Peripheral arterial disease and risk of cardiac death in type 2 diabetes: the Fremantle Diabetes Study

Relationship between peripheral artery disease and combined albuminuria and low estimated glomerular filtration rate among elderly patients with type 2 diabetes mellitus

This study aimed at investigating the combined effects of albuminuria and reduced estimated glomerular filtration rate (eGFR) on peripheral artery disease (PAD) among elderly patients with diabetes. A total of 236 subjects were cross-classified into four groups according to the presence or absence of albuminuria (urinary albumin creatinine ratio (ACR) ≥ 30 mg/g) and low eGFR (<60 mL/min/1.73 m²). Cardiovascular risk factors and the ankle-brachial index (ABI) were also assessed. After multivariate adjustment using logistic regression analysis, the odds ratios (OR) for prevalent PAD related to albuminuria with preserved eGFR, normoalbuminuria with low eGFR and albuminuria with low eGFR compared to normoalbuminuria with preserved eGFR were 1.10 [95% confidence interval (CI) = 0.43-2.79], 3.14 (95% CI = 1.20-8.22) and 3.87 (95% CI = 1.72-8.72), respectively. In conclusion, in elderly patients with type 2 diabetes, both normoalbuminuria with low eGFR and albuminuria with low eGFR are associated independently with PAD.

Clinical impact of the temporal relationship between depression and type 2 diabetes: the Fremantle diabetes study phase II

Background

The clinical features of type 2 diabetes may differ depending on whether first depression episode precedes or follows the diagnosis of diabetes.

Methods

Type 2 patients from the observational community-based Fremantle Diabetes Study Phase II underwent assessment of lifetime depression using the Brief Lifetime Depression Scale (developed and validated for this study) supplemented by information on current depression symptoms (Patient Health Questionnaire, 9-item version) and use of antidepressants. Patients were categorized as never depressed (Group 1), having had depression before diabetes diagnosis (Group 2), diagnosed with depression and diabetes within 2 years of each other (Group 3) and having depression after diabetes diagnosis (Group 4).

Results

Of 1391 patients, 20.8% were assigned to Group 2, 6.0% to Group 3 and 14.5% to Group 4. In Group 2, depression occurred a median 15.6 years before diabetes onset at age 37.2±14.7 years. These patients had similar clinical characteristics to never depressed patients except for reduced self-care behaviours and having more symptomatic peripheral arterial disease. In Group 4, depression occurred a median 9.9 years after diabetes onset at age 59.8±13.0 years. These patients had long duration diabetes, poor glycaemic control, more intensive management and more diabetic complications. Group 4 patients had more current depression than Group 2 but were less likely to be receiving antidepressants.

Conclusions/Interpretation

The clinical features of depression and type 2 diabetes are heterogeneous depending on their temporal relationship. There may be corresponding differences in the pathogenesis of depression in diabetes that have implications for diagnosis and management.

The relationship between hypomagnesemia, metformin therapy and cardiovascular disease complicating type 2 diabetes: the Fremantle Diabetes Study

Background

Low serum magnesium concentrations have been associated with cardiovascular disease risk and outcomes in some general population studies but there are no equivalent studies in diabetes. Metformin may have cardiovascular benefits beyond blood glucose lowering in type 2 diabetes but its association with hypomagnesemia appears paradoxical. The aim of this study was to examine relationships between metformin therapy, magnesium homoeostasis and cardiovascular disease in well-characterized type 2 patients from the community.

Methods and Findings

We studied 940 non-insulin-treated patients (mean±SD age 63.4±11.6 years, 49.0% males) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) who were followed for 12.3±5.3 years. Baseline serum magnesium was measured using stored sera. Multivariate methods were used to determine associates of prevalent and incident coronary heart disease (CHD) and cerebrovascular disease (CVD) as ascertained from self-report and linked morbidity/mortality databases. 19% of patients were hypomagnesemic (serum magnesium <0.70 mmol/L). Patients on metformin, alone or combined with a sulfonylurea, had lower serum magnesium concentrations than those on diet alone (P<0.05). There were no independent associations between serum magnesium or metformin therapy and either CHD or CVD at baseline. Incident CVD, but not CHD, was independently and inversely associated with serum magnesium (hazard ratio (95% CI) 0.28 (0.11–0.74); P = 0.010), but metformin therapy was not a significant variable in these models.

Conclusions

Since hypomagnesemia appears to be an independent risk factor for CVD complicating type 2 diabetes, the value of replacement therapy should be investigated further, especially in patients at high CVD risk.

The pathway to foot ulceration in diabetes

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

Determinants and costs of community nursing in patients with type 2 diabetes from a community-based observational study: the Fremantle Diabetes Study

BACKGROUND

Despite widespread use, there is little information on the extent and impact of community nursing to patients with type 2 diabetes.

OBJECTIVE

To determine the incidence, predictors and costs of community nursing provision to patients with type 2 diabetes in a large community-based representative study of diabetes in an urban Australian setting.

DESIGN

Prospective observational study utilising data linkage.

SETTING

Postcode defined region in Fremantle, Australia.

PARTICIPANTS

All patients with type 2 diabetes enrolled in the Fremantle Diabetes Study between 1993 and 1996.

METHODS

Eligible patients were followed from July 1997, when home nursing data first became available, to death or census in November 2007. Home nursing data from the major community nursing service provider were linked with data from the Fremantle Diabetes Study. Cox and zero-inflated negative binomial (ZINB) regression modelling was used to identify predictors of incident home visits and visit frequency, respectively. Direct costs were estimated from the service provider's unit costs.

RESULTS

During a mean ± SD 8.6 ± 2.9 years of follow-up, 27.8% of 825 patients (aged 65.2 ± 10.3 years at study entry; 51.2% male) received 21,878 home nursing visits (median frequency 31 [interquartile range 9-85] visits, range 1-1446 visits). In Cox and ZINB models, predictors of home nursing included older age, physical disability measures and macrovascular and microvascular complications. Insulin use was an important predictor of the frequency of visits whilst ethnic and economic factors predicted lower frequency. The estimated cost of home nursing, extrapolated nationally, adds 5% to the total Australian direct health care costs of diabetes.

CONCLUSIONS

Home nursing is frequently utilized in the management of type 2 diabetes with considerable individual variation in the use of this service. Given the associated costs, further research into how home nursing can best be employed is indicated.

Impact of critical limb ischemia on long-term cardiac mortality in diabetic patients undergoing percutaneous coronary revascularization

OBJECTIVE

Development of critical limb ischemia (CLI) has been reported as an independent predictor of cardiac mortality in diabetic patients. We aimed to determine whether CLI, managed in a structured setting of close collaboration between different vascular specialists and treated with early endovascular intervention, has any impact on long-term cardiac mortality of diabetic patients initially presenting with symptomatic coronary artery disease (CAD).

RESEARCH DESIGN AND METHODS

We designed a prospective observational study of 764 consecutive diabetic patients undergoing percutaneous coronary intervention (PCI) in whom development of CLI was assessed by a dedicated diabetic foot clinic. Cardiac mortality at 4-year follow-up was the primary end point of the study.

RESULTS

Among the 764 patients, 111 (14%) developed CLI (PCI-CLI group) and underwent revascularization of 145 limbs, with procedural success in 140 (96%). PCI-CLI patients at baseline had lower left ventricular ejection fraction (51 ± 11% vs. 53 ± 10%, P = 0.008), higher prevalence of dialysis (7% vs. 0.3%, P < 0.0001), and longer diabetes duration (13 ± 8 vs. 11 ± 7 years, P = 0.02) compared with PCI-only patients. At 4-year follow-up, cardiac mortality occurred in 10 (9%) PCI-CLI patients vs. 42 (6%) PCI-only patients (P = 0.2). Time-dependent Cox regression model for cardiac death revealed that CLI was not associated with an increased risk of cardiac mortality (hazard ratio 1.08 [95% CI 0.89-3.85]; P = 0.1).

CONCLUSIONS

The development of promptly assessed and aggressively treated CLI was not significantly associated with increased risk of long-term cardiac mortality in diabetic patients initially presenting with symptomatic CAD.

Continuing disparities in cardiovascular risk factors and complications between aboriginal and Anglo-Celt Australians with type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To determine whether disparities in the nature and management of type 2 diabetes persist between Aboriginal and the majority Anglo-Celt patients in an urban Australian community.

RESEARCH DESIGN AND METHODS

Baseline data from the observational Fremantle Diabetes Study collected from 1993 to 1996 (phase I) and from 2008 to 2011 (phase II) were analyzed. Patients characterized as Aboriginal or Anglo-Celt by self-report and supporting data underwent comprehensive assessment, including questionnaires, examination, and biochemical testing in a single laboratory. Generalized linear modeling with age/sex adjustment was used to examine differences in changes in variables in the two groups between phases I and II.

RESULTS

The indigenous participants were younger at entry and at diabetes diagnosis than the Anglo-Celt participants in both phases. They were also less likely to be educated beyond primary level and were more likely to be smokers. HbA(1c) decreased in both groups over time (Aboriginal median 9.6% [interquartile range 7.8-10.7%] to 8.4% [6.6-10.6%] vs. Anglo-Celt median 7.1% [6.2-8.4%] to 6.7% [6.2-7.5%]), but the gap persisted (P = 0.65 for difference between phases I and II by ethnic group). Aboriginal patients were more likely to have microvascular disease in both phases. The prevalence of peripheral arterial disease (ankle-brachial index ≤0.90 or lower-extremity amputation) increased in Aboriginal but decreased in Anglo-Celt participants (15.8-29.7 vs. 30.7-21.5%; P = 0.055).

CONCLUSIONS

Diabetes management has improved for Aboriginal and Anglo-Celt Australian patients, but disparities in cardiovascular risk factors and complications persist.

Ankle-brachial index and cardiovascular outcomes in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial

BACKGROUND

Peripheral arterial disease increases cardiovascular risk in many patient populations. The risks associated with an abnormal ankle-brachial index (ABI) in patients with type 2 diabetes and stable coronary artery disease have not been well described with respect to thresholds and types of cardiovascular events.

METHODS

We examined 2,368 patients in the BARI 2D trial who underwent ABI assessment at baseline. Death and major cardiovascular events (death, myocardial infarction and stroke) during follow-up (average 4.3 years) were assessed across the ABI spectrum and by categorized ABI: low (≤0.90), normal (0.91-1.3), high (>1.3), or noncompressible.

RESULTS

A total of 12,568 person-years were available for mortality analysis. During follow-up, 316 patients died, and 549 had major cardiovascular events. After adjustment for potential confounders, with normal ABI as the referent group, a low ABI conferred an increased risk of death (relative risk [RR] 1.6, CI 1.2-2.2, P = .0005) and major cardiovascular events (RR 1.4, CI 1.1-1.7, P = .004). Patients with a high ABI had similar outcomes as patients with a normal ABI, but risk again increased in patients with a noncompressible ABI with a risk of death (RR 1.9, CI 1.3-2.8, P = .001) and major cardiovascular event (RR 1.5, CI 1.1-2.1, P = .01).

CONCLUSIONS

In patients with coronary artery disease and type 2 diabetes, ABI screening and identification of ABI abnormalities including a low ABI (<1.0) or noncompressible artery provide incremental prognostic information.

Outcomes of three years of teamwork on critical limb ischemia in patients with diabetes and foot lesions

To evaluate the outcomes of a multidisciplinary team working on diabetic foot (DF) patients with critical limb ischemia (CLI) in a specialized center, the authors retrospectively traced all the patients admitted in their department in 3 consecutive years with a diagnosis of CLI. From January 2006 to December 2008, 245 consecutive DF patients with CLI according the TransAtlantic interSociety Consensus II criteria were included in the study. Treatment strategy was decided by a team of diabetologists, inteventional radiologists, and vascular surgeons. Technical and clinical success, mortality, and ulcer recurrence were evaluated at 6 months and at a mean follow-up of 19.5 ± 13.4 months. Percutaneous transluminal angioplasty (PTA) was performed in 189 (77%) patients, whereas medical treatment, open surgical revascularization (OSR), and primary amputation were performed in 44 (18.3%), 11 (4.3%), and 1 (0.5%) patients, respectively. Revascularization was successful in 227/233 (97.4%) patients. At follow-up, the overall clinical success rate was 60.4%; it was significantly (P = .001) higher after revascularization (75.9%) compared with medical treatment (48.3%). During follow-up, surgical interventions in the foot were 1.5 ± 0.4 in those treated with PTA, 1.6 ± 0.5 in those treated with OSR, and 0.3 ± 0.8 in those receiving medical therapy (P < .05 compared with the others). Ulcer recurrence occurred in 29 (11.8%) patients: 4 (1.6%) in PTA, 2 (0.8%) in OSR, and 23 (9.4%) in the medical therapy group (P < .05). Major amputation rate was 9.3%, being significantly (P = .04) lower after revascularization (5.2%) compared with medical therapy alone (13.8%). Cumulative mortality rate was 10.6%. In conclusion, this study confirms the positive role of a PTA-first approach for revascularizing the complex cases of DF with CLI in a teamwork management strategy.

Prevalence of and risk factors for abnormal ankle-brachial index in patients with type 2 diabetes

BACKGROUND

The aim of the present study was to examine abnormalities in the ankle-brachial index (ABI) and related risk factors in patients with type 2 diabetes.

METHODS

Between September 2003 and June 2010, the ABI was determined in 3924 outpatients attending the Diabetes Center of the People's Liberation Army 306th Hospital. In addition, demographic and laboratory data were collected. The risk factors for an abnormal ABI were determined using univariate and stepwise logistic regression analysis.

RESULTS

The ABI was normal (0.91-1.3) in 93.1% of patients, low (<0.9) in 5.2%, and high (>1.3) in 1.7%. The prevalence of abnormal lower ABI was greater in elderly (≥ 65 years) patients (12.2%) than in younger (< 65 years) patients (3.6%). Using normal ABI as the reference, low ABI in younger patients was found to be independently associated with HbA1c, the urinary albumin:creatinine ratio, diabetic peripheral neuropathy, diabetic retinopathy, and cerebrovascular disease. A low ABI in elderly patients was found to be independently associated with age, smoking, HbA1c, uric acid, total cholesterol, diabetic peripheral neuropathy, diabetic retinopathy, diabetic nephropathy and cerebrovascular disease. A high ABI in younger patients was associated with being male.

CONCLUSIONS

The prevalence of an abnormal ABI was high in patients with type 2 diabetes, especially elderly patients. Early identification and intensive treatment are needed to improve the quality of life and overall prognosis of patients with type 2 diabetes.

Clinical usefulness of assessment of ankle-brachial index and carotid stenosis in type 2 diabetic population--three-year cohort follow-up of mortality

We evaluated the clinical usefulness of assessing the ankle-brachial index (ABI) and carotid stenosis (CS) in a type 2 diabetic population. Patients with type 2 diabetes and coronary artery disease (n = 265) were enrolled in a prospective 3-year cohort study. The cardiovascular mortality rate was 8.7% (23 of 265) during the 36-month study and the all-cause mortality rate was 9.5% (25 of 265). Multivariate logistic regression analysis revealed that age (odds ratio [OR] 2.09), hypertension (OR 7.99), obesity (OR 4.86), internal CS (OR 262.17), and Gensini score (OR 1.15) were independent predictors of cardiovascular mortality. Mean ABI value (OR 0.15) was the only predictor of all-cause mortality in this population. The ABI and carotid artery ultrasound have independent prognostic value in a type 2 diabetic population.

Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies

BACKGROUND

Numerous studies have demonstrated that both smoking and diabetes are risk factors for mortality and caused-specific cardiovascular events. However, few studies systematically investigated to what extent the excess risk could be attributed to smoking among diabetic patients.

METHODS

Literature references were searched up to April 2011 in MEDLINE and EMBASE, supplemented by manual searches. Inclusion criteria were prospective cohort studies, assessment of the association between smoking and total mortality, cardiovascular death, incidence of coronary heart disease (CHD), stroke and myocardial infarction (MI) in diabetic patients.

RESULTS

Of 3758 studies in the literature searched, 46 were eligible with approximately 130,000 diabetic patients. The relative risk (RR) comparing smokers with nonsmokers was 1.48[95% confidential interval (CI): 1.34-1.64] for total mortality (27 studies), 1.36(1.22-1.52) for cardiovascular mortality (9 studies), 1.54(1.31-1.82) for CHD (13 studies), 1.44(1.28-1.61) for stroke (9 studies) and 1.52(1.25-1.83) for MI (7 studies). Furthermore, the excess risk was observed among former and current smokers with a greater risk in current smokers. Subgroup analysis showed that the increased risk appeared to be consistent regardless of several study characteristics with the RRs ranging from 1.31 to 1.94 for all-cause mortality, 1.37 to 2.28 for CHD, 1.21 to 1.87 for stroke, 1.13 to 1.74 for cardiovascular mortality and 1.15 to 2.01 for MI.

CONCLUSION

Smoking amplified the risk of mortality as well as cardiovascular events and the effect size for CHD appeared to be higher than other events in diabetic patients. Moreover, a trend of decreasing risk was observed among smoking quitters.

The epidemiology and characteristics of type 2 diabetes in urban, community-based young people

As little is known about the impact of type 2 diabetes amongst Australian youth despite international increases in childhood obesity, we aimed to identify and characterize people aged<25 years with type 2 diabetes in an urban community with 60,000 people aged 10-24 years. The estimated maximum prevalence (59/100,000 persons) was lower than US estimates but higher than in Asia and Europe. In eight patients assessed in detail, obesity and related comorbidities were common, and quality of life was low.

Prevalence of neuropathy and peripheral arterial disease and the impact of treatment in people with screen-detected type 2 diabetes: the ADDITION-Denmark study

OBJECTIVE

There is limited evidence on how intensive multifactorial treatment (IT) improves outcomes of diabetes when initiated in the lead time between detection by screening and diagnosis in routine clinical practice. We examined the effects of early detection and IT of type 2 diabetes in primary care on the prevalence of diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) 6 years later in a pragmatic, cluster-randomized parallel group trial.

RESEARCH DESIGN AND METHODS

A stepwise screening program in 190 general practices in Denmark was used to identify 1,533 people with type 2 diabetes. General practices were randomized to deliver either IT or routine care (RC) as recommended through national guidelines. Participants were followed for 6 years and measures of DPN and PAD were applied.

RESULTS

We found no statistically significant effect of IT on the prevalence of DPN and PAD compared with RC. The prevalence of an ankle brachial index ≤0.9 was 9.1% (95% CI 6.0-12.2) in the RC arm and 7.3% (5.0-9.6) in the IT arm. In participants tested for vibration detection threshold and light touch sensation, the prevalence of a least one abnormal test was 34.8% (26.7-43.0) in the RC arm and 30.1% (24.1-36.1) in the IT arm.

CONCLUSIONS

In a population with screen-detected type 2 diabetes, we did not find that screening followed by IT led to a statistically significant difference in the prevalence of DPN and PAD 6 years after diagnosis. However, treatment levels were high in both groups.

Economic impact of moderate weight loss in patients with Type 2 diabetes: the Fremantle Diabetes Study

AIM

To assess the change in the cost of diabetes medication attributable to moderate weight loss in patients with Type 2 diabetes.

METHODS

Longitudinal data collected annually from 590 patients participating in the observational, community-based Fremantle Diabetes Study were examined to determine whether moderate weight loss (≥ 5% of initial body weight) was independently associated with diabetes medication cost during 4 years' follow-up.

RESULTS

Overall, the weight of the cohort decreased significantly during 4.3 ± 0.4 years' follow-up by 1.3 ± 6.2 kg (-1.4 ± 7.9% baseline body weight; trend P < 0.001). Moderate weight loss was achieved by 31%. HbA(1c) improved significantly in the group with moderate weight loss compared with the group without moderate weight loss [-4 ± 16 mmol/mol (-0.3 ± 1.5%) vs. 0 ± 17 mmol/mol (0.0 ± 1.5%), P = 0.015]. Mean (bias-corrected 95% confidence intervals) diabetes medication costs were $A820 ($A744-907) during follow-up. As the cost distribution was highly right-skewed and contained zeros, it was square root (√) transformed before multiple linear regression analysis. The most parsimonious model of baseline associates of √(diabetes medication cost) included glycaemic control, diabetes treatment, diabetes duration, BMI, systolic blood pressure, serum HDL cholesterol (negative), taking lipid-lowering medication and age (negative) (adjusted R(2) = 73.6%). After adjusting for these variables, √(diabetes medication cost) was negatively associated with moderate weight loss (P = 0.026). After entering average values for the cohort into the model, the cost of diabetes medications between baseline and fourth review for an average patient with no weight loss was $A752 compared with $A652 for a patient who attained moderate weight loss, a saving of $A100 (-13.3%).

DISCUSSION

These data highlight the economic and clinical benefits of moderate weight loss in Type 2 diabetes.

Plasma osteoprotegerin is related to carotid and peripheral arterial disease, but not to myocardial ischemia in type 2 diabetes mellitus

Background

Cardiovascular disease (CVD) is frequent in type 2 diabetes mellitus patients due to accelerated atherosclerosis. Plasma osteoprotegerin (OPG) has evolved as a biomarker for CVD. We examined the relationship between plasma OPG levels and different CVD manifestations in type 2 diabetes.

Methods

Type 2 diabetes patients without known CVD referred consecutively to a diabetes clinic for the first time (n = 305, aged: 58.6 ± 11.3 years, diabetes duration: 4.5 ± 5.3 years) were screened for carotid arterial disease, peripheral arterial disease, and myocardial ischemia by means of carotid artery ultrasonography, peripheral ankle and toe systolic blood pressure measurements, and myocardial perfusion scintigraphy (MPS). In addition, plasma OPG concentrations and other CVD-related markers were measured.

Results

The prevalence of carotid arterial disease, peripheral arterial disease, and myocardial ischemia was 42%, 15%, and 30%, respectively. Plasma OPG was significantly increased in patients with carotid and peripheral arterial disease compared to patients without (p < 0.001, respectively), however, this was not the case for patients with myocardial ischemia versus those without (p = 0.71). When adjusted for age, HbA1c and U-albumin creatinine ratio in a multivariate logistic regression analysis, plasma OPG remained strongly associated with carotid arterial disease (adjusted OR: 2.12; 95% CI: 1.22-3.67; p = 0.008), but not with peripheral arterial disease or myocardial ischemia.

Conclusions

Increased plasma OPG concentration is associated with carotid and peripheral arterial disease in patients with type 2 diabetes, whereas no relation is observed with respect to myocardial ischemia on MPS. The reason for this discrepancy is unknown.

Trial registration number

at http://www.clinicaltrial.gov: NCT00298844

NT-proBNP levels, atherosclerosis and vascular function in asymptomatic type 2 diabetic patients with microalbuminuria: peripheral reactive hyperaemia index but not NT-proBNP is an independent predictor of coronary atherosclerosis

Intensive multifactorial treatment aimed at cardiovascular (CV) risk factor reduction in type 2 diabetic patients with microalbuminuria can diminish fatal and non-fatal CV. Plasma N-terminal (NT)-proBNP predicts CV mortality in diabetic patients but the utility of P-NT-proBNP in screening for atherosclerosis is unclear. We examined the interrelationship between P-NT-proBNP, presence of atherosclerosis and/or vascular dysfunction in the coronary, carotid and peripheral arteries in asymptomatic type 2 diabetic patients with microalbuminuria that received intensive multifactorial treatment.

METHODS AND RESULTS

P-NT-proBNP was measured in 200 asymptomatic type 2 patients without known cardiac disease that received intensive multifactorial treatment for CV risk reduction. Patients were examined for coronary, carotid and peripheral atherosclerosis, as defined by coronary calcium score≥400, carotid intima-media thickness (CIMT)>0.90 mm, ankle-brachial index<0.90, and/or toe-brachial index<0.64, respectively. Carotid artery compliance was also determined and the reactive hyperaemia index (RHI) measured by peripheral artery tonometry was used as a surrogate for endothelial function.P-NT-proBNP was associated with atherosclerosis in the unadjusted analysis, but not after adjustment for conventional risk factors. P-NT-proBNP was not associated with vascular dysfunction. The prevalence of atherosclerosis in the coronary, carotid and peripheral arteries was 35%, 10% and 21% of all patients, respectively. In total 49% had atherosclerosis in one territory and 15.6% and 1.0% in two and three territories. Low RHI was an independent predictor of coronary atherosclerosis (odds ratio [CI], 2.60 [1.15-5.88] and systolic blood pressure was the only independent determinant of CIMT (0.02 mm increase in CIMT per 10 mmHg increase in systolic blood pressure [p=0.003]).

CONCLUSIONS

Half of asymptomatic patients with type 2 diabetes mellitus and microalbuminuria had significant atherosclerosis in at least one vascular territory despite receiving intensive multifactorial treatment for CV risk reduction. Coronary atherosclerosis was most prevalent, whereas carotid disease was more rarely observed. RHI but not plasma NT-proBNP was predictive of coronary atherosclerosis.

Reliability of the Baltimore Activity Scale Questionnaire for Intermittent Claudication

We assessed the reliability of the Baltimore Activity Scale for Intermittent Claudication (BASIC) for the evaluation of physical activity levels in individuals with intermittent claudication. We also identify the characteristics of the patients that influence the reliability of this questionnaire. A total of 38 men and women with peripheral artery disease and symptoms of intermittent claudication participated in the study. BASIC was administered to patients by the same evaluator at 2 different visits, separated by 7 days. The concordance coefficient ranged from .43 (How often do you walk at a fast pace?) to .85 (What happens when you feel pain while you walk?). The concordance coefficient of BASIC total score was .60. Higher concordance coefficients were observed in women (.66 vs .55), in younger patients (.63 vs .56), and in patients with lower ankle-brachial index (.64 vs .55). The reliability of BASIC questionnaire ranged from moderate to good in patients with claudication.

Sex-specific differences in metabolic control, cardiovascular risk, and interventions in patients with type 2 diabetes mellitus

BACKGROUND

Sex-specific differences appear particularly relevant in the management of type 2 diabetes mellitus (T2DM), with women experiencing greater increases in cardiovascular morbidity and mortality than do men.

OBJECTIVE

The aim of this article was to investigate the influence of biological sex on clinical care and microvascular and macrovascular complications in patients with T2DM in a Central European university diabetes clinic.

METHODS

In a cross-sectional study, sex-specific disparities in metabolic control, cardiovascular risk factors, and diabetic complications, as well as concomitant medication use and adherence to treatment recommendations, were evaluated in 350 consecutive patients who were comparable for age, diabetes duration, and body mass index. Study inclusion criteria included age ≤75 years, T2DM, a documented history of presence or absence of coronary heart disease (CHD), and informed consent. Patients were followed in the diabetes outpatient clinic between November 2007 and March 2008.

RESULTS

Two hundred and one patients with T2DM met inclusion criteria (93 [46.3%] women, 108 [53.7%] men). Women with T2DM had higher mean (SE) systolic blood pressure (155.4 [22.5] vs 141.0 [19.8] mm Hg for men; P < 0.001) and total cholesterol (TC) (5.28 [1.34] vs 4.86 [1.29] mmol/L for men; P < 0.05), but a lower TC:HDL-C ratio (4.1 [1.19] vs 4.5 [1.2] for men; P < 0.05). Slightly more men (32.4%) than women (26.9%) reached the therapeutic goal of <7.0% for glycosylated hemoglobin. Women with shorter diabetes duration (<10 years) received oral antihyperglycemic therapy less frequently (P < 0.05). Women with longer disease duration had hypertension more frequently than did their male counterparts (100% vs 86.0%, respectively; P < 0.01). Despite a similar rate of CHD, men were twice as likely as women to have had coronary interventions (percutaneous transluminal coronary angioplasty/coronary artery bypass graft, 25.0% vs 12.9%, respectively; P < 0.05). Women with CHD also had a higher rate of cerebral ischemia than did men (27.6% vs 5.4%, respectively; P < 0.05) and received aspirin less frequently for secondary prevention (P < 0.001). Men had greater overall adherence to diabetes and cardiovascular risk guidelines than did women (66.4% vs 58.9%, respectively; P < 0.01).

CONCLUSIONS

In this study of diabetes clinic outpatients, women with T2DM had a worse cardiovascular risk profile and achieved therapeutic goals less frequently than did men. Treatment strategies should be improved in both sexes, but women with diabetes may be in need of more aggressive treatment, especially when cardiovascular disease is present.

Progression of diabetic retinopathy correlated with muscle perfusion disturbances of the lower limbs, with clinically important diagnostic recommendations

INTRODUCTION

The objective of this study was to investigate the relationship between microvascular and macrovascular disturbances in patients with type 2 diabetes, as shown by results of ophthalmological examination and by vascular and perfusion examinations of the lower limbs.

MATERIAL AND METHODS

A total of 85 patients with type 2 diabetes and an additional cardiovascular risk factor were enrolled in the study. All patients underwent complex ophthalmological examination, including fundus colour photography and fluorescein angiography, and were divided into two groups: group I with signs of diabetic non-proliferative retinopathy (NPDR), and group II with signs of diabetic proliferative retinopathy (P/PDR). After collection of the general medical history and analysis of medical data, patients underwent vascular and muscle perfusion examination of the lower limbs.

RESULTS

In the P/PDR group, disturbances of lower-limb perfusion were more frequent than in the NPDR group. Analysis of the blood flow and results of lower-limb muscle perfusion for the two groups showed a significant relationship with the severity of microvascular complications observed in examination of the fundus.

CONCLUSIONS

Ophthalmological assessment of the progression of diabetic retinopathy in patients with type 2 diabetes is a reliable indicator of the changes in peripheral vessel systems and perfusion defects in the lower limbs.

Use and utility of ankle brachial index in patients with diabetes

Ankle brachial index (ABI) is a simple method to screen peripheral arterial disease (PAD) and to evaluate cardiovascular (CV) prognosis in the general population. Measuring it requires a hand-held Doppler probe but it can be done also with an automatic device. ABI is an effective tool for clinical practice or clinical studies. However, in diabetic patients, it has some specific caveats. Sensitivity of the standard threshold of 0.9 appears to be lower in diabetic patients with complications. Moreover, highly frequent arterial medial calcifications in diabetes increase ABI. It has been demonstrated that measurements >1.3 are well correlated with both an increased prevalence of PAD and CV risk. Therefore, ABI thresholds of less than 0.9 and more than 1.3 are highly suspicious for PAD and high CV risk in diabetic patients. However, when there is concomitant clinical peripheral neuropathy or high risk of arterial calcification, the efficiency of ABI seems to be limited. In this case, other methods should be applied, toe pressure, in particular. Thus, the ABI could be used in patients with diabetes, but values should be interpreted with precision, according to the clinical situation.

Apolipoprotein E genotype and mortality in Southern European and Anglo-Celt patients with type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To determine whether cardiac and all-cause mortality are lower in Southern European (SE) patients than in Anglo-Celt (AC) patients with type 2 diabetes in an urban Australian setting, and, if so, whether ethnicity-specific differences in apolipoprotein E (APOE) genotypes are contributory.

DESIGN

Longitudinal observational cohort study.

METHODS

We analysed detailed data from 1057 patients from the community-based Fremantle Diabetes Study, 238 were of an SE migrant background and 819 of AC ethnicity. Cox proportional hazards modelling was used to identify independent predictors of cardiac and all-cause mortality.

RESULTS

During 9.8±3.5 years of follow-up, 411 (38.9%) participants died, 161 (39.2%) from cardiac causes. Significant positive baseline independent predictors of cardiac death were age, male gender, coronary heart disease, cerebrovascular disease, peripheral arterial disease, retinopathy and peripheral neuropathy (P≤0.004), while maternal history of diabetes was protective (P=0.014). After adjusting for these variables, APOE4 carriage was predictive (hazard ratio (95% confidence interval) 1.61 (1.01-2.58); P=0.048). SE ethnicity did not add significantly to the model either as a single variable or as an interaction term with APOE4 carriage (P≥0.86). Significant independent predictors of all-cause mortality were age, male gender, smoking, coronary heart disease, cerebrovascular disease, peripheral arterial disease, retinopathy, peripheral neuropathy and microalbuminuria (P≤0.047), while overweight/obesity, lipid-lowering therapy and recent exercise were protective (P≤0.008). APOE4 carriage, SE ethnicity and their interaction did not add to the model (P≥0.32).

CONCLUSIONS

SE ethnicity does not confer an independent survival advantage in community-based Australian type 2 diabetic patients, but APOE4 carriers are at higher risk of cardiac death.

Sulphonylurea-metformin combination therapy, cardiovascular disease and all-cause mortality: the Fremantle Diabetes Study

AIM

To determine whether combination of metformin-sulphonylurea is associated with an increased risk of cardiovascular disease (CVD) and mortality in an urban community-based cohort of type 2 patients.

METHODS

We studied 1271 (98.2%) of 1294 type 2 participants in the observational Fremantle Diabetes Study (mean age 64.2 years, 48.8% males) who had detailed diabetes-specific therapy recorded at baseline and complete follow-up data. Mortality and hospital discharge data were collected over 13 174 patient-years (mean +/- SD: 10.4 +/- 3.9 years). Cox proportional hazards modelling was used to determine whether baseline diabetes treatments were independently associated with cardiovascular mortality, hospitalization for/death from CVD or all-cause mortality after adjustment for other explanatory variables.

RESULTS

During follow-up, 523 deaths occurred (41.1%) of which 269 (51.4%) were attributed to CVD. Hospitalization for CVD as principal diagnosis occurred at least once for 481 (37.8%) participants. In Kaplan-Meier analyses, there were significant differences in cardiovascular mortality, hospitalization for/death from CVD and all-cause mortality between diabetes therapy groups (p < 0.001). Compared with diet and metformin monotherapy, those treated with metformin-sulphonylurea had higher cardiovascular and all-cause mortality (p < or = 0.024). Insulin users had significantly higher cardiovascular mortality, hospitalization for/death from CVD and all-cause mortality than those on combination therapy (p < or = 0.016). After adjustment for significant variables in the most parsimonious models, diabetes treatment was not independently associated with any of the three study endpoints (p > or = 0.49).

CONCLUSIONS

Combination metformin-sulphonylurea appears as safe as other blood glucose-lowering therapies used for type 2 diabetes.

Serum uric acid does not predict cardiovascular or all-cause mortality in type 2 diabetes: the Fremantle Diabetes Study

AIMS/HYPOTHESIS

To determine whether serum uric acid: (1) is associated with cardiovascular disease (CVD) death and/or all-cause mortality in type 2 diabetes; and (2) consistent with published data, predicts these outcomes in older patients and those of southern European ethnicity.

METHODS

We studied those 1,268 (98%) of 1,294 type 2 participants in the observational Fremantle Diabetes Study who had a fasting serum uric acid measured at baseline. Mortality data were collected over a mean (+/-SD) 10.3 +/- 3.9 years. Cox proportional hazards modelling was used to determine independent baseline predictors of CVD and all-cause death including fasting serum uric acid as a continuous variable and quartiles.

RESULTS

During follow up, 525 deaths occurred (41.4% of the cohort) of which 271 (51.6%) were attributed to CVD. In univariate analyses, patients in the highest uric acid quartile had the greatest CVD and all-cause mortality (p = 0.007 and p = 0.001). After adjustment for significant variables in the most parsimonious model, baseline serum uric acid was not an independent associate of CVD or all-cause mortality whether entered as a continuous variable (HR 1.11 [95% CI 0.96-1.27] and 1.10 [95% CI 0.98-1.22] for a 0.1 mmol/l increase, respectively) or as quartiles (p > 0.10). Analyses of 638 patients >65 years of age and 231 of southern European ethnicity produced similar results.

CONCLUSIONS/INTERPRETATION

Serum uric acid was not an independent predictor of CVD or all-cause mortality in our community-based type 2 patients. Fasting serum uric acid concentrations do not appear to be prognostically useful in type 2 diabetes.

Maternal family history of diabetes is associated with a reduced risk of cardiovascular disease in women with type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To investigate whether parental family history of diabetes influences cardiovascular outcomes in type 2 diabetes.

RESEARCH DESIGN AND METHODS

We studied 1,294 type 2 diabetic patients (mean age 64.1 years, 51.2% female) recruited to a community-based cohort study from 1993 to 1996 and followed until mid-2006. A data linkage system assessed all-cause and cardiac mortality, incident myocardial infarction, and stroke. Cox proportional hazards modeling was used to determine the influence of maternal or paternal family history on these outcomes.

RESULTS

A maternal family history of diabetes was reported by 20.4% of the cohort, 8.3% reported paternal family history, and 2.0% reported both parents affected. Maternal and paternal family history was associated with earlier age of diabetes onset, and maternal family history was associated with worse glycemic control. For all patients, maternal family history was significantly associated with reduced risk of all-cause mortality and cardiac mortality. When analyzed by sex, maternal family history had no effect on male patients, whereas female patients with diabetic mothers had significantly reduced hazard ratios for death from all causes (0.63 [95% CI 0.41-0.96]; P = 0.033), for death from cardiac causes (0.32 [0.14-0.72]; P = 0.006), and for first myocardial infarction (0.45 [0.26-0.76]; P = 0.003). Paternal family history status was not associated with these outcomes.

CONCLUSIONS

A maternal family history of diabetes confers relative protection against cardiovascular disease in female patients but not in male patients with type 2 diabetes. Paternal family history is associated with risks equivalent to those without a family history of diabetes. Some of the clinical heterogeneity of type 2 diabetes is related to maternal transmission effects with differential impact on male and female patients.

Determinants of severe hypoglycemia complicating type 2 diabetes: the Fremantle diabetes study

CONTEXT

There are limited published data characterizing severe hypoglycemia complicating type 2 diabetes.

OBJECTIVE

The objective of the study was to determine the incidence and predictors of severe hypoglycemia in community-dwelling type 2 patients.

DESIGN

This was a longitudinal observational cohort study.

SETTING

This was a community-based study.

PATIENTS

There were 616 patients (mean age 67.0 yr, 52.3% males, median diabetes duration 7.7 yr) assessed in 1998 and followed up to the end of June 2006.

MAIN OUTCOME MEASURES

Severe hypoglycemia defined as that requiring ambulance attendance, emergency department services, and/or hospitalization. Cox proportional hazards modeling was used to determine predictors of first episode, and Poisson, negative binomial, zero-inflated Poisson, and zero-inflated negative binomial regression models identified predictors of frequency.

RESULTS

Fifty-two (8.4%) experienced 66 episodes during 3953 patient-years (incidence 1.7 per 100 patient-years). Those experiencing severe hypoglycemia had one to four episodes. Significant independent predictors of time to first episode were duration of insulin treatment, estimated glomerular filtration rate less than 60 ml/min per 1.73 m(2), peripheral neuropathy, education beyond primary level, and past severe hypoglycemia. The zero-inflated negative binomial provided the best model of severe hypoglycemia frequency. Lower fasting serum glucose and higher glycosylated hemoglobin were significantly associated with frequency, whereas patients at minimal risk of repeated severe hypoglycemia were unlikely to use insulin or to have short-duration insulin treatment, to have renal impairment or peripheral neuropathy, or to be educated beyond primary level.

CONCLUSIONS

Duration of insulin treatment was confirmed as an independent risk factor for severe hypoglycemia. The novel association with educational attainment suggests knowledge-driven intensive glycemic self-management. The positive relationship between frequency and glycosylated hemoglobin may identify patients with unstable glycemic control.

[Usefulness of pulse oximetry in screening of carotid atherosclerosis in patients with type 2 diabetes mellitus]

BACKGROUND AND OBJECTIVE

Pulse oximetry of the toes has been suggested in the screening of peripheral arterial disease. We studied the uselfuness of pulse oximetry in detection of type 2 diabetic patients with carotid atherosclerosis.

SUBJECTS AND METHODS

105 patients with type 2 diabetes mellitus (DM) without previous clinical peripheral arterial disease were enrolled. All patients had (1) ankle-brachial index (ABI) measurement, (2) pulse oximetry to measure SaO(2) of their index fingers and big toes in the supine position and at elevated 30cm and (3) a carotid ultrasound [carotid artery intima-media thickness (IMT) and carotid plaques (CP) measurements]. The ABI was considered abnormal when it was <0.9 and when the pulse oximetry showed a decrease in SaO(2) of >2% of the finger compared to foot or to 30cm foot elevation.

RESULTS

60 patients were men (age of 62+/-7 years, HbA(1c) of 6.9+/-1.0); 58.1% had CP. There were no differences in anthropometric and biochemical results between patients with or without CP. The ABI was <0.9 in 49% and 25% of patients with and without CP, respectively. Neither were there differences in pulse oximetry in patients with CP or in those with ABI <0.9. The IMT did not change in relation to pulse oximetry, but it was higher in patients with CP and with ABI <0.9 than in patients without alterations. These results were independent of the presence of previous clinical macroangiopathy.

CONCLUSION

Pulse oximetry is not a useful screening method of carotid atherosclerosis in type 2 DM.

Cardiovascular event rates in diabetic and nondiabetic individuals with and without established atherothrombosis (from the REduction of Atherothrombosis for Continued Health [REACH] Registry)

The objective of this study was to determine cardiovascular event rates in diabetic patients and nondiabetic subjects from the REACH Registry with established coronary artery disease, cerebrovascular disease, peripheral arterial disease, or multiple risk factors for atherothrombosis. REACH is an international, prospective, and contemporaneous cohort of patients with > or = 3 atherothrombotic risk factors only or established atherothrombotic disease, of which 30,043 have diabetes. The main outcomes after 1-year follow-up were cardiovascular death, myocardial infarction, stroke, major adverse cardiovascular events (MACEs; cardiovascular death, myocardial infarction, or stroke), and MACEs/hospitalization. The MACE rate at 1 year was positively related to the number of atherothrombotic anatomic sites in diabetic patients and nondiabetic subjects, and the rate was higher in those with (3.8%) than without (3.0%, p <0.001) diabetes. Diabetic patients with risk factors only had a lower MACE rate than nondiabetic subjects or diabetic patients with established atherothrombotic disease (2.2% vs 4.0% or 6.0%, respectively, p <0.001 for the 2 comparisons). These differences persisted after adjusting for gender and age. In conclusion, diabetic patients in the REACH Registry have an increased risk of cardiovascular events compared to nondiabetic subjects related to the number of atherothrombotic sites. Although increasing risk, diabetes may not be truly equivalent to previous atherothrombotic events on new cardiovascular event rates.

Aspirin is associated with reduced cardiovascular and all-cause mortality in type 2 diabetes in a primary prevention setting: the Fremantle Diabetes study

OBJECTIVE

To determine whether regular aspirin use (> or =75 mg/day) is independently associated with cardiovascular disease (CVD) and all-cause mortality in community-based patients with type 2 diabetes and no history of CVD.

RESEARCH DESIGN AND METHODS

Of the type 2 diabetic patients recruited to the longitudinal observational Fremantle Diabetes Study, 651 (50.3%) with no prior CVD history at entry between 1993 and 1996 were followed until death or the end of June 2007, representing a total of 7,537 patient-years (mean +/- SD 11.6 +/- 2.9 years). Cox proportional hazards modeling was used to determine independent baseline predictors of CVD and all-cause mortality including regular aspirin use.

RESULTS

There were 160 deaths (24.6%) during follow-up, with 70 (43.8%) due to CVD. In Kaplan-Meier survival analysis, there was no difference in either CVD or all-cause mortality in aspirin users versus nonusers (P = 0.52 and 0.94, respectively, by log-rank test). After adjustment for significant variables in the most parsimonious Cox models, regular aspirin use at baseline independently predicted reduced CVD and all-cause mortality (hazard ratio [HR] 0.30 [95% CI 0.09-0.95] and 0.53 [0.28-0.98[, respectively; P < or = 0.044). In subgroup analyses, aspirin use was independently associated with reduced all-cause mortality in those aged > or =65 years and men.

CONCLUSIONS

Regular low-dose aspirin may reduce all-cause and CVD mortality in a primary prevention setting in type 2 diabetes. All-cause mortality reductions are greatest in men and in those aged > or =65 years. The present observational data support recommendations that aspirin should be used in primary CVD prevention in all but the lowest risk patients.

Myocardial ischemia, carotid, and peripheral arterial disease and their interrelationship in type 2 diabetes patients

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in type 2 diabetes mellitus (T2DM) patients. We examined the relationship between CVD in different vascular territories.

METHODS

T2DM patients without known or suspected CVD (n = 305) referred consecutively to a diabetes clinic for the first time and age-matched nondiabetic reference subjects (n = 40) were screened for myocardial ischemia, carotid, and peripheral arterial disease by means of myocardial perfusion scintigraphy, carotid artery ultrasonography, and peripheral ankle and toe systolic blood pressure measurements.

RESULTS

In the T2DM patients, the prevalence of myocardial ischemia, carotid, and peripheral arterial disease was 30%, 42%, and 15%, respectively, almost three times higher than in the reference subjects (P = 0.007, P = 0.001, and P = 0.09, respectively). T2DM patients with myocardial ischemia, carotid, or peripheral arterial disease had a significantly increased risk of CVD in other vascular territories as well (OR: 1.99, 2.09, and 3.09, respectively). However, 40%, 52%, and 22% of the T2DM patients with myocardial ischemia, carotid, or peripheral arterial disease demonstrated exclusively this particular type of CVD manifestation.

CONCLUSIONS

In T2DM patients, signs of CVD in one vascular territory carry a significantly increased risk of CVD in other territories, although many patients only presented one manifestation.

Severe hypoglycaemia and cognitive impairment in older patients with diabetes: the Fremantle Diabetes Study

AIMS/HYPOTHESIS

The aim was to investigate the relationship between severe hypoglycaemia and cognitive impairment in older patients with diabetes.

METHODS

A sample of 302 diabetic patients aged >/=70 years was assessed for dementia or cognitive impairment without dementia in 2001-2002 and a subsample of non-demented patients (n = 205) was followed to assess cognitive decline. A history of severe hypoglycaemia was determined from self-reports, physician assessments and records of health service use for hypoglycaemia (HSH). Prospective HSH was determined up to 2006. Data analysis, including multiple logistic and Cox regression models, was used to determine whether: (1) there were cross-sectional associations between hypoglycaemia and cognitive status, (2) historical hypoglycaemia predicted cognitive decline, and (3) baseline cognitive status predicted subsequent HSH.

RESULTS

There were significant cross-sectional associations between both cognitive impairment and dementia and hypoglycaemia. Independent risk factors for future HSH included dementia (hazard ratio 3.00, 95% CI 1.06-8.48) and inability to self-manage medications (hazard ratio 4.17, 95% CI 1.43-12.13). However, there were no significant associations between historical hypoglycaemia, incident HSH and cognitive decline.

CONCLUSIONS/INTERPRETATION

Dementia is an important risk factor for hypoglycaemia requiring health service utilisation. We found no evidence that hypoglycaemia contributes to cognitive impairment in older patients with diabetes.

Antiplatelet therapy, Helicobacter pylori infection and complicated peptic ulcer disease in diabetes: the Fremantle Diabetes Study

AIMS

To assess whether, based on its relationship with complications of peptic ulcer disease (PUD), directed Helicobacter pylori serological screening is justified in diabetic patients prior to commencement of antiplatelet therapy.

METHODS

We analysed data from the longitudinal, community-based Fremantle Diabetes Study (FDS). The present substudy included (i) 1301 patients (91.2% of the total FDS sample; mean age 62.0 +/- 13.3 years, 49.5% male) with available sera from baseline assessment between 1993 and 1996, and (ii) a subset of 40 patients admitted to hospital for complicated PUD (bleeding and/or perforation) between baseline and end of June 2006. All hospital admissions for complicated PUD in the population of Western Australia were identified over the same period. Helicobacter pylori IgG antibodies were measured in all patients at baseline and in the subset at the FDS visit prior to hospital admission.

RESULTS

Helicobacter pylori seropositivity was present in 60.6% of FDS patients at baseline and was independently associated with increasing age and non-Anglo-Celt/non-Asian ethnicity. There were 2.9 (95% confidence interval 2.1, 3.9) first admissions for complicated PUD per 1000 patient-years, an incidence more than seven times that in the local general population. Independent baseline predictors of hospital admission were increasing age, serum urea, non-aspirin anticoagulant therapy, sulphonylurea therapy, peripheral arterial disease and diabetic retinopathy, but not aspirin use, H. pylori seropositivity or their interaction.

CONCLUSIONS

There are diabetes-specific risk factors for complicated PUD, including sulphonylurea use and vascular complications. Knowledge of H. pylori serological status does not predict complicated PUD in diabetes regardless of use of antiplatelet therapy.

What's new in lower-extremity arterial disease? WOCN's 2008 clinical practice guideline

Lower-extremity arterial disease (LEAD) affects 8 to 10 million people in the United States, resulting in pain, tissue loss, infection, limb loss, and an impaired quality of life. LEAD is underdiagnosed, undertreated, and often unrecognized. The purpose of this article is to provide a summary of the recommendations from the 2008 evidence-based, clinical practice guideline, Guideline for the Management of Patients With Lower-Extremity Arterial Disease, recently released from the Wound, Ostomy and Continence Nurses Society. This article presents an overview of the process used to develop the guideline, a discussion of risks for LEAD, and specific recommendations for assessment, interventions, patient education, and risk-reduction strategies.

Prevalence and predictors of osteopenia and osteoporosis in adults with Type 1 diabetes

AIMS

To determine the prevalence and biochemical/hormonal determinants of osteopenia and osteoporosis in adults with Type 1 diabetes.

METHODS

One hundred and two patients (52 female, 50 male) with Type 1 diabetes aged 20-71 years underwent cross-sectional assessment of biochemical/hormonal markers of bone metabolism, and bone mineral density (BMD) measurement at forearm, hip and spine using dual energy x-ray absorptiometry. BMD data were available for 102 age- and gender-matched population-based control subjects.

RESULTS

After adjusting for age and body mass index (BMI), osteopenia and osteoporosis were more common at the spine in males with Type 1 diabetes than in control subjects (P = 0.030). In Type 1 males, after adjustment for age and BMI, BMD, T- and Z-scores at the hip, femoral neck and spine were lower compared with age-matched control subjects (P < or = 0.048). Female Type 1 patients and control subjects had similar BMDs and T- and Z-scores at all sites. On multiple linear regression analysis, which adjusted for the natural logarithm of the sex hormone binding globulin concentration, smoking status and alcohol consumption, and (for women) menopausal status, each of BMI, serum ionized calcium and serum alkaline phosphatase (negatively) were independently associated with BMD at the hip and femoral neck in Type 1 diabetic subjects.

CONCLUSIONS

Adult males with Type 1 diabetes have reduced bone density at the hip, femoral neck and spine when compared with age-matched control subjects. Impaired bone formation may occur in Type 1 diabetes.

High prevalence of peripheral arterial disease diagnosed by low ankle-brachial index in Japanese patients with diabetes: the Kyushu Prevention Study for Atherosclerosis

We examined the prevalence of peripheral arterial disease (PAD) in Japanese diabetic patients with ankle-brachial index (ABI). Outpatients with diabetes (n=4249) who were regularly visiting Kyushu University Hospital, its 17 related hospitals, Ryukyu University Hospital and its 6 related hospitals were enrolled in the Kyushu Prevention Study for Atherosclerosis from 2001 to 2003. At baseline, ABI was measured using a device "form PWV/ABI". Valid information was available for 3906 diabetic patients (mean age: 60.8 years) including 1612 elderly patients (>65 years). Patients with a low ABI (<0.9) on either side or on both sides were considered to have PAD. The prevalence of PAD patients with ABI<0.9 was 7.6% in all diabetic subjects. Elderly patients (>65 years) had a higher prevalence of PAD (12.7%) compared with younger patients (<65 years) (4.0%). In addition, the rate of patients who had been diagnosed accurately as having PAD before enrollment was low (24.4%). The prevalence of PAD was high in Japanese patients with diabetes, especially in elderly patients, in contrast to low rates of accurate diagnosis. Better diagnostic efforts and more intensive treatments are needed to improve quality of life and the overall prognosis of life in Japanese diabetic patients.

Predictors of cognitive decline in older individuals with diabetes

OBJECTIVE

The purpose of this study was to determine longitudinal predictors of cognitive decline in older individuals with diabetes who did not have dementia.

RESEARCH DESIGN AND METHODS

Cognitive assessments were performed in 205 subjects with diabetes (mean age 75.3 years) and repeated a median 1.6 years later. The sample was drawn from an existing cohort study, and data on diabetes, cardiovascular risk factors, and complications were collected 7.6 +/- 1.1 years before and at the time of the initial cognitive assessment. Cognitive status was defined using the Clinical Dementia Rating (CDR) scale, and cognitive decline was defined by change in CDR.

RESULTS

The sample included 164 subjects with normal cognition (CDR 0) and 41 with cognitive impairment without dementia (CDR 0.5). At follow-up, 33 (16.1%) had experienced cognitive decline (4 new cases of dementia and 29 cognitive impairment without dementia). Only educational attainment predicted cognitive decline from the data collected 7.6 years before cognitive assessment. Univariate predictors of cognitive decline at the time of the first cognitive assessment included age, education, urinary albumin-to-creatinine ratio (ACR), and treatment with either ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs). With multiple logistic regression controlling for age and education, cognitive decline was predicted by natural logarithm ACR (odds ratio 1.37 [95% CI 1.05-1.78], P = 0.021), whereas treatment with either ACEIs or ARBs was protective (0.28 [0.12-0.65], P = 0.003).

CONCLUSIONS

In this sample of older patients with diabetes, microalbuminuria was a risk factor for cognitive decline, whereas drugs that inhibit the renin-angiotensin system were protective. These observations require confirmation because of their considerable potential clinical implications.

Why to screen heart disease in diabetes

The expanding diabetic epidemic and the high risk of cardiovascular events in diabetic patients suggest that screening heart disease in this population is an important issue. Nonetheless, the advisability of large-scale screening in asymptomatic individuals with diabetes is debated, because available techniques are expensive and have suboptimal diagnostic accuracy. Moreover, all diabetic patients should be treated aggressively as if they all had a positive screening test, because diabetes could be considered a coronary risk equivalent. In this article, we underline the importance of an early diagnosis of coronary artery disease and heart failure in diabetic patients, suggesting that positive screening tests have significant implications in clinical management.

Disparities in self-reported diabetes mellitus among Arab, Chaldean, and black Americans in Southeast Michigan

Diabetes mellitus is an important public health problem that disproportionately affects minorities. Using a cross sectional, convenience sample, we estimated the prevalence of self-reported diabetes for Whites (n = 212), Arabs (n = 1,303), Chaldeans (n = 828), and Blacks (n = 789) in southeast Michigan. In addition, using a logistic regression model, we estimated odds ratios and 95% confidence intervals for the association between ethnicity and diabetes before and after adjusting for demographic, socioeconomic status, health care, chronic conditions, and health behavior variables. The overall age- and sex-adjusted prevalence of diabetes was 7.0%. Estimates were highest for Blacks (8.0%) followed by Arabs and Whites (7.0% for each group) and Chaldeans (6.0%). In the fully adjusted model, the association between ethnicity and diabetes was not statistically significant. Future studies should collect more detailed socioeconomic status, acculturation and health behavior information, which are factors that may affect the relationship between race/ethnicity and diabetes.

Ipsilateral total hip arthroplasty in a dysvascular below-knee amputee for advanced hip osteoarthritis: A case report and review of the literature

This retrospective file review outlines a case study of an 84 year-old man with a transtibial amputation for vascular disease who underwent an ipsilateral total hip replacement (THR). The question being addressed was how surgical techniques, rehabilitation processes and outcomes of joint arthroplasty would need to vary in a case of an ipsilateral dysvascular amputees. The surgery and associated rehabilitation was undertaken for groin pain, falls and reduced mobility due to mechanical osteoarthritis of the hip. The surgical technique and post-operative multidisciplinary rehabilitation is described in detail. Information on exercise regimes, length of stay and follow-up data on function, driving and pain management is presented. The literature is reviewed and all known cases of THR in amputees as well as data on survival of dysvascular amputees is presented. In light of advances in secondary prevention of vascular disease and cardiovascular surgical techniques, amputees with vascular disease may be living longer than they were 20 years ago. They may be beginning to experience the issues associated with aging such as osteoarthritis of the large joints. This case review and others in the literature may suggest that survival rates for vascular amputees be reviewed.