Prevalence and risk factors of peripheral arterial obstructive disease in Taiwanese type 2 diabetic patients

Risk factors for peripheral artery disease and diabetic peripheral neuropathy among patients with type 2 diabetes

AIMS

To investigate the prevalence of peripheral artery disease (PAD) and diabetic peripheral neuropathy (DPN) and the associated risk factors among Chinese patients with type 2 diabetes mellitus.

METHODS

A cross-sectional study was conducted using data between November 1, 2018, and December 31, 2022. PAD was defined as ABI ≤ 0.9. DPN diagnosis involved specialized physician assessments using questionnaires and vibration perception threshold tests. Logistic regression analysis was used to identify related factors. We also evaluated the association between the clustering of risk factors and disease incidence.

RESULTS

The study population comprised 13,315 patients (mean age: 63.3 years). 4.9 % of the patients had PAD and 43.9 % had DPN. Multivariate regression analysis revealed advanced age, smoking, hypertension, coronary heart disease, dyslipidemia, elevated HbA1c, and uric acid levels as independent risk factors for PAD. For DPN, independent risk factors included advanced age, female gender, hypertension, coronary heart disease, elevated total cholesterol, triglycerides, lipoprotein(a), fasting plasma glucose, HbA1c, alkaline phosphatase, cystatin C, albumin-to-creatinine ratio, and elevated homocysteine levels, whereas apolipoprotein A was a protective factor. The clustering of risk factors was prevalent and associated with higher disease risk.

CONCLUSIONS

Our study contributed to identifying high-risk individuals and improving lower limb health among diabetic individuals.

Obesity and Peripheral Artery Disease: Current Evidence and Controversies

PURPOSE OF REVIEW

Obesity is a significant public health problem and a major risk factor for the development and progression of atherosclerosis and its cardiovascular manifestations. Lower extremity peripheral artery disease (PAD) affects 3%-10% of the Western population and, if left untreated, can lead to devastating outcomes with both an increased risk of morbidity and mortality. Interestingly, the association between obesity and PAD remains debatable. Whereas it is well known that PAD and obesity frequently overlap in the same patients, many studies have demonstrated a negative association between obesity and PAD and a protective effect of obesity on disease development and progression, a phenomenon described as the "obesity paradox." Possible mechanisms for this paradox may include genetic background, as assessed by mendelian randomization studies, adipose tissue dysfunction, and body fat distribution rather than adiposity, while other factors, such as sex, ethnicity, sarcopenia in the elderly population, or aggressive treatment of co-existing metabolic conditions in individuals with obesity compared to those with normal weight, could have some impact as well.

RECENT RINDINGS

Few reviews and meta-analyses examining systematically the relationship between obesity and PAD exist. The impact of PAD development due to the presence of obesity remains largely controversial. However, the most current evidence, backed by a recent meta-analysis, suggests a potential protective role of a higher body mass index on PAD-related complications and mortality. In this review, we discuss the association between obesity and PAD development, progression, and management, and the potential pathophysiologic mechanisms linking the two diseases.

Role of obesity related inflammation in pathogenesis of peripheral artery disease in patients of type 2 diabetes mellitus

Objective

Type 2 diabetes mellitus (T2DM) has emerged as one of the greatest global health challenges of twenty-first century. Visceral obesity is one of the most important determinant of insulin resistance (IR) as well as T2DM complications. Therefore this review focuses on the molecular mechanism of obesity induced inflammation, signaling pathways contributing to diabetes, as well as role of lifestyle interventions and medical therapies in the prevention and management of T2DM.

Method

Articles were searched on digital data base PubMed, Cochrane Library, and Web of Science. The key words used for search included Type 2 diabetes mellitus, obesity, insulin resistance, vascular inflammation and peripheral arterial disease.

Result

Visceral obesity is associated with chronic low grade inflammation and activation of immune systems which are involved in pathogenesis of obesity related IR and T2DM.

Conclusion

Metabolic dysregulation of adipose tissue leads to local hypoxia, misfolded/unfolded protein response and increased circulating free fatty acids, which in turn initiate inflammatory signaling cascades in the population of infiltrating cells. Mechanism that relates the role of adipocytokines with insulin sensitivity and glucose homeostasis might throw a light on the development of therapeutic interventions and subsequently might result in the reduction of vascular complications.

Metformin’s effects on varicocele, erectile dysfunction, infertility and prostate-related diseases: A retrospective cohort study

Objectives: To investigate the risk of varicocele, erectile dysfunction (ED), infertility, prostatitis, benign prostate hyperplasia (BPH) and prostate cancer associated with metformin use.

Materials and methods: A total of 261,838 males, mean age 52.39 years (SD: 11.39), with a new-onset type 2 diabetes mellitus in 1999–2009 were identified from Taiwan’s National Health Insurance. Among them, 175,171 were metformin initiators [metformin (+)] and 86,667 were non-metformin initiators [metformin (−)] in the initial 12-month prescriptions of antidiabetic drugs. Follow-up started after the initial 12-month prescriptions. Outcomes were followed up until 31 December 2011. Intention-to-treat (ITT) and per-protocol (PP) hazard ratios comparing metformin (+) to metformin (−) were estimated by Cox regression incorporated with the inverse probability of treatment-weighting using propensity scores.

Results: The median follow-up time ranged 5.55–6.82 years in metformin (−) and 4.36–5.17 years in metformin (+) for different outcomes in ITT analyses. The respective median follow-up time in PP analyses ranged 2.20–2.61 years in metformin (−) and ranged 3.99–4.65 years in metformin (+). In the ITT analyses, for metformin (−), the incidence rates (per 100,000 person-years) of varicocele, ED, infertility, prostatitis, BPH and prostate cancer were 26.42, 455.89, 22.82, 590.23, 4226.19, and 141.69, respectively; and the respective incidence rates for metformin (+) were 25.65, 488.10, 32.60, 510.30, 3685.66, and 116.57. The hazard ratios (95% confidence intervals) comparing metformin (+) to metformin (−) in the ITT analyses were 0.960 (0.784–1.174) for varicocele, 1.077 (1.026–1.130) for ED, 1.368 (1.116–1.676) for infertility, 0.887 (0.849–0.927) for prostatitis, 0.883 (0.868–0.899) for BPH and 0.878 (0.802–0.961) for prostate cancer. The hazard ratios for the respective outcomes in the PP analyses were 0.845 (0.662–1.078), 1.350 (1.264–1.441), 1.396 (1.078–1.808), 0.800 (0.756–0.846), 0.875 (0.855–0.895), and 0.613 (0.548–0.686).

Conclusion: Metformin use in patients with type 2 diabetes mellitus is associated with a neutral effect on varicocele, a higher risk of sexual dysfunction (ED and infertility) and a reduced risk of prostate-related health (prostatitis, BPH and prostate cancer).

U-Shaped Association of Body Mass Index with the Risk of Peripheral Arterial Disease in Chinese Hypertensive Population

Background

High body mass index (BMI) is a well-recognized risk factor for cardiovascular diseases. But its role in peripheral artery disease (PAD) remains perplexing. Our study aims to evaluate the association of BMI with PAD in the Chinese hypertensive population.

Methods

This is a cross-sectional study with enrollment data from the Chinese H-type Hypertension Registry.10896 hypertensive patients aged ≥18 years were included in the final analysis.

Results

The prevalence of PAD diagnosed by ABI in this study was 3.2% (n=351). A U-shaped association between BMI and PAD was found. Per SD increment (3.6 kg/m²) on the left side of the BMI threshold (BMI < 25.7 kg/m²) was associated with a 27% decrease in the adjusted risk of PAD [OR, 0.73; 95% confidence interval (CI) 0.60, 0.89; P=0.002]; BMI was significantly positively associated with the risk of PAD (OR, 1.52; 95% CI 1.52, 1.93; P=0.001) in those with BMI ≥25.7 kg/m².

Conclusion

In summary, a U-shaped association between BMI and the risk of PAD in the Chinese hypertensive population was found. BMI with the lowest risk of PAD was estimated to be 25.7 kg/m².

Peripheral Vascular Disease Susceptibility Based on Diabetes Mellitus and rs17367504 Polymorphism of the MTHFR Gene

PURPOSE

Peripheral vascular disease (PVD) is a life-threatening condition affecting the lower extremities. Common risk factors include type 2 diabetes (T2D), hypertension, dyslipidemia, smoking, and older age. There is a little-documented research on the genetic basis of the disease in Taiwan. We examined the impact of T2D and the blood pressure-associated rs17367504 variant of the Methylenetetrahydrofolate reductase (MTHFR) gene on PVD risk.

MATERIALS AND METHODS

In this population-based association study, we linked data from 8992 participants in Taiwan Biobank (TWB) to their medical records in the National Health Insurance Research Database (NHIRD). Participants were 30 to 70 years old at recruitment and included those assessed between 2008 and 2015. We tested for association of PVD with rs17367504 and T2D using multiple logistic regression models. The rs17367504 variant was assessed using the Axiom-Taiwan Biobank Array Plate (TWB chip: Affymetrix, Inc., Santa Clara, CA, USA).

RESULTS

Among cases with T2D (n = 1294), 158 (12.21%) were identified with PVD. T2D was associated with PVD (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.21-1.91; p<0.001) whereas rs17367504 variant was not (OR, 0.96; CI, 0.76-1.21; p = 0.728 in AG/GG compared to AA homozygotes). However, T2D and rs17367504 had an interactive effect on PVD (p for interaction = 0.0076). Results from our stratified analyses displayed OR of 1.75 (CI, 1.35-2.26; p<0.001) in AA individuals with DM and 0.94 (CI, 0.56-1.58; p = 0.811) in AG+GG individuals with T2D. Using the AA genotype and no T2D as the reference group, the respective OR of PVD was 1.77 (CI, 1.38-2.28; p<0.001) in AA individuals with T2D; 1.18 (CI, 0.91-1.55; p = 0.215) in AG+GG individuals with no T2D, and 1.03 (CI, 0.66-1.60; p = 0.892) in AG+GG individuals with T2D .

CONCLUSION

We found that type 2 diabetes was associated with increased risk of peripheral vascular disease, particularly in AA genotype carriers of the rs17367504 variant in Taiwan.

Use of the ankle-brachial index combined with the percentage of mean arterial pressure at the ankle to improve prediction of all-cause mortality in type 2 diabetes mellitus: an observational study

Background

Peripheral artery disease (PAD) in the lower extremities is a common complication of type 2 diabetes and has been shown to be associated with mortality. The ankle-brachial index (ABI) is a simple noninvasive method to screen PAD, but this method has limited sensitivity. We hypothesized that using the percentage of mean arterial pressure (%MAP) in combination with the ABI would improve the prediction of mortality.

Methods

We retrospectively collected data from patients with type 2 diabetes who had undergone ABI and  %MAP measurements at our hospital. We separated the cohort into four groups according to their ABI and  %MAP values, and we examined whether these indices were associated with mortality.

Results

A total of 5569 patients (mean age, 65 ± 11 years) were enrolled. During the follow-up period (median, 22.9 months), 266 (4.8%) of the enrolled patients died. The combination of ABI and  %MAP was significantly more effective than ABI alone for predicting mortality (C index of 0.62, 95% confidence interval [CI] of 0.57 to 0.65 vs. C index of 0.57, 95% CI of 0.53 to 0.62; P = 0.038). In multivariate analysis (with a reference group defined by ABI > 0.90 and  %MAP ≤ 45%), the highest risk of mortality was seen in patients with ABI ≤ 0.90 and  %MAP > 45% (hazard ratio = 2.045 [95% CI 1.420, 2.945], P < 0.001).

Conclusions

The use of  %MAP alongside ABI appears to significantly improve the prediction of all-cause mortality in patients with type 2 diabetes.

Enablers of and Barriers to Effective Diabetes Self-Care in Iran: A Qualitative Study

Introduction

Self-care behaviors are the most important factor in diabetes management, and improving such behaviors is the cornerstone in helping patients to manage their illness. The current study aimed to determine interfering factors in the self-care process in patients with diabetes.

Methods

The present qualitative study with content-analysis design was performed from March 2017 to April 2019 in Mashhad, Iran. Data collection was started with sampling and continued until saturation. Data were collected through semistructured interviews. Participants comprised 21 patients with diabetes (adults with type 1 or 2 diabetes) aged 31–60 years. Data analysis was performed using the Landman method and MaxQDA 10 software.

Results

Qualitative content analysis showed that patients' self-care behavior was influenced by different factors and conditions. In the current study, four key themes facilitating or preventing self-care behaviors in patients with diabetes were extracted: accessibility, environmental factors, behavioral habits, and personal factors.

Conclusion

A range of personal and environmental factors may play an important role in the formation of self-care behaviors in patients with diabetes, and providing medical, welfare, and social support to such patients can facilitate self-care behavior formation in them. On the other hand, by removing perceived barriers, patients may be better able to adhere to self-care behaviors.

Mean and variability of annual haemoglobin A1c are associated with high-risk peripheral artery disease

BACKGROUND

Glucose variability is predictive of cardiovascular events and all-cause mortality. However, the association between peripheral artery disease and glucose variability has not been thoroughly investigated. Therefore, the standard deviation of annual haemoglobin A1c was assessed in patients with type 2 diabetes for evaluating the different risks of peripheral artery disease.

METHODS

A total of 4144 patients underwent an evaluation for the ankle-brachial index and the percentage of mean arterial pressure at the ankle. The first haemoglobin A1c record was retrospectively collected from each year until the ankle-brachial index measurement.

RESULTS

The standard deviation of annual haemoglobin A1c was higher in patients with ankle-brachial index ⩽0.90 than in those with ankle-brachial index >0.90 (1.1 ± 0.9% vs 1.0 ± 0.8%, p = 0.009) and was higher in patients with percentage of mean arterial pressure ⩾45% than in those with percentage of mean arterial pressure <45% (1.1 ± 0.8% vs 1.0 ± 0.8%, p = 0.007). A high standard deviation and mean of annual haemoglobin A1c are associated with high-risk peripheral artery disease, which is defined as a combination of ankle-brachial index ⩽0.90, percentage of mean arterial pressure ⩾45% or both (odds ratio = 1.306; 95% confidence interval = 1.057-1.615; p = 0.014).

CONCLUSION

Fluctuation in the haemoglobin A1c value indicates higher risk for peripheral artery disease in patients with type 2 diabetes and poor glucose control.

Lower body mass index is not of more benefit for diabetic complications

AIMS/INTRODUCTION

To investigate the relationship between different body mass index (BMI) levels and vascular complications in type 2 diabetes mellitus patients.

MATERIALS AND METHODS

Data were collected from 3,224 individuals with type 2 diabetes mellitus (male/female: 1,635/1,589; age 61.31 ± 11.45 years), using a retrospective case study design. The association of BMI quintiles and diabetes mellitus vascular complications was assessed using multiple logistic regression models adjusting for age, sex, diabetes duration, smoking status, drinking and other confounders, using those with the lowest quintile of BMI as the reference group.

RESULTS

With increasing BMI, the detection rate of diabetic peripheral neuropathy and peripheral arterial disease initially decreased and then it increased, whereas the detection rate of diabetic kidney disease and carotid atherosclerotic plaques showed an upward trend; however, diabetic retinopathy was irregular. The odds ratios of diabetic peripheral neuropathy decreased as BMI increased from the 21st percentile to the 80th percentile initially, and increased when BMI was in >80th percentile. The same result was shown in peripheral arterial disease. BMI >80th percentile showed a 1.426-fold risk of diabetic kidney disease and a 1.336 -fold risk of carotid atherosclerotic plaque.

CONCLUSIONS

In patients with type 2 diabetes mellitus, the relationship between different BMIs and vascular complications varies. A U-shaped relationship was observed between BMI and diabetic peripheral neuropathy, as well as BMI and peripheral arterial disease. BMI is positively correlated with diabetic kidney disease and carotid atherosclerotic plaque; however, it is not correlated with diabetic retinopathy.

Differential prognostic impact between completion and non-completion of a 5-month cardiac rehabilitation program in outpatients with cardiovascular diseases

BACKGROUND

Cardiac rehabilitation (CR) is an essential component of care for patients with cardiovascular diseases (CVD). We aimed to evaluate clinical outcomes in outpatients with CVD who did and did not complete a 5-month CR program.

METHODS

Three hundred thirty-two outpatients with CVD who participated in a 5-month CR program and were followed-up for maximum 5 years were registered. We divided the patients into two groups: those who completed the CR program (success group, n = 175) and those who could not (non-success group, n = 157). Both long-term (5 years) and short-term (5 months) clinical outcomes were compared between the two groups.

RESULTS

There were no significant differences in patient characteristics at baseline between the success and non-success groups. With regard to both long-term and short-term clinical outcomes, the rates of all-cause death and hospital admission in the success group were significantly lower than those in the non-success group by a Kaplan-Meier analysis. There was a significant difference in short-term CVD death and hospital admission between the groups, but not for long-term CVD death and hospital. In long-term period, all-cause death and hospital admission was independently associated with completion of the CR program in addition to the presence of peripheral artery disease and VE vs. VCO₂ slope after adjusting for age, gender, body mass index, types of CVD and medications.

CONCLUSIONS

Completion of a 5-month CR program was associated with the prevention of all-cause death and hospital admission, but not CVD death and hospital admission in the long-term, which suggests that we need to reconsider this issue.

Obesity paradox in peripheral artery disease

BACKGROUND & AIMS

Previous studies have suggested an obesity survival paradox in patients with peripheral artery disease (PAD). We investigated the influence of obesity and underweight on adverse in-hospital outcomes in PAD.

METHODS

Patients diagnosed with PAD based on ICD-code I70.2 of the German nationwide database were stratified for obesity, underweight and a reference group with normal-weight/over-weight and compared regarding adverse in-hospital outcomes.

RESULTS

Between 01/2005-12/2015, 5,611,484 inpatients (64.8% males) were diagnosed with PAD; of those, 8.9% were coded with obesity and 0.3% with underweight. Obese patients were younger (70 (IQR 63/76) vs. 73 (66/80) years, P < 0.001), more frequently female (36.7% vs. 35.1%, P < 0.001), had less cancer (4.9% vs. 7.9%, P < 0.001) and had less treatment with major amputation (2.6% vs. 3.2%, P < 0.001) compared to the reference group. Overall, 277 876 (5.0%) patients died in-hospital. Obese patients showed lower mortality rate (3.2% vs. 5.1%, P < 0.001) compared to the reference group and reduced risk of in-hospital mortality (OR, 0.617 [95%CI 0.607-0.627], P < 0.001). This "obesity paradox" was demonstrated in obesity classes I (OR, 0.475 [95%CI 0.461-0.490], P < 0.001), II (OR, 0.580 [95%CI 0.557-0.605], P < 0.001), and III (OR, 0.895 [95%CI 0.857-0.934], P < 0.001) and was independent of age, sex and comorbidities. Underweight patients revealed higher in-hospital mortality (6.0% vs. 5.1%, P < 0.001) compared to the reference group (OR, 1.179 [95%CI 1.106-1.257], P < 0.001) and showed higher prevalence of cancer (22.0% vs. 7.9%, P < 0.001).

CONCLUSIONS

Coding for obesity is associated with lower in-hospital mortality in PAD patients relative to those with normal-weight/over-weight. This obesity survival paradox was independent of age, gender and comorbidities and observed for all obesity classes.

Relationships between chronic comorbidities and the atherosclerosis indicators ankle-brachial index and brachial-ankle pulse wave velocity in patients with type 2 diabetes mellitus

This study aimed to determine associations between ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) with different comorbidities in patients with type 2 diabetes mellitus (DM). Records of patients with type 2 DM who received an ABI and baPWV examination between August 2013 and February 2015 were retrospectively reviewed. Associations of ABI and baPWV with chronic kidney disease (CKD), chronic liver disease (CLD), coronary artery disease (CAD) and diabetic nephropathy (DN) were examined by regression analysis. A total of 1232 patients (average age, 65.1±10.0 years) were included in the analysis. CKD and DN were associated with low ABI and increased baPWV (all, P<0.001). No associations were found between CAD and CLD and ABI or baPWV. Thus, regression analysis was performed for CKD and DN. Low ABI was associated with risk of CKD in the crude model (OR 0.724, 95% CI 0.648 to 0.808, P<0.001) and adjusted model (OR 0.872, 95% CI 0.762 to 0.999, P=0.048), whereas baPWV was only significant in the crude model (OR 1.199, 95% CI 1.112 to 1.294, P<0.001). Low ABI was associated with risk of DN in the crude model (OR 0.873, 95% CI 0.780 to 0.977, P=0.018) and adjusted model (OR 0.884, 95% CI 0.782 to 0.999, P=0.048). No association was found for baPWV. In conclusion, low ABI was associated with risk of CKD and DN in patients with type 2 diabetes.

Prevalence of peripheral arterial disease among diabetic patients in Santo Domingo, Dominican Republic and associated risk factors

Introduction

Peripheral arterial disease (PAD) is a major risk factor of coronary artery disease and a major complication of atherosclerosis. Peripheral arterial disease can be diagnosed with simple and low cost techniques. There are major risk factors of PAD that have been studied for different countries. However, no such study has been done for the Dominican Republic. We conducted a cross-sectional study to determine the prevalence of PAD and the risk factors among patients with diabetes in Santo Domingo, Dominican Republic.

Material and methods

Six hundred randomly chosen patients with previously diagnosed diabetes were enrolled in our study. Their blood pressure and ankle brachial index were calculated and a questionnaire was provided to gather information regarding gender, age, weight, ethnicity, known duration of diabetes along with any history of smoking, hypertension and hyperlipidemia. A physical examination was also done to assess for any active diabetic ulcers, previous foot ulcers and non-traumatic amputation. A microfilament test was conducted to check for peripheral neuropathy.

Results

Eighty-four diabetic patients were diagnosed with PAD with a prevalence of 14% in Santo Domingo, Dominican Republic. Statistically significant associations (p < 0.05) was found for female gender, presence of active foot ulcers, history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia and peripheral neuropathy. Glycated hemoglobin (HbA_1c), age and smoking were not statistically significant in our study.

Conclusions

Diabetic patients who are either female, have active foot ulcers, a history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia or peripheral neuropathy are more at risk of developing PAD.

Risk factors of peripheral arterial disease: a case control study in Sri Lanka

Background

Peripheral artery disease (PAD) is an important global health problem and contributes to notable proportion of morbidity and mortality. This particular manifestation of systemic atherosclerosis is largely under diagnosed and undertreated. For sustainable preventive strategies in a country, it is mandatory to identify country-specific risk factors. We intended to assess the risk factors of PAD among adults aged 40–74 years.

Methods

This case control study was conducted in 2012–2013 in Sri Lanka. Seventy-nine cases and 158 controls in the age group of 40–74 years were selected for the study in order to have case to control ratio 1:2. The criterion for selecting cases and control was based on Ankle brachial pressure index (ABPI). Cases were selected from those who had ABPI 0.85 or less (ABPI ≤0.85) in either lower limb. Controls were selected from those ABPI score between 1.18 and 1.28 in both lower limbs. Only newly identified individuals with PAD were selected as cases. Controls were selected from the same geographical location and within the 5 year age group as cases.

Results

The history of diabetes mellitus more than 10 years (OR 5.8, 95% CI 2.2–14.2), history of dyslipidemia for more than 10 years (OR 4.9, 95% CI 2.1–16.2), history of hypertension for more than 10 years (OR 3.8, 95% CI 1.8–12.7) and smoking (OR 2.9, 95% CI 1.2–6.9), elevated HsCRP (OR 3.7, 95% CI 1.2–12.0) and hyperhomocysteinemia (OR 3.0, 95% CI 1.1–8.1) were revealed as country specific significant risk factor of PAD.

Conclusions

Diabetes mellitus, hypertension, dyslipidemia, smoking as well as elevated homocysteine and HsCRP found as risk factors of PAD. Longer the duration or higher level exposure to these risk factors has increased the risk of PAD. These findings emphasis the need for routine screening of PAD among patients with the identified risk factors.

Borderline ankle-brachial index is associated with increased prevalence of micro- and macrovascular complications in type 2 diabetes: A cross-sectional analysis of 12,772 patients from the Joint Asia Diabetes Evaluation Program

Borderline ankle-brachial index is increasingly recognised as a marker of cardiovascular risk. We evaluated the impact of borderline ankle-brachial index in 12,772 Chinese type 2 diabetes patients from the Joint Asia Diabetes Evaluation Program between 2007 and 2012. Cardiovascular risk factors, complications and health-related quality of life were compared between patients with normal ankle-brachial index (1.0-1.4), borderline ankle-brachial index (0.90-0.99) and peripheral arterial disease (ankle-brachial index < 0.9). The prevalence of peripheral arterial disease and borderline ankle-brachial index was 4.6% and 9.6%, respectively. Borderline ankle-brachial index patients were older, more likely to be smokers and hypertensive, had longer duration of diabetes, poorer kidney function and poorer health-related quality of life than patients with normal ankle-brachial index. After adjustment for traditional cardiovascular risk factors, borderline ankle-brachial index was an independent predictor of diabetes-related micro- and macrovascular complications including retinopathy (odd ratios: 1.19 (95% confidence interval: 1.04-1.37)), macroalbuminuria (1.31 (1.10-1.56)), chronic kidney disease (1.22 (1.00-1.50)) and stroke (1.31 (1.05-1.64)). These findings suggest that patients with diabetes and borderline ankle-brachial index are at increased cardiovascular risk and may benefit from more intensive management.

Epidemiology of peripheral artery disease

New data on the epidemiology of peripheral artery disease (PAD) are available, and they should be integrated with previous data. We provide an updated, integrated overview of the epidemiology of PAD, a focused literature review was conducted on the epidemiology of PAD. The PAD results were grouped into symptoms, diagnosis, prevalence, and incidence both in the United States and globally, risk factors, progression, coprevalence with other atherosclerotic disease, and association with incident cardiovascular morbidity and mortality. The most common symptom of PAD is intermittent claudication, but noninvasive measures, such as the ankle-brachial index, show that asymptomatic PAD is several times more common in the population than intermittent claudication. PAD prevalence and incidence are both sharply age-related, rising >10% among patients in their 60s and 70s. With aging of the global population, it seems likely that PAD will be increasingly common in the future. Prevalence seems to be higher among men than women for more severe or symptomatic disease. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease, with some differences in the relative importance of factors. Smoking is a particularly strong risk factor for PAD, as is diabetes mellitus, and several newer risk markers have shown independent associations with PAD. PAD is strongly associated with concomitant coronary and cerebrovascular diseases. After adjustment for known cardiovascular disease risk factors, PAD is associated with an increased risk of incident coronary and cerebrovascular disease morbidity and mortality.

Insufficient early detection of peripheral neurovasculopathy and associated factors in rural diabetes residents of Taiwan: a cross-sectional study

BACKGROUND

Diabetic peripheral neuropathy (PN) and peripheral vasculopathy (PV) are major causes of foot ulcers in patients with diabetes. The early detection of PN/PV with appropriate health counseling is the best strategy for preventing foot lesions. The objective of this study is to examine the prevalence and associated risk factors of PN/PV among rural community residents with type 2 diabetes mellitus (T2DM).

METHODS

This cross-sectional descriptive study was conducted in Taiwan from February to October 2012. Type 2 diabetes mellitus and health promotion scale, Michigan neuropathy screening instrument, and ankle-brachial pressure index values were measured.

RESULTS

A total of 404 (55% women) participated in and completed the program. The overall prevalence of PN and PV was 34.5 and 17.1%, respectively. The majority of the participants (90%) did not receive early PN/PV detection by health care providers. After adjustment for the potential confounding factors, multivariate analysis indicated that the factors determining PN/PV were age (P <0.001), living around sea coastal regions (P <0.001), high HbA1C level (P <0.01), and fewer regular health-promoting behaviors (P <0.01).

CONCLUSION

There was a high prevalence of PN/PV among rural T2DM residents who received insufficient early detection. The early detection of PN/PV and provision of health education with customized health-promoting behaviors of people with diabetes in the rural community are important issues.

Comparison of characteristics and healing course of diabetic foot ulcers by etiological classification: neuropathic, ischemic, and neuro-ischemic type

AIMS

To identify differences in the characteristics of patients with diabetic foot ulcers (DFUs) according to their etiological classification and to compare their healing time.

METHODS

Over a 4.5-year period, 73 patients with DFUs were recruited. DFUs were etiologically classified as being of neuropathic, ischemic, or neuro-ischemic origin. Descriptive analyses were performed to characterize study subjects, foot-related factors, and healing outcome and time. Duration of healing was assessed using the Kaplan-Meier method. Healing time among the three types was compared using the log rank test.

RESULTS

The number of patients manifesting neuropathic, ischemic, and neuro-ischemic ulcers was 30, 20, and 14, respectively. Differences were identified for age, diabetes duration, body mass index, hypertension, and estimated glomerular filtration rate. Patients with neuro-ischemic ulcers had better ankle-brachial index, skin perfusion pressure (SPP), and transcutaneous oxygen pressure values compared to those with ischemic ulcers. The average time in which 50% of patients had healed wounds was 70, 113, and 233 days for neuropathic, neuro-ischemic, and ischemic ulcers, respectively. Main factors associated with healing were age and SPP values.

CONCLUSIONS

Based on the etiological ulcer type, DFU healing course and several patient factors differed. Failure to consider the differences in DFU etiology may have led to heterogeneity of results in previous studies on DFUs.

Risk factors for peripheral artery disease among patients with diabetes in Saudi Arabia

Little is known about the risk factors for peripheral artery disease (PAD) among diabetic patients in Saudi Arabia. We therefore investigated the association of traditional and non-traditional PAD risk factors, as well as clinical markers, with the prevalence of PAD in 598 diabetic patients in Saudi Arabia. PAD was diagnosed as an ankle–brachial index (ABI) <0.9. Information on socio-demographic variables, smoking status, duration of diabetes, and medication were collected by questionnaire. Body weight, height, blood pressure and clinical markers were also measured. The prevalence of PAD in this population was 23.1%. Hypertension (OR (odds ratio) = 2.13, 95% CI: 1.29–3.52), obesity (OR=1.75, 95% CI: 1.13–2.73) and longer duration of diabetes (OR for ≥20 years vs 2–4 years = 3.30, 95% CI: 1.66–6.58) were independently and significantly associated with a higher prevalence of PAD. Participants with the highest quartile of fasting blood glucose and homocysteine levels had a 67% (OR=1.67, 95% CI: 0.89–3.31) and 78% (OR=1.78, 95% CI: 0.87–3.66) higher prevalence of PAD, respectively. Our study identified several important and largely modifiable risk factors for PAD in this Saudi population with diabetes. These findings underscored the importance of reducing cardiovascular risk factors in patients with diabetes.

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.

Prevalence and clinical characteristics of lower limb atherosclerotic lesions in newly diagnosed patients with ketosis-onset diabetes: a cross-sectional study

BACKGROUND

The clinical features of atherosclerotic lesions in ketosis-onset diabetes are largely absent. We aimed to compare the characteristics of lower limb atherosclerotic lesions among type 1, ketosis-onset and non-ketotic type 2 diabetes.

METHODS

A cross-sectional study was performed in newly diagnosed Chinese patients with diabetes, including 53 type 1 diabetics with positive islet-associated autoantibodies, 208 ketosis-onset diabetics without islet-associated autoantibodies, and 215 non-ketotic type 2 diabetics. Sixty-two subjects without diabetes were used as control. Femoral intima-media thickness (FIMT), lower limb atherosclerotic plaque and stenosis were evaluated and compared among the four groups based on ultrasonography. The risk factors associated with lower limb atherosclerotic plaque were evaluated via binary logistic regression in patients with diabetes.

RESULTS

After adjusting for age and sex, the prevalence of lower limb plaque in the patients with ketosis-onset diabetes (47.6%) was significantly higher than in the control subjects (25.8%, p = 0.013), and showed a higher trend compared with the patients with type 1 diabetes (39.6%, p = 0.072), but no difference was observed in comparison to the patients with non-ketotic type 2 diabetes (62.3%, p = 0.859). The mean FIMT in the ketosis-onset diabetics (0.73 ± 0.17 mm) was markedly greater than that in the control subjects (0.69 ± 0.13 mm, p = 0.045) after controlling for age and sex, but no significant differences were found between the ketosis-onset diabetics and the type 1 diabetics (0.71 ± 0.16 mm, p = 0.373), and the non-ketotic type 2 diabetics (0.80 ± 0.22 mm, p = 0.280), respectively. Age and FIMT were independent risk factors for the presence of lower limb plaque in both the ketosis-onset and non-ketotic type 2 diabetic patients, while sex and age in the type 1 diabetic patients.

CONCLUSIONS

The prevalence and risk of lower limb atherosclerotic plaque in the ketosis-onset diabetes were remarkably higher than in the control subjects without diabetes. The features and risk factors of lower limb atherosclerotic lesions in the ketosis-onset diabetes resembled those in the non-ketotic type 2 diabetes, but different from those in the type 1 diabetes. Our findings provide further evidences to support the classification of ketosis-onset diabetes as a subtype of type 2 diabetes rather than idiopathic type 1 diabetes.

Protocol for a randomised blocked design study using telephone and text-messaging to support cardiac patients with diabetes: a cross cultural international collaborative project

BACKGROUND

The prevalence of type 2 diabetes is rising internationally. Patients with diabetes have a higher risk of cardiovascular events accounting for substantial premature morbidity and mortality, and health care expenditure. Given healthcare workforce limitations, there is a need to improve interventions that promote positive self-management behaviours that enable patients to manage their chronic conditions effectively, across different cultural contexts. Previous studies have evaluated the feasibility of including telephone and Short Message Service (SMS) follow up in chronic disease self-management programs, but only for single diseases or in one specific population. Therefore, the aim of this study is to evaluate the feasibility and short-term efficacy of incorporating telephone and text messaging to support the care of patients with diabetes and cardiac disease, in Australia and in Taiwan.

METHODS/DESIGN

A randomised controlled trial design will be used to evaluate a self-management program for people with diabetes and cardiac disease that incorporates the use of simple remote-access communication technologies. A sample size of 180 participants from Australia and Taiwan will be recruited and randomised in a one-to-one ratio to receive either the intervention in addition to usual care (intervention) or usual care alone (control). The intervention will consist of in-hospital education as well as follow up utilising personal telephone calls and SMS reminders. Primary short term outcomes of interest include self-care behaviours and self-efficacy assessed at baseline and four weeks.

DISCUSSION

If the results of this investigation substantiate the feasibility and efficacy of the telephone and SMS intervention for promoting self management among patients with diabetes and cardiac disease in Australia and Taiwan, it will support the external validity of the intervention. It is anticipated that empirical data from this investigation will provide valuable information to inform future international collaborations, while providing a platform for further enhancements of the program, which has potential to benefit patients internationally.

TRIAL REGISTRATION

ACTRN 12611001196932.

The role of triglyceride in cardiovascular disease in asian patients with type 2 diabetes--a systematic review

In Asian populations, diabetes mellitus is increasing and has become an important health problem in recent decades. Cardiovascular disease (CVD) is one of the most important complications and the most common cause of death in diabetic patients. Among the risk factors of CVD, elevated low-density lipoprotein cholesterol has been a major concern. Studies suggested that serum triglyceride may also play a role in predicting CVD in patients with type 2 diabetes mellitus, but the association is still debated. In this review, we summarized published studies focusing on the relationship between serum triglyceride and CVD disease in Asian diabetic patients. Ten studies conducted in six different Asian countries (three from Hong Kong, two from Taiwan, tow from Japan, one from Indonesia, one from South India, and one from South Korea) were summarized and discussed. CVD was subdivided into coronary heart disease, stroke, and peripheral arterial disease. Of the ten studies analyzed, one focused on CVD, five on coronary heart disease, three on stroke, three on peripheral arterial disease, and one on mortality from CVD. Studies from Hong Kong, Taiwan, and Japan suggested that triglyceride is a significant and independent risk factor for coronary heart disease, but not a significant risk factor for stroke (studies conducted in Japan and South Korea) or peripheral arterial disease (studies conducted in Taiwan, Indonesia, and South India). Although serum triglyceride may be a significant risk factor for coronary heart disease in Asian diabetic patients, clinical trials evaluating whether lowering triglycerides using fibrates can reduce the risk of coronary heart disease in these patients need to be initiated.

Differences in the perceptions of self-care, health education barriers and educational needs between diabetes patients and nurses

Abstract This study examined the differing perceptions of diabetic patients and their nurses regarding the completion of self-care activities, barriers to participation in diabetes health education, and diabetic patients' educational needs to promote better health care for patients with diabetes in Taiwan. This study employed a cross-sectional survey. The data were collected during 2009. Questionnaires were developed to collect data on a convenience sample of 312 patients with type 2 diabetes and 202 nurses recruited from diabetes clinics in Taiwan. Perceptions of self-care behavior were statistically significantly different between patients and nurses (t=-5.05, P<0.000). The patients perceived themselves to be more successful at completing self-care tasks whereas nurses perceived patients to be less successful at completing self-care tasks. Nurses perceived patients to experience greater difficulties in diabetes health education (t=18.36, P<0.000). Nurses perceived there to be a greater need for health education as compared with patients (t=9.03, P<0.000).

Determinants of Self-Management Among Diabetic Patients

Diabetes self-management (DSM) is a complex behavior and various factors influence it. Despite continual recommendations to DSM, implementation of this behavior still remains a major health problem for diabetic patients. Identifying effective factors in DSM is useful to promote health in diabetic patients. The purpose of this study was to test the effects of individual and environmental factors on DSM. Path analysis was used to examine both one-way direct and indirect effects of 7 constructs and 3 demographic factors on DSM in this population (N = 396). Data were collected from a convenience sample of 104 (26.3%) males and 292 (73.7%) females with a median age 53 years. The final model provided a good fit to the data explaining 25% of the variance in DSM. Illness perception and provider–patient communication were the most effective factors in DSM. Knowledge and self-efficacy affected DSM indirectly via illness perception. The results of this study showed that effective DSM interventions should be designed to change illness perception and patient–provider communication, especially in patients with low duration of diabetes and low level of education.

Angiotensin-converting enzyme genotype and peripheral arterial disease in diabetic patients

We investigated the effect of traditional risk factors (hypertension, dyslipidemia and smoking) on the association between angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism and peripheral arterial disease (PAD) in 945 (454 men and 491 women) Taiwanese type 2 diabetic patients with a mean age of 63.5 (SD: 11.4) years. Among them, 81 (31 men and 50 women) had PAD (ankle-brachial index <0.9). The adjusted odds ratios (95% confidence intervals) were 2.48 (1.18–5.21), 1.69 (1.00–2.85) and 1.64 (1.12–2.39), respectively, for recessive (DD versus II + ID), dominant (DD + ID versus II) and additive (II = 0, ID = 1 and DD = 2) models. While analyzing the interaction between DD and the individual risk factor of hypertension, smoking and dyslipidemia, patients with the risk factor and with DD had the highest risk compared to referent patients without the risk factor and with II/ID. The respective adjusted odds ratios were 5.41 (2.05–14.31), 7.38 (1.87–29.06) and 4.64 (1.70–12.64). We did not find a significant interaction between DD and any of the risk factors under multiplicative or additive scale. In conclusion, traditional risk factors (hypertension, smoking and dyslipidemia) play an important role in the association between ACE genotypes and PAD. Patients with DD genotype and traditional risk factors are at the highest risk.

Association of body mass index with peripheral arterial disease in older adults: the Cardiovascular Health Study

The authors hypothesized that the absence of cross-sectional associations of body mass index (BMI; weight (kg)/height (m)(2)) with peripheral arterial disease (PAD) in prior studies may reflect lower weight among persons who smoke or have poor health status. They conducted an observational study among 5,419 noninstitutionalized residents of 4 US communities aged ≥ 65 years at baseline (1989-1990 or 1992-1993). Ankle brachial index was measured, and participants reported their history of PAD procedures. Participants were followed longitudinally for adjudicated incident PAD events. At baseline, mean BMI was 26.6 (standard deviation, 4.6), and 776 participants (14%) had prevalent PAD. During 13.2 (median) years of follow-up through June 30, 2007, 276 incident PAD events occurred. In cross-sectional analysis, each 5-unit increase in BMI was inversely associated with PAD (prevalence ratio (PR) = 0.92, 95% confidence interval (CI): 0.85, 1.00). However, among persons in good health who had never smoked, the direction of association was opposite (PR = 1.20, 95% CI: 0.94, 1.52). Similar results were observed between BMI calculated using weight at age 50 years and PAD prevalence (PR = 1.30, 95% CI: 1.11, 1.51) and between BMI at baseline and incident PAD events occurring during follow-up (hazard ratio = 1.32, 95% CI: 1.00, 1.76) among never smokers in good health. Greater BMI is associated with PAD in older persons who remain healthy and have never smoked. Normal weight maintenance may decrease PAD incidence and associated comorbidity in older age.

Effectiveness of a self-efficacy program for persons with diabetes: a randomized controlled trial

The aim of this study was to examine the effects of a self-efficacy program for persons with type 2 diabetes in Taiwan. A randomized controlled trial was designed (n = 145), with 72 participants in the intervention group and 73 in the control group. The participants were pretested to establish a baseline and then post-tests were undertaken 3 and 6 months after the baseline data were collected. The participants in the intervention group received the standard diabetes education program and an additional self-efficacy program. The scores for efficacy expectations, outcome expectations, and self-care activities had significantly increased in the intervention group at the 3 and 6 month follow-ups, when compared to those of the control group. A smaller proportion of the participants in the intervention group had been hospitalized or had visited an emergency room than in the control group at the 6 month follow-up. This study revealed that a self-efficacy program for diabetes was acceptable and effective in the short term in the self-management of persons with type 2 diabetes.

Relationships among depression, anxiety, self-care behaviour and diabetes education difficulties in patients with type-2 diabetes: a cross-sectional questionnaire survey

BACKGROUND

Since psychosocial issues appear to be common among people with diabetes, addressing these problems may improve outcomes. Specifically, it is important to understand the factors associated with anxiety and depression in patients with diabetes.

OBJECTIVE

The purpose of this study was to investigate the relationships between self-care behaviour, diabetes education difficulties, depression and anxiety among patients with type-2 diabetes in Taiwan.

DESIGN

This study was cross-sectional and consisted of descriptive statistics and correlations in terms of analyses.

SETTING

Three teaching hospitals, one from each of the northern, middle and southern parts of Taiwan, were selected for data collection.

PARTICIPANT

A total of 312 patients diagnosed with type-2 diabetes were recruited to participate in this study. The inclusion criteria of the study subjects included a diagnosis of type-2 diabetes beyond the age of 18 years and the ability to communicate in Mandarin.

METHODS

Various questionnaires were used to assess demographic, disease characteristics, self-care behaviour, diabetes education difficulty, depression and anxiety data.

RESULTS

(1) Rates of disturbance for depression (10.6%) and anxiety (20.5%) among type-2 diabetes patients were lower than those in Western countries. (2) Anxiety was positively correlated with age (r=0.15, p<0.01), complications (r=0.27, p<0.01), diabetes education difficulty (r=0.39, p<0.01) and depression (r=0.54, p<0.01), but negatively correlated with body mass index (BMI) (r=0.20, p<0.01). (3) A total of 50.5% of variance in anxiety was explained by age, complications, BMI, diabetes education difficulty and depression. (4) A total of 42.8% of variance in depression was explained by BMI, diabetes education difficulty and anxiety.

CONCLUSION

Depression and anxiety are common among patients with diabetes and can have significant effects on the outcome of their medical illness. Addressing psychosocial factors of people with diabetes may improve effects of patient education and disease self-management.

Low estimated glomerular filtration rate is a major determinant of low ankle-brachial index and toe-brachial index in type 2 diabetes

We enrolled 1461 Taiwanese type 2 diabetic outpatients with ankle-brachial index (ABI) and toe-brachial index (TBI) examinations, excluding participants with history of stroke, end-stage renal disease, malignancy, acute myocardial infarction, amputation, and overt calcification of the lower limbs (ABI > 1.3). Ankle-brachial index values <0.9 were found in 2.8% of the patients and 5.7% had TBI < 0.6. Estimated glomerular filtration rate (eGFR; 90 ± 33 mL/min per 1.73 m2) obtained from 473 patients correlated significantly with both ABI and TBI. Progressive eGFR decline was observed in 419 participants with normal ABI and TBI, 35 with normal ABI but low TBI, and 19 with low ABI and normal or low TBI (P for trend < .001). After adjusting for confounding factors, age and eGFR were significantly associated with TBI and ABI. Low eGFR is associated with peripheral arterial disease in type 2 diabetes with mild to moderate renal insufficiency.

Association of peripheral artery disease and long-term mortality in hemodialysis patients

BACKGROUND

Peripheral artery disease (PAD) is a common complication in hemodialysis patients. The ankle-brachial blood pressure index (ABI) has been widely used to screen for subclinical PAD. In the present study, we investigated the association between ABI and long-term (up to 8.8 years) mortality among hemodialysis patients.

METHODS

A total of 86 consecutive patients receiving maintenance hemodialysis who underwent an ABI examination between 2001 and 2003 were retrospectively enrolled in this study. Patients with an ABI of less than 0.9 were considered as having PAD; those with an ABI of more than 0.9 in both legs were considered as being free from PAD. We examined the relationship between mortality and several risk factors.

RESULTS

During the follow-up period, 43 deaths were recorded. In the univariate regression analysis, the mortality hazard ratio (HR) of patients with PAD was 1.67 (95% confidence interval [CI], 1.18-2.28). Other predictive variables for mortality included male gender, age, and diabetes mellitus (P = 0.006, P = 0.024, and P = 0.023, respectively). A multivariate Cox analysis identified PAD and male gender as independent predictors of mortality (P = 0.033 and P = 0.028, respectively). The impact of age and diabetes mellitus on mortality was no longer significant in the multivariate analysis.

CONCLUSION

After a relatively long-term observation period, a multivariate analysis indicated that PAD acted independently of other risk factors, including advanced age and the presence of diabetes mellitus. ABI measurements can be used to identify high-risk hemodialysis patients requiring intensive follow-up care.

Peripheral Arterial Disease in Community-based Patients with Diabetes in Singapore: Results from a Primary Healthcare Study

Introduction: Peripheral arterial disease (PAD) is an important complication of diabetes mellitus (DM), significantly associated with increased morbidity and mortality secondary to amputations, strokes and coronary artery disease. Information on DM patients with PAD is limited in our ethnically diverse population in Singapore. We aimed to determine the prevalence, risk factors and co-morbidities of PAD in patients managed for DM in the primary care setting. Materials and Methods: A cross-sectional study was conducted among 521 diabetics in 9 of the 18 government-aided clinics in the community. Data including demographics, presence of co-morbidities and vascular risk factors were collected using an interviewer-administered questionnaire, and Ankle-Brachial Index (ABI) was calculated from systolic ankle and brachial pressure measurements. Results: The prevalence of PAD, defined as resting ABI of <0.9 on either leg and/or a history of gangrene or non-traumatic amputation was 15.2% [95% confidence interval (CI), 12.3-18.5]. This prevalence of PAD was higher in patients with pre-existing microvascular and other macrovascular complications. In multivariate analysis, prevalence of PAD was positively associated with increasing age (OR, 1.08; 95% CI, 1.05-1.12), Malay versus Chinese ethnicity (OR, 2.27; 95% CI, 1.09-4.70), low HDL-cholesterol (OR, 1.87; 95% CI, 1.04-3.37), and insulin treatment (OR, 2.98; 95%CI, 1.39-6.36). Conclusion: PAD is an important cause of concern among patients with diabetes, with a high prevalence which further increases with increasing age and duration of DM, and exhibits ethnic variation. Risk factors identified in this study may improve early identification of PAD, allowing for prompt interventions, with a potential to reduce long-term morbidity and mortality. Key words: Ethnic variation, Macrovascular complications, Risk factors

Peripheral arterial disease and clinical risks in Taiwanese hemodialysis patients

Peripheral arterial disease (PAD) is associated with significant morbidity and mortality and is an important marker of systemic atherosclerosis. However, little is known about the associated risk factors for PAD in patients on maintenance hemodialysis (HD). We collected the basic data and possible risk factors associated with PAD for 277 patients on maintenance HD. Furthermore, we measured ankle-brachial blood pressure index (ABI) in these patients. PAD was defined as an ABI value less than 0.90. The prevalence of PAD in our HD center was 22.8% (61/268). Advanced age (P = 0.006), longer history of HD (P < 0.001), diabetes (P = 0.002) and presence of PAD symptoms (P < 0.001) were independent predictors of PAD. PAD patients with diabetes had shorter history of HD (P = 0.001). 2-vessel PAD had higher serum cholesterol in HD patients (>or= 200 vs < 200 mg/dL; Odds ratio, 12.12, 95% confidence interval, 2.199-67.79; P < 0.004).

Prevalence and risk factors for peripheral artery disease in an Asian population with diabetes mellitus

We describe the prevalence and risk factors for PAD in Asian Malays with diabetes. A population-based study of 3,280 (78.7% response) Malay persons aged 40-80 years in Singapore was conducted. ABI was measured in all participants with a history of diabetes (N=634). PAD was defined to be present if ABI <or= 0.9. All participants had standardised interviews, clinical examinations and laboratory investigation for risk factor assessment. The crude prevalence of PAD was 10.4% (95% CI: 8.3%-13.0%). After age standardisation to the 2000 Singapore Census population, the prevalence was 5% (95% CI: 3.8-8.6). In multivariate analyses, the presence of PAD was associated with older age (OR 1.05; 95% CI: 1.01-1.09, per year increase), female gender (OR 4.18; 95% CI: 1.67-10.43), cigarette smoking (OR 2.55; 95% CI: 1.05-6.20), higher systolic blood pressure (OR 1.28; 95% CI: 1.13-1.45), a history of myocardial infarction (OR 3.69; 95% CI: 1.79-7.61) and stroke (OR 3.06 95% CI: 1.25-7.50). In this Asian Malay population with diabetes, we found a high prevalence of PAD.The major risk factors for PAD among persons with diabetes are similar to studies in Caucasian populations, suggesting that strategies aimed at controlling the modifiable factors may reduce the prevalence of PAD in Asian populations.

Diabetic nephropathy and risk factors for peripheral artery disease in Chinese with type 2 diabetes mellitus

The risk for peripheral arterial disease (PAD) is increased in patients with chronic kidney disease. We investigated the effects of renal function on PAD in Chinese with type 2 diabetes mellitus. This study enrolled a total of 2983 (1342 men and 1641 women) Chinese adults with diabetes. The mean age was 63.2 +/- 11.9 years. Peripheral arterial disease was diagnosed by an ankle-brachial index less than 0.9. Renal function was evaluated by serum creatinine (SCr), estimated glomerular filtration rate, and urinary albumin-creatinine ratio (ACR). Risk factors for PAD were evaluated using multiple logistic regression analysis. Age, cholesterol, and high-density lipoprotein cholesterol (HDL-C) (inverse association) were significant risk factors in men, whereas age, body mass index (inverse association), low-density lipoprotein cholesterol, and HDL-C (inverse association) were significant risk factors for diabetic women. After adjustment for age, body mass index, blood pressure, glycosylated hemoglobin, cholesterol, HDL-C, low-density lipoprotein cholesterol, and triglyceride levels, we found that SCr levels greater than 1.5 mg/dL, estimated glomerular filtration rate less than 60 mL/min, and urinary ACR greater than 30 mg/g were independent risk factors for PAD in diabetic men and that SCr levels greater than 1.4 mg/dL and urinary ACR greater than 30 mg/g were independently associated with PAD in diabetic women. The risk factors for PAD are somewhat different between men and women with diabetes in Chinese population in Taiwan. Diabetic nephropathy is significantly associated with PAD in this patient population.

Subclinical Peripheral Artery Disease in Patients Undergoing Peritoneal Dialysis: Risk Factors and Outcome

Background

Peripheral artery disease (PAD) is highly prevalent among patients in end-stage renal disease. The ankle–brachial index (ABI) is believed to be highly correlated with the subclinical PAD of lower extremities but little is known about the associated risk factors and outcome for PAD and ABI in patients on peritoneal dialysis (PD).

Methods

We performed a cohort study of 153 patients from a single center receiving stable PD for more than 3 months. These patients were screened for subclinical PAD using the ABI measurement. The ABI was measured and a ratio of <0.9 was considered abnormal. Clinical outcomes included actuarial patient and technique survival in this study.

Results

30 patients were classified into a subclinical PAD group. The prevalence of PAD (subclinical and overt) in our PD center was 19.61% (30/153). Advanced age, preexisting diabetes, preexisting cardiovascular and/or cerebrovascular disease (CVD), lower renal Kt/V urea, lower renal creatinine clearance (WCrCl), lower serum albumin level, and higher serum triglyceride level were risk factors for PAD in our PD center. Bivariate analysis showed that ABI was positively correlated with residual renal Kt/V urea and WCrCl, but was not correlated with peritoneal Kt/V urea and WCrCl. Patient and technique survival rates were significantly lower in the low ABI group than in the normal ABI group.

Conclusions

ABI is highly correlated with advanced age, preexisting diabetes, preexisting CVD, serum albumin, serum triglyceride, and residual renal clearance in PD patients. Also, lower ABI is independently associated with a high risk of patient mortality and PD technique failure.

Analysis of traditional and nontraditional risk factors for peripheral arterial disease in elderly type 2 diabetic patients in Taiwan

AIMS

Diagnosing peripheral arterial disease (PAD) and recognizing its associated risk factors in diabetes is important due to high cardiovascular disease and limb loss risk. However, both traditional and nontraditional risk factors have seldom been analyzed in the same diabetic cohort. The aim of this study was to examine the traditional and nontraditional risk factors for PAD in elderly type 2 diabetic patients.

METHODS

Five hundred and eighty type 2 diabetic subjects aged >or=60 years were cross-sectionally studied. Diagnosis of PAD was by ankle-brachial index (ABI) <0.90 on either leg. The association between traditional and nontraditional risk factors of PAD was analyzed.

RESULTS

Among the confounders, age, diabetes duration, HDL cholesterol, albuminuria, CKD (chronic kidney disease), hsCRP and insulin use differed between patients with and without PAD. Multiple logistic regression revealed that only CKD, insulin use, albuminuria, elevated hsCRP level (>3mg/l) and low HDL cholesterol were independent risk factors.

CONCLUSIONS

The findings of this study highlight the importance of monitoring nontraditional risk factors of PAD in diabetes. Implementing effective interventions to improve management of these risk factors may lower the risk for PAD.

Self-efficacy, outcome expectations and self-care behaviour in people with type 2 diabetes in Taiwan

AIMS

To explore differences in self-care behaviour according to demographic and illness characteristics; and relationships among self-care behaviour and demographic and illness characteristics, efficacy expectations and outcome expectations of people with type 2 diabetes in Taiwan.

BACKGROUND

Most people with diabetes do not control their disease appropriately in Taiwan. Enhanced self-efficacy towards managing diseases can be an effective way of improving disease control as proposed by the self-efficacy model which provides a useful framework for understanding adherence to self-care behaviours.

DESIGN AND METHODS

The sample comprised 145 patients with type 2 diabetes aged 30 years or more from diabetes outpatient clinics in Taipei. Data were collected using a self-administered questionnaire for this study. One-way anova, t-tests, Pearson product moment correlation and hierarchical regression were analysed for the study.

RESULTS

Significant differences were found: between self-care behaviour and complications (t = -2.52, p < 0.01) and patient education (t = -1.96, p < 0.05). Self-care behaviour was significantly and positively correlated with duration of diabetes (r = 0.36, p < 0.01), efficacy expectations (r = 0.54, p < 0.01) and outcome expectations (r = 0.44, p < 0.01). A total of 39.1% of variance in self-care behaviour can be explained by duration of diabetes, efficacy expectations and outcome expectations.

CONCLUSIONS

Findings support the use of the self-efficacy model as a framework for understanding adherence to self-care behaviour.

RELEVANCE TO CLINICAL PRACTICE

Using self-efficacy theory when designing patient education interventions for people with type 2 diabetes will enhance self-management routines and assist in reducing major complications in the future.

Effect of parental hypertension and/or parental diabetes on hypertension in Taiwanese diabetic patients

BACKGROUND

Both type 2 diabetes mellitus (T2DM) and hypertension aggregate in families. It is a common thought that diabetic patients with parental diabetes and/or parental hypertension are more likely to develop hypertension. This study evaluated the separate and joint effects of parental hypertension and parental diabetes on the prevalence of hypertension in patients with T2DM.

MATERIALS AND METHODS

A total of 89 956 patients from a national cohort were interviewed by telephone. Information about age, sex, onset age of diabetes, body height, body weight, systolic (SBP) and diastolic blood pressure (DBP), smoking, hypertension, and paternal and maternal history of diabetes and hypertension were obtained. Hypertension was defined in two ways: (1) a positive history; or (2) a positive history or a reported SBP > or = 140 mmHg and/or DBP > or = 90 mmHg in patients without a hypertension history.

RESULTS

While analysed separately in logistic models, both parental diabetes and parental hypertension were positively associated with hypertension. However, when both were analysed together, only parental hypertension was positively associated with hypertension, with paternal and maternal hypertension exerting a similar effect of an approximately 2.5-fold higher risk. While considering the effect of parental hypertension, both paternal and maternal diabetes was significantly associated with a lower risk of hypertension with odds ratios of approximately 0.8. Parental hypertension was also significantly associated with increased SBP and DBP; and parental diabetes with lower values in multiple linear regression.

CONCLUSIONS

Parental hypertension is strongly associated with hypertension. However, parental diabetes may be protective if the effect of parental hypertension is considered.

Prevalence and Risk Factors of Peripheral Arterial Disease in a Selected Thai Population

Peripheral arterial disease (PAD) is a condition with high mortality, but it is amenable to secondary prevention. Data on its prevalence in Thailand are scarce. To study the prevalence of PAD in a middle-class, urban Thai population, a cross-sectional study was conducted at the Electric Generating Authority of Thailand's head plant, Nonthaburi, in 2002 and 2003 on all surviving and contactable employees and former employees who had participated in the first cardiovascular risk factors survey in 1985. Participants completed a structured questionnaire detailing their medical history, and they underwent a physical examination. A diagnosis of PAD was made when the ankle-brachial index (ABI) was < 0.9. Ankle-brachial index data were available for 98% of participants in the survey; 75% were men, and participants' ages ranged from 52 to 73 years. The overall prevalence of PAD was 5.2%. The age-standardized prevalence of PAD was 4% in men and 9% in women. Multiple logistic regression analysis found hypertension (OR = 1.7), female gender (OR = 1.9), current smoking (OR = 3.0), current alcohol drinking (OR = 0.41), and overweight (body mass index [BMI] > 25 kg/m 2, OR = 0.54) to be significant (P < .05) predictors of PAD. The prevalence of PAD in urban, middle-class Thais was similar to that in the population in developed countries.

Multi-country study on the prevalence and clinical features of peripheral arterial disease in Asian type 2 diabetes patients at high risk of atherosclerosis

OBJECTIVE

PAD-SEARCH was the first international study to investigate the prevalence of peripheral arterial disease (PAD) in Asian type 2 diabetic patients and to demonstrate the relationships between putative risk factors and PAD.

SUBJECTS AND METHODS

In total 6625 type 2 diabetic patients aged 50 and older were enrolled and determined ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) in Korea, China, Taiwan, Hong Kong, Indonesia, Thailand and the Philippines.

RESULTS

Mean patient age was 63.7+/-8.2 years and mean duration of diabetes was 10.3+/-8.0 years. One thousand one hundred and seventy-two (17.7%) subjects were diagnosed as PAD by ABI (< or =0.9). PAD subjects had a significantly longer duration of diabetes, hypertension, higher HbA1c, and a significantly lower mean BMI than non-PAD subjects. In terms of lipid profiles, triglyceride was the only significant variable. Notably, mean ABI and baPWV in females were significantly poorer than age matched males in subjects with a normal ABI. However, mean ABI and baPWV in males were significantly poorer than in age matched females in subjects with PAD.

CONCLUSIONS

These findings suggest that PAD is a common complication in Asian type 2 diabetic patients. Therefore, PAD screening and treatment should be emphasized for Asian diabetic patients with high risk factors.

Mortality, causes of death and associated risk factors in a cohort of diabetic patients after lower-extremity amputation: a 6.5-year follow-up study in Taiwan

BACKGROUND

To determine the mortality, causes of death and associated risk factors in Taiwanese diabetic patients after lower-extremity amputation (LEA).

METHODS

A total of 358 diabetic patients (191 men and 167 women, aged 66.6+/-10.3 years) after LEA from the Taiwanese cohort of 778 cases previously recruited in the multinational Global Lower Extremity Amputation Study were followed. Risk factors included age, sex, smoking, body mass index (BMI), hypertension, systolic (SBP) and diastolic blood pressure (DBP), and LEA level. Mortality was ascertained from the National Death Registry.

RESULTS

With a follow-up period of up to 6.5 (median: 4.0) years and 1239.17 patient-years, 214 patients died. Crude mortality rate was 172.7 per 1000 patient-years and median survival time 4.1 years. The underlying cause of death was recorded as diabetes mellitus in 57.9% of those who died and none to disease of arteries, arterioles and capillaries. After adjustment for age and sex, smoking, SBP as a continuous variable, SBP >or=140 mm Hg and BMI <18.5 kg/m(2) (underweight) were predictors for mortality with respective odds ratios (95% confidence intervals) of 1.580 (1.030-2.425), 1.011 (1.000-1.022), 1.363 (1.007-1.845) and 1.889 (1.203-2.968); but hypertension, DBP as a continuous variable and DBP >or=90 mm Hg, BMI as a continuous variable and LEA level were not.

CONCLUSIONS

Mortality after LEA in Taiwanese diabetic patients is high. The most common cause of death was recorded as diabetes mellitus. After adjustment for age and sex, smoking, SBP and underweight are predictive for mortality; while LEA level is not.

Sex Difference in the Distribution of Atherosclerotic Risk Factors and Their Association With Peripheral Arterial Disease in Taiwanese Type 2 Diabetic Patients

BACKGROUND

There appear to be sex differences in the risk factors for peripheral arterial disease (PAD) in type 2 diabetic patients, but studies in Taiwanese patients have not been conducted.

METHODS AND RESULTS

A total of 610 (268 men, 342 women) Taiwanese patients aged 63.3+/-10.8 years were evaluated. PAD was diagnosed by an ankle - brachial index <0.9. Risk factors included age, sex, body mass index (BMI), waist circumference (WC), smoking, menopause, diabetes duration, hypertension, insulin therapy, systolic and diastolic blood pressures, fasting glucose, total cholesterol (TC), triglyceride (TG), high- (HDL-C) and low-density lipoprotein-cholesterol (LDL-C), apolipoproteins A1 (ApoA1) and B (ApoB) and uric acid (UA). When compared with the men, the women were significantly older and had longer duration, smaller WC, higher levels of systolic blood pressure, TC, TG, HDL-C, LDL-C, ApoA1 and ApoB, lower levels of UA, fewer smokers and more insulin users. Stepwise logistic regression showed age, BMI (inverse association) and systolic blood pressure as independent risk factors for men [respective odds ratios (OR): 1.080 (1.024-1.139), 0.832 (0.713-0.971) and 1.028 (1.005-1.051)]; and for women they were age, UA and insulin therapy [respective OR: 1.113 (1.056-1.173), 1.340 (1.101-1.630) and 4.173 (1.974-8.824).

CONCLUSIONS

PAD risk factors differ significantly between the sexes.