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Purola PKM, Ojamo MUI, Gissler M, Uusitalo HMT. Changes in Visual Impairment due to Diabetic Retinopathy During 1980-2019 Based on Nationwide Register Data. Diabetes Care 2022; 45:2020-2027. [PMID: 35838317 PMCID: PMC9472510 DOI: 10.2337/dc21-2369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 06/10/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate changes in the incidence, prevalence, severity, and onset age of visual impairment (VI) due to diabetic retinopathy (DR) and compare these trends in the screening and treatment of diabetes during 40 years based on Finnish national register data. RESEARCH DESIGN AND METHODS We included people with VI with nonproliferative DR (NPDR; n = 2,490, 73% women) or proliferative DR (PDR; n = 2,026, 53% women) as the main diagnosis for VI during 1980-2019 in the Finnish Register of Visual Impairment. The number of patients with treated diabetes during 1986-2019 was obtained from the Social Insurance Institution of Finland registers based on reimbursed medication data. RESULTS The annual incidence of reported VI due to DR has decreased since it peaked in the 1990s: regarding NPDR, it decreased from 102.3 to 5.5 per 100,000 patients with treated diabetes between the 1990s and 2010s; regarding PDR, the respective change was from 39.9 to 7.4. The incidence of patients with diabetes treated for DR increased during this period. Annual prevalence of reported VI and differences between sexes steadily decreased in the 2000s and 2010s. The severity of reported VI has decreased, and the age at the onset of reported VI increased during the 40 years. CONCLUSIONS Prevalence and incidence of VI due to DR have dramatically decreased and shifted to older age during the 40 years despite the increasing prevalence of diabetes. These positive trends highlight the successful development and effectiveness of screening and therapies for diabetes and DR.
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Affiliation(s)
- Petri K M Purola
- SILK, Department of Ophthalmology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Finnish Register of Visual Impairment, Finnish Federation of the Visually Impaired, Helsinki, Finland
| | - Matti U I Ojamo
- Finnish Register of Visual Impairment, Finnish Federation of the Visually Impaired, Helsinki, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland.,Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Hannu M T Uusitalo
- SILK, Department of Ophthalmology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Finnish Register of Visual Impairment, Finnish Federation of the Visually Impaired, Helsinki, Finland.,Tays Eye Centre, Tampere University Hospital, Tampere, Finland
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van der Heijden AA, Nijpels G, Badloe F, Lovejoy HL, Peelen LM, Feenstra TL, Moons KGM, Slieker RC, Herings RMC, Elders PJM, Beulens JW. Prediction models for development of retinopathy in people with type 2 diabetes: systematic review and external validation in a Dutch primary care setting. Diabetologia 2020; 63:1110-1119. [PMID: 32246157 PMCID: PMC7228897 DOI: 10.1007/s00125-020-05134-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/21/2020] [Indexed: 12/14/2022]
Abstract
AIMS/HYPOTHESIS The aims of this study were to identify all published prognostic models predicting retinopathy risk applicable to people with type 2 diabetes, to assess their quality and accuracy, and to validate their predictive accuracy in a head-to-head comparison using an independent type 2 diabetes cohort. METHODS A systematic search was performed in PubMed and Embase in December 2019. Studies that met the following criteria were included: (1) the model was applicable in type 2 diabetes; (2) the outcome was retinopathy; and (3) follow-up was more than 1 year. Screening, data extraction (using the checklist for critical appraisal and data extraction for systemic reviews of prediction modelling studies [CHARMS]) and risk of bias assessment (by prediction model risk of bias assessment tool [PROBAST]) were performed independently by two reviewers. Selected models were externally validated in the large Hoorn Diabetes Care System (DCS) cohort in the Netherlands. Retinopathy risk was calculated using baseline data and compared with retinopathy incidence over 5 years. Calibration after intercept adjustment and discrimination (Harrell's C statistic) were assessed. RESULTS Twelve studies were included in the systematic review, reporting on 16 models. Outcomes ranged from referable retinopathy to blindness. Discrimination was reported in seven studies with C statistics ranging from 0.55 (95% CI 0.54, 0.56) to 0.84 (95% CI 0.78, 0.88). Five studies reported on calibration. Eight models could be compared head-to-head in the DCS cohort (N = 10,715). Most of the models underestimated retinopathy risk. Validating the models against different severities of retinopathy, C statistics ranged from 0.51 (95% CI 0.49, 0.53) to 0.89 (95% CI 0.88, 0.91). CONCLUSIONS/INTERPRETATION Several prognostic models can accurately predict retinopathy risk in a population-based type 2 diabetes cohort. Most of the models include easy-to-measure predictors enhancing their applicability. Tailoring retinopathy screening frequency based on accurate risk predictions may increase the efficiency and cost-effectiveness of diabetic retinopathy care. REGISTRATION PROSPERO registration ID CRD42018089122.
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Affiliation(s)
- Amber A van der Heijden
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC - location VUmc, van der Boechorststraat 7, 1081 BT, Amsterdam, the Netherlands.
| | - Giel Nijpels
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC - location VUmc, van der Boechorststraat 7, 1081 BT, Amsterdam, the Netherlands
| | - Fariza Badloe
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC - location VUmc, van der Boechorststraat 7, 1081 BT, Amsterdam, the Netherlands
| | - Heidi L Lovejoy
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC - location VUmc, van der Boechorststraat 7, 1081 BT, Amsterdam, the Netherlands
| | - Linda M Peelen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Talitha L Feenstra
- Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
- Centre for Nutrition, Prevention and Health Services, Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Roderick C Slieker
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ron M C Herings
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
- PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
| | - Petra J M Elders
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC - location VUmc, van der Boechorststraat 7, 1081 BT, Amsterdam, the Netherlands
| | - Joline W Beulens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC - location VUmc, Amsterdam, the Netherlands
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Strain WD, Tsang C, Hurst M, McEwan P, Unadkat M, Meadowcroft S, Shardlow R, Evans M. What Next After Metformin in Type 2 Diabetes? Selecting the Right Drug for the Right Patient. Diabetes Ther 2020; 11:1381-1395. [PMID: 32424798 PMCID: PMC7261289 DOI: 10.1007/s13300-020-00834-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Metformin is the recommended initial treatment in type 2 diabetes mellitus (T2DM), but when this does not give adequate glucose control the choice of which second-line drug to use is uncertain as none have been found to have a better overall glycaemic response. In this real-world study dipeptidyl peptidase 4 inhibitors (DPP4i), sulphonylureas (SU), thiazolidinediones (TZD) and sodium glucose co-transporter 2 inhibitors (SGLT2i) were compared for their effectiveness in lowering glycated haemoglobin (HbA1c) levels for a particular individual based on their clinical characteristics. METHODS A retrospective analysis was undertaken of electronic health records of people with T2DM prescribed metformin alongside a DPP4i, SU, TZD or SGLT2i at second-line. Regression modelling was used to model the changes in HbA1c from baseline at month 6 and month 12 for the individual therapies, adjusting for demographic and clinical characteristics. RESULTS There were 7170 people included in the study. Treatment at second-line with SUs, DPP4i, TZDs and SGLT2i resulted in similar percentages of people achieving the recommended HbA1c target of < 7.5% (58 mmol/mol) at both 6 and 12 months. For those receiving SGLT2i and SUs, the greatest improvement in HbA1c was observed in relatively younger and older people, respectively. Trends were detected between other baseline characteristics and HbA1c improvement by drug class, but they were not statistically significant. Non-adherence rates were low for all drug classes. People with a higher medication possession ratio (≥ 80%) also had greater improvements in HbA1c at 12 months. CONCLUSION This study identified patients' phenotypic characteristics that may have the potential to influence individual treatment response. Accounting for these characteristics in clinical treatment decisions may facilitate individualised prescribing by being able to select the right drug for the right patient.
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Affiliation(s)
- W David Strain
- Diabetes and Vascular Research Centre, University of Exeter Medical School, Exeter, UK
| | - Carmen Tsang
- Health Economics and Outcomes Research Ltd., Cardiff, UK
| | - Michael Hurst
- Health Economics and Outcomes Research Ltd., Cardiff, UK
| | - Phil McEwan
- Health Economics and Outcomes Research Ltd., Cardiff, UK
| | | | | | | | - Marc Evans
- University Hospital Llandough, Cardiff, UK.
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Coates V, Slevin M, Carey M, Slater P, Davies M. Declining structured diabetes education in those with type 2 diabetes: A plethora of individual and organisational reasons. PATIENT EDUCATION AND COUNSELING 2018; 101:696-702. [PMID: 29103881 DOI: 10.1016/j.pec.2017.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/18/2017] [Accepted: 10/20/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE to identify the expressed reasons adults with type 2 diabetes decline structured diabetes education (SDE). METHODS cross sectional survey of 335 adults with type 2 diabetes who had declined SDE within the past two years, from across Northern Ireland and England. Standardised instruments comprising The Diabetes Attitude Scale, Diabetes Empowerment Scale (Short Form), and Diabetes Knowledge Test plus a questionnaire to elicit the reasons for declining SDE were used. RESULTS Mean age 57.6 years (±21.1) 50.7% males, predominantly of White ethnicity (85.7%). They were most frequently invited to attend by a diabetes specialist nurse (36%), general practitioner (27%) or practice nurse (19%). Although a diversity of reasons for declining SDE were cited the most common were; 'The course was too long' (47.2%), 'I have other health problems' (41.2%) and they had other priorities (33.4%). Hierarchical cluster analysis revealed that expressed reasons for declining SDE were highly individualised. CONCLUSION The wide range of reasons that impeded attendance suggests there is no simple solution that will improve attendance rates. PRACTICE IMPLICATIONS In the same way that medical treatment for diabetes is becoming increasingly individualised, educational provision should be encouraged to move away from a one size fits all model.
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Affiliation(s)
- Vivien Coates
- Institute of Nursing and Health Research, Ulster University, Magee campus, Londonderry BT48 7JL, United Kingdom; Western Health and Social Care Trust, Altnagelvin Hospital,Glenshane Road, Londonderry BT47 6SB, United Kingdom.
| | - Mary Slevin
- Institute of Nursing and Health Research, Ulster University, Cromore Road, Coleraine BT52 1SA, United Kingdom
| | - Marian Carey
- Leicester Diabetes Centre (Air Wing), Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, United Kingdom
| | - Paul Slater
- Institute of Nursing and Health Research, Ulster University, Shore Road, Newtownabbey, Co Antrim BT37 0QB, United Kingdom
| | - Mark Davies
- Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, United Kingdom
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Sanches M, Abuhaiba SI, d'Almeida OC, Quendera B, Gomes L, Moreno C, Guelho D, Castelo-Branco M. Diabetic brain or retina? Visual psychophysical performance in diabetic patients in relation to GABA levels in occipital cortex. Metab Brain Dis 2017; 32:913-921. [PMID: 28361261 DOI: 10.1007/s11011-017-9986-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 03/03/2017] [Indexed: 10/19/2022]
Abstract
Visual impairment is one of the most feared complications of Type 2 Diabetes Mellitus. Here, we aimed to investigate the role of occipital cortex γ-aminobutyric acid (GABA) as a predictor of visual performance in type 2 diabetes. 18 type 2 diabetes patients were included in a longitudinal prospective one-year study, as well as 22 healthy age-matched controls. We collected demographic data, HbA1C and used a novel set of visual psychophysical tests addressing color, achromatic luminance and speed discrimination in both groups. Psychophysical tests underwent dimension reduction with principle component analysis into three synthetic variables: speed, achromatic luminance and color discrimination. A MEGA-PRESS magnetic resonance brain spectroscopy sequence was used to measure occipital GABA levels in the type 2 diabetes group. Retinopathy grading and retinal microaneurysms counting were performed in the type 2 diabetes group for single-armed correlations. Speed discrimination thresholds were significantly higher in the type 2 diabetes group in both visits; mean difference (95% confidence interval), [0.86 (0.32-1.40) in the first visit, 0.74 (0.04-1.44) in the second visit]. GABA from the occipital cortex predicted speed and achromatic luminance discrimination thresholds within the same visit (r = 0.54 and 0.52; p = 0.02 and 0.03, respectively) in type 2 diabetes group. GABA from the occipital cortex also predicted speed discrimination thresholds one year later (r = 0.52; p = 0.03) in the type 2 diabetes group. Our results suggest that speed discrimination is impaired in type 2 diabetes and that occipital cortical GABA is a novel predictor of visual psychophysical performance independently from retinopathy grade, metabolic control or disease duration in the early stages of the disease.
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Affiliation(s)
- Mafalda Sanches
- Institute for Nuclear Sciences Applied to Health (ICNAS), University of Coimbra, Coimbra, Portugal
- CNC.IBILI, University of Coimbra, Coimbra, Portugal
| | - Sulaiman I Abuhaiba
- Institute for Nuclear Sciences Applied to Health (ICNAS), University of Coimbra, Coimbra, Portugal
- CNC.IBILI, University of Coimbra, Coimbra, Portugal
- PhD Programme in Experimental Biology and Biomedicine (PDBEB), CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
- Institute for Interdisciplinary Research (IIIUC), University of Coimbra, Coimbra, Portugal
| | - Otília C d'Almeida
- Institute for Nuclear Sciences Applied to Health (ICNAS), University of Coimbra, Coimbra, Portugal
- CNC.IBILI, University of Coimbra, Coimbra, Portugal
- Visual Neuroscience Laboratory, Institute for Biomedical Imaging and Life Sciences (IBILI), Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal
| | - Bruno Quendera
- CNC.IBILI, University of Coimbra, Coimbra, Portugal
- Visual Neuroscience Laboratory, Institute for Biomedical Imaging and Life Sciences (IBILI), Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal
| | - Leonor Gomes
- Department of Endocrinology, Coimbra University and Hospital Centre (CHUC), Coimbra, Portugal
| | - Carolina Moreno
- Department of Endocrinology, Coimbra University and Hospital Centre (CHUC), Coimbra, Portugal
| | - Daniela Guelho
- Department of Endocrinology, Coimbra University and Hospital Centre (CHUC), Coimbra, Portugal
| | - Miguel Castelo-Branco
- Institute for Nuclear Sciences Applied to Health (ICNAS), University of Coimbra, Coimbra, Portugal.
- CNC.IBILI, University of Coimbra, Coimbra, Portugal.
- Visual Neuroscience Laboratory, Institute for Biomedical Imaging and Life Sciences (IBILI), Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, Celas, 3000-548, Coimbra, Portugal.
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Maa AY, Wojciechowski B, Hunt KJ, Dismuke C, Shyu J, Janjua R, Lu X, Medert CM, Lynch MG. Early Experience with Technology-Based Eye Care Services (TECS): A Novel Ophthalmologic Telemedicine Initiative. Ophthalmology 2017; 124:539-546. [PMID: 28081944 DOI: 10.1016/j.ophtha.2016.11.037] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The aging population is at risk of common eye diseases, and routine eye examinations are recommended to prevent visual impairment. Unfortunately, patients are less likely to seek care as they age, which may be the result of significant travel and time burdens associated with going to an eye clinic in person. A new method of eye-care delivery that mitigates distance barriers and improves access was developed to improve screening for potentially blinding conditions. We present the quality data from the early experience (first 13 months) of Technology-Based Eye Care Services (TECS), a novel ophthalmologic telemedicine program. DESIGN With TECS, a trained ophthalmology technician is stationed in a primary care clinic away from the main hospital. The ophthalmology technician follows a detailed protocol that collects information about the patient's eyes. The information then is interpreted remotely. Patients with possible abnormal findings are scheduled for a face-to-face examination in the eye clinic. PARTICIPANTS Any patient with no known ocular disease who desires a routine eye screening examination is eligible. METHODS Technology-Based Eye Care Services was established in 5 primary care clinics in Georgia surrounding the Atlanta Veterans Affairs hospital. MAIN OUTCOME MEASURES Four program operation metrics (patient satisfaction, eyeglass remakes, disease detection, and visit length) and 2 access-to-care metrics (appointment wait time and no-show rate) were tracked. RESULTS Care was rendered to 2690 patients over the first 13 months of TECS. The program has been met with high patient satisfaction (4.95 of 5). Eyeglass remake rate was 0.59%. Abnormal findings were noted in 36.8% of patients and there was >90% agreement between the TECS reading and the face-to-face findings of the physician. TECS saved both patient (25% less) and physician time (50% less), and access to care substantially improved with 99% of patients seen within 14 days of contacting the eye clinic, with a TECS no-show rate of 5.2%. CONCLUSIONS The early experience with TECS has been promising. Tele-ophthalmology has the potential to improve operational efficiency, reduce cost, and significantly improve access to care. Although further study is necessary, TECS shows potential to help prevent avoidable vision loss.
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Affiliation(s)
- April Y Maa
- Ophthalmology Division, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia.
| | - Barbara Wojciechowski
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph A. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
| | - Kelly J Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph A. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
| | - Clara Dismuke
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph A. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
| | - Jason Shyu
- Ophthalmology Division, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Rabeea Janjua
- Ophthalmology Division, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Xiaoqin Lu
- Ophthalmology Division, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia
| | | | - Mary G Lynch
- Ophthalmology Division, Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia
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Ezquer M, Urzua CA, Montecino S, Leal K, Conget P, Ezquer F. Intravitreal administration of multipotent mesenchymal stromal cells triggers a cytoprotective microenvironment in the retina of diabetic mice. Stem Cell Res Ther 2016; 7:42. [PMID: 26983784 PMCID: PMC4793534 DOI: 10.1186/s13287-016-0299-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/13/2016] [Accepted: 02/24/2016] [Indexed: 02/08/2023] Open
Abstract
Background Diabetic retinopathy is a common complication of diabetes and the leading cause of irreversible vision loss in the Western world. The reduction in color/contrast sensitivity due to the loss of neural cells in the ganglion cell layer of the retina is an early event in the onset of diabetic retinopathy. Multipotent mesenchymal stromal cells (MSCs) are an attractive tool for the treatment of neurodegenerative diseases, since they could differentiate into neuronal cells, produce high levels of neurotrophic factors and reduce oxidative stress. Our aim was to determine whether the intravitreal administration of adipose-derived MSCs was able to prevent the loss of retinal ganglion cells in diabetic mice. Methods Diabetes was induced in C57BL6 mice by the administration of streptozotocin. When retinal pro-damage mechanisms were present, animals received a single intravitreal dose of 2 × 105 adipose-derived MSCs or the vehicle. Four and 12 weeks later we evaluated: (a) retinal ganglion cell number (immunofluorescence); (b) neurotrophic factor levels (real-time quantitative polymerase chain reaction (RT-qPCR) and enzyme-linked immunosorbent assay (ELISA)); (c) retinal apoptotic rate (TUNEL); (d) retinal levels of reactive oxygen species and oxidative damage (ELISA); (e) electrical response of the retina (electroretinography); (f) pro-angiogenic and anti-angiogenic factor levels (RT-qPCR and ELISA); and (g) retinal blood vessels (angiography). Furthermore, 1, 4, 8 and 12 weeks post-MSC administration, the presence of donor cells in the retina and their differentiation into neural and perivascular-like cells were assessed (immunofluorescence and flow cytometry). Results MSC administration completely prevented retinal ganglion cell loss. Donor cells remained in the vitreous cavity and did not differentiate into neural or perivascular-like cells. Nevertheless, they increased the intraocular levels of several potent neurotrophic factors (nerve growth factor, basic fibroblast growth factor and glial cell line-derived neurotrophic factor) and reduced the oxidative damage in the retina. Additionally, MSC administration has a neutral effect on the electrical response of the retina and did not result in a pathological neovascularization. Conclusions Intravitreal administration of adipose-derived MSCs triggers an effective cytoprotective microenvironment in the retina of diabetic mice. Thus, MSCs represent an interesting tool in order to prevent diabetic retinopathy. Electronic supplementary material The online version of this article (doi:10.1186/s13287-016-0299-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marcelo Ezquer
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Av. Las Condes 12438, Lo Barnechea, Santiago, 7710162, Chile
| | - Cristhian A Urzua
- Departamento de Oftalmología, Facultad de Medicina, Universidad de Chile, Av. Independencia 1027, Santiago, Chile
| | - Scarleth Montecino
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Av. Las Condes 12438, Lo Barnechea, Santiago, 7710162, Chile
| | - Karla Leal
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Av. Las Condes 12438, Lo Barnechea, Santiago, 7710162, Chile
| | - Paulette Conget
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Av. Las Condes 12438, Lo Barnechea, Santiago, 7710162, Chile
| | - Fernando Ezquer
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Av. Las Condes 12438, Lo Barnechea, Santiago, 7710162, Chile.
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Ezquer F, Ezquer M, Arango-Rodriguez M, Conget P. Could donor multipotent mesenchymal stromal cells prevent or delay the onset of diabetic retinopathy? Acta Ophthalmol 2014; 92:e86-95. [PMID: 23773776 DOI: 10.1111/aos.12113] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diabetes mellitus is a complex metabolic disease that has become a global epidemic with more than 285 million cases worldwide. Major medical advances over the past decades have substantially improved its management, extending patients' survival. The latter is accompanied by an increased risk of developing chronic macro- and microvascular complications. Amongst them, diabetic retinopathy (DR) is the most common and frightening. Furthermore, during the past two decades, it has become the leading cause of visual loss. Irrespective of the type of diabetes, DR follows a well-known clinical and temporal course characterized by pericytes and neuronal cell loss, formation of acellular-occluded capillaries, occasional microaneurysms, increased leucostasis and thickening of the vascular basement membrane. These alterations progressively affect the integrity of retinal microvessels, leading to the breakdown of the blood-retinal barrier, widespread haemorrhage and neovascularization. Finally, tractional retinal detachment occurs leading to blindness. Nowadays, there is growing evidence that local inflammation and oxidative stress play pivotal roles in the pathogenesis of DR. Both processes have been associated with pericytes and neuronal degeneration observed early during DR progression. They may also be linked to sustained retinal vasculature damage that results in abnormal neovascularization. Currently, DR therapeutic options depend on highly invasive surgical procedures performed only at advanced stages of the disease, and which have proved to be ineffective to restore visual acuity. Therefore, the availability of less invasive and more effective strategies aimed to prevent or delay the onset of DR is highly desirable. Multipotent mesenchymal stromal cells, also referred to as mesenchymal stem cells (MSCs), are promising healing agents as they contribute to tissue regeneration by pleiotropic mechanisms, with no evidence of significant adverse events. Here, we revise the pathophysiology of DR to identify therapeutic targets for donor MSCs. Also, we discuss whether an MSC-based therapy could prevent or delay the onset of DR.
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Affiliation(s)
- Fernando Ezquer
- Institute of Science, Faculty of Medicine Clinica Alemana Universidad del Desarrollo, Lo Barnechea, Santiago, Chile
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Hellgren KJ, Bengtsson B, Agardh E. Functional and structural change in diabetic eyes. Interim results from an ongoing longitudinal prospective study. Acta Ophthalmol 2013; 91:672-7. [PMID: 23025256 DOI: 10.1111/j.1755-3768.2012.02508.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To presents results after 18 months of follow-up of a longitudinal study aiming at exploring the correlation between diabetic retinal vascular lesions and functional change. METHODS Patients were consecutively recruited from attendees to the screening program for diabetic retinopathy. Subjects are followed every sixth month for the first 3 years and thereafter annually up to 5 years. Progression of diabetic retinopathy is evaluated using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale and improvement/deterioration in visual fields by predefined significance limits for change. RESULTS Of 81 subjects, with no/mild/moderate diabetic retinopathy included, 76 have passed the 18-month visit. At that time, retinal progression by two steps according to the ETDRS scale had occurred in two subjects. Visual acuity was -0.14 logMAR and had decreased with two letters (0.04 logMAR) (p < 0.001) from baseline. The global visual field index mean deviation was almost unchanged with a negligible improvement of 0.03 dB (p = 0.79). In 21 subjects, repeated significant deterioration was seen in ≥10% of all points tested in the field, while almost no improved points were noted. The two subjects with retinal progression were not among those 21 with indication of perimetric progression. CONCLUSIONS This is, to our knowledge, the first longitudinal study evaluating change of visual fields in a representative diabetic cohort with no or mild/moderate retinopathy. In this interim report, we demonstrate deteriorated perimetric sensitivity in subjects already at 18 months of follow-up. The results will have implications for evaluating change in visual function in future clinical trials.
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Affiliation(s)
- Karl-Johan Hellgren
- Department of Clinical Sciences, Ophthalmology, Skåne University Hospital, Lund University, Malmö, SwedenDepartment of Ophthalmology, County Hospital of Värmland, Karlstad, Sweden
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Makura CBT, Nirantharakumar K, Girling AJ, Saravanan P, Narendran P. Effects of physical activity on the development and progression of microvascular complications in type 1 diabetes: retrospective analysis of the DCCT study. BMC Endocr Disord 2013; 13:37. [PMID: 24083407 PMCID: PMC3850661 DOI: 10.1186/1472-6823-13-37] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 09/17/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To examine the effects of physical activity on the development and progression of microvascular complications in patients with type 1 diabetes. METHODS A retrospective analysis of data from the Diabetes Control and Complications trial was undertaken. Physical activity data was collected at baseline for each of 1441 recruits, converted to metabolic equivalent of task values, and categorised according to the American College of Sports Medicine recommendations. The rates of development/progression of diabetic retinopathy, nephropathy and neuropathy were compared in those who achieved over twice recommended, up to twice recommended, and less than recommended metabolic equivalent of task levels of activity. The DCCT study had a mean duration of follow up of 6.5 years ending in 1993. RESULTS A total of 271 subjects had a sustained three-step progression in diabetic retinopathy. The rates of development or progression of retinopathy showed no significant association with physical activity level. The number of outcomes for nephropathy and neuropathy were small and there was no significant association with physical activity level. CONCLUSIONS We found no evidence that physical activity improves microvascular outcomes in type 1 diabetes. However we demonstrate no evidence of harm. We suggest that physical activity continues to play an important role in the management of type 1 diabetes.
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Affiliation(s)
- Caroline BT Makura
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | | | - Alan J Girling
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | | | - Parth Narendran
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
- Department of Diabetes, University Hospital Birmingham, Birmingham, UK
- Room 229, Institute of Biomedical Research, The Medical School, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Fenwick E, Rees G, Pesudovs K, Dirani M, Kawasaki R, Wong TY, Lamoureux E. Social and emotional impact of diabetic retinopathy: a review. Clin Exp Ophthalmol 2012; 40:27-38. [PMID: 21575125 DOI: 10.1111/j.1442-9071.2011.02599.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
People with vision-threatening diabetic retinopathy are likely to experience enhanced social and emotional strain. Critically, those with both vision-threatening diabetic retinopathy and psychosocial problems may have significantly reduced levels of functioning compared with psychologically healthy counterparts. This can cause inadequate compliance, increased strain on family functioning, worse diabetes control, increased progression of diabetic retinopathy and, consequently, further psychosocial stress resulting in a number of concerning implications for disease management, clinical outcomes and healthcare costs. However, the emotional and social health consequences of diabetic retinopathy have not yet been systematically explored. This information is crucial as it allows for a targeted approach to treatment and prevention and avoidance of the potentially detrimental implications described above. Therefore, this paper reviews the current qualitative and quantitative evidence regarding the social and emotional impact of diabetic retinopathy and identifies directions for future research. Key search terms were applied to the electronic databases Pubmed, ISI Web of Science and Embase and the bibliographies of relevant papers were systematically reviewed for additional references. Overall, the evidence suggests that diabetic retinopathy and associated vision loss have several debilitating effects, including disruption of family functioning, relationships and roles; increased social isolation and dependence; and deterioration of work prospects resulting in increased financial strain. Adverse emotional responses include fear, anxiety, vulnerability, guilt, loss of confidence, anger, stress and self-perception issues. However, the research to date is largely qualitative in nature, with most quantitative studies being small, cross-sectional and somewhat outdated. Similarly, the outcome measures used in many studies to date are suboptimal in terms of content and validity. Therefore, this review identifies the need for improved outcome measures to provide valid, meaningful measurement of the social and emotional impact of diabetic retinopathy and discusses potential directions for future research such as item banking and computer adaptive testing.
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Affiliation(s)
- Eva Fenwick
- Centre for Eye Research Australia, the Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Middleton AV, LaVoie NR, Brown LE. Sources of uncertainty in type 2 diabetes: explication and implications for health communication theory and clinical practice. HEALTH COMMUNICATION 2012; 27:591-601. [PMID: 22260354 DOI: 10.1080/10410236.2011.618435] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
According to the American Diabetes Association, nearly 24 million Americans live with type 2 diabetes, and clinical data project that this figure will increase 165% from 2000 to 2050. Thus, there is a pressing need to understand not only the physiological and medical needs, but also the psychological demands associated with the illness. Even though uncertainty has been explicated in various other illness contexts and potentially shapes the experience of type 2 diabetes, very little attention has been paid to the nature of uncertainty in this context. The present study examines the nature of uncertainty through qualitative interviews with 49 individuals diagnosed with type 2 diabetes. Using grounded theory methods, various themes emerged relative to the sources of uncertainty. These themes are discussed in light of their potential extension of health communication theory and application to intervention and educational programs for individuals living with type 2 diabetes.
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Affiliation(s)
- Ashley V Middleton
- Department of Communication, University of Illinois, Urbana-Champaign, Urbana, IL 61801, USA.
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13
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Radha V, Kanthimathi S, Mohan V. Genetics of Type 2 diabetes in Asian Indians. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/dmt.11.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2022]
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de Fine Olivarius N, Siersma V, Almind GJ, Nielsen NV. Prevalence and progression of visual impairment in patients newly diagnosed with clinical type 2 diabetes: a 6-year follow up study. BMC Public Health 2011; 11:80. [PMID: 21294871 PMCID: PMC3045948 DOI: 10.1186/1471-2458-11-80] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 02/04/2011] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Many diabetic patients fear visual loss as the worst consequence of diabetes. In most studies the main eye pathology is assigned as the cause of visual impairment. This study analysed a broad range of possible ocular and non-ocular predictors of visual impairment prospectively in patients newly diagnosed with clinical type 2 diabetes. METHODS Data were from a population-based cohort of 1,241 persons newly diagnosed with clinical, often symptomatic type 2 diabetes aged ≥ 40 years. After 6 years, 807 patients were followed up. Standard eye examinations were done by practising ophthalmologists. RESULTS At diabetes diagnosis median age was 65.5 years. Over 6 years, the prevalence of blindness (visual acuity of best seeing eye ≤ 0.1) rose from 0.9% (11/1,241) to 2.4% (19/807) and the prevalence of moderate visual impairment (> 0.1; < 0.5) rose from 5.4% (67/1,241) to 6.7% (54/807). The incidence (95% confidence interval) of blindness was 40.2 (25.3-63.8) per 10,000 patient-years. Baseline predictors of level of visual acuity (age, age-related macular degeneration (AMD), cataract, living alone, low self-rated health, and sedentary life-style) and speed of continued visual loss (age, AMD, diabetic retinopathy (DR), cataract, living alone, and high fasting triglycerides) were identified. CONCLUSIONS In a comprehensive assessment of predictors of visual impairment, even in a health care system allowing self-referral to free eye examinations, treatable eye pathologies such as DR and cataract emerge together with age as the most notable predictors of continued visual loss after diabetes diagnosis. Our results underline the importance of eliminating barriers to efficient eye care by increasing patients' and primary care practitioners' awareness of the necessity of regular eye examinations and timely surgical treatment.
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Affiliation(s)
- Niels de Fine Olivarius
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
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Sjølie AK, Dodson P, Hobbs FRR. Does renin-angiotensin system blockade have a role in preventing diabetic retinopathy? A clinical review. Int J Clin Pract 2011; 65:148-53. [PMID: 21235695 DOI: 10.1111/j.1742-1241.2010.02552.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Diabetes management has increasingly focused on the prevention of macrovascular disease, in particular for type 2 diabetes. Diabetic retinopathy, one of the main microvascular complications of diabetes, is also an important public health problem. Much of the care invested in retinopathy relates to treatment rather than prevention of disease. Tight glycaemic and blood pressure control helps to reduce the risk of retinopathy, but this is not easy to achieve in practice and additional treatments are needed for both primary and secondary prevention of retinopathy. A renin-angiotensin system (RAS) has been identified in the eye and found to be upregulated in retinopathy. This has led to specific interest in the role of RAS blockade in retinopathy prevention. The recent DIRECT programme assessed use of the angiotensin receptor blocker (ARB) candesartan in type 1 and type 2 diabetes. Although the primary trial end-points were not met, there was a clear trend to less severe retinopathy with RAS blockade. A smaller trial, RASS, reported reduced retinopathy progression in type 1 diabetes from RAS blockade with both the ARB losartan and the angiotensin converting enzyme (ACE) inhibitor enalapril. The clinical implications of these new data are discussed.
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Affiliation(s)
- A K Sjølie
- Department of Ophthalmology, University of Southern Denmark.
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Silva PS, Cavallerano JD, Sun JK, Aiello LM, Aiello LP. Effect of systemic medications on onset and progression of diabetic retinopathy. Nat Rev Endocrinol 2010; 6:494-508. [PMID: 20664533 DOI: 10.1038/nrendo.2010.122] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Diabetic retinopathy remains a leading cause of visual loss worldwide. Patients with diabetes mellitus commonly have multiple comorbidities treated with a wide variety of medications. Systemic medications that target glycemic control and coexisting conditions may have beneficial or deleterious effects on the onset or progression of diabetic retinopathy. In addition, data is accumulating to suggest that the use of systemic therapy primarily to address ocular complications of diabetic retinopathy may be a promising therapeutic approach. This article reviews our current understanding of the ocular-specific effects of systemic medications commonly used by patients with diabetes mellitus, including those directed at control of hyperglycemia, dyslipidemia, hypertension, cardiac disease, anemia, inflammation and cancer. Current clinical evidence is strongest for the use of angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers in preventing the onset or slowing the progression of early diabetic retinopathy. To a more limited extent, evidence of a benefit of fibrates for diabetic macular edema exists. Numerous other agents hold considerable promise or potential risk. Thus, these compounds must undergo further rigorous study to determine the actual clinical efficacy and adverse effects before definitive therapeutic care recommendations can be offered.
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Affiliation(s)
- Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Department of Ophthalmology, Harvard Medical School, 1 Joslin Place, Boston, MA 02215, USA
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Chaturvedi N, Porta M, Klein R, Orchard T, Fuller J, Parving HH, Bilous R, Sjølie AK. Effect of candesartan on prevention (DIRECT-Prevent 1) and progression (DIRECT-Protect 1) of retinopathy in type 1 diabetes: randomised, placebo-controlled trials. Lancet 2008; 372:1394-402. [PMID: 18823656 DOI: 10.1016/s0140-6736(08)61412-9] [Citation(s) in RCA: 306] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Results of previous studies suggest that renin-angiotensin system blockers might reduce the burden of diabetic retinopathy. We therefore designed the DIabetic REtinopathy Candesartan Trials (DIRECT) Programme to assess whether candesartan could reduce the incidence and progression of retinopathy in type 1 diabetes. METHODS Two randomised, double-blind, parallel-design, placebo-controlled trials were done in 309 centres worldwide. Participants with normotensive, normoalbuminuric type 1 diabetes without retinopathy were recruited to the DIRECT-Prevent 1 trial and those with existing retinopathy were recruited to DIRECT-Protect 1, and were assigned to candesartan 16 mg once a day or matching placebo. After 1 month, the dose was doubled to 32 mg. Investigators and participants were unaware of the treatment allocation status. The primary endpoints were incidence and progression of retinopathy and were defined as at least a two-step and at least a three-step increase on the Early Treatment Diabetic Retinopathy Study (ETDRS) scale, respectively. These trials are registered with ClinicalTrials.gov, numbers NCT00252733 for DIRECT-Prevent 1 and NCT00252720 for DIRECT-Protect 1. FINDINGS 1421 participants (aged 18-50 years) were randomly assigned to candesartan (n=711) or to placebo (n=710) in DIRECT-Prevent 1, and 1905 (aged 18-55 years) to candesartan (n=951) or to placebo (n=954) in DIRECT-Protect 1. Incidence of retinopathy was seen in 178 (25%) participants in the candesartan group versus 217 (31%) in the placebo group. Progression of retinopathy occurred in 127 (13%) participants in the candesartan group versus 124 (13%) in the placebo group. Hazard ratio (HR for candesartan vs placebo) was 0.82 (95% CI 0.67-1.00, p=0.0508) for incidence of retinopathy and 1.02 (0.80-1.31, p=0.85) for progression of retinopathy. The post-hoc outcome of at least a three-step increase for incidence yielded an HR of 0.65 (0.48-0.87, p=0.0034), which was attenuated but still significant after adjustment for baseline characteristics (0.71, 0.53-0.95, p=0.046). Final ETDRS level was more likely to have improved with candesartan treatment in both DIRECT-Prevent 1 (odds 1.16, 95% CI 1.05-1.30, p=0.0048) and DIRECT-Protect 1 (1.12, 95% CI 1.01-1.25, p=0.0264). Adverse events did not differ between the treatment groups. INTERPRETATION Although candesartan reduces the incidence of retinopathy, we did not see a beneficial effect on retinopathy progression.
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Affiliation(s)
- Nish Chaturvedi
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College Healthcare NHS Trust, London, UK
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Pradeepa R, Anitha B, Mohan V, Ganesan A, Rema M. Risk factors for diabetic retinopathy in a South Indian Type 2 diabetic population--the Chennai Urban Rural Epidemiology Study (CURES) Eye Study 4. Diabet Med 2008; 25:536-42. [PMID: 18346159 DOI: 10.1111/j.1464-5491.2008.02423.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS To determine risk factors for diabetic retinopathy (DR) in an urban South Indian Type 2 diabetic population. METHODS The Chennai Urban Rural Epidemiology Study is a large cross-sectional study conducted in Chennai, South India. A total of 1736 Type 2 diabetic subjects were recruited for this study, which included 1382 known diabetic subjects (90.4% response rate) and 354 randomly selected, newly detected diabetic subjects diagnosed by oral glucose tolerance test. All subjects underwent four-field stereo retinal colour photography, graded by the Early Treatment Diabetic Retinopathy Study protocol. RESULTS Of the 1736 Type 2 diabetic subjects photographed, photographs could be graded in 1715 subjects. Stepwise ordinal logistic regression analysis revealed that male gender (P = 0.041), duration of diabetes (P < 0.0001), glycated haemoglobin (HbA(1c); P < 0.0001), macroalbuminuria (P = 0.0002) and insulin therapy (P = 0.0001) were significantly associated with severity of DR. The risk for developing DR was 7.7 times (95% confidence interval 4.71-12.48, P < 0.0001) for elevated postprandial plasma glucose levels compared with 4.2 times (95% confidence interval 2.78-6.34, P < 0.0001) for elevated fasting plasma glucose when the fourth quartile values were compared with the first quartile glucose values. CONCLUSIONS In South Indian Type 2 diabetic subjects, duration of diabetes, HbA1c, male gender, macroalbuminuria and insulin therapy were independent risk factors for severity of DR. Postprandial hyperglycaemia indicated a higher risk for DR compared with elevated fasting plasma glucose levels.
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Affiliation(s)
- R Pradeepa
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, Gopalapuram, Chennai, India
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