) chronic hyperglycemia-fracture risk link to perhaps be harder to detect than it otherwise might have been. It’s of note that these guys did not have access to data on hypoglycemic episodes. They observe later in the paper that: “If hypoglycemia was a major contributing factor, we might have expected a negative effect of HbA1c on fracture risk; our data indicated the opposite.” I don’t think you can throw out hypoglycemia as a contributing factor that easily.

Anyway, a few final observations from the paper:

CONCLUSIONS Type 1 diabetes was associated with increased risk of incident fracture that began in childhood and extended across the life span. Participants with type 1 diabetes sustained a disproportionately greater number of lower extremity fractures. These findings have important public health implications, given the increasing prevalence of type 1 diabetes and the morbidity and mortality associated with hip fractures.”

“To our knowledge, this is the first study to show that the increased fracture risk in type 1 diabetes begins in childhood. This finding has important implications for researchers planning future studies and for clinicians caring for patients in this population. Although peak bone mass is attained by the end of the third decade of life, peak bone accrual occurs in adolescence in conjunction with the pubertal growth spurt (31). This critical time for bone accrual may represent a period of increased skeletal vulnerability and also a window of opportunity for the implementation of therapies to improve bone formation (32). This is an especially important consideration in the population with type 1 diabetes, because the incidence of this disease peaks in early adolescence. Three-quarters of individuals will develop the condition before 18 years of age, and therefore before attainment of peak bone mass (33). The development and evaluation of therapies aimed at increasing bone formation and strength in adolescence may lead to a lifelong reduction in fracture risk.”

“The underlying mechanism for the increased fracture risk in patients with type 1 diabetes is not fully understood. Current evidence suggests that bone quantity and quality may both be abnormal in this condition. Clinical studies using dual-energy X-ray absorptiometry and peripheral quantitative computed tomography have identified mild to modest deficits in BMD and bone structure in both pediatric and adult participants with type 1 diabetes (6,8,34). Deficits in BMD are unlikely to be the only factor contributing to skeletal fragility in type 1 diabetes, however, as evidenced by a recent meta-analysis that found that the increased fracture risk seen in type 1 diabetes could not be explained by deficits in BMD alone (16). Recent cellular and animal models have shown that insulin signaling in osteoblasts and osteoblast progenitor cells promotes postnatal bone acquisition, suggesting that the insulin deficiency inherent in type 1 diabetes is a significant contributor to the pathogenesis of skeletal disease (35). Other proposed mechanisms contributing to skeletal fragility in type 1 diabetes include chronic hyperglycemia (36), impaired production of IGF-1 (37), and the accumulation of advanced glycation end products in bone (38). Our results showed that a higher average HbA1c was associated with an increased risk of fracture in participants with type 1 diabetes, supporting the hypothesis that chronic hyperglycemia and its sequelae contribute to skeletal fragility.”

“In summary, our study found that participants of all ages with type 1 diabetes were at increased risk of fracture. The adverse effect of type 1 diabetes on the skeleton is an underrecognized complication that is likely to grow into a significant public health burden given the increasing incidence and prevalence of this disease. […] Our novel finding that children with type 1 diabetes were already at increased risk of fracture suggests that therapeutic interventions aimed at children and adolescents may have an important effect on reducing lifelong fracture risk.”

August 15, 2017 Posted by | Diabetes, Epidemiology, Medicine, Studies | Leave a comment

Infectious Disease Surveillance (II)

Some more observation from the book below.

“There are three types of influenza viruses — A, B, and C — of which only types A and B cause widespread outbreaks in humans. Influenza A viruses are classified into subtypes based on antigenic differences between their two surface glycoproteins, hemagglutinin and neuraminidase. Seventeen hemagglutinin subtypes (H1–H17) and nine neuraminidase subtypes (N1–N9) have been identifed. […] The internationally accepted naming convention for influenza viruses contains the following elements: the type (e.g., A, B, C), geographical origin (e.g., Perth, Victoria), strain number (e.g., 361), year of isolation (e.g., 2011), for influenza A the hemagglutinin and neuraminidase antigen description (e.g., H1N1), and for nonhuman origin viruses the host of origin (e.g., swine) [4].”

“Only two antiviral drug classes are licensed for chemoprophylaxis and treatment of influenza—the adamantanes (amantadine and rimantadine) and the neuraminidase inhibitors (oseltamivir and zanamivir). […] Antiviral resistant strains arise through selection pressure in individual patients during treatment [which can lead to treatment failure]. […] they usually do not transmit further (because of impaired virus fitness) and have limited public health implications. On the other hand, primarily resistant viruses have emerged in the past decade and in some cases have completely replaced the susceptible strains. […] Surveillance of severe influenza illness is challenging because most cases remain undiagnosed. […] In addition, most of the influenza burden on the healthcare system is because of complications such as secondary bacterial infections and exacerbations of pre-existing chronic diseases, and often influenza is not suspected as an underlying cause. Even if suspected, the virus could have been already cleared from the respiratory secretions when the testing is performed, making diagnostic confirmation impossible. […] Only a small proportion of all deaths caused by influenza are classified as influenza-related on death certificates. […] mortality surveillance based only on death certificates is not useful for the rapid assessment of an influenza epidemic or pandemic severity. Detection of excess mortality in real time can be done by establishing specific monitoring systems that overcome these delays [such as sentinel surveillance systems, US].”

“Influenza vaccination programs are extremely complex and costly. More than half a billion doses of influenza vaccines are produced annually in two separate vaccine production cycles, one for the Northern Hemisphere and one for the Southern Hemisphere [54]. Because the influenza virus evolves constantly and vaccines are reformulated yearly, both vaccine effectiveness and safety need to be monitored routinely. Vaccination campaigns are also organized annually and require continuous public health efforts to maintain an acceptable level of vaccination coverage in the targeted population. […] huge efforts are made and resources spent to produce and distribute influenza vaccines annually. Despite these efforts, vaccination coverage among those at risk in many parts of the world remains low.”

“The Active Bacterial Core surveillance (ABCs) network and its predecessor have been examples of using surveillance as information for action for over 20 years. ABCs has been used to measure disease burden, to provide data for vaccine composition and recommended-use policies, and to monitor the impact of interventions. […] sites represent wide geographic diversity and approximately reflect the race and urban-to-rural mix of the U.S. population [37]. Currently, the population under surveillance is 19–42 million and varies by pathogen and project. […] ABCs has continuously evolved to address challenging questions posed by the six pathogens (H. influenzae; GAS [Group A Streptococcus], GBS [Group B Streptococcus], S.  pneumoniae, N. meningitidis, and MRSA) and other emerging infections. […] For the six core pathogens, the objectives are (1) to determine the incidence and epidemiologic characteristics of invasive disease in geographically diverse populations in the United States through active, laboratory, and population-based surveillance; (2) to determine molecular epidemiologic patterns and microbiologic characteristics of isolates collected as part of routine surveillance in order to track antimicrobial resistance; (3) to detect the emergence of new strains with new resistance patterns and/or virulence and contribute to development and evaluation of new vaccines; and (4) to provide an infrastructure for surveillance of other emerging pathogens and for conducting studies aimed at identifying risk factors for disease and evaluating prevention policies.”

“Food may become contaminated by over 250 bacterial, viral, and parasitic pathogens. Many of these agents cause diarrhea and vomiting, but there is no single clinical syndrome common to all foodborne diseases. Most of these agents can also be transmitted by nonfoodborne routes, including contact with animals or contaminated water. Therefore, for a given illness, it is often unclear whether the source of infection is foodborne or not. […] Surveillance systems for foodborne diseases provide extremely important information for prevention and control.”

“Since 1995, the Centers for Disease Control and Prevention (CDC) has routinely used an automated statistical outbreak detection algorithm that compares current reports of each Salmonella serotype with the preceding 5-year mean number of cases for the same geographic area and week of the year to look for unusual clusters of infection [5]. The sensitivity of Salmonella serotyping to detect outbreaks is greatest for rare serotypes, because a small increase is more noticeable against a rare background. The utility of serotyping has led to its widespread adoption in surveillance for food pathogens in many countries around the world [6]. […] Today, a new generation of subtyping methods […] is increasing the specificity of laboratory-based surveillance and its power to detect outbreaks […] Molecular subtyping allows comparison of the molecular “fingerprint” of bacterial strains. In the United States, the CDC coordinates a network called PulseNet that captures data from standardized molecular subtyping by PFGE [pulsed field gel electrophoresis]. By comparing new submissions and past data, public health officials can rapidly identify geographically dispersed clusters of disease that would otherwise not be apparent and evaluate them as possible foodborne-disease outbreaks [8]. The ability to identify geographically dispersed outbreaks has become increasingly important as more foods are mass-produced and widely distributed. […] Similar networks have been developed in Canada, Europe, the Asia Pacifc region, Latin America and the Caribbean region, the Middle Eastern region and, most recently, the African region”.

“Food consumption and practices have changed during the past 20 years in the United States, resulting in a shift from readily detectable, point-source outbreaks (e.g., attendance at a wedding dinner), to widespread outbreaks that occur over many communities with only a few illnesses in each community. One of the changes has been establishment of large food-producing facilities that disseminate products throughout the country. If a food product is contaminated with a low level of pathogen, contaminated food products are distributed across many states; and only a few illnesses may occur in each community. This type of outbreak is often difficult to detect. PulseNet has been critical for the detection of widely dispersed outbreaks in the United States [17]. […] The growth of the PulseNet database […] and the use of increasingly sophisticated epidemiological approaches have led to a dramatic increase in the number of multistate outbreaks detected and investigated.”

“Each year, approximately 35 million people are hospitalized in the United States, accounting for 170 million inpatient days [1,2]. There are no recent estimates of the numbers of healthcare-associated infections (HAI). However, two decades ago, HAI were estimated to affect more than 2 million hospital patients annually […] The mortality attributed to these HAI was estimated at about 100,000 deaths annually. […] Almost 85% of HAI in the United States are associated with bacterial pathogens, and 33% are thought to be preventable [4]. […] The primary purpose of surveillance [in the context of HAI] is to alert clinicians, epidemiologists, and laboratories of the need for targeted prevention activities required to reduce HAI rates. HAI surveillance data help to establish baseline rates that may be used to determine the potential need to change public health policy, to act and intervene in clinical settings, and to assess the effectiveness of microbiology methods, appropriateness of tests, and allocation of resources. […] As less than 10% of HAI in the United States occur as recognized epidemics [18], HAI surveillance should not be embarked on merely for the detection of outbreaks.”

“There are two types of rate comparisons — intrahospital and interhospital. The primary goals of intrahospital comparison are to identify areas within the hospital where HAI are more likely to occur and to measure the efficacy of interventional efforts. […] Without external comparisons, hospital infection control departments may [however] not know if the endemic rates in their respective facilities are relatively high or where to focus the limited fnancial and human resources of the infection control program. […] The CDC has been the central aggregating institution for active HAI surveillance in the United States since the 1960s.”

“Low sensitivity (i.e., missed infections) in a surveillance system is usually more common than low specificity (i.e., patients reported to have infections who did not actually have infections).”

“Among the numerous analyses of CDC hospital data carried out over the years, characteristics consistently found to be associated with higher HAI rates include affiliation with a medical school (i.e., teaching vs. nonteaching), size of the hospital and ICU categorized by the number of beds (large hospitals and larger ICUs generally had higher infection rates), type of control or ownership of the hospital (municipal, nonprofit, investor owned), and region of the country [43,44]. […] Various analyses of SENIC and NNIS/NHSN data have shown that differences in patient risk factors are largely responsible for interhospital differences in HAI rates. After controlling for patients’ risk factors, average lengths of stay, and measures of the completeness of diagnostic workups for infection (e.g., culturing rates), the differences in the average HAI rates of the various hospital groups virtually disappeared. […] For all of these reasons, an overall HAI rate, per se, gives little insight into whether the facility’s infection control efforts are effective.”

“Although a hospital’s surveillance system might aggregate accurate data and generate appropriate risk-adjusted HAI rates for both internal and external comparison, comparison may be misleading for several reasons. First, the rates may not adjust for patients’ unmeasured intrinsic risks for infection, which vary from hospital to hospital. […] Second, if surveillance techniques are not uniform among hospitals or are used inconsistently over time, variations will occur in sensitivity and specificity for HAI case finding. Third, the sample size […] must be sufficient. This issue is of concern for hospitals with fewer than 200 beds, which represent about 10% of hospital admissions in the United States. In most CDC analyses, rates from hospitals with very small denominators tend to be excluded [37,46,49]. […] Although many healthcare facilities around the country aggregate HAI surveillance data for baseline establishment and interhospital comparison, the comparison of HAI rates is complex, and the value of the aggregated data must be balanced against the burden of their collection. […] If a hospital does not devote sufficient resources to data collection, the data will be of limited value, because they will be replete with inaccuracies. No national database has successfully dealt with all the problems in collecting HAI data and each varies in its ability to address these problems. […] While comparative data can be useful as a tool for the prevention of HAI, in some instances no data might be better than bad data.”

August 10, 2017 Posted by | Books, Data, Epidemiology, Infectious disease, Medicine, Statistics | Leave a comment

A few diabetes papers of interest

i. Long-term Glycemic Variability and Risk of Adverse Outcomes: A Systematic Review and Meta-analysis.

“This systematic review and meta-analysis evaluates the association between HbA1c variability and micro- and macrovascular complications and mortality in type 1 and type 2 diabetes. […] Seven studies evaluated HbA1c variability among patients with type 1 diabetes and showed an association of HbA1c variability with renal disease (risk ratio 1.56 [95% CI 1.08–2.25], two studies), cardiovascular events (1.98 [1.39–2.82]), and retinopathy (2.11 [1.54–2.89]). Thirteen studies evaluated HbA1c variability among patients with type 2 diabetes. Higher HbA1c variability was associated with higher risk of renal disease (1.34 [1.15–1.57], two studies), macrovascular events (1.21 [1.06–1.38]), ulceration/gangrene (1.50 [1.06–2.12]), cardiovascular disease (1.27 [1.15–1.40]), and mortality (1.34 [1.18–1.53]). Most studies were retrospective with lack of adjustment for potential confounders, and inconsistency existed in the definition of HbA1c variability.

CONCLUSIONS HbA1c variability was positively associated with micro- and macrovascular complications and mortality independently of the HbA1c level and might play a future role in clinical risk assessment.”

Two observations related to the paper: One, although only a relatively small number of studies were included in the review, the number of patients included in some of those included studies was rather large – the 7 type 1 studies thus included 44,021 participants, and the 13 type 2 studies included in total 43,620 participants. Two, it’s noteworthy that some of the associations already look at least reasonably strong, despite interest in HbA1c variability being a relatively recent phenomenon. Confounding might be an issue, but then again it almost always might be, and to give an example, out of 11 studies analyzing the association between renal disease and HbA1c variability included in the review, ten of them support a link and the only one which does not was a small study on pediatric patients which was almost certainly underpowered to investigate such a link in the first place (the base rate of renal complications is, as mentioned before here on this blog quite recently (link 3), quite low in pediatric samples).

ii. Risk of Severe Hypoglycemia in Type 1 Diabetes Over 30 Years of Follow-up in the DCCT/EDIC Study.

(I should perhaps note here that I’m already quite familiar with the context of the DCCT/EDIC study/studies, and although readers may not be, and although background details are included in the paper, I decided not to cover such details here although they would make my coverage of the paper easier to understand. I instead decided to limit my coverage of the paper to a few observations which I myself found to be of interest.)

“During the DCCT, the rates of SH [Severe Hypoglycemia, US], including episodes with seizure or coma, were approximately threefold greater in the intensive treatment group than in the conventional treatment group […] During EDIC, the frequency of SH increased in the former conventional group and decreased in the former intensive group so that the difference in SH event rates between the two groups was no longer significant (36.6 vs. 40.8 episodes per 100 patient-years, respectively […] By the end of DCCT, with an average of 6.5 years of follow-up, 65% of the intensive group versus 35% of the conventional group experienced at least one episode of SH. In contrast, ∼50% of participants within each group reported an episode of SH during the 20 years of EDIC.”

“Of [the] participants reporting episodes of SH, during the DCCT, 54% of the intensive group and 30% of the conventional group experienced four or more episodes, whereas in EDIC, 37% of the intensive group and 33% of the conventional group experienced four or more events […]. Moreover, a subset of participants (14% [99 of 714]) experienced nearly one-half of all SH episodes (1,765 of 3,788) in DCCT, and a subset of 7% (52 of 709) in EDIC experienced almost one-third of all SH episodes (888 of 2,813) […] Fifty-one major accidents occurred during the 6.5 years of DCCT and 143 during the 20 years of EDIC […] The most frequent type of major accident was that involving a motor vehicle […] Hypoglycemia played a role as a possible, probable, or principal cause in 18 of 28 operator-caused motor vehicle accidents (MVAs) during DCCT […] and in 23 of 54 operator-caused MVAs during EDIC”.

“The T1D Exchange Clinic Registry recently reported that 8% of 4,831 adults with T1D living in the U.S. had a seizure or coma event during the 3 months before their most recent annual visit (11). During EDIC, we observed that 27% of the cohort experienced a coma or seizure event over the 20 years of 3-month reporting intervals (∼1.4% per year), a much lower annual risk than in the T1D Exchange Clinic Registry. In part, the open enrollment of patients into the T1D Exchange may be reflected without the exclusion of participants with a history of SH as in the DCCT and other clinical trials. The current data support the clinical perception that a small subset of individuals is more susceptible to SH (7% of patients with 11 or more SH episodes during EDIC, which represents 32% of all SH episodes in EDIC) […] a history of SH during DCCT and lower current HbA1c levels were the two major factors associated with an increased risk of SH during EDIC. Safety concerns were the reason why a history of frequent SH events was an exclusion criterion for enrollment in DCCT. […] Of note, we found that participants who entered the DCCT as adolescents were more likely to experience SH during EDIC.”

“In summary, although event rates in the DCCT/EDIC cohort seem to have fallen and stabilized over time, SH remains an ever-present threat for patients with T1D who use current technology, occurring at a rate of ∼36–41 episodes per 100 patient-years, even among those with longer diabetes duration. Having experienced one or more such prior events is the strongest predictor of a future SH episode.”

I didn’t actually like that summary. If a history of severe hypoglycemia was an exclusion criterion in the DCCT trial, which it was, then the event rate you’d get from this data set is highly likely to provide a biased estimator of the true event rate, as the Exchange Clinic Registry data illustrate. The true population event rate in unselected samples is higher.

Another note which may also be important to add is that many diabetics who do not have a ‘severe event’ during a specific time period might still experience a substantial number of hypoglycemic episodes; ‘severe events’ (which require the assistance of another individual) is a somewhat blunt instrument in particular for assessing quality-of-life aspects of hypoglycemia.

iii. The Presence and Consequence of Nonalbuminuric Chronic Kidney Disease in Patients With Type 1 Diabetes.

“This study investigated the prevalence of nonalbuminuric chronic kidney disease in type 1 diabetes to assess whether it increases the risk of cardiovascular and renal outcomes as well as all-cause mortality. […] This was an observational follow-up of 3,809 patients with type 1 diabetes from the Finnish Diabetic Nephropathy Study. […] mean age was 37.6 ± 11.8 years and duration of diabetes 21.2 ± 12.1 years. […] During 13 years of median follow-up, 378 developed end-stage renal disease, 415 suffered an incident cardiovascular event, and 406 died. […] At baseline, 78 (2.0%) had nonalbuminuric chronic kidney disease. […] Nonalbuminuric chronic kidney disease did not increase the risk of albuminuria (hazard ratio [HR] 2.0 [95% CI 0.9–4.4]) or end-stage renal disease (HR 6.4 [0.8–53.0]) but did increase the risk of cardiovascular events (HR 2.0 [1.4–3.5]) and all-cause mortality (HR 2.4 [1.4–3.9]). […] ESRD [End-Stage Renal Disease] developed during follow-up in 0.3% of patients with nonalbuminuric non-CKD [CKD: Chronic Kidney Disease], in 1.3% of patients with nonalbuminuric CKD, in 13.9% of patients with albuminuric non-CKD, and in 63.0% of patients with albuminuric CKD (P < 0.001).”

CONCLUSIONS Nonalbuminuric chronic kidney disease is not a frequent finding in patients with type 1 diabetes, but when present, it is associated with an increased risk of cardiovascular morbidity and all-cause mortality but not with renal outcomes.”

iv. Use of an α-Glucosidase Inhibitor and the Risk of Colorectal Cancer in Patients With Diabetes: A Nationwide, Population-Based Cohort Study.

This one relates closely to stuff covered in Horowitz & Samsom’s book about Gastrointestinal Function in Diabetes Mellitus which I just finished (and which I liked very much). Here’s a relevant quote from chapter 7 of that book (which is about ‘Hepato-biliary and Pancreatic Function’):

“Several studies have provided evidence that the risk of pancreatic cancer is increased in patients with type 1 and type 2 diabetes mellitus [136,137]. In fact, diabetes has been associated with an increased risk of several cancers, including those of the pancreas, liver, endometrium and kidney [136]. The pooled relative risk of pancreatic cancer for diabetics vs. non-diabetics in a meta-analysis was 2.1 (95% confidence interval 1.6–2.8). Patients presenting with diabetes mellitus within a period of 12 months of the diagnosis of pancreatic cancer were excluded because in these cases diabetes may be an early presenting sign of pancreatic cancer rather than a risk factor [137]”.

They don’t mention colon cancer there, but it’s obvious from the research which has been done – and which is covered extensively in that book – that diabetes has the potential to cause functional changes in a large number of components of the digestive system (and I hope to cover this kind of stuff in a lot more detail later on) so the fact that some of these changes may lead to neoplastic changes should hardly be surprising. However evaluating causal pathways is more complicated here than it might have been, because e.g. pancreatic diseases may also themselves cause secondary diabetes in some patients. Liver pathologies like hepatitis B and C also display positive associations with diabetes, although again causal pathways here are not completely clear; treatments used may be a contributing factor (interferon-treatment may induce diabetes), but there are also suggestions that diabetes should be considered one of the extrahepatic manifestations of hepatitis. This stuff is complicated.

The drug mentioned in the paper, acarbose, is incidentally a drug also discussed in some detail in the book. It belongs to a group of drugs called alpha glucosidase inhibitors, and it is ‘the first antidiabetic medication designed to act through an influence on intestinal functions.’ Anyway, some quotes from the paper:

“We conducted a nationwide, population-based study using a large cohort with diabetes in the Taiwan National Health Insurance Research Database. Patients with newly diagnosed diabetes (n = 1,343,484) were enrolled between 1998 and 2010. One control subject not using acarbose was randomly selected for each subject using acarbose after matching for age, sex, diabetes onset, and comorbidities. […] There were 1,332 incident cases of colorectal cancer in the cohort with diabetes during the follow-up period of 1,487,136 person-years. The overall incidence rate was 89.6 cases per 100,000 person-years. Patients treated with acarbose had a 27% reduction in the risk of colorectal cancer compared with control subjects. The adjusted HRs were 0.73 (95% CI 0.63–0.83), 0.69 (0.59–0.82), and 0.46 (0.37–0.58) for patients using >0 to <90, 90 to 364, and ≥365 cumulative defined daily doses of acarbose, respectively, compared with subjects who did not use acarbose (P for trend < 0.001).

CONCLUSIONS Acarbose use reduced the risk of incident colorectal cancer in patients with diabetes in a dose-dependent manner.”

It’s perhaps worth mentioning that the prevalence of type 1 is relatively low in East Asian populations and that most of the patients included were type 2 (this is also clearly indicated by this observation from the paper: “The median age at the time of the initial diabetes diagnosis was 54.1 years, and the median diabetes duration was 8.9 years.”). Another thing worth mentioning is that colon cancer is a very common type of cancer, and so even moderate risk reductions here at the individual level may translate into a substantial risk reduction at the population level. A third thing, noted in Horowitz & Samsom’s coverage, is that the side effects of acarbose are quite mild, so widespread use of the drug is not out of the question, at least poor tolerance is not likely to be an obstacle; the drug may cause e.g. excessive flatulence and something like 10% of patients may have to stop treatment because of gastrointestinal side effects, but although the side effects are annoying and may be unacceptable to some patients, they are not dangerous; it’s a safe drug which can be used even in patients with renal failure (a context where some of the other oral antidiabetic treatments available are contraindicated).

v. Diabetes, Lower-Extremity Amputation, and Death.

“Worldwide, every 30 s, a limb is lost to diabetes (1,2). Nearly 2 million people living in the U.S. are living with limb loss (1). According to the World Health Organization, lower-extremity amputations (LEAs) are 10 times more common in people with diabetes than in persons who do not have diabetes. In the U.S. Medicare population, the incidence of diabetic foot ulcers is ∼6 per 100 individuals with diabetes per year and the incidence of LEA is 4 per 1,000 persons with diabetes per year (3). LEA in those with diabetes generally carries yearly costs between $30,000 and $60,000 and lifetime costs of half a million dollars (4). In 2012, it was estimated that those with diabetes and lower-extremity wounds in the U.S. Medicare program accounted for $41 billion in cost, which is ∼1.6% of all Medicare health care spending (47). In 2012, in the U.K., it was estimated that the National Health Service spent between £639 and 662 million on foot ulcers and LEA, which was approximately £1 in every £150 spent by the National Health Service (8).”

“LEA does not represent a traditional medical complication of diabetes like myocardial infarction (MI), renal failure, or retinopathy in which organ failure is directly associated with diabetes (2). An LEA occurs because of a disease complication, usually a foot ulcer that is not healing (e.g., organ failure of the skin, failure of the biomechanics of the foot as a unit, nerve sensory loss, and/or impaired arterial vascular supply), but it also occurs at least in part as a consequence of a medical plan to amputate based on a decision between health care providers and patients (9,10). […] 30-day postoperative mortality can approach 10% […]. Previous reports have estimated that the 1-year post-LEA mortality rate in people with diabetes is between 10 and 50%, and the 5-year mortality rate post-LEA is between 30 and 80% (4,1315). More specifically, in the U.S. Medicare population mortality within a year after an incident LEA was 23.1% in 2006, 21.8% in 2007, and 20.6% in 2008 (4). In the U.K., up to 80% will die within 5 years of an LEA (8). In general, those with diabetes with an LEA are two to three times more likely to die at any given time point than those with diabetes who have not had an LEA (5). For perspective, the 5-year death rate after diagnosis of malignancy in the U.S. was 32% in 2010 (16).”

“Evidence on why individuals with diabetes and an LEA die is based on a few mainly small (e.g., <300 subjects) and often single center–based (13,1720) studies or <1 year duration of evaluation (11). In these studies, death is primarily associated with a previous history of cardiovascular disease and renal insufficiency, which are also major complications of diabetes; these complications are also associated with an increased risk of LEA. The goal of our study was to determine whether complications of diabetes well-known to be associated with death in those with diabetes such as cardiovascular disease and renal failure fully explain the higher rate of death in those who have undergone an LEA.”

“This is the largest and longest evaluation of the risk of death among those with diabetes and LEA […] Between 2003 and 2012, 416,434 individuals met the entrance criteria for the study. This cohort accrued an average of 9.0 years of follow-up and a total of 3.7 million diabetes person-years of follow-up. During this period of time, 6,566 (1.6%) patients had an LEA and 77,215 patients died (18.5%). […] The percentage of individuals who died within 30 days, 1 year, and by year 5 of their initial code for an LEA was 1.0%, 9.9%, and 27.2%, respectively. For those >65 years of age, the rates were 12.2% and 31.7%, respectively. For the full cohort of those with diabetes, the rate of death was 2.0% after 1 year of follow up and 7.3% after 5 years of follow up. In general, those with an LEA were more than three times more likely to die during a year of follow-up than an individual with diabetes who had not had an LEA. […] In any given year, >5% of those with diabetes and an LEA will die.”

“From 2003 to 2012, the HR [hazard rate, US] for death after an LEA was 3.02 (95% CI 2.90, 3.14). […] our a priori assumption was that the HR associating LEA with death would be fully diminished (i.e., it would become 1) when adjusted for the other risk factor variables. However, the fully adjusted LEA HR was diminished only ∼22% to 2.37 (95% CI 2.27, 2.48). With the exception of age >65 years, individual risk factors, in general, had minimal effect (<10%) on the HR of the association between LEA and death […] We conducted sensitivity analyses to determine the general statistical parameters of an unmeasured risk factor that could remove the association of LEA with death. We found that even if there existed a very strong risk factor with an HR of death of three, a prevalence of 10% in the general diabetes population, and a prevalence of 60% in those who had an LEA, LEA would still be associated with a statistically significant and clinically important risk of 1.30. These findings are describing a variable that would seem to be so common and so highly associated with death that it should already be clinically apparent. […] In summary, individuals with diabetes and an LEA are more likely to die at any given point in time than those who have diabetes but no LEA. While some of this variation can be explained by other known complications of diabetes, the amount that can be explained is small. Based on the results of this study, including a sensitivity analysis, it is highly unlikely that a “new” major risk factor for death exists. […] LEA is often performed because of an end-stage disease process like chronic nonhealing foot ulcer. By the time a patient has a foot ulcer and an LEA is offered, they are likely suffering from the end-stage consequence of diabetes. […] We would […] suggest that patients who have had an LEA require […] vigilant follow-up and evaluation to assure that their medical care is optimized. It is also important that GPs communicate to their patients about the risk of death to assure that patients have proper expectations about the severity of their disease.”

vi. Trends in Health Care Expenditure in U.S. Adults With Diabetes: 2002–2011.

Before quoting from the paper, I’ll remind people reading along here that ‘total medical expenditures’ != ‘total medical costs’. Lots of relevant medical costs are not included when you focus only on direct medical expenditures (sick days, early retirement, premature mortality and productivity losses associated therewith, etc., etc.). With that out of the way…

“This study examines trends in health care expenditures by expenditure category in U.S. adults with diabetes between 2002 and 2011. […] We analyzed 10 years of data representing a weighted population of 189,013,514 U.S. adults aged ≥18 years from the Medical Expenditure Panel Survey. […] Relative to individuals without diabetes ($5,058 [95% CI 4,949–5,166]), individuals with diabetes ($12,180 [11,775–12,586]) had more than double the unadjusted mean direct expenditures over the 10-year period. After adjustment for confounders, individuals with diabetes had $2,558 (2,266–2,849) significantly higher direct incremental expenditures compared with those without diabetes. For individuals with diabetes, inpatient expenditures rose initially from $4,014 in 2002/2003 to $4,183 in 2004/2005 and then decreased continuously to $3,443 in 2010/2011, while rising steadily for individuals without diabetes. The estimated unadjusted total direct expenditures for individuals with diabetes were $218.6 billion/year and adjusted total incremental expenditures were approximately $46 billion/year. […] in the U.S., direct medical costs associated with diabetes were $176 billion in 2012 (1,3). This is almost double to eight times the direct medical cost of other chronic diseases: $32 billion for COPD in 2010 (10), $93 billion for all cancers in 2008 (11), $21 billion for heart failure in 2012 (12), and $43 billion for hypertension in 2010 (13). In the U.S., total economic cost of diabetes rose by 41% from 2007 to 2012 (2). […] Our findings show that compared with individuals without diabetes, individuals with diabetes had significantly higher health expenditures from 2002 to 2011 and the bulk of the expenditures came from hospital inpatient and prescription expenditures.”


August 10, 2017 Posted by | Books, Cancer/oncology, Cardiology, Diabetes, Economics, Epidemiology, Gastroenterology, Health Economics, Medicine, Nephrology, Pharmacology | Leave a comment

Infectious Disease Surveillance (I)

Concepts and Methods in Infectious Disease Surveillance […] familiarizes the reader with basic surveillance concepts; the legal basis for surveillance in the United States and abroad; and the purposes, structures, and intended uses of surveillance at the local, state, national, and international level. […] A desire for a readily accessible, concise resource that detailed current methods and challenges in disease surveillance inspired the collaborations that resulted in this volume. […] The book covers major topics at an introductory-to-intermediate level and was designed to serve as a resource or class text for instructors. It can be used in graduate level courses in public health, human and veterinary medicine, as well as in undergraduate programs in public health–oriented disciplines. We hope that the book will be a useful primer for frontline public health practitioners, hospital epidemiologists, infection-control practitioners, laboratorians in public health settings, infectious disease researchers, and medical informatics specialists interested in a concise overview of infectious disease surveillance.”

I thought the book was sort of okay, but not really all that great. I assume part of the reason I didn’t like it as much as I might have is that someone like me don’t really need to know all the details about, say, the issues encountered in Florida while they were trying to implement electronic patient records, or whether or not the mandated reporting requirements for brucellosis in, say, Texas are different from those of, say, Florida – but the book has a lot of that kind of information. Useful knowledge if you work with this stuff, but if you don’t and you’re just curious about the topic ‘in a general way’ those kinds of details can subtract a bit from the experience. A lot of chapters cover similar topics and don’t seem all that well coordinated, in the sense that details which could easily have been left out of specific chapters without any significant information loss (because those details were covered elsewhere in the publication) are included anyway; we are probably told at least ten times what is the difference between active and passive surveillance. It probably means that the various chapters can be read more or less independently (you don’t need to read chapter 5 to understand the coverage in chapter 11), but if you’re reading the book from cover to cover the way I was that sort of approach is not ideal. However in terms of the coverage included in the individual chapters and the content in general, I feel reasonably confident that if you’re actually working in public health or related fields and so a lot of this stuff might be ‘work-relevant’ (especially if you’re from the US), it’s probably a very useful book to keep around/know about. I didn’t need to know how many ‘NBS-states’ there are, and whether or not South Carolina is such a state, but some people might.

As I’ve pointed out before, a two star goodreads rating on my part (which is the rating I gave this publication) is not an indication that I think a book is terrible, it’s an indication that the book is ‘okay’.

Below I’ve added some quotes and observations from the book. The book is an academic publication but it is not a ‘classic textbook’ with key items in bold etc.; I decided to use bold to highlight key concepts and observations below, to make the post easier to navigate later on (none of the bolded words below were in bold in the original text), but aside from that I have made no changes to the quotes included in this post. I would note that given that many of the chapters included in the book are not covered by copyright (many chapters include this observation: “Materials appearing in this chapter are prepared by individuals as part of their official duties as United States government employees and are not covered by the copyright of the book, and any views expressed herein do not necessarily represent the views of the United States government.”) I may decide to cover the book in a bit more detail than I otherwise would have.

“The methods used for infectious disease surveillance depend on the type of disease. Part of the rationale for this is that there are fundamental differences in etiology, mode of transmission, and control measures between different types of infections. […] Despite the fact that much of surveillance is practiced on a disease-specific basis, it is worth remembering that surveillance is a general tool used across all types of infectious and, noninfectious conditions, and, as such, all surveillance methods share certain core elements. We advocate the view that surveillance should not be regarded as a public health “specialty,” but rather that all public health practitioners should understand the general principles underlying surveillance.”

“Control of disease spread is achieved through public health actions. Public health actions resulting from information gained during the investigation usually go beyond what an individual physician can provide to his or her patients presenting in a clinical setting. Examples of public health actions include identifying the source of infection […] identifying persons who were in contact with the index case or any infected person who may need vaccines or antiinfectives to prevent them from developing the infection; closure of facilities implicated in disease spread; or isolation of sick individuals or, in rare circumstances, quarantining those exposed to an infected person. […] Monitoring surveillance data enables public health authorities to detect sudden changes in disease occurrence and distribution, identify changes in agents or host factors, and detect changes in healthcare practices […] The primary use of surveillance data at the local and state public health level is to identify cases or outbreaks in order to implement immediate disease control and prevention activities. […] Surveillance data are also used by states and CDC to monitor disease trends, demonstrate the need for public health interventions such as vaccines and vaccine policy, evaluate public health activities, and identify future research priorities. […] The final and most-important link in the surveillance chain is the application of […] data to disease prevention and control. A surveillance system includes a functional capacity for data collection, analysis, and dissemination linked to public health programs [6].

“The majority of reportable disease surveillance is conducted through passive surveillance methods. Passive surveillance means that public health agencies inform healthcare providers and other entities of their reporting requirements, but they do not usually conduct intensive efforts to solicit all cases; instead, the public health agency waits for the healthcare entities to submit case reports. Because passive surveillance is often incomplete, public health agencies may use hospital discharge data, laboratory testing records, mortality data, or other sources of information as checks on completeness of reporting and to identify additional cases. This is called active surveillance. Active surveillance usually includes intensive activities on the part of the public health agency to identify all cases of a specific reportable disease or group of diseases. […] Because it can be very labor intensive, active surveillance is usually conducted for a subset of reportable conditions, in a defined geographic locale and for a defined period of time.”

“Active surveillance may be conducted on a routine basis or in response to an outbreak […]. When an outbreak is suspected or identified, another type of surveillance known as enhanced passive surveillance may also be initiated. In enhanced passive surveillance methods, public health may improve communication with the healthcare community, schools, daycare centers, and other facilities and request that all suspected cases be reported to public health. […] Case-based surveillance is supplemented through laboratory-based surveillance activities. As opposed to case-based surveillance, the focus is on laboratory results themselves, independent of whether or not an individual’s result is associated with a “case” of illness meeting the surveillance case definition. Laboratory-based surveillance is conducted by state public health laboratories as well as the healthcare community (e.g., hospital, private medical office, and commercial laboratories). […] State and local public health entities participate in sentinel surveillance activities. With sentinel methods, surveillance is conducted in a sample of reporting entities, such as healthcare providers or hospitals, or in a specific population known to be an early indicator of disease activity (e.g., pediatric). However, because the goal of sentinel surveillance is not to identify every case, it is not necessarily representative of the underlying population of interest; and results should be interpreted accordingly.”

Syndromic surveillance identifies unexpected changes in prediagnostic information from a variety of sources to detect potential outbreaks [56]. Sources include work- or school-absenteeism records, pharmacy sales for over-the-counter pharmaceuticals, or emergency room admission data [51]. During the 2009 H1N1 pandemic, syndromic surveillance of emergency room visits for influenza-like illness correlated well with laboratory diagnosed cases of influenza [57]. […] According to a 2008 survey of U.S. health departments, 88% of respondents reported that they employ syndromic-based approaches as part of routine surveillance [21].

“Public health operated for many decades (and still does to some extent) using stand-alone, case-based information systems for collection of surveillance data that do not allow information sharing between systems and do not permit the ability to track the occurrences of different diseases in a specific person over time. One of the primary objectives of NEDSS [National Electronic Disease Surveillance System] is to promote person-based surveillance and integrated and interoperable surveillance systems. In an integrated person-based system, information is collected to create a public health record for a given person for different diseases over time. This enables public health to track public health conditions associated with a person over time, allowing analyses of public health events and comorbidities, as well as more robust public health interventions. An interoperable system can exchange information with other systems. For example, data are shared between surveillance systems or between other public health or clinical systems, such as an electronic health record or outbreak management system. Achieving the goal of establishing a public health record for an individual over time does not require one monolithic system that supports all needs; this can, instead, be achieved through integration and/or interoperability of systems.

“For over a decade, public health has focused on automation of reporting of laboratory results to public health from clinical laboratories and healthcare providers. Paper-based submission of laboratory results to public health for reportable conditions results in delays in receipt of information, incomplete ascertainment of possible cases, and missing information on individual reports. All of these aspects are improved through automation of the process [39–43].”

“During the pre-vaccine era, rotavirus infected nearly every unvaccinated child before their fifth birthday. In the absence of vaccine, multiple rotavirus infections may occur during infancy and childhood. Rotavirus causes severe diarrhea and vomiting (acute gastroenteritis [AGE]), which can lead to dehydration, electrolyte depletion, complications of viremia, shock, and death. Nearly one-half million children around the world die of rotavirus infections each year […] [In the US] this virus was responsible for 40–50% of hospitalizations because of acute gastroenteritis during the winter months in the era before vaccines were introduced. […] Because first infections have been shown to induce strong immunity against severe rotavirus reinfections [3] and because vaccination mimics such first infections without causing illness, vaccination was identified as the optimal strategy for decreasing the burden associated with severe and fatal rotavirus diarrhea. Any changes that may be later attributed to vaccination effects require knowledge of the pre-licensure (i.e., baseline) rates and trends in the target disease as a reference […] Efforts to obtain baseline data are necessary before a vaccine is licensed and introduced [13]. […] After the first year of widespread rotavirus vaccination coverage in 2008, very large and consistent decreases in rotavirus hospitalizations were noted around the country. Many of the decreases in childhood hospitalizations resulting from rotavirus were 90% or more, compared with the pre-licensure, baseline period.”

There is no single perfect data source for assessing any VPD [Vaccine-Preventable Disease, US]. Meaningful surveillance is achieved by the much broader approach of employing diverse datasets. The true impact of a vaccine or the accurate assessment of disease trends in a population is more likely the result of evaluating many datasets having different strengths and weaknesses. Only by understanding these strengths and weaknesses can a public health practitioner give the appropriate consideration to the findings derived from these data. […] In a Phase III clinical trial, the vaccine is typically administered to large numbers of people who have met certain inclusionary and exclusionary criteria and are then randomly selected to receive either the vaccine or a placebo. […] Phase III trials represent the “best case scenario” of vaccine protection […] Once the Phase III trials show adequate protection and safety, the vaccine may be licensed by the FDA […] When the vaccine is used in routine clinical practice, Phase IV trials (called post-licensure studies or post-marketing studies) are initiated. These are the evaluations conducted during the course of VPD surveillance that delineate additional performance information in settings where strict controls on who receives the vaccine are not present. […] Often, measuring vaccine performance in the broader population yields slightly lower protective results compared to Phase III clinical trials […] During these post-licensure Phase IV studies, it is not the vaccine’s efficacy but its effectiveness that is assessed. […] Administrative datasets may be created by research institutions, managed-care organizations, or national healthcare utilization repositories. They are not specifically created for VPD surveillance and may contain coded data […] on health events. They often do not provide laboratory confirmation of specific diseases, unlike passive and active VPD surveillance. […] administrative datasets offer huge sample sizes, which allow for powerful inferences within the confines of any data limitations.”

August 6, 2017 Posted by | Books, Epidemiology, Infectious disease, Medicine, Pharmacology | Leave a comment

Beyond Significance Testing (IV)

Below I have added some quotes from chapters 5, 6, and 7 of the book.

“There are two broad classes of standardized effect sizes for analysis at the group or variable level, the d family, also known as group difference indexes, and the r family, or relationship indexes […] Both families are metric- (unit-) free effect sizes that can compare results across studies or variables measured in different original metrics. Effect sizes in the d family are standardized mean differences that describe mean contrasts in standard deviation units, which can exceed 1.0 in absolute value. Standardized mean differences are signed effect sizes, where the sign of the statistic indicates the direction of the corresponding contrast. Effect sizes in the r family are scaled in correlation units that generally range from 1.0 to +1.0, where the sign indicates the direction of the relation […] Measures of association are unsigned effect sizes and thus do not indicate directionality.”

“The correlation rpb is for designs with two unrelated samples. […] rpb […] is affected by base rate, or the proportion of cases in one group versus the other, p and q. It tends to be highest in balanced designs. As the design becomes more unbalanced holding all else constant, rpb approaches zero. […] rpb is not directly comparable across studies with dissimilar relative group sizes […]. The correlation rpb is also affected by the total variability (i.e., ST). If this variation is not constant over samples, values of rpb may not be directly comparable.”

“Too many researchers neglect to report reliability coefficients for scores analyzed. This is regrettable because effect sizes cannot be properly interpreted without knowing whether the scores are precise. The general effect of measurement error in comparative studies is to attenuate absolute standardized effect sizes and reduce the power of statistical tests. Measurement error also contributes to variation in observed results over studies. Of special concern is when both score reliabilities and sample sizes vary from study to study. If so, effects of sampling error are confounded with those due to measurement error. […] There are ways to correct some effect sizes for measurement error (e.g., Baguley, 2009), but corrected effect sizes are rarely reported. It is more surprising that measurement error is ignored in most meta-analyses, too. F. L. Schmidt (2010) found that corrected effect sizes were analyzed in only about 10% of the 199 meta-analytic articles published in Psychological Bulletin from 1978 to 2006. This implies that (a) estimates of mean effect sizes may be too low and (b) the wrong statistical model may be selected when attempting to explain between-studies variation in results. If a fixed
effects model is mistakenly chosen over a random effects model, confidence intervals based on average effect sizes tend to be too narrow, which can make those results look more precise than they really are. Underestimating mean effect sizes while simultaneously overstating their precision is a potentially serious error.”

“[D]emonstration of an effect’s significance — whether theoretical, practical, or clinical — calls for more discipline-specific expertise than the estimation of its magnitude”.

“Some outcomes are categorical instead of continuous. The levels of a categorical outcome are mutually exclusive, and each case is classified into just one level. […] The risk difference (RD) is defined as pCpT, and it estimates the parameter πC πT. [Those ‘n-resembling letters’ is how wordpress displays pi; this is one of an almost infinite number of reasons why I detest blogging equations on this blog and usually do not do this – US] […] The risk ratio (RR) is the ratio of the risk rates […] which rate appears in the numerator versus the denominator is arbitrary, so one should always explain how RR is computed. […] The odds ratio (OR) is the ratio of the within-groups odds for the undesirable event. […] A convenient property of OR is that it can be converted to a kind of standardized mean difference known as logit d (Chinn, 2000). […] Reporting logit d may be of interest when the hypothetical variable that underlies the observed dichotomy is continuous.”

“The risk difference RD is easy to interpret but has a drawback: Its range depends on the values of the population proportions πC and πT. That is, the range of RD is greater when both πC and πT are closer to .50 than when they are closer to either 0 or 1.00. The implication is that RD values may not be comparable across different studies when the corresponding parameters πC and πT are quite different. The risk ratio RR is also easy to interpret. It has the shortcoming that only the finite interval from 0 to < 1.0 indicates lower risk in the group represented in the numerator, but the interval from > 1.00 to infinity is theoretically available for describing higher risk in the same group. The range of RR varies according to its denominator. This property limits the value of RR for comparing results across different studies. […] The odds ratio or shares the limitation that the finite interval from 0 to < 1.0 indicates lower risk in the group represented in the numerator, but the interval from > 1.0 to infinity describes higher risk for the same group. Analyzing natural log transformations of OR and then taking antilogs of the results deals with this problem, just as for RR. The odds ratio may be the least intuitive of the comparative risk effect sizes, but it probably has the best overall statistical properties. This is because OR can be estimated in prospective studies, in studies that randomly sample from exposed and unexposed populations, and in retrospective studies where groups are first formed based on the presence or absence of a disease before their exposure to a putative risk factor is determined […]. Other effect sizes may not be valid in retrospective studies (RR) or in studies without random sampling ([Pearson correlations between dichotomous variables, US]).”

“Sensitivity and specificity are determined by the threshold on a screening test. This means that different thresholds on the same test will generate different sets of sensitivity and specificity values in the same sample. But both sensitivity and specificity are independent of population base rate and sample size. […] Sensitivity and specificity affect predictive value, the proportion of test results that are correct […] In general, predictive values increase as sensitivity and specificity increase. […] Predictive value is also influenced by the base rate (BR), the proportion of all cases with the disorder […] In general, PPV [positive predictive value] decreases and NPV [negative…] increases as BR approaches zero. This means that screening tests tend to be more useful for ruling out rare disorders than correctly predicting their presence. It also means that most positive results may be false positives under low base rate conditions. This is why it is difficult for researchers or social policy makers to screen large populations for rare conditions without many false positives. […] The effect of BR on predictive values is striking but often overlooked, even by professionals […]. One misunderstanding involves confusing sensitivity and specificity, which are invariant to BR, with PPV and NPV, which are not. This means that diagnosticians fail to adjust their estimates of test accuracy for changes in base rates, which exemplifies the base rate fallacy. […] In general, test results have greater impact on changing the pretest odds when the base rate is moderate, neither extremely low (close to 0) nor extremely high (close to 1.0). But if the target disorder is either very rare or very common, only a result from a highly accurate screening test will change things much.”

“The technique of ANCOVA [ANalysis of COVAriance, US] has two more assumptions than ANOVA does. One is homogeneity of regression, which requires equal within-populations unstandardized regression coefficients for predicting outcome from the covariate. In nonexperimental designs where groups differ systematically on the covariate […] the homogeneity of regression assumption is rather likely to be violated. The second assumption is that the covariate is measured without error […] Violation of either assumption may lead to inaccurate results. For example, an unreliable covariate in experimental designs causes loss of statistical power and in nonexperimental designs may also cause inaccurate adjustment of the means […]. In nonexperimental designs where groups differ systematically, these two extra assumptions are especially likely to be violated. An alternative to ANCOVA is propensity score analysis (PSA). It involves the use of logistic regression to estimate the probability for each case of belonging to different groups, such as treatment versus control, in designs without randomization, given the covariate(s). These probabilities are the propensities, and they can be used to match cases from nonequivalent groups.”

August 5, 2017 Posted by | Books, Epidemiology, Papers, Statistics | Leave a comment

A few diabetes papers of interest

i. Clinically Relevant Cognitive Impairment in Middle-Aged Adults With Childhood-Onset Type 1 Diabetes.

“Modest cognitive dysfunction is consistently reported in children and young adults with type 1 diabetes (T1D) (1). Mental efficiency, psychomotor speed, executive functioning, and intelligence quotient appear to be most affected (2); studies report effect sizes between 0.2 and 0.5 (small to modest) in children and adolescents (3) and between 0.4 and 0.8 (modest to large) in adults (2). Whether effect sizes continue to increase as those with T1D age, however, remains unknown.

A key issue not yet addressed is whether aging individuals with T1D have an increased risk of manifesting “clinically relevant cognitive impairment,” defined by comparing individual cognitive test scores to demographically appropriate normative means, as opposed to the more commonly investigated “cognitive dysfunction,” or between-group differences in cognitive test scores. Unlike the extensive literature examining cognitive impairment in type 2 diabetes, we know of only one prior study examining cognitive impairment in T1D (4). This early study reported a higher rate of clinically relevant cognitive impairment among children (10–18 years of age) diagnosed before compared with after age 6 years (24% vs. 6%, respectively) or a non-T1D cohort (6%).”

“This study tests the hypothesis that childhood-onset T1D is associated with an increased risk of developing clinically relevant cognitive impairment detectable by middle age. We compared cognitive test results between adults with and without T1D and used demographically appropriate published norms (1012) to determine whether participants met criteria for impairment for each test; aging and dementia studies have selected a score ≥1.5 SD worse than the norm on that test, corresponding to performance at or below the seventh percentile (13).”

“During 2010–2013, 97 adults diagnosed with T1D and aged <18 years (age and duration 49 ± 7 and 41 ± 6 years, respectively; 51% female) and 138 similarly aged adults without T1D (age 49 ± 7 years; 55% female) completed extensive neuropsychological testing. Biomedical data on participants with T1D were collected periodically since 1986–1988.  […] The prevalence of clinically relevant cognitive impairment was five times higher among participants with than without T1D (28% vs. 5%; P < 0.0001), independent of education, age, or blood pressure. Effect sizes were large (Cohen d 0.6–0.9; P < 0.0001) for psychomotor speed and visuoconstruction tasks and were modest (d 0.3–0.6; P < 0.05) for measures of executive function. Among participants with T1D, prevalent cognitive impairment was related to 14-year average A1c >7.5% (58 mmol/mol) (odds ratio [OR] 3.0; P = 0.009), proliferative retinopathy (OR 2.8; P = 0.01), and distal symmetric polyneuropathy (OR 2.6; P = 0.03) measured 5 years earlier; higher BMI (OR 1.1; P = 0.03); and ankle-brachial index ≥1.3 (OR 4.2; P = 0.01) measured 20 years earlier, independent of education.”

“Having T1D was the only factor significantly associated with the between-group difference in clinically relevant cognitive impairment in our sample. Traditional risk factors for age-related cognitive impairment, in particular older age and high blood pressure (24), were not related to the between-group difference we observed. […] Similar to previous studies of younger adults with T1D (14,26), we found no relationship between the number of severe hypoglycemic episodes and cognitive impairment. Rather, we found that chronic hyperglycemia, via its associated vascular and metabolic changes, may have triggered structural changes in the brain that disrupt normal cognitive function.”

Just to be absolutely clear about these results: The type 1 diabetics they recruited in this study were on average not yet fifty years old, yet more than one in four of them were cognitively impaired to a clinically relevant degree. This is a huge effect. As they note later in the paper:

“Unlike previous reports of mild/modest cognitive dysfunction in young adults with T1D (1,2), we detected clinically relevant cognitive impairment in 28% of our middle-aged participants with T1D. This prevalence rate in our T1D cohort is comparable to the prevalence of mild cognitive impairment typically reported among community-dwelling adults aged 85 years and older (29%) (20).”

The type 1 diabetics included in the study had had diabetes for roughly a decade more than I have. And the number of cognitively impaired individuals in that sample corresponds roughly to what you find when you test random 85+ year-olds. Having type 1 diabetes is not good for your brain.

ii. Comment on Nunley et al. Clinically Relevant Cognitive Impairment in Middle-Aged Adults With Childhood-Onset Type 1 Diabetes.

This one is a short comment to the above paper, below I’ve quoted ‘the meat’ of the comment:

“While the […] study provides us with important insights regarding cognitive impairment in adults with type 1 diabetes, we regret that depression has not been taken into account. A systematic review and meta-analysis published in 2014 identified significant objective cognitive impairment in adults and adolescents with depression regarding executive functioning, memory, and attention relative to control subjects (2). Moreover, depression is two times more common in adults with diabetes compared with those without this condition, regardless of type of diabetes (3). There is even evidence that the co-occurrence of diabetes and depression leads to additional health risks such as increased mortality and dementia (3,4); this might well apply to cognitive impairment as well. Furthermore, in people with diabetes, the presence of depression has been associated with the development of diabetes complications, such as retinopathy, and higher HbA1c values (3). These are exactly the diabetes-specific correlates that Nunley et al. (1) found.”

“We believe it is a missed opportunity that Nunley et al. (1) mainly focused on biological variables, such as hyperglycemia and microvascular disease, and did not take into account an emotional disorder widely represented among people with diabetes and closely linked to cognitive impairment. Even though severe or chronic cases of depression are likely to have been excluded in the group without type 1 diabetes based on exclusion criteria (1), data on the presence of depression (either measured through a diagnostic interview or by using a validated screening questionnaire) could have helped to interpret the present findings. […] Determining the role of depression in the relationship between cognitive impairment and type 1 diabetes is of significant importance. Treatment of depression might improve cognitive impairment both directly by alleviating cognitive depression symptoms and indirectly by improving treatment nonadherence and glycemic control, consequently lowering the risk of developing complications.”

iii. Prevalence of Diabetes and Diabetic Nephropathy in a Large U.S. Commercially Insured Pediatric Population, 2002–2013.

“[W]e identified 96,171 pediatric patients with diabetes and 3,161 pediatric patients with diabetic nephropathy during 2002–2013. We estimated prevalence of pediatric diabetes overall, by diabetes type, age, and sex, and prevalence of pediatric diabetic nephropathy overall, by age, sex, and diabetes type.”

“Although type 1 diabetes accounts for a majority of childhood and adolescent diabetes, type 2 diabetes is becoming more common with the increasing rate of childhood obesity and it is estimated that up to 45% of all new patients with diabetes in this age-group have type 2 diabetes (1,2). With the rising prevalence of diabetes in children, a rise in diabetes-related complications, such as nephropathy, is anticipated. Moreover, data suggest that the development of clinical macrovascular complications, neuropathy, and nephropathy may be especially rapid among patients with young-onset type 2 diabetes (age of onset <40 years) (36). However, the natural history of young patients with type 2 diabetes and resulting complications has not been well studied.”

I’m always interested in the identification mechanisms applied in papers like this one, and I’m a little confused about the high number of patients without prescriptions (almost one-third of patients); I sort of assume these patients do take (/are given) prescription drugs, but get them from sources not available to the researchers (parents get prescriptions for the antidiabetic drugs, and the researchers don’t have access to these data? Something like this..) but this is a bit unclear. The mechanism they employ in the paper is not perfect (no mechanism is), but it probably works:

“Patients who had one or more prescription(s) for insulin and no prescriptions for another antidiabetes medication were classified as having type 1 diabetes, while those who filled prescriptions for noninsulin antidiabetes medications were considered to have type 2 diabetes.”

When covering limitations of the paper, they observe incidentally in this context that:

“Klingensmith et al. (31) recently reported that in the initial month after diagnosis of type 2 diabetes around 30% of patients were treated with insulin only. Thus, we may have misclassified a small proportion of type 2 cases as type 1 diabetes or vice versa. Despite this, we found that 9% of patients had onset of type 2 diabetes at age <10 years, consistent with the findings of Klingensmith et al. (8%), but higher than reported by the SEARCH for Diabetes in Youth study (<3%) (31,32).”

Some more observations from the paper:

“There were 149,223 patients aged <18 years at first diagnosis of diabetes in the CCE database from 2002 through 2013. […] Type 1 diabetes accounted for a majority of the pediatric patients with diabetes (79%). Among these, 53% were male and 53% were aged 12 to <18 years at onset, while among patients with type 2 diabetes, 60% were female and 79% were aged 12 to <18 years at onset.”

“The overall annual prevalence of all diabetes increased from 1.86 to 2.82 per 1,000 during years 2002–2013; it increased on average by 9.5% per year from 2002 to 2006 and slowly increased by 0.6% after that […] The prevalence of type 1 diabetes increased from 1.48 to 2.32 per 1,000 during the study period (average increase of 8.5% per year from 2002 to 2006 and 1.4% after that; both P values <0.05). The prevalence of type 2 diabetes increased from 0.38 to 0.67 per 1,000 during 2002 through 2006 (average increase of 13.3% per year; P < 0.05) and then dropped from 0.56 to 0.49 per 1,000 during 2007 through 2013 (average decrease of 2.7% per year; P < 0.05). […] Prevalence of any diabetes increased by age, with the highest prevalence in patients aged 12 to <18 years (ranging from 3.47 to 5.71 per 1,000 from 2002 through 2013).” […] The annual prevalence of diabetes increased over the study period mainly because of increases in type 1 diabetes.”

“Dabelea et al. (8) reported, based on data from the SEARCH for Diabetes in Youth study, that the annual prevalence of type 1 diabetes increased from 1.48 to 1.93 per 1,000 and from 0.34 to 0.46 per 1,000 for type 2 diabetes from 2001 to 2009 in U.S. youth. In our study, the annual prevalence of type 1 diabetes was 1.48 per 1,000 in 2002 and 2.10 per 1,000 in 2009, which is close to their reported prevalence.”

“We identified 3,161 diabetic nephropathy cases. Among these, 1,509 cases (47.7%) were of specific diabetic nephropathy and 2,253 (71.3%) were classified as probable cases. […] The annual prevalence of diabetic nephropathy in pediatric patients with diabetes increased from 1.16 to 3.44% between 2002 and 2013; it increased by on average 25.7% per year from 2002 to 2005 and slowly increased by 4.6% after that (both P values <0.05).”

Do note that the relationship between nephropathy prevalence and diabetes prevalence is complicated and that you cannot just explain an increase in the prevalence of nephropathy over time easily by simply referring to an increased prevalence of diabetes during the same time period. This would in fact be a very wrong thing to do, in part but not only on account of the data structure employed in this study. One problem which is probably easy to understand is that if more children got diabetes but the same proportion of those new diabetics got nephropathy, the diabetes prevalence would go up but the diabetic nephropathy prevalence would remain fixed; when you calculate the diabetic nephropathy prevalence you implicitly condition on diabetes status. But this just scratches the surface of the issues you encounter when you try to link these variables, because the relationship between the two variables is complicated; there’s an age pattern to diabetes risk, with risk (incidence) increasing with age (up to a point, after which it falls – in most samples I’ve seen in the past peak incidence in pediatric populations is well below the age of 18). However diabetes prevalence increases monotonously with age as long as the age-specific death rate of diabetics is lower than the age-specific incidence, because diabetes is chronic, and then on top of that you have nephropathy-related variables, which display diabetes-related duration-dependence (meaning that although nephropathy risk is also increasing with age when you look at that variable in isolation, that age-risk relationship is confounded by diabetes duration – a type 1 diabetic at the age of 12 who’s had diabetes for 10 years has a higher risk of nephropathy than a 16-year old who developed diabetes the year before). When a newly diagnosed pediatric patient is included in the diabetes sample here this will actually decrease the nephropathy prevalence in the short run, but not in the long run, assuming no changes in diabetes treatment outcomes over time. This is because the probability that that individual has diabetes-related kidney problems as a newly diagnosed child is zero, so he or she will unquestionably only contribute to the denominator during the first years of illness (the situation in the middle-aged type 2 context is different; here you do sometimes have newly-diagnosed patients who have developed complications already). This is one reason why it would be quite wrong to say that increased diabetes prevalence in this sample is the reason why diabetic nephropathy is increasing as well. Unless the time period you look at is very long (e.g. you have a setting where you follow all individuals with a diagnosis until the age of 18), the impact of increasing prevalence of one condition may well be expected to have a negative impact on the estimated risk of associated conditions, if those associated conditions display duration-dependence (which all major diabetes complications do). A second factor supporting a default assumption of increasing incidence of diabetes leading to an expected decreasing rate of diabetes-related complications is of course the fact that treatment options have tended to increase over time, and especially if you take a long view (look back 30-40 years) the increase in treatment options and improved medical technology have lead to improved metabolic control and better outcomes.

That both variables grew over time might be taken to indicate that both more children got diabetes and that a larger proportion of this increased number of children with diabetes developed kidney problems, but this stuff is a lot more complicated than it might look and it’s in particular important to keep in mind that, say, the 2005 sample and the 2010 sample do not include the same individuals, although there’ll of course be some overlap; in age-stratified samples like this you always have some level of implicit continuous replacement, with newly diagnosed patients entering and replacing the 18-year olds who leave the sample. As long as prevalence is constant over time, associated outcome variables may be reasonably easy to interpret, but when you have dynamic samples as well as increasing prevalence over time it gets difficult to say much with any degree of certainty unless you crunch the numbers in a lot of detail (and it might be difficult even if you do that). A factor I didn’t mention above but which is of course also relevant is that you need to be careful about how to interpret prevalence rates when you look at complications with high mortality rates (and late-stage diabetic nephropathy is indeed a complication with high mortality); in such a situation improvements in treatment outcomes may have large effects on prevalence rates but no effect on incidence. Increased prevalence is not always bad news, sometimes it is good news indeed. Gleevec substantially increased the prevalence of CML.

In terms of the prevalence-outcomes (/complication risk) connection, there are also in my opinion reasons to assume that there may be multiple causal pathways between prevalence and outcomes. For example a very low prevalence of a condition in a given area may mean that fewer specialists are educated to take care of these patients than would be the case for an area with a higher prevalence, and this may translate into a more poorly developed care infrastructure. Greatly increasing prevalence may on the other hand lead to a lower level of care for all patients with the illness, not just the newly diagnosed ones, due to binding budget constraints and care rationing. And why might you have changes in prevalence; might they not sometimes rather be related to changes in diagnostic practices, rather than changes in the True* prevalence? If that’s the case, you might not be comparing apples to apples when you’re comparing the evolving complication rates. There are in my opinion many reasons to believe that the relationship between chronic conditions and the complication rates of these conditions is far from simple to model.

All this said, kidney problems in children with diabetes is still rare, compared to the numbers you see when you look at adult samples with longer diabetes duration. It’s also worth distinguishing between microalbuminuria and overt nephropathy; children rarely proceed to develop diabetes-related kidney failure, although poor metabolic control may mean that they do develop this complication later, in early adulthood. As they note in the paper:

“It has been reported that overt diabetic nephropathy and kidney failure caused by either type 1 or type 2 diabetes are uncommon during childhood or adolescence (24). In this study, the annual prevalence of diabetic nephropathy for all cases ranged from 1.16 to 3.44% in pediatric patients with diabetes and was extremely low in the whole pediatric population (range 2.15 to 9.70 per 100,000), confirming that diabetic nephropathy is a very uncommon condition in youth aged <18 years. We observed that the prevalence of diabetic nephropathy increased in both specific and unspecific cases before 2006, with a leveling off of the specific nephropathy cases after 2005, while the unspecific cases continued to increase.”

iv. Adherence to Oral Glucose-Lowering Therapies and Associations With 1-Year HbA1c: A Retrospective Cohort Analysis in a Large Primary Care Database.

“Between a third and a half of medicines prescribed for type 2 diabetes (T2DM), a condition in which multiple medications are used to control cardiovascular risk factors and blood glucose (1,2), are not taken as prescribed (36). However, estimates vary widely depending on the population being studied and the way in which adherence to recommended treatment is defined.”

“A number of previous studies have used retrospective databases of electronic health records to examine factors that might predict adherence. A recent large cohort database examined overall adherence to oral therapy for T2DM, taking into account changes of therapy. It concluded that overall adherence was 69%, with individuals newly started on treatment being significantly less likely to adhere (19).”

“The impact of continuing to take glucose-lowering medicines intermittently, but not as recommended, is unknown. Medication possession (expressed as a ratio of actual possession to expected possession), derived from prescribing records, has been identified as a valid adherence measure for people with diabetes (7). Previous studies have been limited to small populations in managed-care systems in the U.S. and focused on metformin and sulfonylurea oral glucose-lowering treatments (8,9). Further studies need to be carried out in larger groups of people that are more representative of the general population.

The Clinical Practice Research Database (CPRD) is a long established repository of routine clinical data from more than 13 million patients registered with primary care services in England. […] The Genetics of Diabetes and Audit Research Tayside Study (GoDARTS) database is derived from integrated health records in Scotland with primary care, pharmacy, and hospital data on 9,400 patients with diabetes. […] We conducted a retrospective cohort study using [these databases] to examine the prevalence of nonadherence to treatment for type 2 diabetes and investigate its potential impact on HbA1c reduction stratified by type of glucose-lowering medication.”

“In CPRD and GoDARTS, 13% and 15% of patients, respectively, were nonadherent. Proportions of nonadherent patients varied by the oral glucose-lowering treatment prescribed (range 8.6% [thiazolidinedione] to 18.8% [metformin]). Nonadherent, compared with adherent, patients had a smaller HbA1c reduction (0.4% [4.4 mmol/mol] and 0.46% [5.0 mmol/mol] for CPRD and GoDARTs, respectively). Difference in HbA1c response for adherent compared with nonadherent patients varied by drug (range 0.38% [4.1 mmol/mol] to 0.75% [8.2 mmol/mol] lower in adherent group). Decreasing levels of adherence were consistently associated with a smaller reduction in HbA1c.”

“These findings show an association between adherence to oral glucose-lowering treatment, measured by the proportion of medication obtained on prescription over 1 year, and the corresponding decrement in HbA1c, in a population of patients newly starting treatment and continuing to collect prescriptions. The association is consistent across all commonly used oral glucose-lowering therapies, and the findings are consistent between the two data sets examined, CPRD and GoDARTS. Nonadherent patients, taking on average <80% of the intended medication, had about half the expected reduction in HbA1c. […] Reduced medication adherence for commonly used glucose-lowering therapies among patients persisting with treatment is associated with smaller HbA1c reductions compared with those taking treatment as recommended. Differences observed in HbA1c responses to glucose-lowering treatments may be explained in part by their intermittent use.”

“Low medication adherence is related to increased mortality (20). The mean difference in HbA1c between patients with MPR <80% and ≥80% is between 0.37% and 0.55% (4 mmol/mol and 6 mmol/mol), equivalent to up to a 10% reduction in death or an 18% reduction in diabetes complications (21).”

v. Health Care Transition in Young Adults With Type 1 Diabetes: Perspectives of Adult Endocrinologists in the U.S.

“Empiric data are limited on best practices in transition care, especially in the U.S. (10,1316). Prior research, largely from the patient perspective, has highlighted challenges in the transition process, including gaps in care (13,1719); suboptimal pediatric transition preparation (13,20); increased post-transition hospitalizations (21); and patient dissatisfaction with the transition experience (13,1719). […] Young adults with type 1 diabetes transitioning from pediatric to adult care are at risk for adverse outcomes. Our objective was to describe experiences, resources, and barriers reported by a national sample of adult endocrinologists receiving and caring for young adults with type 1 diabetes.”

“We received responses from 536 of 4,214 endocrinologists (response rate 13%); 418 surveys met the eligibility criteria. Respondents (57% male, 79% Caucasian) represented 47 states; 64% had been practicing >10 years and 42% worked at an academic center. Only 36% of respondents reported often/always reviewing pediatric records and 11% reported receiving summaries for transitioning young adults with type 1 diabetes, although >70% felt that these activities were important for patient care.”

“A number of studies document deficiencies in provider hand-offs across other chronic conditions and point to the broader relevance of our findings. For example, in two studies of inflammatory bowel disease, adult gastroenterologists reported inadequacies in young adult transition preparation (31) and infrequent receipt of medical histories from pediatric providers (32). In a study of adult specialists caring for young adults with a variety of chronic diseases (33), more than half reported that they had no contact with the pediatric specialists.

Importantly, more than half of the endocrinologists in our study reported a need for increased access to mental health referrals for young adult patients with type 1 diabetes, particularly in nonacademic settings. Report of barriers to care was highest for patient scenarios involving mental health issues, and endocrinologists without easy access to mental health referrals were significantly more likely to report barriers to diabetes management for young adults with psychiatric comorbidities such as depression, substance abuse, and eating disorders.”

“Prior research (34,35) has uncovered the lack of mental health resources in diabetes care. In the large cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study (36) […] diabetes providers often reported not having the resources to manage mental health problems; half of specialist diabetes physicians felt unable to provide psychiatric support for patients and one-third did not have ready access to outside expertise in emotional or psychiatric matters. Our results, which resonate with the DAWN findings, are particularly concerning in light of the vulnerability of young adults with type 1 diabetes for adverse medical and mental health outcomes (4,34,37,38). […] In a recent report from the Mental Health Issues of Diabetes conference (35), which focused on type 1 diabetes, a major observation included the lack of trained mental health professionals, both in academic centers and the community, who are knowledgeable about the mental health issues germane to diabetes.”

August 3, 2017 Posted by | Diabetes, Epidemiology, Medicine, Nephrology, Neurology, Pharmacology, Psychiatry, Psychology, Statistics, Studies | Leave a comment

A few SSC comments

I recently left a few comments in an open thread on SSC, and I figured it might make sense to crosspost some of the comments made there here on the blog. I haven’t posted all my contributions to the debate here, rather I’ve just quoted some specific comments and observations which might be of interest. I’ve also added some additional remarks and comments which relate to the topics discussed. Here’s the main link (scroll down to get to my comments).

“One thing worth keeping in mind when evaluating pre-modern medicine characterizations of diabetes and the natural history of diabetes is incidentally that especially to the extent that one is interested in type 1 survivorship bias is a major problem lurking in the background. Prognostic estimates of untreated type 1 based on historical accounts of how long people could live with the disease before insulin are not in my opinion likely to be all that reliable, because the type of patients that would be recognized as (type 1) diabetics back then would tend to mainly be people who had the milder forms, because they were the only ones who lived long enough to reach a ‘doctor’; and the longer they lived, and the milder the sub-type, the more likely they were to be studied/’diagnosed’. I was a 2-year old boy who got unwell on a Tueday and was hospitalized three days later. Avicenna would have been unlikely to have encountered me, I’d have died before he saw me. (Similar lines of reasoning might lead to an argument that the incidence of diseases like type 1 diabetes may also today be underdiagnosed in developing countries with poorly developed health care systems.)”

Douglas Knight mentioned during our exchange that medical men of the far past might have been more likely to attend to patients with acute illnesses than patients with chronic conditions, making them more likely to attend to such cases than would otherwise be the case, a point I didn’t discuss in any detail during the exchange. I did however think it important to note here that information exchange was significantly slower, and transportation costs were much higher, in the past than they are today. This should make such a bias less relevant, all else equal. Avicenna and his colleagues couldn’t take a taxi, or learn by phone that X is sick. He might have preferentially attended to the acute cases he learned about, but given high transportation costs and inefficient communication channels he might often never arrive in time, or at all. A particular problem here is that there are no good data on the unobserved cases, because the only cases we know about today are the ones people like him have told us about.

Some more comments:

“One thing I was considering adding to my remarks about survivorship bias is that it is not in my opinion unlikely that what you might term the nature of the disease has changed over the centuries; indeed it might still be changing today. Globally the incidence of type 1 has been increasing for decades and nobody seems to know why, though there’s consensus about an environmental trigger playing a major role. Maybe incidence is not the only thing that’s changed, maybe e.g. the time course of the ‘average case’ has also changed? Maybe due to secondary factors; better nutritional status now equals slower progression of beta cell failure than was the case in the past? Or perhaps the other way around: Less exposure to bacterial agents the immune system throughout evolutionary time has been used to having to deal with today means that the autoimmune process is accelerated today, compared to in the far past where standards of hygiene were different. Who knows? […] Maybe survivorship bias wasn’t that big of a deal, but I think one should be very cautious about which assumptions one might implicitly be making along the way when addressing questions of this sort of nature. Some relevant questions will definitely be unknowable due to lack of good data which we will never be able to obtain.”

I should perhaps interpose here that even if survivorship bias ‘wasn’t that big of a deal’, it’s still sort of a big problem in the analytical setting because it seems perfectly plausible to me to be making the assumption that it might even so have been a big deal. These kinds of problems magnify our error bars and reduce confidence in our conclusions, regardless of the extent to which they actually played a role. When you know the exact sign and magnitude of a given moderating effect you can try to correct for it, but this is very difficult to do when a large range of moderator effect sizes might be considered plausible. It might also here be worth mentioning explicitly that biases such as the survivorship bias mentioned can of course impact a lot of things besides just the prognostic estimates; for example if a lot of cases never come to the attention of the medical people because these people were unavailable (due to distance, cost, lack of information, etc.) to the people who were sick, incidence and prevalence will also implicitly be underestimated. And so on. Back to the comments:

“Once you had me thinking that it might have been harder [for people in the past] to distinguish [between type 1 and type 2 diabetes] than […] it is today, I started wondering about this, and the comments below relate to this topic. An idea that came to mind in relation to the type 1/type 2 distinction and the ability of people in the past to make this distinction: I’ve worked on various identification problems present in the diabetes context before, and I know that people even today make misdiagnoses and e.g. categorize type 1 diabetics as type 2. I asked a diabetes nurse working in the local endocrinology unit about this at one point, and she told me they had actually had a patient not long before then who had been admitted a short while after having been diagnosed with type 2. Turned out he was type 1, so the treatment failed. Misdiagnoses happen for multiple reasons, one is that obese people also sometimes develop type 1, and if it’s an acute onset setting the weight loss is not likely to be very significant. Patient history should in such a case provide the doctor with the necessary clues, but if the guy making the diagnosis is a stressed out GP who’s currently treating a lot of obese patients for type 2, mistakes happen. ‘Pre-scientific method’ this sort of individual would have been inconvenient to encounter, because a ‘counter-example’ like that supposedly demonstrating that the obese/thin(/young/old, acute/protracted…) distinction was ‘invalid’ might have held a lot more weight than it hopefully would today in the age of statistical analysis. A similar problem would be some of the end-stage individuals: A type 1 pre-insulin would be unlikely to live long enough to develop long term complications of the disease, but would instead die of DKA. The problem is that some untreated type 2 patients also die of DKA, though the degree of ketosis varies in type 2 patients. DKA in type 2 could e.g. be triggered by a superimposed cardiovascular event or an infection, increasing metabolic demands to an extent that can no longer be met by the organism, and so might well present just as acutely as it would in a classic acute-onset type 1 case. Assume the opposite bias you mention is playing a role; the ‘doctor’ in the past is more likely to see the patients in such a life-threatening setting than in the earlier stages. He observes a 55 year old fat guy dying in a very similar manner to the way a 12 year old girl died a few months back – very characteristic symptoms, breath smells fruity, Kussmaul respiration, polyuria and polydipsia…). What does he conclude? Are these different diseases?”

Making the doctor’s decision problem even harder is of course the fact that type 2 diabetes even today often goes undiagnosed until complications arise. Some type 2 patients get their diagnosis only after they had their first heart attack as a result of their illness. So the hypothetical obese middle-aged guy presenting with DKA might not have been known by anyone to be ‘a potentially different kind of diabetic’.

‘The Nybbler’ asked this question in the thread: “Wouldn’t reduced selection pressure be a major reason for increase of Type I diabetes? Used to be if you had it, chance of surviving to reproduce was close to nil.”

I’ll mention here that I’ve encountered this kind of theorizing before, but that I’ve never really addressed it – especially the second part – explicitly, though I’ve sometimes felt like doing that. I figured this post might be a decent place to at least scratch the surface. The idea that there are more type 1 diabetics now than there used to be because type 1 diabetics used to die of their disease and now they don’t (…and so now they are able to transmit their faulty genes to subsequent generations, leading to more diabetic individuals over time) sounds sort of reasonable if you don’t know very much about diabetes, but it sounds less reasonable to people who do. Genes matter, and changed selection pressures have probably played a role, but I find it hard to believe this particular mechanism is a major factor. I have included both my of my replies to ‘Nybbler’ below:

First comment:

“I’m not a geneticist and this is sort-of-kind-of near the boundary area of where I feel comfortable providing answers (given that others may be more qualified to evaluate questions like this than I am). However a few observations which might be relevant are the following:

i) Although I’ll later go on to say that vertical transmission is low, I first have to point out that some people who developed type 1 diabetes in the past did in fact have offspring, though there’s no doubt about the condition being fitness-reducing to a very large degree. The median age of diagnosis of type 1 is somewhere in the teenage years (…today. Was it the same way 1000 years ago, or has the age profile changed over time? This again relates to questions asked elsewhere in this discussion…), but people above the age of 30 get type 1 too.

ii) Although type 1 display some level of familia[l] clustering, most cases of type 1 are not the result of diabetics having had children who then proceed to inherit their parents’ disease. To the extent that reduced selection is a driver of increased incidence, the main cause would be broad selection effects pertaining to immune system functioning in general in the total population at risk (i.e. children in general, including many children with what might be termed suboptimal immune system functioning, being more likely to survive and later develop type 1 diabetes), not effects derived from vertical transmission of the disease (from parent to child). Roughly 90% of newly diagnosed type 1 diabetics in population studies have a negative family history of the disease, and on average only 2% of the children of type 1 diabetic mothers, and 5% of the children of type 1 diabetic fathers, go on to develop type 1 diabetes themselves.

iii) Historically vertical transmission has even in modern times been low. On top of the quite low transmission rates mentioned above, until well into the 80es or 90es many type 1 diabetic females were explicitly advised by their medical care providers not to have children, not because of the genetic risk of disease transmission but because pregnancy outcomes were likely to be poor; and many of those who disregarded the advice gave birth to offspring who were at a severe fitness disadvantage from the start. Poorly controlled diabetes during pregnancy leads to a very high risk of birth defects and/or miscarriage, and may pose health risks to the mother as well through e.g. an increased risk of preeclampsia (relevant link). It is only very recently that we’ve developed the knowledge and medical technology required to make pregnancy a reasonably safe option for female diabetics. You still had some diabetic females who gave birth before developing diabetes, like in the far past, and the situation was different for males, but either way I feel reasonably confident claiming that if you look for genetic causes of increasing incidence, vertical transmission should not be the main factor to consider.

iv) You need to be careful when evaluating questions like these to keep a distinction between questions relating to drivers of incidence and questions relating to drivers of prevalence at the back of your mind. These two sets of questions are not equivalent.

v) If people are interested to know more about the potential causes of increased incidence of type 1 diabetes, here’s a relevant review paper.”

I followed up with a second comment a while later, because I figured a few points of interest might not have been sufficiently well addressed in my first comment:


A few additional remarks.

i) “Temporal trends in chronic disease incidence rates are almost certainly environmentally induced. If one observes a 50% increase in the incidence of a disorder over 20 yr, it is most likely the result of changes in the environment because the gene pool cannot change that rapidly. Type 1 diabetes is a very dynamic disease. […] results clearly demonstrate that the incidence of type 1 diabetes is rising, bringing with it a large public health problem. Moreover, these findings indicate that something in our environment is changing to trigger a disease response. […] With the exception of a possible role for viruses and infant nutrition, the specific environmental determinants that initiate or precipitate the onset of type 1 diabetes remain unclear.” (Type 1 Diabetes, Etiology and Treatment. Just to make it perfectly clear that although genes matter, environmental factors are the most likely causes of the rising levels of incidence we’ve seen in recent times.)

ii. Just as you need to always keep incidence and prevalence in mind when analyzing these things (for example low prevalence does not mean incidence is necessarily low, or was low in the past; low prevalence could also be a result of a combination of high incidence and high case mortality. I know from experience that even diabetes researchers tend to sometimes overlook stuff like this), you also need to keep the distinction between genotype and phenotype in mind. Given the increased importance of one or more environmental triggers in modern times, penetrance is likely to have changed over time. This means for example that ‘a diabetic genotype’ may have been less fitness reducing in the past than it is today, even if the associated ‘diabetic phenotype’ may on the other hand have been much more fitness reducing than it is now; people who developed diabetes died, but many of the people who might in the current environment be considered high-risk cases may not have been high risk in the far past, because the environmental trigger causing disease was absent, or rarely encountered. Assessing genetic risk for diabetes is complicated, and there’s no general formula for calculating this risk either in the type 1 or type 2 case; monogenic forms of diabetes do exist, but they account for a very small proportion of cases (1-5% of diabetes in young individuals) – most cases are polygenic and display variable levels of penetrance. Note incidentally that a story of environmental factors becoming more important over time is actually implicitly also, to the extent that diabetes is/has been fitness-reducing, a story of selection pressures against diabetic genotypes potentially increasing over time, rather than the opposite (which seems to be the default assumption when only taking into account stuff like the increased survival rates of type 1 diabetics over time). This stuff is complicated.”

I wasn’t completely happy with my second comment (I wrote it relatively fast and didn’t have time to go over it in detail after I’d written it), so I figured it might make sense to add a few details here. One key idea here is of course that you need to distinguish between people who are ‘vulnerable’ to developing type 1 diabetes, and people who actually do develop the disease. If fewer people who today would be considered ‘vulnerable’ developed the disease in the past than is the case now, selection against the ‘vulnerable’ genotype would – all else equal – have been lower throughout evolutionary time than it is today.

All else is not equal because of insulin treatment. But a second key point is that when you’re interested in fitness effects, mortality is not the only variable of interest; many diabetic women who were alive because of insulin during the 20th century but who were also being discouraged from having children may well have left no offspring. Males who committed suicide or died from kidney failure in their twenties likely also didn’t leave many offspring. Another point related to the mortality variable is that although diabetes mortality might in the past have been approximated reasonably well by a simple binary outcome variable/process (no diabetes = alive, diabetes = dead), type 1 diabetes has had large effects on mortality rates also throughout the chunk of history during which insulin has been a treatment option; mortality rates 3 or 4 times higher than those of non-diabetics are common in population studies, and such mortality rates add up over time even if base rates are low, especially in a fitness context, as they for most type 1 diabetics are at play throughout the entire fertile period of the life history. Type 2 diabetes is diagnosed mainly in middle-aged individuals, many of whom have already completed their reproductive cycle, but type 1 diabetes is very different in that respect. Of course there are multiple indirect effects at play as well here, e.g. those of mate choice; which is the more attractive potential partner, the individual with diabetes or the one without? What if the diabetic also happens to be blind?

A few other quotes from the comments:

“The majority of patients on insulin in the US are type 2 diabetics, and it is simply wrong that type 2 diabetics are not responsive to insulin treatment. They were likely found to be unresponsive in early trials because of errors of dosage, as they require higher levels of the drug to obtain the same effect as will young patients diagnosed with type 1 (the primary group on insulin in the 30es). However, insulin treatment is not the first-line option in the type 2 context because the condition can usually be treated with insulin-sensitizing agents for a while, until they fail (those drugs will on average fail in something like ~50% of subjects within five years of diagnosis, which is the reason – combined with the much (order(/s, depending on where you are) of magnitude) higher prevalence of type 2 – why a majority of patients on insulin have type 2), and these tend to a) be more acceptable to the patients (a pill vs an injection) and b) have fewer/less severe side effects on average. One reason which also played a major role in delaying the necessary use of insulin to treat type 2 diabetes which could not be adequately controlled via other means was incidentally the fact that insulin ca[u]ses weight gain, and the obesity-type 2 link was well known.”

“Type 1 is autoimmune, and most cases of type 2 are not, but some forms of type 2 seem to have an autoimmune component as well (“the overall autoantibody frequency in type 2 patients varies between 6% and 10%” – source) (these patients, who can be identified through genetic markers, will on average proceed to insulin dependence because of treatment failure in the context of insulin sensitizing-agents much sooner than is usually the case in patients with type 2). In general type 1 is caused by autoimmune beta cell destruction and type 2 mainly by insulin resistance, but combinations of the two are also possible […], and patients with type 1 can develop insulin resistance just as patients with type 2 can lose beta cells via multiple pathways. The major point here being that the sharp diagnostic distinction between type 1 and type 2 is a major simplification of what’s really going on, and it’s hiding a lot of heterogeneity in both samples. Some patients with type 1 will develop diabetes acutely or subacutely, within days or hours, whereas others will have elevated blood glucose levels for months before medical attention is received and a diagnosis is made (you can tell whether or not blood glucose has been elevated pre-diagnosis by looking at one of the key diagnostic variables, Hba1c, which is a measure of the average blood glucose over the entire lifetime of a red blood cell (~3-4 months) – in some newly diagnosed type 1s, this variable is elevated, in others it is not. Some type 1 patients will develop other autoimmune conditions later on, whereas others will not, and some will be more likely to develop complications than others who have the same level of glycemic control.

Type 1 and type 2 diabetes are quite different conditions, but in terms of many aspects of the diseases there are significant degrees of overlap (for example they develop many of the same complications, for similar (pathophysiological) reasons), yet they are both called diabetes. You don’t want to treat a type 2 diabetic with insulin if he can be treated with metformin, and treating a type 1 with metformin will not help – so different treatments are required.”

“In terms of whether it’s ideal to have one autistic diagnostic group or two (…or three, or…) [this question was a starting point for the debate from which I quote, but I decided not to go much into this topic here], I maintain that to a significant extent the answer to that question relates to what the diagnosis is supposed to accomplish. If it makes sense for researchers to be able to distinguish, which it probably does, but it is not necessary for support organizers/providers to know the subtype in order to provide aid, then you might end up with one ‘official’ category and two (or more) ‘research categories’. I would be fine with that (but again I don’t find this discussion interesting). Again a parallel might be made to diabetes research: Endocrinologists are well aware that there’s a huge amount of variation in both the type 1 and type 2 samples, to the extent that it’s sort of silly to even categorize these illnesses using the same name, but they do it anyway for reasons which are sort of obvious. If you’re type 1 diabetic and you have an HLA mutation which made you vulnerable to diabetes and you developed diabetes at the age of 5, well, we’ll start you on insulin, try to help you achieve good metabolic control, and screen you regularly for complications. If on the other hand you’re an adult guy who due to a very different genetic vulnerability developed type 1 diabetes at the age of 30 (and later on Graves’ disease at the age of 40, due to the same mutation), well, we’ll start you on insulin, try to help you achieve good metabolic control, and screen you regularly for complications. The only thing type 1 diabetics have in common is the fact that their beta cells die due to some autoimmune processes. But it could easily be conceived of instead as literally hundreds of different diseases. Currently the distinctions between the different disease-relevant pathophysiological processes don’t matter very much in the treatment context, but they might do that at some point in the future, and if that happens the differences will start to become more important. People might at that point start to talk about type 1a diabetes, which might be the sort you can delay or stop with gene therapy, and type 1b which you can’t delay or stop (…yet). Lumping ‘different’ groups together into one diagnostic category is bad if it makes you overlook variation which is important, and this may be a problem in the autism context today, but regardless of the sizes of the diagnostic groups you’ll usually still end up with lots of residual (‘unexplained’) variation.”

I can’t recall to which extent I’ve discussed this last topic – the extent to which type 1 diabetes is best modeled as one illness or many – but it’s an important topic to keep at the back of your mind when you’re reading the diabetes literature. I’m assuming that in some contexts the subgroup heterogeneities, e.g. in terms of treatment response, will be much more important than in other contexts, so you probably need specific subject matter knowledge to make any sort of informed decision about to which extent potential unobserved heterogeneities may be important in a specific setting, but even if you don’t have that ‘a healthy skepticism’, derived from keeping the potential for these factors to play a role in mind, is likely to be more useful than the alternative. In that context I think the (poor, but understandable) standard practice of lumping together type 1 and type 2 diabetics in studies may lead many people familiar with the differences between the two conditions to think along the lines that as long as you know the type, you’re good to go – ‘at least this study only looked at type 1 individuals, not like those crappy studies which do not distinguish between type 1 and type 2, so I can definitely trust these results to apply to the subgroup of type 1 diabetics in which I’m interested’ – and I think this tendency, to the extent that it exists, is unfortunate.

July 8, 2017 Posted by | autism, Diabetes, Epidemiology, Genetics, Medicine, Psychology | Leave a comment

A few papers

i. Quality of life of adolescents with autism spectrum disorders: comparison to adolescents with diabetes.

“The goals of our study were to clarify the consequences of autistic disorder without mental retardation on […] adolescents’ daily lives, and to consider them in comparison with the impact of a chronic somatic disease (diabetes) […] Scores for adolescents with ASD were significantly lower than those of the control and the diabetic adolescents, especially for friendships, leisure time, and affective and sexual relationships. On the other hand, better scores were obtained for the relationships with parents and teachers and for self-image. […] For subjects with autistic spectrum disorders and without mental retardation, impairment of quality of life is significant in adolescence and young adulthood. Such adolescents are dissatisfied with their relationships, although they often have real motivation to succeed with them.”

As someone who has both conditions, that paper was quite interesting. A follow-up question of some personal interest to me would of course be this: How do the scores/outcomes of these two groups compare to the scores of the people who have both conditions simultaneously? This question is likely almost impossible to answer in any confident manner, certainly if the conditions are not strongly dependent (unlikely), considering the power issues; global prevalence of autism is around 0.6% (link), and although type 1 prevalence is highly variable across countries, the variation just means that in some countries almost nobody gets it whereas in other countries it’s just rare; prevalence varies from 0.5 per 100.000 to 60 per 100.000 children aged 0-15 years. Assuming independence, if you look at combinations of the sort of conditions which affect one in a hundred people with those affecting one in a thousand, you’ll need on average in the order of 100.000 people to pick up just one individual with both of the conditions of interest. It’s bothersome to even try to find people like that, and good luck doing any sort of sensible statistics on that kind of sample. Of course type 1 diabetes prevalence increases with age in a way that autism does not because people continue to be diagnosed with it into late adulthood, whereas most autistics are diagnosed as children, so this makes the rarity of the condition less of a problem in adult samples, but if you’re looking at outcomes it’s arguable whether it makes sense to not differentiate between someone diagnosed with type 1 diabetes as a 35 year old and someone diagnosed as a 5 year old (are these really comparable diseases, and which outcomes are you interested in?). At least that is the case for developed societies where people with type 1 diabetes have high life expectancies; in less developed societies there may be stronger linkage between incidence and prevalence because of high mortality in the patient group (because people who get type 1 diabetes in such countries may not live very long because of inadequate medical care, which means there’s a smaller disconnect between how many new people get the disease during each time period and how many people in total have the disease than is the case for places where the mortality rates are lower). You always need to be careful about distinguishing between incidence and prevalence when dealing with conditions like T1DM with potential high mortality rates in settings where people have limited access to medical care because differential cross-country mortality patterns may be important.

ii. Exercise for depression (Cochrane review).


Depression is a common and important cause of morbidity and mortality worldwide. Depression is commonly treated with antidepressants and/or psychological therapy, but some people may prefer alternative approaches such as exercise. There are a number of theoretical reasons why exercise may improve depression. This is an update of an earlier review first published in 2009.


To determine the effectiveness of exercise in the treatment of depression in adults compared with no treatment or a comparator intervention. […]

Selection criteria 

Randomised controlled trials in which exercise (defined according to American College of Sports Medicine criteria) was compared to standard treatment, no treatment or a placebo treatment, pharmacological treatment, psychological treatment or other active treatment in adults (aged 18 and over) with depression, as defined by trial authors. We included cluster trials and those that randomised individuals. We excluded trials of postnatal depression.

Thirty-nine trials (2326 participants) fulfilled our inclusion criteria, of which 37 provided data for meta-analyses. There were multiple sources of bias in many of the trials; randomisation was adequately concealed in 14 studies, 15 used intention-to-treat analyses and 12 used blinded outcome assessors.For the 35 trials (1356 participants) comparing exercise with no treatment or a control intervention, the pooled SMD for the primary outcome of depression at the end of treatment was -0.62 (95% confidence interval (CI) -0.81 to -0.42), indicating a moderate clinical effect. There was moderate heterogeneity (I² = 63%).

When we included only the six trials (464 participants) with adequate allocation concealment, intention-to-treat analysis and blinded outcome assessment, the pooled SMD for this outcome was not statistically significant (-0.18, 95% CI -0.47 to 0.11). Pooled data from the eight trials (377 participants) providing long-term follow-up data on mood found a small effect in favour of exercise (SMD -0.33, 95% CI -0.63 to -0.03). […]

Authors’ conclusions

Exercise is moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only shows a smaller effect in favour of exercise. When compared to psychological or pharmacological therapies, exercise appears to be no more effective, though this conclusion is based on a few small trials.”

iii. Risk factors for suicide in individuals with depression: A systematic review.

“The search strategy identified 3374 papers for potential inclusion. Of these, 155 were retrieved for a detailed evaluation. Thirty-two articles fulfilled the detailed eligibility criteria. […] Nineteen studies (28 publications) were included. Factors significantly associated with suicide were: male gender (OR = 1.76, 95% CI = 1.08–2.86), family history of psychiatric disorder (OR = 1.41, 95% CI= 1.00–1.97), previous attempted suicide (OR = 4.84, 95% CI = 3.26–7.20), more severe depression (OR = 2.20, 95% CI = 1.05–4.60), hopelessness (OR = 2.20, 95% CI = 1.49–3.23) and comorbid disorders, including anxiety (OR = 1.59, 95% CI = 1.03–2.45) and misuse of alcohol and drugs (OR = 2.17, 95% CI = 1.77–2.66).
Limitations: There were fewer studies than suspected. Interdependence between risk factors could not be examined.”

iv. Cognitive behaviour therapy for social anxiety in autism spectrum disorder: a systematic review.

“Individuals who have autism spectrum disorders (ASD) commonly experience anxiety about social interaction and social situations. Cognitive behaviour therapy (CBT) is a recommended treatment for social anxiety (SA) in the non-ASD population. Therapy typically comprises cognitive interventions, imagery-based work and for some individuals, behavioural interventions. Whether these are useful for the ASD population is unclear. Therefore, we undertook a systematic review to summarise research about CBT for SA in ASD.”

I mostly include this review here to highlight how reviews aren’t everything – I like them, but you can’t do reviews when a field hasn’t been studied. This is definitely the case here. The review was sort of funny, but also depressing. So much work for so little insight. Here’s the gist of it:

“Using a priori criteria, we searched for English-language peer-reviewed empirical studies in five databases. The search yielded 1364 results. Titles, abstracts and relevant publications were independently screened by two reviewers. Findings: Four single case studies met the review inclusion criteria; data were synthesised narratively. Participants (three adults and one child) were diagnosed with ASD and social anxiety disorder.”

You search the scientific literature systematically, you find more than a thousand results, and you carefully evaluate which ones of them should be included in this kind of study …and what you end up with is 4 individual case studies…

(I won’t go into the results of the study as they’re pretty much worthless.)

v. Immigrant Labor Market Integration across Admission Classes.

“We examine patterns of labor market integration across immigrant groups. The study draws on Norwegian longitudinal administrative data covering labor earnings and social insurance claims over a 25‐year period and presents a comprehensive picture of immigrant‐native employment and social insurance differentials by admission class and by years since entry.”

Some quotes from the paper:

“A recent study using 2011 administrative data from Sweden finds an average employment gap to natives of 30 percentage points for humanitarian migrants (refugees) and 26 percentage point for family immigrants (Luik et al., 2016).”

“A considerable fraction of the immigrants leaves the country after just a few years. […] this is particularly the case for immigrants from the old EU and for students and work-related immigrants from developing countries. For these groups, fewer than 50 percent remain in the country 5 years after entry. For refugees and family migrants, the picture is very different, and around 80 percent appear to have settled permanently in the country. Immigrants from the new EU have a settlement pattern somewhere in between, with approximately 70 percent settled on a permanent basis. An implication of such differential outmigration patterns is that the long-term labor market performance of refugees and family immigrants is of particular economic and fiscal importance. […] the varying rates of immigrant inflows and outflows by admission class, along with other demographic trends, have changed the composition of the adult (25‐66) population between 1990 and 2015. In this population segment, the overall immigrant share increased from 4.9 percent in 1990 to 18.7 percent in 2015 — an increase by a factor of 3.8 over 25 years. […] Following the 2004 EU enlargement, the fraction of immigrants in Norway has increased by a steady rate of approximately one percentage point per year.”

“The trends in population and employment shares varies considerably across admission classes, with employment shares of refugees and family immigrants lagging their growth in population shares. […] In 2014, refugees and family immigrants accounted for 12.8 percent of social insurance claims, compared to 5.7 percent of employment (and 7.7 percent of the adult population). In contrast, the two EU groups made up 9.3 percent of employment (and 8.8 percent of the adult population) but only 3.6 percent of social insurance claimants. Although these patterns do illuminate the immediate (short‐term) fiscal impacts of immigration at each particular point in time, they are heavily influenced by each year’s immigrant composition – in terms of age, years since migration, and admission classes – and therefore provide little information about long‐term consequences and impacts of fiscal sustainability. To assess the latter, we need to focus on longer‐term integration in the Norwegian labor market.”

Which they then proceed to do in the paper. From the results of those analyses:

“For immigrant men, the sample average share in employment (i.e., whose main source of income is work) ranges from 58 percent for refugees to 89 percent for EU immigrants, with family migrants somewhere between (around 80 percent). The average shares with social insurance as the main source of income ranges from only four percent for EU immigrants to as much as 38 percent for refugees. The corresponding shares for native men are 87 percent in employment and 12 percent with social insurance as their main income source. For women, the average shares in employment vary from 46 percent for refugees to 85 percent for new EU immigrants, whereas the average shares in social insurance vary from five percent for new EU immigrants to 42 percent for refugees. The corresponding rates for native women are 80 percent in employment and 17 percent with social insurance as their main source of income.”

“The profiles estimated for refugees are particularly striking. For men, we find that the native‐immigrant employment gap reaches its minimum value at 20 percentage points after five to six years of residence. The gap then starts to increase quite sharply again, and reaches 30 percentage points after 15 years. This development is mirrored by a corresponding increase in social insurance dependency. For female refugees, the employment differential reaches its minimum of 30 percentage points after 5‐9 years of residence. The subsequent decline is less dramatic than what we observe for men, but the differential stands at 35 percentage points 15 years after admission. […] The employment difference between refugees from Bosnia and Somalia is fully 22.2 percentage points for men and 37.7 points for women. […] For immigrants from the old EU, the employment differential is slightly in favor of immigrants regardless of years since migration, and the social insurance differentials remain consistently negative. In other words, employment of old EU immigrants is almost indistinguishable from that of natives, and they are less likely to claim social insurance benefits.”

vi. Glucose Peaks and the Risk of Dementia and 20-Year Cognitive Decline.

“Hemoglobin A1c (HbA1c), a measure of average blood glucose level, is associated with the risk of dementia and cognitive impairment. However, the role of glycemic variability or glucose excursions in this association is unclear. We examined the association of glucose peaks in midlife, as determined by the measurement of 1,5-anhydroglucitol (1,5-AG) level, with the risk of dementia and 20-year cognitive decline.”

“Nearly 13,000 participants from the Atherosclerosis Risk in Communities (ARIC) study were examined. […] Over a median time of 21 years, dementia developed in 1,105 participants. Among persons with diabetes, each 5 μg/mL decrease in 1,5-AG increased the estimated risk of dementia by 16% (hazard ratio 1.16, P = 0.032). For cognitive decline among participants with diabetes and HbA1c <7% (53 mmol/mol), those with glucose peaks had a 0.19 greater z score decline over 20 years (P = 0.162) compared with those without peaks. Among participants with diabetes and HbA1c ≥7% (53 mmol/mol), those with glucose peaks had a 0.38 greater z score decline compared with persons without glucose peaks (P < 0.001). We found no significant associations in persons without diabetes.

CONCLUSIONS Among participants with diabetes, glucose peaks are a risk factor for cognitive decline and dementia. Targeting glucose peaks, in addition to average glycemia, may be an important avenue for prevention.”

vii. Gaze direction detection in autism spectrum disorder.

“Detecting where our partners direct their gaze is an important aspect of social interaction. An atypical gaze processing has been reported in autism. However, it remains controversial whether children and adults with autism spectrum disorder interpret indirect gaze direction with typical accuracy. This study investigated whether the detection of gaze direction toward an object is less accurate in autism spectrum disorder. Individuals with autism spectrum disorder (n = 33) and intelligence quotients–matched and age-matched controls (n = 38) were asked to watch a series of synthetic faces looking at objects, and decide which of two objects was looked at. The angle formed by the two possible targets and the face varied following an adaptive procedure, in order to determine individual thresholds. We found that gaze direction detection was less accurate in autism spectrum disorder than in control participants. Our results suggest that the precision of gaze following may be one of the altered processes underlying social interaction difficulties in autism spectrum disorder.”

“Where people look at informs us about what they know, want, or attend to. Atypical or altered detection of gaze direction might thus lead to impoverished acquisition of social information and social interaction. Alternatively, it has been suggested that abnormal monitoring of inner states […], or the lack of social motivation […], would explain the reduced tendency to follow conspecific gaze in individuals with ASD. Either way, a lower tendency to look at the eyes and to follow the gaze would provide fewer opportunities to practice GDD [gaze direction detection – US] ability. Thus, impaired GDD might either play a causal role in atypical social interaction, or conversely be a consequence of it. Exploring GDD earlier in development might help disentangle this issue.”

June 1, 2017 Posted by | Diabetes, Economics, Epidemiology, Medicine, Neurology, Psychiatry, Psychology, Studies | Leave a comment

Imported Plant Diseases

I found myself debating whether or not I should read Lewis, Petrovskii, and Potts’ text The Mathematics Behind Biological Invasions a while back, but at the time I in the end decided that it would simply be too much work to justify the potential payoff – so instead of reading the book, I decided to just watch the above lecture and leave it at that. This lecture is definitely a very poor textbook substitute, and I was strongly debating whether or not to blog it because it just isn’t very good; the level of coverage is very low. Which is sad, because some of the diseases discussed in the lecture – like e.g. wheat leaf rust – are really important and worth knowing about. One of the important points made in the lecture is that in the context of potential epidemics, it can be difficult to know when and how to intervene because of the uncertainty involved; early action may be the more efficient choice in terms of resource use, but the earlier you intervene, the less certain will be the intervention payoff and the less you’ll know about stuff like transmission patterns (…would outbreak X ever really have spread very wide if we had not intervened? We don’t observe the counterfactual…). Such aspects of course are not only relevant to plant-diseases, and the lecture also contains other basic insights from epidemiology which apply to other types of disease – but if you’ve ever opened a basic epidemiology text you’ll know all these things already.

May 22, 2017 Posted by | Biology, Botany, Ecology, Epidemiology, Lectures | Leave a comment

A few diabetes papers of interest

i. Association Between Blood Pressure and Adverse Renal Events in Type 1 Diabetes.

“The Joint National Committee and American Diabetes Association guidelines currently recommend a blood pressure (BP) target of <140/90 mmHg for all adults with diabetes, regardless of type (13). However, evidence used to support this recommendation is primarily based on data from trials of type 2 diabetes (46). The relationship between BP and adverse outcomes in type 1 and type 2 diabetes may differ, given that the type 1 diabetes population is typically much younger at disease onset, hypertension is less frequently present at diagnosis (3), and the basis for the pathophysiology and disease complications may differ between the two populations.

Prior prospective cohort studies (7,8) of patients with type 1 diabetes suggested that lower BP levels (<110–120/70–80 mmHg) at baseline entry were associated with a lower risk of adverse renal outcomes, including incident microalbuminuria. In one trial of antihypertensive treatment in type 1 diabetes (9), assignment to a lower mean arterial pressure (MAP) target of <92 mmHg (corresponding to ∼125/75 mmHg) led to a significant reduction in proteinuria compared with a MAP target of 100–107 mmHg (corresponding to ∼130–140/85–90 mmHg). Thus, it is possible that lower BP (<120/80 mmHg) reduces the risk of important renal outcomes, such as proteinuria, in patients with type 1 diabetes and may provide a synergistic benefit with intensive glycemic control on renal outcomes (1012). However, fewer studies have examined the association between BP levels over time and the risk of more advanced renal outcomes, such as stage III chronic kidney disease (CKD) or end-stage renal disease (ESRD)”.

“The primary objective of this study was to determine whether there is an association between lower BP levels and the risk of more advanced diabetic nephropathy, defined as macroalbuminuria or stage III CKD, within a background of different glycemic control strategies […] We included 1,441 participants with type 1 diabetes between the ages of 13 and 39 years who had previously been randomized to receive intensive versus conventional glycemic control in the Diabetes Control and Complications Trial (DCCT). The exposures of interest were time-updated systolic BP (SBP) and diastolic BP (DBP) categories. Outcomes included macroalbuminuria (>300 mg/24 h) or stage III chronic kidney disease (CKD) […] During a median follow-up time of 24 years, there were 84 cases of stage III CKD and 169 cases of macroalbuminuria. In adjusted models, SBP in the 2 (95% CI 1.05–1.21), and a 1.04 times higher risk of ESRD (95% CI 0.77–1.41) in adjusted Cox models. Every 10 mmHg increase in DBP was associated with a 1.17 times higher risk of microalbuminuria (95% CI 1.03–1.32), a 1.15 times higher risk of eGFR decline to 2 (95% CI 1.04–1.29), and a 0.80 times higher risk of ESRD (95% CI 0.47–1.38) in adjusted models. […] Because these data are observational, they cannot prove causation. It remains possible that subtle kidney disease may lead to early elevations in BP, and we cannot rule out the potential for reverse causation in our findings. However, we note similar trends in our data even when imposing a 7-year lag between BP and CKD ascertainment.”

CONCLUSIONS A lower BP (<120/70 mmHg) was associated with a substantially lower risk of adverse renal outcomes, regardless of the prior assigned glycemic control strategy. Interventional trials may be useful to help determine whether the currently recommended BP target of 140/90 mmHg may be too high for optimal renal protection in type 1 diabetes.”

It’s important to keep in mind when interpreting these results that endpoints like ESRD and stage III CKD are not the only relevant outcomes in this setting; even mild-stage kidney disease in diabetics significantly increase the risk of death from cardiovascular disease, and a substantial proportion of patients may die from cardiovascular disease before reaching a late-stage kidney disease endpoint (here’s a relevant link).

Identifying Causes for Excess Mortality in Patients With Diabetes: Closer but Not There Yet.

“A number of epidemiological studies have quantified the risk of death among patients with diabetes and assessed the causes of death (26), with highly varying results […] Overall, the studies to date have confirmed that diabetes is associated with an increased risk of all-cause mortality, but the magnitude of this excess risk is highly variable, with the relative risk ranging from 1.15 to 3.15. Nevertheless, all studies agree that mortality is mainly attributable to cardiovascular causes (26). On the other hand, studies of cancer-related death have generally been lacking despite the diabetes–cancer association and a number of plausible biological mechanisms identified to explain this link (8,9). In fact, studies assessing the specific causes of noncardiovascular death in diabetes have been sparse. […] In this issue of Diabetes Care, Baena-Díez et al. (10) report on an observational study of the association between diabetes and cause-specific death. This study involved 55,292 individuals from 12 Spanish population cohorts with no prior history of cardiovascular disease, aged 35 to 79 years, with a 10-year follow-up. […] This study found that individuals with diabetes compared with those without diabetes had a higher risk of cardiovascular death, cancer death, and noncardiovascular noncancer death with similar estimates obtained using the two statistical approaches. […] Baena-Díez et al. (10) showed that individuals with diabetes have an approximately threefold increased risk of cardiovascular mortality, which is much higher than what has been reported by recent studies (5,6). While this may be due to the lack of adjustment for important confounders in this study, there remains uncertainty regarding the magnitude of this increase.”

“[A]ll studies of excess mortality associated with diabetes, including the current one, have produced highly variable results. The reasons may be methodological. For instance, it may be that because of the wide range of age in these studies, comparing the rates of death between the patients with diabetes and those without diabetes using a measure based on the ratio of the rates may be misleading because the ratio can vary by age [it almost certainly does vary by age, US]. Instead, a measure based on the difference in rates may be more appropriate (16). Another issue relates to the fact that the studies include patients with longstanding diabetes of variable duration, resulting in so-called prevalent cohorts that can result in muddled mortality estimates since these are necessarily based on a mix of patients at different stages of disease (17). Thus, a paradigm change may be in order for future observational studies of diabetes and mortality, in the way they are both designed and analyzed. With respect to cancer, such studies will also need to tease out the independent contribution of antidiabetes treatments on cancer incidence and mortality (1820). It is thus clear that the quantification of the excess mortality associated with diabetes per se will need more accurate tools.”

iii. Risk of Cause-Specific Death in Individuals With Diabetes: A Competing Risks Analysis. This is the paper some of the results of which were discussed above. I’ll just include the highlights here:

RESULTS We included 55,292 individuals (15.6% with diabetes and overall mortality of 9.1%). The adjusted hazard ratios showed that diabetes increased mortality risk: 1) cardiovascular death, CSH = 2.03 (95% CI 1.63–2.52) and PSH = 1.99 (1.60–2.49) in men; and CSH = 2.28 (1.75–2.97) and PSH = 2.23 (1.70–2.91) in women; 2) cancer death, CSH = 1.37 (1.13–1.67) and PSH = 1.35 (1.10–1.65) in men; and CSH = 1.68 (1.29–2.20) and PSH = 1.66 (1.25–2.19) in women; and 3) noncardiovascular noncancer death, CSH = 1.53 (1.23–1.91) and PSH = 1.50 (1.20–1.89) in men; and CSH = 1.89 (1.43–2.48) and PSH = 1.84 (1.39–2.45) in women. In all instances, the cumulative mortality function was significantly higher in individuals with diabetes.

CONCLUSIONS Diabetes is associated with premature death from cardiovascular disease, cancer, and noncardiovascular noncancer causes.”


Diabetes is associated with premature death from cardiovascular diseases (coronary heart disease, stroke, and heart failure), several cancers (liver, colorectal, and lung), and other diseases (chronic obstructive pulmonary disease and liver and kidney disease). In addition, the cause-specific cumulative mortality for cardiovascular, cancer, and noncardiovascular noncancer causes was significantly higher in individuals with diabetes, compared with the general population. The dual analysis with CSH and PSH methods provides a comprehensive view of mortality dynamics in the population with diabetes. This approach identifies the individuals with diabetes as a vulnerable population for several causes of death aside from the traditionally reported cardiovascular death.”

iv. Disability-Free Life-Years Lost Among Adults Aged ≥50 Years With and Without Diabetes.

RESEARCH DESIGN AND METHODS Adults (n = 20,008) aged 50 years and older were followed from 1998 to 2012 in the Health and Retirement Study, a prospective biannual survey of a nationally representative sample of adults. Diabetes and disability status (defined by mobility loss, difficulty with instrumental activities of daily living [IADL], and/or difficulty with activities of daily living [ADL]) were self-reported. We estimated incidence of disability, remission to nondisability, and mortality. We developed a discrete-time Markov simulation model with a 1-year transition cycle to predict and compare lifetime disability-related outcomes between people with and without diabetes. Data represent the U.S. population in 1998.

RESULTS From age 50 years, adults with diabetes died 4.6 years earlier, developed disability 6–7 years earlier, and spent about 1–2 more years in a disabled state than adults without diabetes. With increasing baseline age, diabetes was associated with significant (P < 0.05) reductions in the number of total and disability-free life-years, but the absolute difference in years between those with and without diabetes was less than at younger baseline age. Men with diabetes spent about twice as many of their remaining years disabled (20–24% of remaining life across the three disability definitions) as men without diabetes (12–16% of remaining life across the three disability definitions). Similar associations between diabetes status and disability-free and disabled years were observed among women.

CONCLUSIONS Diabetes is associated with a substantial reduction in nondisabled years, to a greater extent than the reduction of longevity. […] Using a large, nationally representative cohort of Americans aged 50 years and older, we found that diabetes is associated with a substantial deterioration of nondisabled years and that this is a greater number of years than the loss of longevity associated with diabetes. On average, a middle-aged adult with diabetes has an onset of disability 6–7 years earlier than one without diabetes, spends 1–2 more years with disability, and loses 7 years of disability-free life to the condition. Although other nationally representative studies have reported large reductions in complications (9) and mortality among the population with diabetes in recent decades (1), these studies, akin to our results, suggest that diabetes continues to have a substantial impact on morbidity and quality of remaining years of life.”

v. Association Between Use of Lipid-Lowering Therapy and Cardiovascular Diseases and Death in Individuals With Type 1 Diabetes.

“People with type 1 diabetes have a documented shorter life expectancy than the general population without diabetes (1). Cardiovascular disease (CVD) is the main cause of the excess morbidity and mortality, and despite advances in management and therapy, individuals with type 1 diabetes have a markedly elevated risk of cardiovascular events and death compared with the general population (2).

Lipid-lowering treatment with hydroxymethylglutaryl-CoA reductase inhibitors (statins) prevents major cardiovascular events and death in a broad spectrum of patients (3,4). […] We hypothesized that primary prevention with lipid-lowering therapy (LLT) can reduce the incidence of cardiovascular morbidity and mortality in individuals with type 1 diabetes. The aim of the study was to examine this in a nationwide longitudinal cohort study of patients with no history of CVD. […] A total of 24,230 individuals included in 2006–2008 NDR with type 1 diabetes without a history of CVD were followed until 31 December 2012; 18,843 were untreated and 5,387 treated with LLT [Lipid-Lowering Therapy] (97% statins). The mean follow-up was 6.0 years. […] Hazard ratios (HRs) for treated versus untreated were as follows: cardiovascular death 0.60 (95% CI 0.50–0.72), all-cause death 0.56 (0.48–0.64), fatal/nonfatal stroke 0.56 (0.46–0.70), fatal/nonfatal acute myocardial infarction 0.78 (0.66–0.92), fatal/nonfatal coronary heart disease 0.85 (0.74–0.97), and fatal/nonfatal CVD 0.77 (0.69–0.87).

CONCLUSIONS This observational study shows that LLT is associated with 22–44% reduction in the risk of CVD and cardiovascular death among individuals with type 1 diabetes without history of CVD and underlines the importance of primary prevention with LLT to reduce cardiovascular risk in type 1 diabetes.”

vi. Prognostic Classification Factors Associated With Development of Multiple Autoantibodies, Dysglycemia, and Type 1 Diabetes—A Recursive Partitioning Analysis.

“In many prognostic factor studies, multivariate analyses using the Cox proportional hazards model are applied to identify independent prognostic factors. However, the coefficient estimates derived from the Cox proportional hazards model may be biased as a result of violating assumptions of independence. […] RPA [Recursive Partitioning Analysis] classification is a useful tool that could prioritize the prognostic factors and divide the subjects into distinctive groups. RPA has an advantage over the proportional hazards model in identifying prognostic factors because it does not require risk factor independence and, as a nonparametric technique, makes no requirement on the underlying distributions of the variables considered. Hence, it relies on fewer modeling assumptions. Also, because the method is designed to divide subjects into groups based on the length of survival, it defines groupings for risk classification, whereas Cox regression models do not. Moreover, there is no need to explicitly include covariate interactions because of the recursive splitting structure of tree model construction.”

“This is the first study that characterizes the risk factors associated with the transition from one preclinical stage to the next following a recommended staging classification system (9). The tree-structured prediction model reveals that the risk parameters are not the same across each transition. […] Based on the RPA classification, the subjects at younger age and with higher GAD65Ab [an important biomarker in the context of autoimmune forms of diabetes, US – here’s a relevant link] titer are at higher risk for progression to multiple positive autoantibodies from a single autoantibody (seroconversion). Approximately 70% of subjects with a single autoantibody were positive for GAD65Ab, much higher than for insulin autoantibody (24%) and IA-2A [here’s a relevant link – US] (5%). Our study results are consistent with those of others (2224) in that seroconversion is age related. Previous studies in infants and children at an early age have shown that progression from single to two or more autoantibodies occurs more commonly in children 25). The subjects ≤16 years of age had almost triple the 5-year risk compared with subjects >16 years of age at the same GAD65Ab titer level. Hence, not all individuals with a single islet autoantibody can be thought of as being at low risk for disease progression.”

“This is the first study that identifies the risk factors associated with the timing of transitions from one preclinical stage to the next in the development of T1D. Based on RPA risk parameters, we identify the characteristics of groups with similar 5-year risks for advancing to the next preclinical stage. It is clear that individuals with one or more autoantibodies or with dysglycemia are not homogeneous with regard to the risk of disease progression. Also, there are differences in risk factors at each stage that are associated with increased risk of progression. The potential benefit of identifying these groups allows for a more informed discussion of diabetes risk and the selective enrollment of individuals into clinical trials whose risk more appropriately matches the potential benefit of an experimental intervention. Since the risk levels in these groups are substantial, their definition makes possible the design of more efficient trials with target sample sizes that are feasible, opening up the field of prevention to additional at-risk cohorts. […] Our results support the evidence that autoantibody titers are strong predictors at each transition leading to T1D development. The risk of the development of multiple autoantibodies was significantly increased when the GAD65Ab titer level was elevated, and the risk of the development of dysglycemia was increased when the IA-2A titer level increased. These indicate that better risk prediction on the timing of transitions can be obtained by evaluating autoantibody titers. The results also suggest that an autoantibody titer should be carefully considered in planning prevention trials for T1D in addition to the number of positive autoantibodies and the type of autoantibody.”

May 17, 2017 Posted by | Diabetes, Epidemiology, Health Economics, Immunology, Medicine, Nephrology, Statistics, Studies | Leave a comment

A few diabetes papers of interest

A couple of weeks ago I decided to cover some of the diabetes articles I’d looked at and bookmarked in the past, but there were a lot of articles and I did not get very far. This post will cover some more of these articles I had failed to cover here despite intending to do so at some point. Considering that I these days relatively regularly peruse e.g. the Diabetes Care archives I am thinking of making this sort of post a semi-regular feature of the blog.

i. Association Between Diabetes and Hippocampal Atrophy in Elderly Japanese: The Hisayama Study.

“A total of 1,238 community-dwelling Japanese subjects aged ≥65 years underwent brain MRI scans and a comprehensive health examination in 2012. Total brain volume (TBV), intracranial volume (ICV), and hippocampal volume (HV) were measured using MRI scans for each subject. We examined the associations between diabetes-related parameters and the ratios of TBV to ICV (an indicator of global brain atrophy), HV to ICV (an indicator of hippocampal atrophy), and HV to TBV (an indicator of hippocampal atrophy beyond global brain atrophy) after adjustment for other potential confounders.”

“The multivariable-adjusted mean values of the TBV-to-ICV, HV-to-ICV, and HV-to-TBV ratios were significantly lower in the subjects with diabetes compared with those without diabetes (77.6% vs. 78.2% for the TBV-to-ICV ratio, 0.513% vs. 0.529% for the HV-to-ICV ratio, and 0.660% vs. 0.676% for the HV-to-TBV ratio; all P < 0.01). These three ratios decreased significantly with elevated 2-h postload glucose (PG) levels […] Longer duration of diabetes was significantly associated with lower TBV-to-ICV, HV-to-ICV, and HV-to-TBV ratios. […] Our data suggest that a longer duration of diabetes and elevated 2-h PG levels, a marker of postprandial hyperglycemia, are risk factors for brain atrophy, particularly hippocampal atrophy.”

“Intriguingly, our findings showed that the subjects with diabetes had significantly lower mean HV-to-TBV ratio values, indicating […] that the hippocampus is predominantly affected by diabetes. In addition, in our subjects a longer duration and a midlife onset of diabetes were significantly associated with a lower HV, possibly suggesting that a long exposure of diabetes particularly worsens hippocampal atrophy.”

The reason why hippocampal atrophy is a variable of interest to these researchers is that hippocampal atrophy is a feature of Alzheimer’s Disease, and diabetics have an elevated risk of AD. This is incidentally far from the first study providing some evidence for the existence of potential causal linkage between impaired glucose homeostasis and AD (see e.g. also this paper, which I’ve previously covered here on the blog).

ii. A Population-Based Study of All-Cause Mortality and Cardiovascular Disease in Association With Prior History of Hypoglycemia Among Patients With Type 1 Diabetes.

“Although patients with T1DM may suffer more frequently from hypoglycemia than those with T2DM (8), very few studies have investigated whether hypoglycemia may also increase the risk of CVD (6,9,10) or death (1,6,7) in patients with T1DM; moreover, the results of these studies have been inconclusive (6,9,10) because of the dissimilarities in their methodological aspects, including their enrollment of populations with T1DM with different levels of glycemic control, application of different data collection methods, and adoption of different lengths of observational periods.”

“Only a few population-based studies have examined the potential cumulative effect of repeated severe hypoglycemia on all-cause mortality or CVD incidence in T1DM (9). The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study of T2DM found a weakly inverse association between the annualized number of hypoglycemic episodes and the risk of death (11,12). By contrast, some studies find that repeated hypoglycemia may be an aggravating factor to atherosclerosis in T1DM (13,14). Studies on the compromised sympathetic-adrenal reaction in patients with repeated hypoglycemia have been inconclusive regarding whether such a reaction may further damage intravascular coagulation and thrombosis (15) or decrease the vulnerability of these patients to adverse health outcomes (12).

Apart from the lack of information on the potential dose–gradient effect associated with severe hypoglycemic events in T1DM from population-based studies, the risks of all-cause mortality/CVD incidence associated with severe hypoglycemia occurring at different periods before all-cause mortality/CVD incidence have never been examined. In this study, we used the population-based medical claims of a cohort of patients with T1DM to examine whether the risks of all-cause mortality/CVD incidence are associated with previous episodes of severe hypoglycemia in different periods and whether severe hypoglycemia may pose a dose–gradient effect on the risks of all-cause mortality/CVD incidence.”

“Two nested case-control studies with age- and sex-matched control subjects and using the time-density sampling method were performed separately within a cohort of 10,411 patients with T1DM in Taiwan. The study enrolled 564 nonsurvivors and 1,615 control subjects as well as 743 CVD case subjects and 1,439 control subjects between 1997 and 2011. History of severe hypoglycemia was identified during 1 year, 1–3 years, and 3–5 years before the occurrence of the study outcomes.”

“Prior severe hypoglycemic events within 1 year were associated with higher risks of all-cause mortality and CVD (adjusted OR 2.74 [95% CI 1.96–3.85] and 2.02 [1.35–3.01], respectively). Events occurring within 1–3 years and 3–5 years before death were also associated with adjusted ORs of 1.94 (95% CI 1.39–2.71) and 1.68 (1.15–2.44), respectively. Significant dose–gradient effects of severe hypoglycemia frequency on mortality and CVD were observed within 5 years. […] we found that a greater frequency of severe hypoglycemia occurring 1 year before death was significantly associated with a higher OR of all-cause mortality (1 vs. 0: 2.45 [95% CI 1.65–3.63]; ≥2 vs. 0: 3.49 [2.01–6.08], P < 0.001 for trend). Although the strength of the association was attenuated, a significant dose–gradient effect still existed for severe hypoglycemia occurring in 1–3 years (P < 0.001 for trend) and 3–5 years (P < 0.015 for trend) before death. […] Exposure to repeated severe hypoglycemic events can lead to higher risks of mortality and CVD.”

“Our findings are supported by two previous studies that investigated atherosclerosis risk in T1DM (13,14). The DCCT/EDIC project reported that the prevalence of coronary artery calcification, an established atherosclerosis marker, was linearly correlated with the incidence rate of hypoglycemia on the DCCT stage (14). Giménez et al. (13) also demonstrated that repeated episodes of hypoglycemia were an aggravating factor for preclinical atherosclerosis in T1DM. […] The mechanism of hypoglycemia that predisposes to all-cause mortality/CVD incidence remains unclear.”

iii. Global Estimates on the Number of People Blind or Visually Impaired by Diabetic Retinopathy: A Meta-analysis From 1990 to 2010.

“On the basis of previous large-scale population-based studies and meta-analyses, diabetic retinopathy (DR) has been recognized as one of the most common and important causes for visual impairment and blindness (1–19). These studies in general showed that DR was the leading cause of blindness globally among working-aged adults and therefore has a significant socioeconomic impact (20–22).”

“A previous meta-analysis (21) summarizing 35 studies with more than 20,000 patients with diabetes estimated a prevalence of any DR of 34.6%, of diabetic macular edema of 6.8%, and of vision-threating DR of 10.2% within the diabetes population. […] Yau et al. (21) estimated that ∼93 million people had some DR and 28 million people had sight-threatening stages of DR. However, this meta-analysis did not address the prevalence of visual impairment and blindness due to DR and thus the impact of DR on the general population. […] We therefore conducted the present meta-analysis of all available population-based studies performed worldwide within the last two decades as part of the Global Burden of Disease Study 2010 (GBD) to estimate the number of people affected by blindness and visual impairment.”

“DR [Diabetic Retinopathy] ranks as the fifth most common cause of global blindness and of global MSVI [moderate and severe vision impairment] (25). […] this analysis estimates that, in 2010, 1 out of every 39 blind people had blindness due to DR and 1 out of every 52 people had visual impairment due to DR. […] Globally in 2010, out of overall 32.4 million blind and 191 million visually impaired people, 0.8 million were blind and 3.7 million were visually impaired because of DR, with an alarming increase of 27% and 64%, respectively, spanning the two decades from 1990 to 2010. DR accounted for 2.6% of all blindness in 2010 and 1.9% of all MSVI worldwide, increasing from 2.1% and 1.3%, respectively, in 1990. […] The number of persons with visual impairment due to DR worldwide is rising and represents an increasing proportion of all blindness/MSVI causes. Age-standardized prevalence of DR-related blindness/MSVI was higher in sub-Saharan Africa and South Asia.”

“Our data suggest that the percentage of blindness and MSVI attributable to DR was lower in low-income regions with younger populations than in high-income regions with older populations. There are several reasons that may explain this observation. First, low-income societies may have a higher percentage of unoperated cataract or undercorrected refractive error–related blindness and MSVI (25), which is probably related to access to visual and ocular health services. Therefore, the proportional increase in blindness and MSVI attributable to DR may be rising because of the decreasing proportion attributable to cataract (25) as a result of the increasing availability of cataract surgery in many parts of the world (29) during the past decade. Improved visualization of the fundus afforded by cataract surgery should also improve the detection of DR. The increase in the percentage of global blindness caused by DR within the last two decades took place in all world regions except Western Europe and high-income North America where there was a slight decrease. This decrease may reflect the effect of intensified prevention and treatment of DR possibly in part due to the introduction of intravitreal injections of steroids and anti-VEGF (vascular endothelial growth factor) drugs (30,31).

Second, in regions with poor medical infrastructure, patients with diabetes may not live long enough to experience DR (32). This reduces the number of patients with diabetes, and, furthermore, it reduces the number of patients with DR-related vision loss. Studies in the literature have reported that the prevalence of severe DR decreased from 1990 to 2010 (21) while the prevalence of diabetes simultaneously increased (27), which implies a reduction in the prevalence of severe DR per person with diabetes. […] Third, […] younger populations may have a lower prevalence of diabetes (33). […] Therefore, considering further economic development in rural regions, improvements in medical infrastructure, the general global demographic transition to elderly populations, and the association between increasing economic development and obesity, we project the increase in the proportion of DR-related blindness and MSVI to continue to rise in the future.”

iv. Do Patient Characteristics Impact Decisions by Clinicians on Hemoglobin A1c Targets?

“In setting hemoglobin A1c (HbA1c) targets, physicians must consider individualized risks and benefits of tight glycemic control (1,2) by recognizing that the risk-benefit ratio may become unfavorable in certain patients, including the elderly and/or those with multiple comorbidities (3,4). Customization of treatment goals based on patient characteristics is poorly understood, partly due to insufficient data on physicians’ decisions in setting targets. We used the National Health and Nutrition Examination Survey (NHANES) to analyze patient-reported HbA1c targets set by physicians and to test whether targets are correlated with patient characteristics.”

“we did not find any evidence that U.S. physicians systematically consider important patient-specific information when selecting the intensity of glycemic control. […] the lack of variation with patient characteristics suggests overreliance on a general approach, without consideration of individual variation in the risks and benefits (or patient preference) of tight control.”

v. Cardiovascular Autonomic Neuropathy, Sexual Dysfunction, and Urinary Incontinence in Women With Type 1 Diabetes.

“This study evaluated associations among cardiovascular autonomic neuropathy (CAN), female sexual dysfunction (FSD), and urinary incontinence (UI) in women with type I diabetes mellitus (T1DM). […] We studied 580 women with T1DM in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study (DCCT/EDIC).”

“At EDIC year 17, FSD was observed in 41% of women and UI in 30%. […] We found that CAN was significantly more prevalent among women with FSD and/or UI, because 41% of women with FSD and 44% with UI had positive measures of CAN compared with 30% without FSD and 38% without UI at EDIC year 16/17. We also observed bivariate associations between FSD and several measures of CAN […] In long-standing T1DM, CAN may predict development of FSD and may be a useful surrogate for generalized diabetic autonomic neuropathy.”

“Although autonomic dysfunction has been considered an important factor in the etiology of many diabetic complications, including constipation, exercise intolerance, bladder dysfunction, erectile dysfunction, orthostatic hypotension, and impaired neurovascular function, our study is among the first to systematically demonstrate a link between CAN and FSD in a large cohort of well-characterized patients with T1DM (14).”

vi. Correlates of Medication Adherence in the TODAY Cohort of Youth With Type 2 Diabetes.

“A total of 699 youth 10–17 years old with recent-onset type 2 diabetes and ≥80% adherence to metformin therapy for ≥8 weeks during a run-in period were randomized to receive one of three treatments. Participants took two study pills twice daily. Adherence was calculated by pill count from blister packs returned at visits. High adherence was defined as taking ≥80% of medication; low adherence was defined as taking <80% of medication.”

“In this low socioeconomic cohort, high and low adherence did not differ by sex, age, family income, parental education, or treatment group. Adherence declined over time (72% high adherence at 2 months, 56% adherence at 48 months, P < 0.0001). A greater percentage of participants with low adherence had clinically significant depressive symptoms at baseline (18% vs. 12%, P = 0.0415). No adherence threshold predicted the loss of glycemic control. […] Most pediatric type 1 diabetes studies (5–7) consistently document a correlation between adherence and race, ethnicity, and socioeconomic status, and studies of adults with type 2 diabetes (8,9) have documented that depressed patients are less adherent to their diabetes regimen. There is a dearth of information in the literature regarding adherence to medication in pediatric patients with type 2 diabetes.”

“In the cohort, the presence of baseline clinically significant depressive symptoms was associated with subsequent lower adherence. […] The TODAY cohort demonstrated deterioration in study medication adherence over time, irrespective of treatment group assignment. […] Contrary to expectation, demographic factors (sex, race-ethnicity, household income, and parental educational level) did not predict medication adherence. The lack of correlation with these factors in the TODAY trial may be explained by the limited income and educational range of the families in the TODAY trial. Nearly half of the families in the TODAY trial had an annual income of <$25,000, and, for over half of the families, the highest level of parental education was a high school degree or lower. In addition, our run-in criteria selected for more adherent subjects. All subjects had to have >80% adherence to M therapy for ≥8 weeks before they could be randomized. This may have limited variability in medication adherence postrandomization. It is also possible that selecting for more adherent subjects in the run-in period also selected for subjects with a lower frequency of depressive symptoms.”

“In the TODAY trial, baseline clinically significant depressive symptoms were more prevalent in the lower-adherence group, suggesting that regular screening for depressive symptoms should be undertaken to identify youth who were at high risk for poor medication adherence. […] Studies in adults with type 2 diabetes (2328) consistently report that depressed patients are less adherent to their diabetes regimen and experience more physical complications of diabetes. Identifying youth who are at risk for poor medication adherence early in the course of disease would make it possible to provide support and, if needed, specific treatment. Although we were not able to determine whether the treatment of depressive symptoms changed adherence over time, our findings support the current guidelines for psychosocial screening in youth with diabetes (29,30).”

vii. Increased Risk of Incident Chronic Kidney Disease, Cardiovascular Disease, and Mortality in Patients With Diabetes With Comorbid Depression.

Another depression-related paper, telling another part of the story. If depressed diabetics are less compliant/adherent, which seems – as per the above study – to be the case both in the context of the adult and pediatric patient population, then you might also expect this reduced compliance/adherence to ‘translate’ into this group having poorer metabolic control, and thus be at higher risk of developing microvascular complications such as nephropathy. This seems to be what we observe, at least according to the findings of this study:

“It is not known if patients with diabetes with depression have an increased risk of chronic kidney disease (CKD). We examined the association between depression and incident CKD, mortality, and incident cardiovascular events in U.S. veterans with diabetes.”

“Among a nationally representative prospective cohort of >3 million U.S. veterans with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2, we identified 933,211 patients with diabetes. Diabetes was ascertained by an ICD-9-CM code for diabetes, an HbA1c >6.4%, or receiving antidiabetes medication during the inclusion period. Depression was defined by an ICD-9-CM code for depression or by antidepressant use during the inclusion period. Incident CKD was defined as two eGFR levels 2 separated by ≥90 days and a >25% decline in baseline eGFR.”

“Depression was associated with 20% higher risk of incident CKD (adjusted hazard ratio [aHR] and 95% CI: 1.20 [1.19–1.21]). Similarly, depression was associated with increased all-cause mortality (aHR and 95% CI: 1.25 [1.24–1.26]). […] The presence of depression in patients with diabetes is associated with higher risk of developing CKD compared with nondepressed patients.”

It’s important to remember that the higher reported eGFRs in the depressed patient group may not be important/significant, and they should not be taken as an indication of relatively better kidney function in this patient population – especially in the type 2 context, the relationship between eGFR and kidney function is complicated. I refer to Bakris et al.‘s text on these topics for details (blog coverage here).

May 6, 2017 Posted by | Cardiology, Diabetes, Epidemiology, Medicine, Nephrology, Neurology, Ophthalmology, Psychology, Studies | Leave a comment

A few diabetes papers of interest

1. Cognitive Dysfunction in Older Adults With Diabetes: What a Clinician Needs to Know. I’ve talked about these topics before here on the blog (see e.g. these posts on related topics), but this is a good summary article. I have added some observations from the paper below:

“Although cognitive dysfunction is associated with both type 1 and type 2 diabetes, there are several distinct differences observed in the domains of cognition affected in patients with these two types. Patients with type 1 diabetes are more likely to have diminished mental flexibility and slowing of mental speed, whereas learning and memory are largely not affected (8). Patients with type 2 diabetes show decline in executive function, memory, learning, attention, and psychomotor efficiency (9,10).”

“So far, it seems that the risk of cognitive dysfunction in type 2 diabetes may be influenced by glycemic control, hypoglycemia, inflammation, depression, and macro- and microvascular pathology (14). The cumulative impact of these conditions on the vascular etiology may further decrease the threshold at which cognition is affected by other neurological conditions in the aging brain. In patients with type 1 diabetes, it seems as though diabetes has a lesser impact on cognitive dysfunction than those patients with type 2 diabetes. […] Thus, the cognitive decline in patients with type 1 diabetes may be mild and may not interfere with their functionality until later years, when other aging-related factors become important. […] However, recent studies have shown a higher prevalence of cognitive dysfunction in older patients (>60 years of age) with type 1 diabetes (5).”

“Unlike other chronic diseases, diabetes self-care involves many behaviors that require various degrees of cognitive pliability and insight to perform proper self-care coordination and planning. Glucose monitoring, medications and/or insulin injections, pattern management, and diet and exercise timing require participation from different domains of cognitive function. In addition, the recognition, treatment, and prevention of hypoglycemia, which are critical for the older population, also depend in large part on having intact cognition.

The reason a clinician needs to recognize different domains of cognition affected in patients with diabetes is to understand which self-care behavior will be affected in that individual. […] For example, a patient with memory problems may forget to take insulin doses, forget to take medications/insulin on time, or forget to eat on time. […] Cognitively impaired patients using insulin are more likely to not know what to do in the event of low blood glucose or how to manage medication on sick days (34). Patients with diminished mental flexibility and processing speed may do well with a simple regimen but may fail if the regimen is too complex. In general, older patients with diabetes with cognitive dysfunction are less likely to be involved in diabetes self-care and glucose monitoring compared with age-matched control subjects (35). […] Other comorbidities associated with aging and diabetes also add to the burden of cognitive impairment and its impact on self-care abilities. For example, depression is associated with a greater decline in cognitive function in patients with type 2 diabetes (36). Depression also can independently negatively impact the motivation to practice self-care.”

“Recently, there is an increasing discomfort with the use of A1C as a sole parameter to define glycemic goals in the older population. Studies have shown that A1C values in the older population may not reflect the same estimated mean glucose as in the younger population. Possible reasons for this discrepancy are the commonly present comorbidities that impact red cell life span (e.g., anemia, uremia, renal dysfunction, blood transfusion, erythropoietin therapy) (45,46). In addition, A1C level does not reflect glucose excursions and variability. […] Thus, it is prudent to avoid A1C as the sole measure of glycemic goal in this population. […] In patients who need insulin therapy, simplification, also known as de-intensification of the regimen, is generally recommended in all frail patients, especially if they have cognitive dysfunction (37,49). However, the practice has not caught up with the recommendations as shown by large observational studies showing unnecessary intensive control in patients with diabetes and dementia (50–52).”

“With advances in the past few decades, we now see a larger number of patients with type 1 diabetes who are aging successfully and facing the new challenges that aging brings. […] Patients with type 1 diabetes are typically proactive in their disease management and highly disciplined. Cognitive dysfunction in these patients creates significant distress for the first time in their lives; they suddenly feel a “lack of control” over the disease they have managed for many decades. The addition of autonomic dysfunction, gastropathy, or neuropathy may result in wider glucose excursions. These patients are usually more afraid of hyperglycemia than hypoglycemia — both of which they have managed for many years. However, cognitive dysfunction in older adults with type 1 diabetes has been found to be associated with hypoglycemic unawareness and glucose variability (5), which in turn increases the risk of severe hypoglycemia (54). The need for goal changes to avoid hypoglycemia and accept some hyperglycemia can be very difficult for many of these patients.”

2. Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006–2013.

“From 2006 to 2013, use increased for metformin (from 47.6 to 53.5%), dipeptidyl peptidase 4 inhibitors (0.5 to 14.9%), and insulin (17.1 to 23.0%) but declined for sulfonylureas (38.8 to 30.8%) and thiazolidinediones (28.5 to 5.6%; all P < 0.001). […] The overall rate of severe hypoglycemia remained the same (1.3 per 100 person-years; P = 0.72), declined modestly among the oldest patients (from 2.9 to 2.3; P < 0.001), and remained high among those with two or more comorbidities (3.2 to 3.5; P = 0.36). […] During the recent 8-year period, the use of glucose-lowering drugs has changed dramatically among patients with T2DM. […] The use of older classes of medications, such as sulfonylureas and thiazolidinediones, declined. During this time, glycemic control of T2DM did not improve in the overall population and remained poor among nearly a quarter of the youngest patients. Rates of severe hypoglycemia remained largely unchanged, with the oldest patients and those with multiple comorbidities at highest risk. These findings raise questions about the value of the observed shifts in drug utilization toward newer and costlier medications.”

“Our findings are consistent with a prior study of drug prescribing in U.S. ambulatory practice conducted from 1997 to 2012 (2). In that study, similar increases in DPP-4 inhibitor and insulin analog prescribing were observed; these changes were accompanied by a 61% increase in drug expenditures (2). Our study extends these findings to drug utilization and demonstrates that these increases occurred in all age and comorbidity subgroups. […] In contrast, metformin use increased only modestly between 2006 and 2013 and remained relatively low among older patients and those with two or more comorbidities. Although metformin is recommended as first-line therapy (26), it may be underutilized as the initial agent for the treatment of T2DM (27). Its use may be additionally limited by coexisting contraindications, such as chronic kidney disease (28).”

“The proportion of patients with a diagnosis of diabetes who did not fill any glucose-lowering medications declined slightly (25.7 to 24.1%; P < 0.001).”

That is, one in four people who had a diagnosis of type 2 diabetes were not taking any prescription drugs for their health condition. I wonder how many of those people have read wikipedia articles like this one

“When considering treatment complexity, the use of oral monotherapy increased slightly (from 24.3 to 26.4%) and the use of multiple (two or more) oral agents declined (from 33.0 to 26.5%), whereas the use of insulin alone and in combination with oral agents increased (from 6.0 to 8.5% and from 11.1 to 14.6%, respectively; all P values <0.001).”

“Between 1987 and 2011, per person medical spending attributable to diabetes doubled (4). More than half of the increase was due to prescription drug spending (4). Despite these spending increases and greater utilization of newly developed medications, we showed no concurrent improvements in overall glycemic control or the rates of severe hypoglycemia in our study. Although the use of newer and more expensive agents may have other important benefits (44), further studies are needed to define the value and cost-effectiveness of current treatment options.”

iii. Among Low-Income Respondents With Diabetes, High-Deductible Versus No-Deductible Insurance Sharply Reduces Medical Service Use.

“Using the 2011–2013 Medical Expenditure Panel Survey, bivariate and regression analyses were conducted to compare demographic characteristics, medical service use, diabetes care, and health status among privately insured adult respondents with diabetes, aged 18–64 years (N = 1,461) by lower (<200% of the federal poverty level) and higher (≥200% of the federal poverty level) income and deductible vs. no deductible (ND), low deductible ($1,000/$2,400) (LD), and high deductible (>$1,000/$2,400) (HD). The National Health Interview Survey 2012–2014 was used to analyze differences in medical debt and delayed/avoided needed care among adult respondents with diabetes (n = 4,058) by income. […] Compared with privately insured respondents with diabetes with ND, privately insured lower-income respondents with diabetes with an LD report significant decreases in service use for primary care, checkups, and specialty visits (27%, 39%, and 77% lower, respectively), and respondents with an HD decrease use by 42%, 65%, and 86%, respectively. Higher-income respondents with an LD report significant decreases in specialty (28%) and emergency department (37%) visits.”

“The reduction in ambulatory visits made by lower-income respondents with ND compared with lower-income respondents with an LD or HD is far greater than for higher-income patients. […] The substantial reduction in checkup (preventive) and specialty visits by those with a lower income who have an HDHP [high-deductible health plan, US] implies a very different pattern of service use compared with lower-income respondents who have ND and with higher-income respondents. Though preventive visits require no out-of-pocket costs, reduced preventive service use with HDHPs is well established and might be the result of patients being unaware of this benefit or their concern about findings that could lead to additional expenses (31). Such sharply reduced service use by low-income respondents with diabetes may not be desirable. Patients with diabetes benefit from assessment of diabetes control, encouragement and reinforcement of behavior change and medication use, and early detection and treatment of diabetes complications or concomitant disease.”

iv. Long-term Mortality and End-Stage Renal Disease in a Type 1 Diabetes Population Diagnosed at Age 15–29 Years in Norway.

OBJECTIVE To study long-term mortality, causes of death, and end-stage renal disease (ESRD) in people diagnosed with type 1 diabetes at age 15–29 years.

RESEARCH DESIGN AND METHODS This nationwide, population-based cohort with type 1 diabetes diagnosed during 1978–1982 (n = 719) was followed from diagnosis until death, emigration, or September 2013. Linkages to the Norwegian Cause of Death Registry and the Norwegian Renal Registry provided information on causes of death and whether ESRD was present.

RESULTS During 30 years’ follow-up, 4.6% of participants developed ESRD and 20.6% (n = 148; 106 men and 42 women) died. Cumulative mortality by years since diagnosis was 6.0% (95% CI 4.5–8.0) at 10 years, 12.2% (10.0–14.8) at 20 years, and 18.4% (15.8–21.5) at 30 years. The SMR [standardized mortality ratio] was 4.4 (95% CI 3.7–5.1). Mean time from diagnosis of diabetes to ESRD was 23.6 years (range 14.2–33.5). Death was caused by chronic complications (32.2%), acute complications (20.5%), violent death (19.9%), or any other cause (27.4%). Death was related to alcohol in 15% of cases. SMR for alcohol-related death was 6.8 (95% CI 4.5–10.3), for cardiovascular death was 7.3 (5.4–10.0), and for violent death was 3.6 (2.3–5.3).

CONCLUSIONS The cumulative incidence of ESRD was low in this cohort with type 1 diabetes followed for 30 years. Mortality was 4.4 times that of the general population, and more than 50% of all deaths were caused by acute or chronic complications. A relatively high proportion of deaths were related to alcohol.”

Some additional observations from the paper:

“Studies assessing causes of death in type 1 diabetes are most frequently conducted in individuals diagnosed during childhood (17) or without evaluating the effect of age at diagnosis (8,9). Reports on causes of death in cohorts of patients diagnosed during late adolescence or young adulthood, with long-term follow-up, are less frequent (10). […] Adherence to treatment during this age is poor and the risk of acute diabetic complications is high (1316). Mortality may differ between those with diabetes diagnosed during this period of life and those diagnosed during childhood.”

“Mortality was between four and five times higher than in the general population […]. The excess mortality was similar for men […] and women […]. SMR was higher in the lower age bands — 6.7 (95% CI 3.9–11.5) at 15–24 years and 7.3 (95% CI 5.2–10.1) at 25–34 years — compared with the higher age bands: 3.7 (95% CI 2.7–4.9) at 45–54 years and 3.9 (95% CI 2.6–5.8) at 55–65 years […]. The Cox regression model showed that the risk of death increased significantly by age at diagnosis (HR 1.1; 95% CI 1.1–1.2; P < 0.001) and was eight to nine times higher if ESRD was present (HR 8.7; 95% CI 4.8–15.5; P < 0.0001). […] the underlying cause of death was diabetes in 57 individuals (39.0%), circulatory in 22 (15.1%), cancer in 18 (12.3%), accidents or intoxications in 20 (13.7%), suicide in 8 (5.5%), and any other cause in 21 (14.4%) […] In addition, diabetes contributed to death in 29.5% (n = 43) and CVD contributed to death in 10.9% (n = 29) of the 146 cases. Diabetes was mentioned on the death certificate for 68.2% of the cohort but for only 30.0% of the violent deaths. […] In 60% (88/146) of the cases the review committee considered death to be related to diabetes, whereas in 40% (58/146) the cause was unrelated to diabetes or had an unknown relation to diabetes. According to the clinical committee, acute complications caused death in 20.5% (30/146) of the cases; 20 individuals died as a result of DKA and 10 from hypoglycemia. […] Chronic complications caused the largest proportion of deaths (47/146; 32.2%) and increased with increasing duration of diabetes […]. Among individuals dying as a result of chronic complications (n = 47), CVD caused death in 94% (n = 44) and renal failure in 6% (n = 3). ESRD contributed to death in 22.7% (10/44) of those dying from CVD. Cardiovascular death occurred at mortality rates seven times higher than those in the general population […]. ESRD caused or contributed to death in 13 of 14 cases, when present.”

“Violence (intoxications, accidents, and suicides) was the leading cause of death before 10 years’ duration of diabetes; thereafter it was only a minor cause […] Insulin was used in two of seven suicides. […] According to the available medical records and autopsy reports, about 20% (29/146) of the deceased misused alcohol. In 15% (22/146) alcohol-related ICD-10 codes were listed on the death certificate (18% [19/106] of men and 8% [3/40] of women). In 10 cases the cause of death was uncertain but considered to be related to alcohol or diabetes […] The SMR for alcohol-related death was high when considering the underlying cause of death (5.0; 95% CI 2.5–10.0), and even higher when considering all alcohol-related ICD-10 codes listed on the death certificate (6.8; 95% CI 4.5–10.3). The cause of death was associated with alcohol in 21.8% (19/87) of those who died with less than 20 years’ diabetes duration. Drug abuse was noted on the death certificate in only two cases.”

“During follow-up, 33 individuals (4.6%; 22 men and 11 women) developed ESRD as a result of diabetic nephropathy. Mean time from diagnosis of diabetes to ESRD was 23.6 years (range 14.2–33.5 years). Cumulative incidence of ESRD by years since diagnosis of diabetes was 1.4% (95% CI 0.7–2.7) at 20 years and 4.8% (95% CI 3.4–6.9) at 30 years.”

“This study highlights three important findings. First, among individuals who were diagnosed with type 1 diabetes in late adolescence and early adulthood and had good access to health care, and who were followed for 30 years, mortality was four to five times that of the general population. Second, 15% of all deaths were associated with alcohol, and the SMR for alcohol-related deaths was 6.8. Third, there was a relatively low cumulative incidence of ESRD (4.8%) 30 years after the diagnosis of diabetes.

We report mortality higher than those from a large, population-based study from Finland that found cumulative mortality around 6% at 20 years’ and 15% at 30 years’ duration of diabetes among a population with age at onset and year of diagnosis similar to those in our cohort (10). The corresponding numbers in our cohort were 12% and 18%, respectively; the discrepancy was particularly high at 20 years. The SMR in the Finnish cohort was lower than that in our cohort (2.6–3.0 vs. 3.7–5.1), and those authors reported the SMR to be lower in late-onset diabetes (at age 15–29 years) compared with early-onset diabetes (at age 23). The differences between the Norwegian and Finnish data are difficult to explain since both reports are from countries with good access to health care and a high incidence of type 1 diabetes.”

However the reason for the somewhat different SMRs in these two reasonably similar countries may actually be quite simple – the important variable may be alcohol:

“Finland and Norway are appropriate to compare because they share important population and welfare characteristics. There are, however, significant differences in drinking levels and alcohol-related mortality: the Finnish population consumes more alcohol and the Norwegian population consumes less. The mortality rates for deaths related to alcohol are about three to four times higher in Finland than in Norway (30). […] The markedly higher SMR in our cohort can probably be explained by the lower mortality rates for alcohol-related mortality in the general population. […] In conclusion, the high mortality reported in this cohort with an onset of diabetes in late adolescence and young adulthood draws attention to people diagnosed during a vulnerable period of life. Both acute and chronic complications cause substantial premature mortality […] Our study suggests that increased awareness of alcohol-related death should be encouraged in clinics providing health care to this group of patients.”

April 23, 2017 Posted by | Diabetes, Economics, Epidemiology, Health Economics, Medicine, Nephrology, Neurology, Papers, Pharmacology, Psychology | Leave a comment

Biodemography of aging (III)

Latent class representation of the Grade of Membership model.
Singular value decomposition.
Affine space.
Lebesgue measure.
General linear position.

The links above are links to topics I looked up while reading the second half of the book. The first link is quite relevant to the book’s coverage as a comprehensive longitudinal Grade of Membership (-GoM) model is covered in chapter 17. Relatedly, chapter 18 covers linear latent structure (-LLS) models, and as observed in the book LLS is a generalization of GoM. As should be obvious from the nature of the links some of the stuff included in the second half of the text is highly technical, and I’ll readily admit I was not fully able to understand all the details included in the coverage of chapters 17 and 18 in particular. On account of the technical nature of the coverage in Part 2 I’m not sure I’ll cover the second half of the book in much detail, though I probably shall devote at least one more post to some of those topics, as they were quite interesting even if some of the details were difficult to follow.

I have almost finished the book at this point, and I have already decided to both give the book five stars and include it on my list of favorite books on goodreads; it’s really well written, and it provides consistently highly detailed coverage of very high quality. As I also noted in the first post about the book the authors have given readability aspects some thought, and I am sure most readers would learn quite a bit from this text even if they were to skip some of the more technical chapters. The main body of Part 2 of the book, the subtitle of which is ‘Statistical Modeling of Aging, Health, and Longevity’, is however probably in general not worth the effort of reading unless you have a solid background in statistics.

This post includes some observations and quotes from the last chapters of the book’s Part 1.

“The proportion of older adults in the U.S. population is growing. This raises important questions about the increasing prevalence of aging-related diseases, multimorbidity issues, and disability among the elderly population. […] In 2009, 46.3 million people were covered by Medicare: 38.7 million of them were aged 65 years and older, and 7.6 million were disabled […]. By 2031, when the baby-boomer generation will be completely enrolled, Medicare is expected to reach 77 million individuals […]. Because the Medicare program covers 95 % of the nation’s aged population […], the prediction of future Medicare costs based on these data can be an important source of health care planning.”

“Three essential components (which could be also referred as sub-models) need to be developed to construct a modern model of forecasting of population health and associated medical costs: (i) a model of medical cost projections conditional on each health state in the model, (ii) health state projections, and (iii) a description of the distribution of initial health states of a cohort to be projected […] In making medical cost projections, two major effects should be taken into account: the dynamics of the medical costs during the time periods comprising the date of onset of chronic diseases and the increase of medical costs during the last years of life. In this chapter, we investigate and model the first of these two effects. […] the approach developed in this chapter generalizes the approach known as “life tables with covariates” […], resulting in a new family of forecasting models with covariates such as comorbidity indexes or medical costs. In sum, this chapter develops a model of the relationships between individual cost trajectories following the onset of aging-related chronic diseases. […] The underlying methodological idea is to aggregate the health state information into a single (or several) covariate(s) that can be determinative in predicting the risk of a health event (e.g., disease incidence) and whose dynamics could be represented by the model assumptions. An advantage of such an approach is its substantial reduction of the degrees of freedom compared with existing forecasting models  (e.g., the FEM model, Goldman and RAND Corporation 2004). […] We found that the time patterns of medical cost trajectories were similar for all diseases considered and can be described in terms of four components having the meanings of (i) the pre-diagnosis cost associated with initial comorbidity represented by medical expenditures, (ii) the cost peak associated with the onset of each disease, (iii) the decline/reduction in medical expenditures after the disease onset, and (iv) the difference between post- and pre-diagnosis cost levels associated with an acquired comorbidity. The description of the trajectories was formalized by a model which explicitly involves four parameters reflecting these four components.”

As I noted earlier in my coverage of the book, I don’t think the model above fully captures all relevant cost contributions of the diseases included, as the follow-up period was too short to capture all relevant costs to be included in the part iv model component. This is definitely a problem in the context of diabetes. But then again nothing in theory stops people from combining the model above with other models which are better at dealing with the excess costs associated with long-term complications of chronic diseases, and the model results were intriguing even if the model likely underperforms in a few specific disease contexts.

Moving on…

“Models of medical cost projections usually are based on regression models estimated with the majority of independent predictors describing demographic status of the individual, patient’s health state, and level of functional limitations, as well as their interactions […]. If the health states needs to be described by a number of simultaneously manifested diseases, then detailed stratification over the categorized variables or use of multivariate regression models allows for a better description of the health states. However, it can result in an abundance of model parameters to be estimated. One way to overcome these difficulties is to use an approach in which the model components are demographically-based aggregated characteristics that mimic the effects of specific states. The model developed in this chapter is an example of such an approach: the use of a comorbidity index rather than of a set of correlated categorical regressor variables to represent the health state allows for an essential reduction in the degrees of freedom of the problem.”

“Unlike mortality, the onset time of chronic disease is difficult to define with high precision due to the large variety of disease-specific criteria for onset/incident case identification […] there is always some arbitrariness in defining the date of chronic disease onset, and a unified definition of date of onset is necessary for population studies with a long-term follow-up.”

“Individual age trajectories of physiological indices are the product of a complicated interplay among genetic and non-genetic (environmental, behavioral, stochastic) factors that influence the human body during the course of aging. Accordingly, they may differ substantially among individuals in a cohort. Despite this fact, the average age trajectories for the same index follow remarkable regularities. […] some indices tend to change monotonically with age: the level of blood glucose (BG) increases almost monotonically; pulse pressure (PP) increases from age 40 until age 85, then levels off and shows a tendency to decline only at later ages. The age trajectories of other indices are non-monotonic: they tend to increase first and then decline. Body mass index (BMI) increases up to about age 70 and then declines, diastolic blood pressure (DBP) increases until age 55–60 and then declines, systolic blood pressure (SBP) increases until age 75 and then declines, serum cholesterol (SCH) increases until age 50 in males and age 70 in females and then declines, ventricular rate (VR) increases until age 55 in males and age 45 in females and then declines. With small variations, these general patterns are similar in males and females. The shapes of the age-trajectories of the physiological variables also appear to be similar for different genotypes. […] The effects of these physiological indices on mortality risk were studied in Yashin et al. (2006), who found that the effects are gender and age specific. They also found that the dynamic properties of the individual age trajectories of physiological indices may differ dramatically from one individual to the next.”

“An increase in the mortality rate with age is traditionally associated with the process of aging. This influence is mediated by aging-associated changes in thousands of biological and physiological variables, some of which have been measured in aging studies. The fact that the age trajectories of some of these variables differ among individuals with short and long life spans and healthy life spans indicates that dynamic properties of the indices affect life history traits. Our analyses of the FHS data clearly demonstrate that the values of physiological indices at age 40 are significant contributors both to life span and healthy life span […] suggesting that normalizing these variables around age 40 is important for preventing age-associated morbidity and mortality later in life. […] results [also] suggest that keeping physiological indices stable over the years of life could be as important as their normalizing around age 40.”

“The results […] indicate that, in the quest of identifying longevity genes, it may be important to look for candidate genes with pleiotropic effects on more than one dynamic characteristic of the age-trajectory of a physiological variable, such as genes that may influence both the initial value of a trait (intercept) and the rates of its changes over age (slopes). […] Our results indicate that the dynamic characteristics of age-related changes in physiological variables are important predictors of morbidity and mortality risks in aging individuals. […] We showed that the initial value (intercept), the rate of changes (slope), and the variability of a physiological index, in the age interval 40–60 years, significantly influenced both mortality risk and onset of unhealthy life at ages 60+ in our analyses of the Framingham Heart Study data. That is, these dynamic characteristics may serve as good predictors of late life morbidity and mortality risks. The results also suggest that physiological changes taking place in the organism in middle life may affect longevity through promoting or preventing diseases of old age. For non-monotonically changing indices, we found that having a later age at the peak value of the index […], a lower peak value […], a slower rate of decline in the index at older ages […], and less variability in the index over time, can be beneficial for longevity. Also, the dynamic characteristics of the physiological indices were, overall, associated with mortality risk more significantly than with onset of unhealthy life.”

“Decades of studies of candidate genes show that they are not linked to aging-related traits in a straightforward manner […]. Recent genome-wide association studies (GWAS) have reached fundamentally the same conclusion by showing that the traits in late life likely are controlled by a relatively large number of common genetic variants […]. Further, GWAS often show that the detected associations are of tiny effect […] the weak effect of genes on traits in late life can be not only because they confer small risks having small penetrance but because they confer large risks but in a complex fashion […] In this chapter, we consider several examples of complex modes of gene actions, including genetic tradeoffs, antagonistic genetic effects on the same traits at different ages, and variable genetic effects on lifespan. The analyses focus on the APOE common polymorphism. […] The analyses reported in this chapter suggest that the e4 allele can be protective against cancer with a more pronounced role in men. This protective effect is more characteristic of cancers at older ages and it holds in both the parental and offspring generations of the FHS participants. Unlike cancer, the effect of the e4 allele on risks of CVD is more pronounced in women. […] [The] results […] explicitly show that the same allele can change its role on risks of CVD in an antagonistic fashion from detrimental in women with onsets at younger ages to protective in women with onsets at older ages. […] e4 allele carriers have worse survival compared to non-e4 carriers in each cohort. […] Sex stratification shows sexual dimorphism in the effect of the e4 allele on survival […] with the e4 female carriers, particularly, being more exposed to worse survival. […] The results of these analyses provide two important insights into the role of genes in lifespan. First, they provide evidence on the key role of aging-related processes in genetic susceptibility to lifespan. For example, taking into account the specifics of aging-related processes gains 18 % in estimates of the RRs and five orders of magnitude in significance in the same sample of women […] without additional investments in increasing sample sizes and new genotyping. The second is that a detailed study of the role of aging-related processes in estimates of the effects of genes on lifespan (and healthspan) helps in detecting more homogeneous [high risk] sub-samples”.

“The aging of populations in developed countries requires effective strategies to extend healthspan. A promising solution could be to yield insights into the genetic predispositions for endophenotypes, diseases, well-being, and survival. It was thought that genome-wide association studies (GWAS) would be a major breakthrough in this endeavor. Various genetic association studies including GWAS assume that there should be a deterministic (unconditional) genetic component in such complex phenotypes. However, the idea of unconditional contributions of genes to these phenotypes faces serious difficulties which stem from the lack of direct evolutionary selection against or in favor of such phenotypes. In fact, evolutionary constraints imply that genes should be linked to age-related phenotypes in a complex manner through different mechanisms specific for given periods of life. Accordingly, the linkage between genes and these traits should be strongly modulated by age-related processes in a changing environment, i.e., by the individuals’ life course. The inherent sensitivity of genetic mechanisms of complex health traits to the life course will be a key concern as long as genetic discoveries continue to be aimed at improving human health.”

“Despite the common understanding that age is a risk factor of not just one but a large portion of human diseases in late life, each specific disease is typically considered as a stand-alone trait. Independence of diseases was a plausible hypothesis in the era of infectious diseases caused by different strains of microbes. Unlike those diseases, the exact etiology and precursors of diseases in late life are still elusive. It is clear, however, that the origin of these diseases differs from that of infectious diseases and that age-related diseases reflect a complicated interplay among ontogenetic changes, senescence processes, and damages from exposures to environmental hazards. Studies of the determinants of diseases in late life provide insights into a number of risk factors, apart from age, that are common for the development of many health pathologies. The presence of such common risk factors makes chronic diseases and hence risks of their occurrence interdependent. This means that the results of many calculations using the assumption of disease independence should be used with care. Chapter 4 argued that disregarding potential dependence among diseases may seriously bias estimates of potential gains in life expectancy attributable to the control or elimination of a specific disease and that the results of the process of coping with a specific disease will depend on the disease elimination strategy, which may affect mortality risks from other diseases.”

April 17, 2017 Posted by | Biology, Books, Cancer/oncology, Demographics, Economics, Epidemiology, Genetics, Health Economics, Medicine, Statistics | Leave a comment

Random stuff

It’s been a long time since I last posted one of these posts, so a great number of links of interest has accumulated in my bookmarks. I intended to include a large number of these in this post and this of course means that I surely won’t cover each specific link included in this post in anywhere near the amount of detail it deserves, but that can’t be helped.

i. Autism Spectrum Disorder Grown Up: A Chart Review of Adult Functioning.

“For those diagnosed with ASD in childhood, most will become adults with a significant degree of disability […] Seltzer et al […] concluded that, despite considerable heterogeneity in social outcomes, “few adults with autism live independently, marry, go to college, work in competitive jobs or develop a large network of friends”. However, the trend within individuals is for some functional improvement over time, as well as a decrease in autistic symptoms […]. Some authors suggest that a sub-group of 15–30% of adults with autism will show more positive outcomes […]. Howlin et al. (2004), and Cederlund et al. (2008) assigned global ratings of social functioning based on achieving independence, friendships/a steady relationship, and education and/or a job. These two papers described respectively 22% and 27% of groups of higher functioning (IQ above 70) ASD adults as attaining “Very Good” or “Good” outcomes.”

“[W]e evaluated the adult outcomes for 45 individuals diagnosed with ASD prior to age 18, and compared this with the functioning of 35 patients whose ASD was identified after 18 years. Concurrent mental illnesses were noted for both groups. […] Comparison of adult outcome within the group of subjects diagnosed with ASD prior to 18 years of age showed significantly poorer functioning for those with co-morbid Intellectual Disability, except in the domain of establishing intimate relationships [my emphasis. To make this point completely clear, one way to look at these results is that apparently in the domain of partner-search autistics diagnosed during childhood are doing so badly in general that being intellectually disabled on top of being autistic is apparently conferring no additional disadvantage]. Even in the normal IQ group, the mean total score, i.e. the sum of the 5 domains, was relatively low at 12.1 out of a possible 25. […] Those diagnosed as adults had achieved significantly more in the domains of education and independence […] Some authors have described a subgroup of 15–27% of adult ASD patients who attained more positive outcomes […]. Defining an arbitrary adaptive score of 20/25 as “Good” for our normal IQ patients, 8 of thirty four (25%) of those diagnosed as adults achieved this level. Only 5 of the thirty three (15%) diagnosed in childhood made the cutoff. (The cut off was consistent with a well, but not superlatively, functioning member of society […]). None of the Intellectually Disabled ASD subjects scored above 10. […] All three groups had a high rate of co-morbid psychiatric illnesses. Depression was particularly frequent in those diagnosed as adults, consistent with other reports […]. Anxiety disorders were also prevalent in the higher functioning participants, 25–27%. […] Most of the higher functioning ASD individuals, whether diagnosed before or after 18 years of age, were functioning well below the potential implied by their normal range intellect.”

Related papers: Social Outcomes in Mid- to Later Adulthood Among Individuals Diagnosed With Autism and Average Nonverbal IQ as Children, Adults With Autism Spectrum Disorders.

ii. Premature mortality in autism spectrum disorder. This is a Swedish matched case cohort study. Some observations from the paper:

“The aim of the current study was to analyse all-cause and cause-specific mortality in ASD using nationwide Swedish population-based registers. A further aim was to address the role of intellectual disability and gender as possible moderators of mortality and causes of death in ASD. […] Odds ratios (ORs) were calculated for a population-based cohort of ASD probands (n = 27 122, diagnosed between 1987 and 2009) compared with gender-, age- and county of residence-matched controls (n = 2 672 185). […] During the observed period, 24 358 (0.91%) individuals in the general population died, whereas the corresponding figure for individuals with ASD was 706 (2.60%; OR = 2.56; 95% CI 2.38–2.76). Cause-specific analyses showed elevated mortality in ASD for almost all analysed diagnostic categories. Mortality and patterns for cause-specific mortality were partly moderated by gender and general intellectual ability. […] Premature mortality was markedly increased in ASD owing to a multitude of medical conditions. […] Mortality was significantly elevated in both genders relative to the general population (males: OR = 2.87; females OR = 2.24)”.

“Individuals in the control group died at a mean age of 70.20 years (s.d. = 24.16, median = 80), whereas the corresponding figure for the entire ASD group was 53.87 years (s.d. = 24.78, median = 55), for low-functioning ASD 39.50 years (s.d. = 21.55, median = 40) and high-functioning ASD 58.39 years (s.d. = 24.01, median = 63) respectively. […] Significantly elevated mortality was noted among individuals with ASD in all analysed categories of specific causes of death except for infections […] ORs were highest in cases of mortality because of diseases of the nervous system (OR = 7.49) and because of suicide (OR = 7.55), in comparison with matched general population controls.”

iii. Adhesive capsulitis of shoulder. This one is related to a health scare I had a few months ago. A few quotes:

Adhesive capsulitis (also known as frozen shoulder) is a painful and disabling disorder of unclear cause in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain. Pain is usually constant, worse at night, and with cold weather. Certain movements or bumps can provoke episodes of tremendous pain and cramping. […] People who suffer from adhesive capsulitis usually experience severe pain and sleep deprivation for prolonged periods due to pain that gets worse when lying still and restricted movement/positions. The condition can lead to depression, problems in the neck and back, and severe weight loss due to long-term lack of deep sleep. People who suffer from adhesive capsulitis may have extreme difficulty concentrating, working, or performing daily life activities for extended periods of time.”

Some other related links below:

The prevalence of a diabetic condition and adhesive capsulitis of the shoulder.
“Adhesive capsulitis is characterized by a progressive and painful loss of shoulder motion of unknown etiology. Previous studies have found the prevalence of adhesive capsulitis to be slightly greater than 2% in the general population. However, the relationship between adhesive capsulitis and diabetes mellitus (DM) is well documented, with the incidence of adhesive capsulitis being two to four times higher in diabetics than in the general population. It affects about 20% of people with diabetes and has been described as the most disabling of the common musculoskeletal manifestations of diabetes.”

Adhesive Capsulitis (review article).
“Patients with type I diabetes have a 40% chance of developing a frozen shoulder in their lifetimes […] Dominant arm involvement has been shown to have a good prognosis; associated intrinsic pathology or insulin-dependent diabetes of more than 10 years are poor prognostic indicators.15 Three stages of adhesive capsulitis have been described, with each phase lasting for about 6 months. The first stage is the freezing stage in which there is an insidious onset of pain. At the end of this period, shoulder ROM [range of motion] becomes limited. The second stage is the frozen stage, in which there might be a reduction in pain; however, there is still restricted ROM. The third stage is the thawing stage, in which ROM improves, but can take between 12 and 42 months to do so. Most patients regain a full ROM; however, 10% to 15% of patients suffer from continued pain and limited ROM.”

Musculoskeletal Complications in Type 1 Diabetes.
“The development of periarticular thickening of skin on the hands and limited joint mobility (cheiroarthropathy) is associated with diabetes and can lead to significant disability. The objective of this study was to describe the prevalence of cheiroarthropathy in the well-characterized Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) cohort and examine associated risk factors […] This cross-sectional analysis was performed in 1,217 participants (95% of the active cohort) in EDIC years 18/19 after an average of 24 years of follow-up. Cheiroarthropathy — defined as the presence of any one of the following: adhesive capsulitis, carpal tunnel syndrome, flexor tenosynovitis, Dupuytren’s contracture, or a positive prayer sign [related link] — was assessed using a targeted medical history and standardized physical examination. […] Cheiroarthropathy was present in 66% of subjects […] Cheiroarthropathy is common in people with type 1 diabetes of long duration (∼30 years) and is related to longer duration and higher levels of glycemia. Clinicians should include cheiroarthropathy in their routine history and physical examination of patients with type 1 diabetes because it causes clinically significant functional disability.”

Musculoskeletal disorders in diabetes mellitus: an update.
“Diabetes mellitus (DM) is associated with several musculoskeletal disorders. […] The exact pathophysiology of most of these musculoskeletal disorders remains obscure. Connective tissue disorders, neuropathy, vasculopathy or combinations of these problems, may underlie the increased incidence of musculoskeletal disorders in DM. The development of musculoskeletal disorders is dependent on age and on the duration of DM; however, it has been difficult to show a direct correlation with the metabolic control of DM.”

Rheumatic Manifestations of Diabetes Mellitus.

Prevalence of symptoms and signs of shoulder problems in people with diabetes mellitus.

Musculoskeletal Disorders of the Hand and Shoulder in Patients with Diabetes.
“In addition to micro- and macroangiopathic complications, diabetes mellitus is also associated with several musculoskeletal disorders of the hand and shoulder that can be debilitating (1,2). Limited joint mobility, also termed diabetic hand syndrome or cheiropathy (3), is characterized by skin thickening over the dorsum of the hands and restricted mobility of multiple joints. While this syndrome is painless and usually not disabling (2,4), other musculoskeletal problems occur with increased frequency in diabetic patients, including Dupuytren’s disease [“Dupuytren’s disease […] may be observed in up to 42% of adults with diabetes mellitus, typically in patients with long-standing T1D” – link], carpal tunnel syndrome [“The prevalence of [carpal tunnel syndrome, CTS] in patients with diabetes has been estimated at 11–30 % […], and is dependent on the duration of diabetes. […] Type I DM patients have a high prevalence of CTS with increasing duration of disease, up to 85 % after 54 years of DM” – link], palmar flexor tenosynovitis or trigger finger [“The incidence of trigger finger [/stenosing tenosynovitis] is 7–20 % of patients with diabetes comparing to only about 1–2 % in nondiabetic patients” – link], and adhesive capsulitis of the shoulder (5–10). The association of adhesive capsulitis with pain, swelling, dystrophic skin, and vasomotor instability of the hand constitutes the “shoulder-hand syndrome,” a rare but potentially disabling manifestation of diabetes (1,2).”

“The prevalence of musculoskeletal disorders was greater in diabetic patients than in control patients (36% vs. 9%, P < 0.01). Adhesive capsulitis was present in 12% of the diabetic patients and none of the control patients (P < 0.01), Dupuytren’s disease in 16% of diabetic and 3% of control patients (P < 0.01), and flexor tenosynovitis in 12% of diabetic and 2% of control patients (P < 0.04), while carpal tunnel syndrome occurred in 12% of diabetic patients and 8% of control patients (P = 0.29). Musculoskeletal disorders were more common in patients with type 1 diabetes than in those with type 2 diabetes […]. Forty-three patients [out of 100] with type 1 diabetes had either hand or shoulder disorders (37 with hand disorders, 6 with adhesive capsulitis of the shoulder, and 10 with both syndromes), compared with 28 patients [again out of 100] with type 2 diabetes (24 with hand disorders, 4 with adhesive capsulitis of the shoulder, and 3 with both syndromes, P = 0.03).”

Association of Diabetes Mellitus With the Risk of Developing Adhesive Capsulitis of the Shoulder: A Longitudinal Population-Based Followup Study.
“A total of 78,827 subjects with at least 2 ambulatory care visits with a principal diagnosis of DM in 2001 were recruited for the DM group. The non-DM group comprised 236,481 age- and sex-matched randomly sampled subjects without DM. […] During a 3-year followup period, 946 subjects (1.20%) in the DM group and 2,254 subjects (0.95%) in the non-DM group developed ACS. The crude HR of developing ACS for the DM group compared to the non-DM group was 1.333 […] the association between DM and ACS may be explained at least in part by a DM-related chronic inflammatory process with increased growth factor expression, which in turn leads to joint synovitis and subsequent capsular fibrosis.”

It is important to note when interpreting the results of the above paper that these results are based on Taiwanese population-level data, and type 1 diabetes – which is obviously the high-risk diabetes subgroup in this particular context – is rare in East Asian populations (as observed in Sperling et al., “A child in Helsinki, Finland is almost 400 times more likely to develop diabetes than a child in Sichuan, China”. Taiwanese incidence of type 1 DM in children is estimated at ~5 in 100.000).

iv. Parents who let diabetic son starve to death found guilty of first-degree murder. It’s been a while since I last saw one of these ‘boost-your-faith-in-humanity’-cases, but they in my impression do pop up every now and then. I should probably keep at hand one of these articles in case my parents ever express worry to me that they weren’t good parents; they could have done a lot worse…

v. Freedom of medicine. One quote from the conclusion of Cochran’s post:

“[I]t is surely possible to materially improve the efficacy of drug development, of medical research as a whole. We’re doing better than we did 500 years ago – although probably worse than we did 50 years ago. But I would approach it by learning as much as possible about medical history, demographics, epidemiology, evolutionary medicine, theory of senescence, genetics, etc. Read Koch, not Hayek. There is no royal road to medical progress.”

I agree, and I was considering including some related comments and observations about health economics in this post – however I ultimately decided against doing that in part because the post was growing unwieldy; I might include those observations in another post later on. Here’s another somewhat older Westhunt post I at some point decided to bookmark – I in particular like the following neat quote from the comments, which expresses a view I have of course expressed myself in the past here on this blog:

“When you think about it, falsehoods, stupid crap, make the best group identifiers, because anyone might agree with you when you’re obviously right. Signing up to clear nonsense is a better test of group loyalty. A true friend is with you when you’re wrong. Ideally, not just wrong, but barking mad, rolling around in your own vomit wrong.”

vi. Economic Costs of Diabetes in the U.S. in 2012.

“Approximately 59% of all health care expenditures attributed to diabetes are for health resources used by the population aged 65 years and older, much of which is borne by the Medicare program […]. The population 45–64 years of age incurs 33% of diabetes-attributed costs, with the remaining 8% incurred by the population under 45 years of age. The annual attributed health care cost per person with diabetes […] increases with age, primarily as a result of increased use of hospital inpatient and nursing facility resources, physician office visits, and prescription medications. Dividing the total attributed health care expenditures by the number of people with diabetes, we estimate the average annual excess expenditures for the population aged under 45 years, 45–64 years, and 65 years and above, respectively, at $4,394, $5,611, and $11,825.”

“Our logistic regression analysis with NHIS data suggests that diabetes is associated with a 2.4 percentage point increase in the likelihood of leaving the workforce for disability. This equates to approximately 541,000 working-age adults leaving the workforce prematurely and 130 million lost workdays in 2012. For the population that leaves the workforce early because of diabetes-associated disability, we estimate that their average daily earnings would have been $166 per person (with the amount varying by demographic). Presenteeism accounted for 30% of the indirect cost of diabetes. The estimate of a 6.6% annual decline in productivity attributed to diabetes (in excess of the estimated decline in the absence of diabetes) equates to 113 million lost workdays per year.”

vii. Total red meat intake of ≥0.5 servings/d does not negatively influence cardiovascular disease risk factors: a systemically searched meta-analysis of randomized controlled trials.

viii. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. Did I blog this paper at some point in the past? I could not find any coverage of it on the blog when I searched for it so I decided to include it here, even if I have a nagging suspicion I may have talked about these findings before. What did they find? The short version is this:

“A modest reduction in salt intake for four or more weeks causes significant and, from a population viewpoint, important falls in blood pressure in both hypertensive and normotensive individuals, irrespective of sex and ethnic group. Salt reduction is associated with a small physiological increase in plasma renin activity, aldosterone, and noradrenaline and no significant change in lipid concentrations. These results support a reduction in population salt intake, which will lower population blood pressure and thereby reduce cardiovascular disease.”

ix. Some wikipedia links:

Heroic Age of Antarctic Exploration (featured).

Wien’s displacement law.

Kuiper belt (featured).

Treason (one quote worth including here: “Currently, the consensus among major Islamic schools is that apostasy (leaving Islam) is considered treason and that the penalty is death; this is supported not in the Quran but in the Hadith.[42][43][44][45][46][47]“).

Lymphatic filariasis.

File:World map of countries by number of cigarettes smoked per adult per year.

Australian gold rushes.

Savant syndrome (“It is estimated that 10% of those with autism have some form of savant abilities”). A small sidenote of interest to Danish readers: The Danish Broadcasting Corporation recently featured a series about autistics with ‘special abilities’ – the show was called ‘The hidden talents’ (De skjulte talenter), and after multiple people had nagged me to watch it I ended up deciding to do so. Most of the people in that show presumably had some degree of ‘savantism’ combined with autism at the milder end of the spectrum, i.e. Asperger’s. I was somewhat conflicted about what to think about the show and did consider blogging it in detail (in Danish?), but I decided against it. However I do want to add here to Danish readers reading along who’ve seen the show that they would do well to repeatedly keep in mind that a) the great majority of autistics do not have abilities like these, b) many autistics with abilities like these presumably do quite poorly, and c) that many autistics have even greater social impairments than do people like e.g. (the very likeable, I have to add…) Louise Wille from the show).

Quark–gluon plasma.

Simo Häyhä.

Chernobyl liquidators.

Black Death (“Over 60% of Norway’s population died in 1348–1350”).

Renault FT (“among the most revolutionary and influential tank designs in history”).

Weierstrass function (“an example of a pathological real-valued function on the real line. The function has the property of being continuous everywhere but differentiable nowhere”).

W Ursae Majoris variable.

Void coefficient. (“a number that can be used to estimate how much the reactivity of a nuclear reactor changes as voids (typically steam bubbles) form in the reactor moderator or coolant. […] Reactivity is directly related to the tendency of the reactor core to change power level: if reactivity is positive, the core power tends to increase; if it is negative, the core power tends to decrease; if it is zero, the core power tends to remain stable. […] A positive void coefficient means that the reactivity increases as the void content inside the reactor increases due to increased boiling or loss of coolant; for example, if the coolant acts as a neutron absorber. If the void coefficient is large enough and control systems do not respond quickly enough, this can form a positive feedback loop which can quickly boil all the coolant in the reactor. This happened in the RBMK reactor that was destroyed in the Chernobyl disaster.”).

Gregor MacGregor (featured) (“a Scottish soldier, adventurer, and confidence trickster […] MacGregor’s Poyais scheme has been called one of the most brazen confidence tricks in history.”).


Irish Civil War.

March 10, 2017 Posted by | Astronomy, autism, Cardiology, Diabetes, Economics, Epidemiology, Health Economics, History, Infectious disease, Mathematics, Medicine, Papers, Physics, Psychology, Random stuff, Wikipedia | Leave a comment