Time Trends in Ischemic Stroke among Type 2 Diabetic and Non-Diabetic Patients: Analysis of the Spanish National Hospital Discharge Data (2003-2012)

Trends in incidence of ischaemic stroke in people with and without diabetes in Ireland 2005-2015

AIMS

We aim to describe the epidemiology of ischaemic stroke and in-hospital mortality associated with stroke among men and women with and without diabetes from 2005 to 2015.

METHODS

Secondary data analysis of national hospital discharge data from the Hospital Inpatient Enquiry database. Stroke incidence and in-hospital mortality rates in people with and without diabetes were calculated. Poisson regression models were used to estimate the incidence rate ratio (IRR) and assess trends over time.

RESULTS

The age-adjusted incidence of stroke was twice as high in people with diabetes compared to those without diabetes (men IRR 2.0 [95% CI 1.95-2.06] and women IRR 2.2 [95% CI 2.12-2.27]). The incidence of ischaemic stroke decreased by an average 1.7% per year in men with diabetes and 3.3% per year in women with diabetes. In people without diabetes, the average annual reduction was smaller (0.2% per year in men and 1% per year in women). In-hospital mortality associated with admission with ischaemic stroke was approximately twice as high in those with diabetes compared to those without diabetes among men [IRR 1.81 (1.67-1.97)] and women [IRR 2 (95% CI 1.84-2.18)].

CONCLUSION

Despite decreases in incidence of ischaemic stroke and associated in-hospital mortality, there remains a twofold increased risk of ischaemic stroke and mortality in people with diabetes. Therefore, priority must be given to management of risk factors for ischaemic stroke in people with diabetes as well as continued development of targeted stroke prevention strategies.

Incidence of Stroke in People With Diabetes Compared to Those Without Diabetes: A Systematic Review

BACKGROUND

One of the goals of the St. Vincent Declaration was to reduce serious complications of diabetes, including strokes. However, it remains uncertain whether this goal has been achieved.

STUDY AIM

To evaluate the incidence of stroke in the diabetic population and its differences regarding sex, ethnicity, age, and region, to compare the incidence rate in people with and without diabetes, and to investigate time trends.

MATERIALS AND METHODS

A systematic review was conducted according to the guidelines for meta-analysis of observational studies in epidemiology (the MOOSE group) and the PRISMA group guidelines.

RESULTS

Nineteen of the 6.470 studies retrieved were included in the analysis. The incidence of stroke in the population with diabetes ranged from 238 per 100,000 person-years in Germany in 2014 to 1191 during the 1990s in the United Kingdom. The relative risk comparing people with diabetes to those without diabetes varied between 1.0 and 2.84 for total stroke, 1.0 and 3.7 for ischemic stroke, and 0.68 and 1.6 for hemorrhagic stroke. Differences between fatal and non-fatal stroke were significant, depending on the time period and the population. We found decreasing time trends in people with diabetes and stable incidence rates of stroke over time in people without diabetes.

CONCLUSION

The considerable differences between results can partly be explained by differences in study designs, statistical methods, definitions of stroke, and methods used to identify patients with diabetes. The lack of evidence arising from these differences ought to be rectified by new studies.

Association between metabolic syndrome and stroke: a population based cohort study

Both metabolic syndrome (MetS) and stroke are associated with increased risk of mortality. Here, we aimed to assess the prevalence of MetS among adults using three definitions (Adult Treatment Panel III (ATP-III), International Diabetes Federation (IDF) and IDF ethnic specific cut-off for Iranian criteria) and its association with stroke. We performed a cross-sectional study of a total of 9991 adult participants of Rafsanjan Cohort Study (RCS), as part of the Prospective epidemiological research studies in Iran (PERSIAN cohort study). The MetS prevalence was evaluated in participants according to the different criteria. Multivariate logistic regression analyses were conducted to assess the association between three definitions of MetS with stroke. We found that MetS was significantly associated with higher odds of stroke according to NCEP-ATP III (odds ratio (OR): 1.89, 95% confidence interval (CI) 1.30-2.74), international IDF (OR:1.66, 95% CI: 1.15-2.40) and Iranian IDF (OR:1.48, 95% CI: 1.04-2.09) after adjusted for variables confounders. Furthermore, after adjustment, in receiver operating characteristic (ROC) curve, the AUROC was 0.79 (95% CI = 0.75-0.82), 0.78(95% CI = 0.74-0.82) and 0.78(95% CI = 0.74-0.81) for presence of MetS according to NCEP-ATP III, international IDF and Iranian IDF, respectively. ROC analyses revealed that all of these three criteria for MetS are "moderately accurate" for the identification of increased stroke risk.In conclusion, our results showed that MetS was associated with increased odds of stroke. Our findings implicate the importance of early identification, treatment, and ultimately prevention of the metabolic syndrome.

Targeting FGF21 in cardiovascular and metabolic diseases: from mechanism to medicine

Cardiovascular and metabolic disease (CVMD) is becoming increasingly prevalent in developed and developing countries with high morbidity and mortality. In recent years, fibroblast growth factor 21 (FGF21) has attracted intensive research interest due to its purported role as a potential biomarker and critical player in CVMDs, including atherosclerosis, coronary artery disease, myocardial infarction, hypoxia/reoxygenation injury, heart failure, type 2 diabetes, obesity, and nonalcoholic steatohepatitis. This review summarizes the recent developments in investigating the role of FGF21 in CVMDs and explores the mechanism whereby FGF21 regulates the development of CVMDs. Novel molecular targets and related pathways of FGF21 (adenosine 5'-monophosphate-activated protein kinase, silent information regulator 1, autophagy-related molecules, and gut microbiota-related molecules) are highlighted in this review. Considering the poor pharmacokinetics and biophysical properties of native FGF21, the development of new generations of FGF21-based drugs has tremendous therapeutic potential. Related preclinical and clinical studies are also summarized in this review to foster clinical translation. Thus, our review provides a timely and insightful overview of the physiology, biomarker potential, molecular targets, and therapeutic potential of FGF21 in CVMDs.

Twenty-Year Temporal Trends in Risk of Ischemic Stroke in Incident Type 2 Diabetes: A Danish Population-Based Cohort Study

OBJECTIVE

We examined temporal trends in risk of first-time ischemic stroke in patients with incident type 2 diabetes mellitus (T2DM) and no prior atherosclerotic cardiovascular disease (ASCVD).

RESEARCH DESIGN AND METHODS

Using nationwide health registries, we identified all patients with incident T2DM without a prior hospital diagnosis of ASCVD from 1996 to 2015 in Denmark. Patients were assigned to 5-year periods based on the date of T2DM diagnosis and were followed for 5 years. Each patient was matched by sex and age with up to three individuals from the general population. Temporal trends in ischemic stroke were examined using Cox regression to compute hazard ratios (HRs). Temporal use of prophylactic cardiovascular medications was also assessed.

RESULTS

The study comprised 288,825 patients with incident T2DM and 782,232 general population individuals. From 1996-2000 to 2011-2015, the 5-year risk of first-time ischemic stroke was approximately halved in the T2DM cohort (5.2% vs. 2.7%; sex- and age-adjusted HR 0.52 [95% CI 0.49-0.55]). Patients diagnosed in 2011-2015 had increased risk of ischemic stroke compared with individuals in the general population; however, the risk difference narrowed over time (5.2% vs. 2.9% in 1996-1999 [difference 2.3%]; 2.7% vs. 2.0% in 2011-2015 [difference 0.7%]). Use of prophylactic cardiovascular medications increased markedly during the overall study period, especially use of statins (from 5% to 50%) and multiple antihypertensive drugs (from 18% to 33%).

CONCLUSIONS

From 1996 to 2015, the 5-year risk of first-time ischemic stroke was approximately halved in patients with incident T2DM and no prior ASCVD, coinciding with markedly increased use of prophylactic cardiovascular medications.

All-cause mortality and cardiovascular events in a Spanish nonagenarian cohort according to type 2 diabetes mellitus status and established cardiovascular disease

Background

Despite the progressive aging of the population in industrialized countries, few studies have focused on the natural history of cardiovascular disease in the very old, and recommendations on prevention of cardiovascular disease in this population are lacking. We aimed to analyze all-cause mortality and cardiovascular events according to prevalent type 2 diabetes mellitus and established cardiovascular disease in nonagenarians from a Mediterranean population.

Methods

We analyzed the primary health records of all nonagenarians living in the Community of Madrid (N = 59,423) and collected data for 4 groups: Group 1, individuals without T2DM or established CVD (T2DM-, CVD-); Group 2, individuals without T2DM but with established CVD (T2DM-, CVD +); Group 3, individuals with T2DM but without established CVD (T2DM + , CVD-); and Group 4, individuals with both T2DM and established CVD (T2DM + , CVD +), taking into account the influence of sex on the outcomes. Follow-up was 2.5 years. The primary outcomes were cumulative incidence and incidence density rates for all-cause mortality, non-fatal myocardial infarction, non-fatal stroke (the first composite primary outcome [CPO1]), combined with heart failure (CPO2). We evaluated the adjusted effect of each group on all-cause mortality (Cox regression).

Results

Mean age was 93.3 ± 2.8 years (74.2% women). Hypertension, dyslipidemia, heart failure, albuminuria, and estimated glomerular filtration rate < 60 mL/min/1.73 m2 were significantly more prevalent in G4 than in the other groups (all p values < 0.001). We observed significantly higher cumulative incidence rates for all-cause mortality, CPO1, and CPO2 in participants belonging to G4 (all p values ≤ 0.001). People in G2 presented higher rates of all-cause mortality, heart failure, CPO1, and CPO2 than people in G3 (all p values ≤ 0.001). In the fully adjusted model, G4 independently predicted all-cause mortality (HR = 1.48 [95% CI, 1.40 to 1.57] vs reference G1 [p < 0.01]). In addition, significant HRs were recorded for cardiovascular disease alone (G2) and type 2 diabetes mellitus alone (G3) (1.13 and 1.14, respectively; both p values < 0.01).

Conclusions

In Spanish nonagenarians, established cardiovascular disease and type 2 diabetes mellitus conferred a modest risk of all-cause mortality. However, the simultaneous presence of both conditions conferred the highest risk of all-cause mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02893-z.

Epidemiology and Economic Burden of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus in Spain: A Systematic Review

INTRODUCTION

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in people with type 2 diabetes mellitus (T2DM). The objectives of this systematic literature review were to identify and synthesize published data describing the epidemiology and mortality of CVD in the T2DM population and the associated economic burden.

METHODS

We conducted a systematic review searching the PubMed and MEDES databases from 2009 to 2019 using predefined selection criteria. Peer-reviewed observational studies reporting primary or secondary data on CVD prevalence, incidence, mortality, resource use and costs in patients with T2DM in Spain, written in English and Spanish, were included. Data were tabulated and summarized descriptively.

RESULTS

Of 706 articles identified, 52 were included in the review. Most studies were based on data from hospital discharge databases and registries. The reported prevalence of CVD among patients with T2DM ranged from 6.9 to 40.8%. The prevalence of coronary heart disease ranged from 4.7 to 37%, stroke from 3.5 to 19.6%, peripheral artery disease from 2.5 to 13.0%, and heart failure from 4.3 to 20.1%. In-hospital CVD mortality rates ranged from 5.6 to 10.8%. Direct costs due to CVD in hospitalized patients with T2DM were increased (> 50%) compared with patients without CVD. No studies analysed indirect costs of CVD in patients with T2DM.

CONCLUSIONS

The burden of CVD among patients with T2DM, combined with the elevated costs of care, highlights the importance of early prevention as part of integrated management of the disease to improve clinical and economic outcomes.

Sex-Related Disparities in the Incidence and Outcomes of Ischemic Stroke among Type 2 Diabetes Patients. A Matched-Pair Analysis Using the Spanish National Hospital Discharge Database for Years 2016-2018

Background: To analyze the incidence, use of therapeutic procedures, and in-hospital outcomes among patients suffering an ischemic stroke (IS) according to the presence of type 2 diabetes mellitus (T2DM) in Spain (2016–2018) and to assess the existence of sex differences. Methods: Matched-pair analysis using the Spanish National Hospital discharge. Results: IS was coded in 92,524 men and 79,731 women (29.53% with T2DM). The adjusted incidence of IS (IRR 2.02; 95% CI 1.99–2.04) was higher in T2DM than non-T2DM subjects, with higher IRRs in both sexes. Men with T2DM had a higher incidence of IS than T2DM women (IRR 1.54; 95% CI 1.51–1.57). After matching patients with T2DM, those with other comorbid conditions, however, significantly less frequently received endovascular thrombectomy and thrombolytic therapy. In-hospital mortality (IHM) was lower among T2DM men than matched non-T2DM men (8.23% vs. 8.71%; p < 0.001). Women with T2DM had a higher IHM rate than T2DM men (11.5% vs. 10.20%; p = 0.004). After adjusting for confounders, women with T2DM had a 12% higher mortality risk than T2DM men (OR 1.12; 95% CI 1.04–1.21). Conclusions: T2DM is associated with higher incidence of IS in both sexes. Men with T2DM have a higher incidence rates of IS than T2DM women. Women with T2DM have a higher risk of dying in the hospital.

Incidence of stroke in the diabetic compared with the non-diabetic population: A systematic review protocol

People with diabetes have a largely increased risk of stroke compared with people without diabetes. Exact data on incidence of stroke in people with and without diabetes are important for improvements in preventive diabetes care, avoidance of fatal outcomes and as a solid basis for health policy and the economy. However, published data are conflicting, underlining the necessity for this systematic review of population-based studies on incidence, relative risks (RRs) and changes in stroke rates over time. The purpose of our review is to evaluate the incidence of stroke in the diabetic population and its differences with regard to sex, ethnicity, age and regions; to compare the incidence rate (IR) in the diabetic and non-diabetic populations and to investigate time trends. We will perform a systematic literature search in MEDLINE, Embase and LILACS designed by an experienced information scientist. Two review authors will independently screen the abstracts and full texts of all references on the basis of inclusion criteria regarding types of study, types of population and the main outcome. Data extraction and assessment of risk of bias will be undertaken by two review authors working independently. We will assess IR or cumulative incidence (CumI) and RR of stroke comparing the diabetic and non-diabetic populations. The attributable risk (AR = proportion of stroke among persons with diabetes that is attributable to diabetes) and the population attributable risk (PAR = proportion of stroke in the whole population that is attributable to diabetes) will be considered where available. In conclusion, this review will help to summarize the available evidence for incidence of stroke in the diabetic and nondiabetic population. The publication of this protocol will contribute to making the search strategy, methods, and assessment of reviews transparent and accessible for all involved professional groups.

Incidence and costs of cardiovascular events in Spanish patients with type 2 diabetes mellitus: a comparison with general population, 2015

INTRODUCTION

Cardiovascular (CV) disease affects a high percentage of patients with type 2 diabetes mellitus (T2DM), especially in the hospital setting, impacting on mortality, complications, quality of life and use of health resources. The aim of this study was to estimate the incidence, mean length of hospital stay (LOHS) and costs attributable to hospital admissions due to CV events in patients with T2DM versus patients without diabetes mellitus (non-DM) in Spain.

RESEARCH DESIGN AND METHODS

Retrospective observational study based on the Spanish National Hospital Discharge Database for 2015. Hospital admissions for patients aged ≥35 years with a diagnosis of CV death, non-fatal acute myocardial infarction (AMI), non-fatal stroke, unstable angina, heart failure and revascularization were evaluated. The International Classification of Diseases, Ninth Revision (250.x0 or 250.x2) coding was used to classify records of patients with T2DM. For each CV complication, the hospital discharges of the two groups, T2DM and non-DM, were precisely matched and the number of hospital discharges, patients, LOHS and mean cost were quantified. Additional analyses assessed the robustness of the results.

RESULTS

Of the 276 925 hospital discharges analyzed, 34.71% corresponded to patients with T2DM. A higher incidence was observed in all the CV complications studied in the T2DM population, with a relative risk exceeding 2 in all cases. The mean LOHS (days) was longer in the T2DM versus the non-DM group for: non-fatal AMI (7.63 vs 7.02, p<0.001), unstable angina (5.11 vs 4.78, p=0.009) and revascularization (7.96 vs 7.57, p<0.001). The mean cost per hospital discharge was higher in the T2DM versus the non-DM group for non-fatal AMI (€6891 vs €6876, p=0.029) and unstable angina (€3386 vs €3304, p<0.001).

CONCLUSIONS

Patients with T2DM had a higher incidence and number of hospital admissions per patient due to CV events versus the non-DM population. This generates a significant clinical and economic burden given the longer admission stay and higher costs associated with some of these complications.

Type 2 Diabetes, Atrial Fibrillation, and Direct Oral Anticoagulation

Type 2 diabetes (T2D) is an independent risk factor of stroke and systemic embolism in patients with atrial fibrillation (AF), and T2D patients with AF-associated stroke seem to have worse clinical outcome and higher risk of unfavorable clinical course compared to individuals without this metabolic disorder. Long-term anticoagulation is indicated in majority of T2D patients with AF to prevent adverse AF-associated embolic events. Direct oral anticoagulants (DOACs), direct oral thrombin inhibitor dabigatran, and direct oral factor Xa inhibitors, rivaroxaban, apixaban, and edoxaban, have emerged as a preferred choice for long-term prevention of stroke in AF patients offering potent and predictable anticoagulation and a favorable pharmacology with low risk of interactions. This article reviews the current data regarding the use of DOACs in individuals with T2D and AF.

Stroke Dysbiosis Index (SDI) in Gut Microbiome Are Associated With Brain Injury and Prognosis of Stroke

Background: Significant dysbiosis occurs in the gut microbiome of stroke patients. Condensing these broad, complex changes into one index would greatly facilitate the clinical usage of gut microbiome data. Here, we formulated a gut microbiota index in patients with acute ischemic stroke based on their gut microbiota dysbiosis patterns and tested whether the index was correlated with brain injury and early outcome.

Methods: A total of 104 patients with acute ischemic stroke and 90 healthy individuals were recruited, and their gut microbiotas were compared and to model a Stroke Dysbiosis Index (SDI), which representing stroke-associated dysbiosis patterns overall. Another 83 patients and 70 controls were recruited for validation. The association of SDI with stroke severity (National Institutes of Health Stroke Scale [NIHSS] score) and outcome (modified Rankin scale [mRS] score: favorable, 0–2; unfavorable, >2) at discharge was also assessed. A middle cerebral artery occlusion (MCAO) model was used in human flora-associated (HFA) animals to explore the causal relationship between gut dysbiosis and stroke outcome.

Results: Eighteen genera were significantly different between stroke patients and healthy individuals. The SDI formula was devised based on these microbiome differences; SDI was significantly higher in stroke patients than in healthy controls. SDI alone discriminated stroke patients from controls with AUCs of 74.9% in the training cohort and 84.3% in the validation cohort. SDI was significantly and positively correlated with NIHSS score on admission and mRS score at discharge. Logistic regression analysis showed that SDI was an independent predictor of severe stroke (NIHSS ≥8) and early unfavorable outcome (mRS >2). Mice receiving fecal transplants from high-SDI patients developed severe brain injury with elevated IL-17⁺ γδ T cells in gut compared to mice receiving transplants from low-SDI patients (all P < 0.05).

Conclusions: We developed an index to measure gut microbiota dysbiosis in stroke patients; this index was significantly correlated with patients' outcome and was causally related to outcome in a mouse model of stroke. Our model facilitates the potential clinical application of gut microbiota data in stroke and adds quantitative evidence linking the gut microbiota to stroke.

Multi-parameters of Magnetic Resonance Imaging to Estimate Ischemia-Reperfusion Injury after Stroke in Hyperglycemic Rats

The aim of the study is to verify the effect of hyperglycemia on ischemia-reperfusion injury and to explore the feasibility of noninvasive observation of ischemic-reperfusion injury in hyperglycemic ischemic stroke by MRI technique. According to the duration of ischemia and blood glucose levels, 40 rats were divided into hyperglycemic ischemic 2-hr (H-I2h), hyperglycemic ischemic 6-hr (H-I6h), non- hyperglycemic ischemic 2-hr (NH-I2h), and non- hyperglycemic ischemic 6-hr (NH-I6h) groups. T2W imaging, DW imaging, T2 mapping, T2* mapping, DCE, and T1 mapping after enhancement sequences were acquired before reperfusion and approximately 3-hr after reperfusion. ADC, T1, T2, T2*, and K^trans values of ischemic lesion were obtained in different groups. After reperfusion, the variation of ADC values showed no significant difference between groups with diabetes and groups without diabetes and between different recanalization time-points (2-hr vs 6-hr). After reperfusion, T2, T2*, and K^trans values increased in different degrees in all four groups. Only the T1 value decreased in all groups. The change of all parameters in groups with hyperglycemia was more obvious than that in groups without hyperglycemia and was more obvious in groups with H-I6h versus those with H-I2h. This study confirms that hyperglycemia aggravates ischemia-reperfusion injury and may be an important risk factor for the prognosis of ischemic stroke. The K^trans values should be noninvasive imaging indicators to monitor blood brain barrier permeability and ischemic-reperfusion injury in ischemic stroke.

National trends in diabetes mellitus hospitalization in Spain 1997-2010: Analysis of over 5.4 millions of admissions

AIMS

To analyze national trends in the rates of hospitalizations (all-cause and by principal discharge diagnosis) in total diabetic population of Spain.

METHODS

We carried out a nation-wide population-based study of all diabetic patients hospitalized between 1997 and 2010. All-cause hospitalizations, hospitalizations by principal discharge diagnosis, mean age, Charlson Comorbidity Index, readmission rates and length of hospital stay were examined. Annual rates adjusted for age and sex were analyzed and trends were calculated.

RESULTS

Over 14-years-period, all-cause hospitalizations of diabetic patients increased significantly, with an average annual percentage change of 2.5 (95%CI: 1.5-3.5; P_trend < 0.01). The greatest increase was observed in heart failure (5.4; 95%CI: 4.8-6.0; P_trend < 0.001), followed by neoplasms (4.9; 95%CI: 3.6-5.8; P_trend < 0.001), pneumonia (2.7; 95%CI: 2.0-4.0; P_trend < 0.001), stroke (2.4; 95%CI: 1.6-3.4; P_trend < 0.001), chronic obstructive pulmonary disease (2.0; 95%CI: 1.4-3.4; P_trend < 0.001) and coronary artery disease (1.6; 95%CI: 1.1-2.3; P_trend < 0.01). The adjusted number of all-cause hospitalizations of patients with diabetes per 100,000 inhabitants increased 2.6-fold. The increase in hospitalizations was significantly higher among patients ≥75 years old. Males experienced a greater increase in all-cause, neoplasm, heart failure, chronic obstructive pulmonary disease, and pneumonia hospitalizations (p < 0.01 for all). Hospitalized diabetic patients were progressively older and had more comorbidities, higher readmission rates and shorter hospital stays (p < 0.05 for all).

CONCLUSIONS

Hospitalizations of diabetic patients more than doubled in Spain during the study period. Heart failure and neoplasms experienced the greatest annual increases and remained the principal causes of hospitalization, probably associated with advanced age and comorbidities of hospitalized diabetics. Coronary and cerebrovascular diseases experienced a lower annual increase, suggesting an improvement in cardiovascular care in diabetes in Spain.

Global trends in diabetes complications: a review of current evidence

In recent decades, large increases in diabetes prevalence have been demonstrated in virtually all regions of the world. The increase in the number of people with diabetes or with a longer duration of diabetes is likely to alter the disease profile in many populations around the globe, particularly due to a higher incidence of diabetes-specific complications, such as kidney failure and peripheral arterial disease. The epidemiology of other conditions frequently associated with diabetes, including infections and cardiovascular disease, may also change, with direct effects on quality of life, demands on health services and economic costs. The current understanding of the international burden of and variation in diabetes-related complications is poor. The available data suggest that rates of myocardial infarction, stroke and amputation are decreasing among people with diabetes, in parallel with declining mortality. However, these data predominantly come from studies in only a few high-income countries. Trends in other complications of diabetes, such as end-stage renal disease, retinopathy and cancer, are less well explored. In this review, we synthesise data from population-based studies on trends in diabetes complications, with the objectives of: (1) characterising recent and long-term trends in diabetes-related complications; (2) describing regional variation in the excess risk of complications, where possible; and (3) identifying and prioritising gaps for future surveillance and study.

Trends in stroke hospitalisation rates in Extremadura between 2002 and 2014: Changing the notion of stroke as a disease of the elderly

BACKGROUND

The incidence of stroke in Spain has been evaluated in several studies, whose results are highly variable and not comparable. No studies of stroke have analysed epidemiological changes in younger patients.

METHOD

We conducted a retrospective observational study using the Spanish health system's Minimum Data Set and included all patients older than 19 hospitalised due to stroke (ICD-9-CM codes 434.01, 434.11, 434.91, 430, 431, 432.9, 436, and 435) between 2002 and 2013. The analysis was performed using joinpoint regression.

RESULTS

A total of 39,321 patients were identified (47.25% were women); 3.73% were aged 20-44, 6.29% were 45-54, 11.49% were 55-64, 23.89% were 65-74, and 54.60% were > 74 years. The hospitalisation rate due to ischaemic stroke has increased significantly in men aged 45-54 (+6.7%; 95% CI, 3.3-10.2) and in women aged 20-44 and 45-54 (+6.1%; 95% CI, 0.8-11.7 and +5.7%; 95% CI, 3.0-8.4, respectively). We also observed a significant increase in the rate of hospitalisation due to ischaemic stroke in men aged over 74 (+4.2%; 95% CI, 1.3-7.2). The rate of hospitalisations due to transient ischaemic attack has also increased significantly whereas the rate of hospitalisations due to brain haemorrhage has stabilised over time.

CONCLUSIONS

Our results provide indirect evidence that the epidemiological profile of stroke is changing based on the increase in hospitalisation rates in young adults.

Mesenteric visceral lipectomy using tissue liquefaction technology reverses insulin resistance and causes weight loss in baboons

BACKGROUND

Visceral obesity is associated with diabetogenic and atherogenic abnormalities, including insulin resistance and increased risk for cardiometabolic diseases and mortality. Rodent lipectomy studies have demonstrated a causal link between visceral fat and insulin resistance, yet human omentectomy studies have failed to replicate this metabolic benefit, perhaps owing to the inability to target the mesentery.

OBJECTIVES

We aimed to demonstrate that safe and effective removal of mesenteric fat could be achieved in obese insulin-resistant baboons using tissue liquefaction technology.

SETTING

Southwest National Primate Research Center, San Antonio, Texas.

METHODS

Tissue liquefaction technology has been developed to enable mesenteric visceral lipectomy (MVL) to be safely performed without disturbing the integrity of surrounding nerves and vessels in the mesentary. After an initial MVL optimization study (n = 3), we then performed MVL (n = 4) or sham surgery (n = 2) in a cohort of insulin-resistant baboons, and the metabolic phenotype was assessed via hyperinsulinemic-euglycemic clamps at baseline and 6 weeks later.

RESULTS

MVL led to a 75% improvement in glucose disposal at 6-weeks follow-up (P = .01). Moreover, despite removing only an average of 430 g of mesenteric fat (~1% of total body mass), MVL led to a 14.4% reduction in total weight (P = .001). Thus, these data demonstrate that mesenteric fat can be safely targeted for removal by tissue liquefaction technology in a nonhuman primate, leading to substantial metabolic improvements, including reversal of insulin resistance and weight loss.

CONCLUSIONS

These data provide the first demonstration of successful adipose tissue removal from the mesentery in a mammal. Importantly, we have demonstrated that when MVL is performed in obese, insulin-resistant baboons, insulin resistance is reversed, and significant weight loss occurs. Therefore, trials performing MVL in humans with abdominal obesity and related metabolic sequelae should be explored as a potential clinical tool to ameliorate insulin resistance and treat type 2 diabetes.

Impact of type 2 diabetes mellitus on in-hospital-mortality after major cardiovascular events in Spain (2002-2014)

BACKGROUND

Diabetes mellitus has long been associated with cardiovascular events. Nevertheless, the higher burden of traditional cardiovascular risk factors reported in high-income countries is offset by a more widespread use of preventive measures and revascularization or other invasive procedures. The aim of this investigation is to describe trends in number of cases and outcomes, in-hospital mortality (IHM) and length of hospital stay (LHS), of hospital admissions for major cardiovascular events between type 2 diabetes (T2DM) and matched non-diabetes patients.

METHODS

Retrospective study using National Hospital Discharge Database, analyzed in 4 years 2002, 2006, 2010, 2014, in Spain. We included patients (≥ 40 years old) with a primary diagnosis of myocardial infarction, ischemic and hemorrhagic stroke, aortic aneurysm and dissection and acute lower limb ischemia in people with T2DM. Cases were matched with controls (without T2DM) by ICD-9-CM codes, sex, age, province of residence and year.

RESULTS

We selected 130,011 matched couples (50,427 with myocardial infarction, 60,236 with stroke, 2599 with aortic aneurysm and dissection and 16,749 with acute lower limb ischemia. Among T2DM patients we found increasing numbers of admissions overtime for stroke (10,794 in 2002 vs 17,559 in 2014), aortic aneurysm and dissection (390 vs 841) and acute lower limb ischemia (3854 vs. 4548). People were progressively older (except for myocardial infarction), had more comorbidities (especially T2DM patients), and were more frequently coded overtime for cardiovascular risk factors (smoking, obesity, hypertension, lipid disorders) and renal diseases. LHS and IHM declined overtime, though IHM only did it significantly in T2DM patients. Multivariable adjustment showed that T2DM patients had a significantly 15% higher mortality rate during admission for myocardial infarction, a 6% higher mortality for stroke, and a 6% higher mortality rate for "all cardiovascular events combined", than non-diabetic matched controls.

CONCLUSIONS

The number of hospital admissions for stroke, aortic aneurysm and dissection and acute lower limb ischemia increased overtime, but remained stable for myocardial infarction. T2DM is associated to higher IHM after major cardiovascular events. Further research is needed to help us understand the reasons for an apparently increased mortality in T2DM patients when admitted to hospital for some major cardiovascular events.

Observational study of vascular dementia in the Spanish elderly population according to type 2 diabetes status: trends in incidence, characteristics and outcomes (2004-2013)

OBJECTIVES

To examine trends overtime in the incidence and in-hospital outcomes of vascular dementia (VaD) hospitalisations in patients aged 70 years or over suffering and not suffering from type 2 diabetes mellitus (T2DM) between 2004 and 2013 in Spain.

DESIGN

Retrospective study.

SETTING

Spain.

PARTICIPANTS

National hospital discharge data were used; patients aged ≥70, discharged from a hospital with VaD as a primary diagnosis, were selected.

MAIN OUTCOME MEASURES

Overall incidence, therapeutic and diagnostic procedures, comorbidities, infectious complications, duration of hospital stays and in-hospital mortality (IHM).

RESULTS

In total, 170 607 admissions for VaD (34.3% with T2DM) were identified. We found a significant upward linear trend in the incidence of VaD for men and women with and without diabetes between 2004 and 2013. The adjusted incidence was higher among people with T2DM over the study period. We found a higher incidence in men than women in all years under study. A positive association between T2DM and VaD hospitalisation was found among both men (IRR 2.14, 95% CI 2.11 to 2.16) and women (incidence rate ratio (IRR) 2.22; 95% CI 2.19 to 2.25). Pneumonia was significantly associated with a higher mortality (OR 2.59, 95% CI 2.52 to 2.67). We found that percutaneous endoscopic gastrostomy was associated with lower IHM (OR 0.37, 95% CI 0.31 to 0.45), while parenteral nutrition had the opposite effect (OR 1.29, 95% CI 1.18 to 1.41). There was no association between diabetes and higher IHM (OR 0.99, 95% CI 0.93 to 1.06). The time-trend analyses of the entire sample showed a significant reduction in mortality in patients with VaD (OR 0.98, 95% CI 0.97 to 0.99).

CONCLUSIONS

Incidence rates for VaD hospitalisations were twice as high in patients with diabetes compared with those without. Men had significantly higher incidence rates than women, regardless of diabetes status. In both groups studied, pneumonia and parenteral nutrition were associated with mortality while percutaneous endoscopic gastrostomy was associated with survival. Having diabetes was not associated with higher IHM after hospitalisation with VaD.

Analysis of cerebrovascular disease mortality trends in Andalusia (1980-2014)

INTRODUCTION

In recent decades, mortality rates for cerebrovascular diseases (CVD) have decreased significantly in many countries. This study analyses recent tendencies in CVD mortality rates in Andalusia (1980-2014) to identify any changes in previously observed sex and age trends.

PATIENTS AND METHODS

CVD mortality and population data were obtained from Spain's National Statistics Institute database. We calculated age-specific and age-standardised mortality rates using the direct method (European standard population). Joinpoint regression analysis was used to estimate the annual percentage change in rates and identify significant changes in mortality trends. We also estimated rate ratios between Andalusia and Spain.

RESULTS

Standardised rates for both males and females showed 3 periods in joinpoint regression analysis: an initial period of significant decline (1980-1997), a period of rate stabilisation (1997-2003), and another period of significant decline (2003-2014).

CONCLUSIONS

Between 1997 and 2003, age-standardised rates stabilised in Andalusia but continued to decrease in Spain as a whole. This increased in the gap between CVD mortality rates in Andalusia and Spain for both sexes and most age groups.

Predictors of in-hospital mortality following major lower extremity amputations in type 2 diabetic patients using artificial neural networks

BACKGROUND

Outcome prediction is important in the clinical decision-making process. Artificial neural networks (ANN) have been used to predict the risk of post-operative events, including survival, and are increasingly being used in complex medical decision making. We aimed to use ANN analysis to estimate predictive factors of in-hospital mortality (IHM) in patients with type 2 diabetes (T2DM) after major lower extremity amputation (LEA) in Spain.

METHODS

We design a retrospective, observational study using ANN models. We used the Spanish National Hospital Discharge Database to select all hospital admissions of major LEA procedure in T2DM patients.

MAIN OUTCOME MEASURES

Predictors of IHM using 4 ANN models: i) with all discharge diagnosis included in the database; ii) with all discharge diagnosis included in the database, excluding infectious diseases; iii) comorbidities included in the Charlson Comorbidities Index; iv) comorbidities included in the Elixhauser Comorbidity Index.

RESULTS

From 2003 to 2013, 40,857 major LEAs in patients with T2DM were identified with a 10.0% IHM. We found that Elixhauser Comorbidity Index model performed better in terms of sensitivity, specificity and precision than Charlson Comorbidity Index model (0.7634 vs 0.7444; 0.9602 vs 0.9121; 0.9511 vs 0.888, respectively). The area under the ROC curve for Elixhauser comorbidity model was 91.7% (95% CI 90.3-93.0) and for Charlson comorbidity model was 88.9% (95% CI; 87.590.2) p = 0.043. Models including all discharge diagnosis with and without infectious diseases showed worse results. In the Elixhauser Comorbidity Index model the most sensitive parameter was age (variable sensitive ratio [VSR] 1.451) followed by female sex (VSR 1.433), congestive heart failure (VSR 1.341), renal failure (VSR 1.274) and chronic pulmonary disease (VSR 1.266).

CONCLUSIONS

Elixhauser Comorbidity Index is a superior comorbidity risk-adjustment model for major LEA survival prediction in patients with T2DM than Charlson Comorbidity Index model using ANN models. Female sex, congestive heart failure, and renal failure are strong predictors of mortality in these patients.

Type 2 diabetes is associated with a higher incidence of hospitalization for pulmonary embolism in Spain: Analysis of hospital discharge data during 2004-2013

BACKGROUND AND OBJECTIVE

We compared the incidence and outcome of pulmonary embolism (PE) in individuals with and without type 2 diabetes mellitus (T2DM) in Spain during 2004-2013.

METHODS

The study was based on National Hospital Discharge Data, and the study population comprised patients hospitalized for PE. Annual incidence rates were classified according to T2DM status. In-hospital mortality (IHM), length of hospital stay (LOHS), comorbidities and use of diagnosis and therapeutic procedures were analysed.

RESULTS

We identified 123 872 discharges of patients (56 361 men and 67 511 women) with PE as their primary diagnosis (15.3% with T2DM). Incidence of discharge diagnoses of PE increased significantly in all groups. Crude rates were higher in diabetic patients. A positive association was identified between T2DM and PE: adjusted IRR was 2.00 (95% CI: 1.95-2.05) for men and 2.50 (95% CI: 2.45-2.57) for women. LOHS, readmissions and IHM decreased significantly for both groups. An association between IHM and risk factors (older age, Charlson comorbidity index >3, atrial fibrillation and cancer) was observed. T2DM was associated with higher IHM in men (OR: 1.22, 95% CI: 1.12-1.32) and women (OR: 1.24, 95% CI: 1.15-1.33). The use of computed tomography pulmonary angiography increased significantly overtime.

CONCLUSION

We confirmed that in both men and women, diabetes was an independent risk factor for IHM. The incidence of discharge of patients with PE increased significantly during the study period. Diabetic men and women had a higher risk of hospitalization for PE than non-diabetic men and women. Diabetic women had higher IHM than diabetic men.