Mortality of Mexican Americans with NIDDM. Retinopathy and other predictors in Starr County, Texas

Suicide death, suicidal ideation and suicide attempt in patients with diabetes: A systematic review and meta-analysis

AIMS

Diabetes has been indicated to be a risk factor for suicide. We aim to estimate the prevalence of suicide in patients with diabetes.

DESIGN

A meta-analysis using PRISMA methodology was adopted to examine the incidence of suicide in diabetic patients.

DATA SOURCES

From inception to October 2022, three online databases (PubMed, China National Knowledge Infrastructure and Web of Science) were used to search studies.

REVIEW METHODS

We used random-effects model to analysis. And our primary outcome was the incidence of suicide death per 100 person-years, and other outcomes were prevalence of suicidal ideation and suicide attempt. To explore the sources of heterogeneity in our study, we performed subgroup and meta-regression analyses.

RESULTS

The suicide death rate in diabetic patients was 0.027 per 100 person-years, with a higher rate for Type 1 Diabetes Mellitus compared to Type 2 Diabetes Mellitus. The prevalence of suicidal ideation in diabetes patients was 0.175, with a higher prevalence in Type 1 Diabetes Mellitus compared to Type 2 Diabetes Mellitus. The prevalence of suicide attempts in diabetes patients was 0.033, indicating a higher rate for Type 2 Diabetes Mellitus compared to Type 1 Diabetes Mellitus.

CONCLUSIONS

The results indicate a high rate of suicide among people with diabetes, and this study identifies populations and regions at high risk for suicide. Our review emphasizes interventions in mental health and the improvement of suicide prevention programmes.

IMPACT

The study investigated suicide death, suicidal ideation and suicide attempt in diabetic individuals. Suicide rates are elevated among diabetic patients, and various patient groups face distinct suicide risks. It is important to prioritize the mental well-being of diabetic individuals and enhance interventions, including personalized approaches, to inform public health efforts aimed at preventing and addressing suicide among diabetic patients.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Retinopathy and Mortality

OBJECTIVE

We evaluated the specific association between retinopathy and all-cause mortality among a national sample of the broader U.S. adult population.

METHODS

Data from the 2005-2008 National Health and Nutrition Examination Survey were used to identify 4,777 adults with complete data regarding screening for nonproliferative retinopathy using Early Treatment Diabetic Retinopathy Study grading criteria, as well as objective retinal imaging assessments using the Canon Non-Mydriatic Retinal Camera CR6-45NM. Participants were not included if they had been diagnosed with coronary artery disease, congestive heart failure, heart attack, or stroke at the baseline assessment.

RESULTS

Both mild and moderate/severe retinopathy were associated with increased all-cause mortality risk in unadjusted and adjusted models. In the adjusted model, and when compared to those with no retinopathy, those with mild and moderate/severe retinopathy, respectively, had 81% (hazard ratio [HR] 1.81, 95% CI 1.29-2.55) and 314% (HR 4.14, 95% CI 1.77-9.69) increased risks of all-cause mortality.

CONCLUSION

In this nationally representative sample of adults, those with mild or moderate/severe retinopathy were at increased risk of all-cause mortality.

Diabetic Microvascular Disease: An Endocrine Society Scientific Statement

Both type 1 and type 2 diabetes adversely affect the microvasculature in multiple organs. Our understanding of the genesis of this injury and of potential interventions to prevent, limit, or reverse injury/dysfunction is continuously evolving. This statement reviews biochemical/cellular pathways involved in facilitating and abrogating microvascular injury. The statement summarizes the types of injury/dysfunction that occur in the three classical diabetes microvascular target tissues, the eye, the kidney, and the peripheral nervous system; the statement also reviews information on the effects of diabetes and insulin resistance on the microvasculature of skin, brain, adipose tissue, and cardiac and skeletal muscle. Despite extensive and intensive research, it is disappointing that microvascular complications of diabetes continue to compromise the quantity and quality of life for patients with diabetes. Hopefully, by understanding and building on current research findings, we will discover new approaches for prevention and treatment that will be effective for future generations.

MANAGEMENT OF ENDOCRINE DISEASE: Suicide risk in patients with diabetes: a systematic review and meta-analysis

BACKGROUND

Previous studies investigating the risk of suicide in diabetes patients reported controversial findings. We did a systematic review and meta-analysis to comprehensively estimate the risk and incidence rate of suicide in diabetic patients.

METHODS

PubMed, EMBASE and PsycINFO were searched for eligible studies. Random-effects meta-analysis was used to calculate the relative risk (RR) and the incidence rate of suicide in diabetes patients. We also calculated the proportion of deaths attributable to suicide among diabetes patients.

RESULTS

54 studies were finally included, including 28 studies on the suicide risk associated with diabetes, 47 studies on the incidence rate of suicide and 45 studies on the proportion of deaths attributable to suicide. Meta-analysis showed that diabetes could significantly increase the risk of suicide (RR = 1.56; 95% CI: 1.29-1.89; P < 0.001). Subgroup analysis showed that the RR of suicide associated with type 1 diabetes was 2.25 (95% CI: 1.50-3.38; P < 0.001). The pooled incidence rate of suicide in patients with diabetes was 2.35 per 10 000 person-years (95% CI: 1.51-3.64). The pooled proportions of long-term deaths attributable to suicide in type 1 diabetes patients and type 2 diabetes patients were 7.7% (95% CI: 6.0-9.8) and 1.3% (95% CI: 0.6-2.6), respectively.

CONCLUSION

This meta-analysis suggests that diabetes can significantly increase the risk of suicide. Suicide has an obvious contribution to mortality in diabetic patients, especially among type 1 diabetes patients. Effective strategies to decrease suicide risk and improve mental health outcomes in diabetes patients are needed.

Association of disease-specific causes of visual impairment and 10-year mortality amongst Indigenous Australians: the Central Australian Ocular Health Study

IMPORTANCE

Visual impairment significantly impairs the length and quality of life, but little is known of its impact in Indigenous Australians.

BACKGROUND

To investigate the association of disease-specific causes of visual impairment with all-cause mortality.

DESIGN

A retrospective cohort analysis.

PARTICIPANTS

A total of 1347 Indigenous Australians aged over 40 years.

METHODS

Participants visiting remote medical clinics underwent clinical examinations including visual acuity, subjective refraction and slit-lamp examination of the anterior and posterior segments. The major ocular cause of visual impairment was determined. Patients were assessed periodically in these remote clinics for the succeeding 10 years after recruitment. Mortality rates were obtained from relevant departments.

MAIN OUTCOME MEASURES

All-cause 10-year mortality and its association with disease-specific causes of visual impairment.

RESULTS

The all-cause mortality rate for the entire cohort was 29.3% at the 10-year completion of follow-up. Of those with visual impairment, the overall mortality rate was 44.9%. The mortality rates differed for those with visual impairment due to cataract (59.8%), diabetic retinopathy (48.4%), trachoma (46.6%), 'other' (36.2%) and refractive error (33.4%) (P < 0.0001). Only those with visual impairment from diabetic retinopathy were any more likely to die during the 10 years of follow-up when compared with those without visual impairment (HR 1.70; 95% CI, 1.00-2.87; P = 0.049).

CONCLUSIONS AND RELEVANCE

Visual impairment was associated with all-cause mortality in a cohort of Indigenous Australians. However, diabetic retinopathy was the only ocular disease that significantly increased the risk of mortality. Visual impairment secondary to diabetic retinopathy may be an important predictor of mortality.

Prediction of risk of diabetic retinopathy for all-cause mortality, stroke and heart failure: Evidence from epidemiological observational studies

To examine and quantify the potential relation between diabetic retinopathy (DR) and risk of all-cause mortality, stroke and heart failure (HF).The resources of meta-analysis of epidemiological observational studies were from Pub-med, EMBASE, CINAHL, Cochrane Library, conference, and proceedings.Random/fixed effects models were used to calculate pooled subgroup analysis stratified by different grades of DR was performed to explore the potential source of heterogeneity. Statistical manipulations were undertaken using program STATA.Of the included 25 studies, comprising 142,625 participants, 19 studies were concluded to find the relation of DR to all-cause mortality, 5 for stroke, and 3 for HF. Risk ratio (RR) for all-cause mortality with the presence of DR was 2.33 (95% CI 1.92-2.81) compared with diabetic individuals without DR. Evidences showed a higher risk of all-cause mortality associated with DR in patients with T2D or T1D (RR 2.25, 95% CI 1.91-2.65. RR 2.68, 95% CI 1.34-5.36). According to different grades of DR in patients with T2D, RR for all-cause mortality varied, the risk of nonproliferative diabetic retinopathy (NPDR) was 1.38 (1.11-1.70), while the risk of proliferative diabetic retinopathy (PDR) was 2.32 (1.75-3.06). There was no evidence of significant heterogeneity (Cochran Q test P = 0.29 vs 0.26, I = 19.6% vs 22.6%, respectively). Data from 5 studies in relation to DR and the risk of stroke showed that DR was significantly associated with increased risk of stroke (RR = 1.74, 95%CI: 1.35-2.24), compared with patients without DR. Furthermore, DR (as compared with individuals without DR) was associated with a marginal increased risk of HF in patients with diabetes mellitus (DM) (n = 3 studies; RR 2.24, 95% CI 0.98-5.14, P = 0.056).Our results showed that DR increased the risk of all-cause mortality, regardless of the different stages, compared with the diabetic individuals without DR. DR predicted increased risk of stroke and HF. Although only 3 studies about HF were available, the association between DR and HF should be careful.

Vascular responsiveness in type 2 diabetes mellitus (T2DM)

BACKGROUND

Diabetic retinopathy is used for staging of progression of micro and macro-vascular complications of patients with DM. Our hypothesis was that diabetic patients at different stages of retinopathy would have different vascular responsiveness that will be used as a surrogate marker of macro-vascular disease for risk assessment of cardiovascular complications.

METHODS

A prospective study enrolled 96 patients. Twenty-three healthy volunteers (44 ± 11 years), 25 diabetic patients without retinopathy (63 ± 11 years), 25 patients with non-proliferative retinopathy [NPDR] (62 ± 9 years) and 23 patients with proliferative diabetic retinopathy [PDR] (59 ± 10 years). All patients underwent an ophthalmologic examination to diagnose retinopathy staging, and vascular responsiveness evaluation that included endothelial function evaluation (using the brachial artery method to measure flow mediated diameter change (FMD%)) and measuring the ankle-brachial blood pressure ratio, a measure of arterial stiffness.

RESULTS

Endothelial function was severely impaired in all diabetic patients. Patients with PDR had an FMD% of -3.1 ± 6.6%, patients with NPDR had -3.3 ± 9.2%, patients without retinopathy -1.9 ± 7.4% (P = NS between all groups of patients). Healthy controls had an FMD% of 16.5 ± 7.5% with a significant difference (P < 0.001) compared with each group of patients. No difference in FMD% was observed among patients (P = 0.93 between PDR and NPDR groups, P = 0.54 between NPDR and no retinopathy groups and P = 0.71 between patients without retinopathy and those with PDR).The ankle brachial (ABI) ratio was 1.03 ± 0.28 in the PDR group, 1.14 ± 0.24 in the NPDR group and 0.97 ± 0.18 in the no-retinopathy group. Healthy volunteers had an ABI of 1.07 ± 0.18. No difference was observed between ABI of PDR and NPDR patients (P = 0.17) and between patients without retinopathy and PDR patients (P = 0.91). However, a significant difference was observed between the NPDR and no-retinopathy groups (P = 0.008). No significant difference was found between ABI ratios when compared with the control group (P = 0.62 for PDR, P = 0.26 for NPDR and P = 0.07 for the no-retinopathy group). No difference was observed in age and BMI among all groups of patients (P = NS for all). Patients were older (P < 0.001) and had a higher BMI (P < 0.001). Interestingly there was no difference in height among groups of patients, but controls were significantly taller compared with each group of patients (P < 0.02).

CONCLUSIONS

All patients with T2DM had severe endothelial dysfunction with no difference among the different retinopathy groups. In our patients, all patients had a normal arterial stiffness but patients without retinopathy who had the highest arterial stiffness. We could not distinguish vascular traits that would define diabetic patients at the highest risk to develop cardiovascular complications.

Liver and Other Gastrointestinal Cancers Are Frequent in Mexican Americans

BACKGROUND

Disease patterns in Mexican American health-disparity populations differ from larger US populations.

AIMS

This study is aimed to determine frequency of gastrointestinal cancers in Mexican Americans.

METHODS

We analyzed self-reported data from the Cameron County Hispanic Cohort where we find high rates of risk factors for cancer: obesity (48.5 %) and diabetes (30.7 %). Participants provided cancer histories about themselves and first- and second-degree relatives. Logistic regression models assessed risk factors. Frequencies of cancer sites were ranked and validated using concurrent age local cancer registry data.

RESULTS

Among 9,249 individuals (participants and their relatives), there were 1,184 individuals with reports of cancer. Among cohort participants under 70 years of age, the most significant risk factor for all-cause cancers was diabetes (OR 3.57, 95 % CI 1.32, 9.62). Participants with metabolic syndrome were significantly more likely to report cancer in relatives [1.73 (95 % CI 1.26, 2.37]. Among cancers in fathers, liver cancer was ranked third, stomach fourth, colorectal sixth, and pancreas tenth. In mothers, stomach was third, liver fourth, colorectal seventh, and pancreas eleventh. The unusual prominence of these cancers in Mexican Americans, including liver cancer, was supported by age-adjusted incidence in local registry data.

CONCLUSIONS

Gastrointestinal system cancers, particularly, liver cancer, in a Mexican American health disparity cohort and their relatives rank higher than in other ethnicities and are associated with high rates of diabetes and metabolic syndrome. Effective prevention of diabetes and low-tech, high-quality screening strategies for gastrointestinal cancers are needed in health disparity communities.

Factors associated with poor glycemic control in older Mexican American diabetics aged 75 years and older

OBJECTIVE

This study examines the prevalence and correlates of poor glycemic control in Mexican Americans aged 75 years and older with diabetes.

METHODS

Data are from the 5(th) wave (2004-05) of the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE). A total of 2,069 Mexican Americans aged 75 and over were interviewed. Six hundred eighty nine subjects (33.5%) reported having been diagnosed with diabetes and 209 (30.3%) subjects agreed to a blood test of their HbA(1)c level.

RESULTS

Of the 209 diabetic subjects with an HbA(1)c test, 73 (34.9%) had good glycemic control (HbA(1)c <7%) and 136 (65.1%) had poor glycemic control (HbA(1)c >7%). Bivariate analysis revealed that subjects with poor control had longer disease duration, had lower education, used the glucometer more frequently, and had more diabetes-complications when compared to those in the good glycemic control group. Multivariable logistic regression analysis found the following factors associated with poor glycemic control: <8 years of education, foreign-born, smoking, obesity, longer disease duration, daily glucometer use, and having macro-complications.

DISCUSSION

Prevalence of poor glycemic control is very high in this population with very high and rising prevalence of diabetes. Further studies are needed to explore the effect of these and other characteristics on glycemic control among older Mexican Americans and to develop appropriate interventions to improve diabetes outcomes and increase life-expectancy.

Diabetic retinopathy predicts all-cause mortality and cardiovascular events in both type 1 and 2 diabetes: meta-analysis of observational studies

OBJECTIVE

The prognostic significance of diabetic retinopathy (DR) for death and cardiovascular (CV) outcomes is debated. We investigated the association of DR with all-cause mortality and CV events in patients with diabetes by a systematic review and meta-analysis.

RESEARCH DESIGN AND METHODS

The electronic databases Medline and Embase were searched for cohort studies that evaluated DR in type 2 or type 1 diabetic patients and reported total mortality and/or fatal and nonfatal CV events, including myocardial infarction, angina pectoris, coronary artery bypass graft, ischemic changes on a conventional 12-lead electrocardiogram, transient ischemic attack, nonfatal stroke, or lower leg amputation. Data extraction was performed by two reviewers independently. Pooled effect estimates were obtained by using random-effects meta-analysis.

RESULTS

The analysis included 20 studies that fulfilled the inclusion criteria, providing data from 19,234 patients. In patients with type 2 diabetes (n = 14,896), the presence of any degree of DR increased the chance for all-cause mortality and/or CV events by 2.34 (95% CI 1.96-2.80) compared with patients without DR. In patients with type 1 diabetes (n = 4,438), the corresponding odds ratio was 4.10 (1.50-11.18). These associations remained after adjusting for traditional CV risk factors. DR was also predictive of all-cause mortality in type 2 diabetes (odds ratio 2.41 [1.87-3.10]) and type 1 diabetes (3.65 [1.05-12.66]).

CONCLUSIONS

The presence of DR was associated with an increased risk of all-cause mortality and CV events in both type 2 and type 1 diabetic patients.

All-cause mortality among Japanese-Brazilians according to nutritional characteristics

The aim of this study was to verify the association between nutritional variables and mortality in a Japanese-Brazilian cohort. In 1993, 647 subjects were interviewed with food frequency questionnaires and scheduled for physical procedures (weight, height, blood pressure) and biochemical tests (oral glucose tolerance test). Student's t test was used to compare the mean values of target variables between living and deceased subjects. Mortality rate and hazard ratios were obtained (crude and adjusted) according to the nutritional variables. Overall mortality rates were 21.4 and 11.7/1,000 person-years for males and females, respectively. Smoking, diabetes, sedentary lifestyle, hypertension, higher mean age, high blood pressure, high blood glucose, and higher percent weight gain and rate of weight gain were observed in the history of deceased subjects. After adjusting for control variables, an increase was observed in mortality among individuals with lower carbohydrate and cholesterol intake. The results suggest that mortality risk factors like age, chronic diseases, sedentary lifestyle, smoking, and inadequate diet must also be acting in the Japanese-Brazilian population.

Diabetic retinopathy is associated with an increased incidence of cardiovascular events in Type 2 diabetic patients

AIMS

We investigated the association of diabetic retinopathy with the risk of incident cardiovascular disease (CVD) events in a large cohort of Type 2 diabetic adults.

METHODS

Our study cohort comprised 2103 Type 2 diabetic outpatients who were free of diagnosed CVD at baseline. Retinal findings were classified based on fundoscopy (by a single ophthalmologist) to categories of no retinopathy, non-proliferative retinopathy and proliferative/laser-treated retinopathy. Outcomes measures were incident CVD events (i.e. non-fatal myocardial infarction, non-fatal ischaemic stroke, coronary revascularization procedures or cardiovascular death).

RESULTS

During approximately 7 years of follow-up, 406 participants subsequently developed incident CVD events, whereas 1697 participants remained free of diagnosed CVD. After adjustment for age, body mass index, waist circumference, smoking, lipids, glycated haemoglobin, diabetes duration and medications use, patients with non-proliferative or proliferative/laser-treated retinopathy had a greater risk (P < 0.001 for all) of incident CVD events than those without retinopathy [hazard ratio 1.61 (95% confidence interval 1.2-2.6) and 3.75 (2.0-7.4) for men, and 1.67 (1.3-2.8) and 3.81 (2.2-7.3) for women, respectively]. After additional adjustment for hypertension and advanced nephropathy (defined as overt proteinuria and/or estimated glomerular filtration rate < or = 60 ml/min/1.73 m(2)), the risk of incident CVD remained markedly increased in those with proliferative/laser-treated retinopathy [hazard ratio 2.08 (1.02-3.7) for men and 2.41 (1.05-3.9) for women], but not in those with non-proliferative retinopathy.

CONCLUSIONS

Diabetic retinopathy (especially in its more advanced stages) is associated with an increased CVD incidence independent of other known cardiovascular risk factors.

Diabetic retinopathy and coronary implantation of sirolimus-eluting stents

INTRODUCTION

The prognostic value of identifying the retinal status of diabetic patients undergoing coronary implantation of drug-eluting stents is unknown.

METHODS

We evaluated the outcomes of 318 consecutive patients undergoing implantation of sirolimus-eluting stents for coronary artery disease. Patients were divided into 5 groups according to the diabetic and retinal status: diabetic patients without retinopathy (43 patients); diabetic patients with nonproliferative retinopathy (34); diabetic patients with proliferative retinopathy (37); diabetic patients with unknown retinal status (30); and nondiabetic patients (174).

RESULTS

During a mean follow-up of 385 days, 64 patients had target-vessel failure (defined as a composite of death from cardiac causes, myocardial infarction, and target-vessel revascularization). At 1 year, Kaplan-Meier estimates of the rate of target-vessel failure were 15.3% for diabetic patients without retinopathy, 56.6% for those with nonproliferative retinopathy, 17.3% for those with proliferative retinopathy, 19.0% for those with unknown retinal status, and 16.0% for nondiabetic patients. After adjustment for the potential confounders and differences between groups, the relation of nonproliferative retinopathy to target-vessel failure remained significant. In an analysis in which diabetic patients without retinopathy were used as the reference group, the hazard ratios for target-vessel failure were 3.9 for those with nonproliferative retinopathy, 1.3 for those with proliferative retinopathy, 1.1 for those with unknown retinal status, and 1.4 for nondiabetic patients (P for trend = 0.015).

CONCLUSIONS

As compared with diabetic patients without retinopathy, those with nonproliferative retinopathy have an increased risk for target-vessel failure after coronary implantation of sirolimus-eluting stents.

Type 2 diabetes and tuberculosis in a dynamic bi-national border population

The epidemic of type 2 diabetes in the United States prompted us to explore the association between diabetes and tuberculosis (TB) on the South Texas-Mexico border, in a large population of mostly non-hospitalized TB patients. We examined 6 years of retrospective data from all TB patients (n=5049) in South Texas and northeastern Mexico and found diabetes self-reported by 27.8% of Texan and 17.8% of Mexican TB patients, significantly exceeding national self-reported diabetes rates for both countries. Diabetes comorbidity substantially exceeded that of HIV/AIDS. Patients with TB and diabetes were older, more likely to have haemoptysis, pulmonary cavitations, be smear positive at diagnosis, and remain positive at the end of the first (Texas) or second (Mexico) month of treatment. The impact of type 2 diabetes on TB is underappreciated, and in the light of its epidemic status in many countries, it should be actively considered by TB control programmes, particularly in older patients.

Biological surrogates for enhancing cardiovascular risk prediction in type 2 diabetes mellitus

The identification of individuals at increased risk for cardiovascular disease (CVD) events is the critical first step toward reducing CVD morbidity and mortality. Accurate models for cardiac risk stratification benefit high-risk patients, who stand to gain the most from aggressive treatments, including pharmacologic therapies for blood pressure control, lipid lowering, glycemic control, and smoking cessation, as well as lower risk patients, who may avoid the added expense and complications from unnecessary medications and procedures. The further stratification of CVD risk in patients with diabetes mellitus may be important in individualizing therapy and in developing future clinical trials to examine new approaches for CVD event reduction in patients with diabetes. This review examines the utility of various surrogate markers of CVD specifically in patients with diabetes by looking first at markers already recommended by both American Diabetes Association (ADA) and American Heart Association (AHA) treatment guidelines, followed by the most recent data on selected markers not routinely used.

Retinopathy predicts cardiovascular mortality in type 2 diabetic men and women

OBJECTIVE

To investigate the association of retinopathy with the risk of all-cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in type 2 diabetic subjects in a population-based 18-year follow-up study with particular emphasis on sex differences.

RESEARCH DESIGN AND METHODS

Our study cohort comprised 425 Finnish type 2 diabetic men and 399 type 2 diabetic women who were free of CVD at baseline. The findings were classified based on standardized clinical ophthalmoscopy to categories of no retinopathy, background retinopathy, and proliferative retinopathy. The study end points were all-cause, CVD, and CHD mortality.

RESULTS

Adjusted Cox model hazard ratios (95% CIs) of all-cause, CVD, and CHD mortality in men were 1.34 (0.98-1.83), 1.30 (0.86-1.96), and 1.18 (0.74-1.89), respectively, for background retinopathy and 3.05 (1.70-5.45), 3.32 (1.61-6.78), and 2.54 (1.07-6.04), respectively, for proliferative retinopathy and in women 1.61 (1.17-2.22), 1.71 (1.17-2.51), and 1.79 (1.13-2.85), respectively, for background retinopathy and 2.92 (1.41-6.06), 3.17 (1.38-7.30), and 4.98 (2.06-12.06), respectively, for proliferative retinopathy.

CONCLUSIONS

Proliferative retinopathy in both sexes and background retinopathy in women predicted all-cause, CVD, and CHD death. These associations were independent of current smoking, hypertension, total cholesterol, HDL cholesterol, glycemic control of diabetes, duration of diabetes, and proteinuria. This suggests the presence of common background pathways for diabetic microvascular and macrovascular disease other than those included in the conventional risk assessment of CVD. The sex difference observed in the association of background retinopathy with macrovascular disease warrants closer examination.

The beneficial effect of coronary-artery-bypass surgery on survival in patients with diabetic retinopathy

OBJECTIVE

The presence of retinopathy is a predictor of mortality following coronary revascularization in diabetics. We studied whether revascularization by coronary-artery-bypass surgery (CABG), as compared with percutaneous coronary intervention (PCI), influences the prognosis in diabetics with retinopathy.

METHODS

Between April 1996 and March 2004, 1489 patients underwent revascularization as an initial procedure. Among these a total of 319 diabetics underwent retinal examination prior to the initial revascularization. These patients were classified according to whether they had retinopathy and whether they had undergone CABG, either initially or after PCI. Mortality rates were estimated from the time of initial revascularization procedure.

RESULTS

The average follow-up from the time of initial revascularization was 48.2+/-28.6 months. In 153 diabetics with retinopathy, 59 eventually underwent CABG. During the entire follow-up period, there were 2 (3.4%) deaths in diabetics with retinopathy who underwent CABG and 14 (14.9%) deaths in those who did not have CABG. Mortality curves differed significantly between the two groups (P = 0.007). After adjustment for risk factors, the relative risk of death was 0.13 afforded by CABG (95% CI, 0.03-0.62; P = 0.011). In 166 diabetics without retinopathy, mortality curves were similar between the patients who underwent CABG and those who did not have CABG (P = 0.94).

CONCLUSIONS

CABG conferred a survival advantage in diabetics with retinopathy. In contrast, no survival advantage was evident in diabetics without retinopathy undergoing CABG. Retinal status should be taken into consideration when considering revascularization strategy for diabetics who have coronary artery disease.

[Diabetic retinopathy and mortality in type 2 diabetic patients]

BACKGROUND AND OBJECTIVE

This study was intended to assess the independent contribution of retinopathy to mortality in type 2 diabetic patients.

PATIENTS AND METHOD

Prospective cohort study. Type 2 diabetic patients with available fundus were included. The clinical end-point was total mortality. The main independent variable was baseline presence of background or proliferative retinopathy. Cox regression models were adjusted for age, sex, duration of diabetes, classical risk factors and baseline presence of nephropathy and cardiovascular disease.

RESULTS

458 patients were included (181 male, 277 females), with a median follow-up of 8 years (inter-quartile range, 6.7-9). There were 125 patients (27.3%) with background retinopathy and 46 (10%) with proliferative retinopathy. Mortality incidence rates per 1,000 patients-year were 20/1,000 (non retinopathy), 36.8/1,000 (background retinopathy) and 45.9/1,000 (proliferative retinopathy) with p = 0.0021. In the multivariate analysis, background retinopathy (HR = 1.87; 95% CI, 1.1-3.1; p = 0.019) and proliferative retinopathy (HR = 2.6; 95% CI, 1.3-5.1; p = 0.0048) were independent predictors of mortality. Other independent predictors were age (HR [1 year] = 1.13; 95% CI, 1.1-1.17; p < 0.0001), total cholesterol (HR [1 mmol/l] = 0.76; 95% CI, 0.6-0.97; p = 0.026), baseline insulin treatment (HR = 1.9; 95% CI, 1,1-3.2; p = 0.017) and baseline proteinuria (HR = 4.1; 95% CI, 2-8.5; p = 0.0001).

CONCLUSIONS

The presence of retinopathy increases the mortality risk in type 2 diabetic patients.

Diabetes in the Hispanic or Latino population: genes, environment, culture, and more

The Hispanic or Latino population is the largest minority group in the United States, currently representing 13.7% of the total U.S. population. Hispanics or Latinos usually suffer from higher rates of type 2 diabetes, obesity, metabolic syndrome, and their multiple vascular complications. Inadequate nutrition and reduced physical activity in the setting of an increased genetic predisposition to type 2 diabetes have contributed to the inexorable rise in metabolic abnormalities in Hispanics in the United States, which now affect many children and adolescents. It is evident that multiple medical, cultural, and socioeconomic factors influence the development of diabetes, its course, and its consequences. Our health care system is barely prepared to face the challenge of managing diabetes in this high-risk group. Culturally oriented clinical care, education, outreach and research programs are needed to better identify the challenges to create opportunities to improve the lives of Hispanics or Latinos with diabetes or at risk for the disease.

Diabetic retinopathy is associated with mortality and cardiovascular disease incidence: the EURODIAB prospective complications study

OBJECTIVE

To study the relationship of nonproliferative and proliferative retinopathy with all-cause mortality and cardiovascular disease (CVD) incidence in type 1 diabetic patients and, additionally, the role of cardiovascular risk factors in these associations.

RESEARCH DESIGN AND METHODS

This prospective study included 2,237 type 1 diabetic patients from 31 centers in 16 European countries at baseline, aged 15-60 years, who were examined for retinopathy by taking two-field 45 degrees fundus photographs, which were centrally graded. Mortality and cardiovascular morbidity follow-up was assessed 6-8 years after baseline examination according to a standardized protocol.

RESULTS

After 7.9 years of follow-up, 64 patients had died and 128 patients had incident CVD. The age- and sex-adjusted hazard ratios (HRs) of all-cause mortality were 1.45 (95% CI 0.71-2.96) and 4.16 (1.96-8.84) in patients with nonproliferative and proliferative retinopathy at baseline, respectively. Adjustments for cardiovascular risk factors completely obliterated the association with nonproliferative retinopathy, whereas the association with proliferative retinopathy remained twofold increased, although nonsignificant. The age- and sex-adjusted HRs of incident CVD were 1.73 (1.15-2.60) and 2.05 (1.22-3.45) in patients with nonproliferative and proliferative retinopathy, respectively. After adjustments for cardiovascular risk factors, both associations were attenuated and lost statistical significance.

CONCLUSIONS

This study shows that type 1 diabetic patients with nonproliferative or proliferative retinopathy have an increased risk for all-cause mortality and incident CVD. The presence of cardiovascular risk factors explained the associations to a large extent, except for the associations with proliferative retinopathy, which suggests that other shared mechanisms may be involved.

Associations of mortality and diabetes complications in patients with type 1 and type 2 diabetes: early treatment diabetic retinopathy study report no. 27

OBJECTIVE

Diabetes is a leading cause of morbidity and mortality. The purpose of this study is to assess the associations between diabetes complications and mortality in the Early Treatment Diabetic Retinopathy Study (ETDRS).

RESEARCH DESIGN AND METHODS

We examined demographic, clinical, and laboratory characteristics of the 3,711 subjects enrolled in the ETDRS, a randomized controlled clinical trial designed to evaluate the role of laser photocoagulation and aspirin therapy for diabetic retinopathy. The outcome assessed was all-cause mortality. Multivariable Cox proportional hazards regression was used to assess associations between diabetes complications and mortality for type 1 and type 2 diabetes separately.

RESULTS

The 5-year estimates of all-cause mortality were 5.5 and 18.9% for patients with type 1 and type 2 diabetes, respectively. In patients with type 1 diabetes, amputation (hazard ratio [HR] 5.08 [95% CI 2.06-12.54]) and poor visual acuity (1.74 [1.10-2.75]) remained significantly associated with mortality, after adjusting for other diabetes complications and baseline characteristics. In patients with type 2 diabetes, macrovascular disease and worsening levels of nephropathy, neuropathy, retinopathy, and visual acuity are associated with progressively increasing risks of mortality, after controlling for other baseline risk factors.

CONCLUSIONS

Amputation is the strongest predictor for mortality in patients with type 1 diabetes. All complications independently predict mortality in patients with type 2 diabetes. There is an increased risk for mortality as the degree of each complication worsens. Additional studies are needed to investigate the effectiveness of tertiary prevention to decrease mortality in these patients.

The prevalence of coronary heart disease in Type 2 diabetic patients in Italy: the DAI study

AIMS

Type 2 diabetes is associated with at least a twofold increase in risk of coronary heart disease (CHD). We aimed to estimate the prevalence of CHD in the population of Type 2 diabetics cared for by the Italian network of outpatient diabetic units.

METHODS

The DAI (Diabetes and Informatics study group, Italian Association of Diabetologists, and Italian National Institute of Health) study is a multicentre cohort study of patients with Type 2 diabetes. Patients were classified as having CHD if they had: (i) a history for hospital admission for either an acute myocardial infarction (AMI) or angina; (ii) a positive ECG for prior AMI or angina; (iii) a positive history for coronary artery bypass graft; or (iv) a positive history for percutaneous transluminal coronary angioplasty.

RESULTS

A cohort of 19 468 patients was analysed: 3157 patients had CHD. The majority of events (80%) had occurred after the diagnosis of diabetes and were considered in the CHD prevalence estimate. The prevalence of CHD, adjusted by age and sex, was 9.9%: 11.0% male and 9.0% female. Angina without AMI occurred in 1306 patients; this condition was more frequent in females while a documented AMI was more frequent in males. Therapeutic procedures were performed more frequently in males. A positive association with CHD was found for gender, age at visit, duration of diabetes, hypertension, relatives with CHD, tryglicerides and microvascular complications.

CONCLUSIONS

The prevalence of CHD in this cohort is lower than previously reported; nevertheless, patients attending the diabetic care units may not be fully representative of the general diabetic population in Italy. Revascularization is less frequent in females than in males; microvascular complications and a worse metabolic control are significantly associated with CHD.

Glaucoma and survival: the National Health Interview Survey 1986-1994

OBJECTIVE

Associations between glaucoma and survival have not been studied extensively, in part, because of the relatively low prevalence of this condition. This study examines associations between self-reported glaucoma and mortality in a nationally representative sample of U.S. adults.

DESIGN

Annual cross-sectional multistage area probability survey of the U.S. civilian noninstitutionalized population living at addressed dwellings.

PARTICIPANTS

Mortality linkage with >96% of participants from the 1986 to 1994 National Health Interview Survey was performed by the National Center for Health Statistics through 1997. Complete data were available on 116796 adults >or=018 years old.

METHODS

Adults within randomly selected households were administered a chronic conditions list that included questions about glaucoma and visual impairment. Proxy information on these conditions was obtained when household members were unavailable for interview. Statistical methods included Cox regression models with adjustments for covariates, as well as for the complex sample survey design.

MAIN OUTCOME MEASURE

All-cause mortality and cardiovascular and cancer mortality.

RESULTS

A total of 1559 (1.3%) glaucoma cases were reported. Nearly 19% of participants with reported glaucoma also had reported visual impairment (n = 303). Mortality linkage identified 8949 deaths; the average follow-up was 7.0 years. After controlling for survey design, gender, age, race, marital status, education level, and self-rated health, participants with reported glaucoma but without reported visual impairment were at significantly increased risk of death relative to participants without reported glaucoma, irrespective of visual impairment status (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.19-1.53); similar associations were found for participants with reported glaucoma and visual impairment vs. participants with no reported glaucoma (HR, 1.39; 95% CI, 1.14-1.71). An increased risk of cardiovascular disease mortality was found for participants with reported glaucoma both without (HR, 1.31; 95% CI, 1.11-1.55) and with (HR, 1.53; 95% CI, 1.15-2.05) reported visual impairment. Risk of mortality due to cancer was increased only in participants with reported glaucoma but without reported visual impairment (HR, 1.57; 95% CI, 1.25-1.98); this association was stronger when the mortality analysis was restricted to cancers amenable to early screening, including breast, cervical, colon, and prostate cancer (HR, 1.99; 95% CI, 1.41-2.81).

CONCLUSIONS

Among adults residing in the United States, reported glaucoma is associated with an increased risk of all-cause and cardiovascular disease mortality. Associations between glaucoma and cancer were inconsistent and may reflect, in part, a detection bias, in which glaucoma is more likely to be diagnosed in adults receiving health care because of other medical conditions.

Prevalence of diabetes mellitus and related conditions in a south Texas Mexican American sample

The prevalence of self-reported diabetes mellitus in a Mexican American sample population living in Hidalgo County in south Texas was examined along with risk for related sequelae. Data from a stratified random sample of 849 Mexican American men and women ages 45 and older were examined. A subsample of 193 diabetics was compared to 656 nondiabetics with respect to hospitalization, reasons for hospitalization, and other related medical conditions. The prevalence of self-reported diabetes for both men and women was 25.9%. Hospitalization rates for diabetics over a 1-year period and a 5-year period were significantly higher than nondiabetics. Hypertension, cardiac problems, amputations, kidney or urinary problems, eye problems, and joint and bone problems were significantly more common in the diabetics sample than in the nondiabetic sample. The data indicate that diabetes in Mexican Americans may be undertreated in south Texas.

Sequence variation within the neuropeptide Y gene and obesity in Mexican Americans

OBJECTIVE

Recently, we reported evidence for linkage between neuropeptide Y (NPY) and both obesity and several obesity-related quantitative measures in a sample of Mexican Americans from Starr County, Texas. The purpose of this study was to investigate putative variation within the coding and promoter regions of NPY.

RESEARCH METHODS AND PROCEDURES

Five young, obese individuals (body mass index [BMI] 33 to 45 kg/m2, age 14 to 30 years); five adult, lean individuals (BMI 20 to 26 kg/m2, age 39 to 65 years); and five sibling pairs sharing no alleles that were identical by descent at a marker locus proximal to NPY were selected for fluorescence-based sequencing of approximately 1100 base pairs (bp) immediately 5' from the start site and all four exons of NPY. We identified a total of eight variant sites, including a 2-bp insertion/deletion (I/D) within a putative negative regulatory region (-880I/D) and a 17-bp deletion at the exon 1/intron 1 junction (69I/D). The -880I/D and 69I/D variants were typed in a separate random sample of Mexican Americans (N = 914) from Starr County, Texas.

RESULTS

Analyses of variance resulted in a significant association between -880I/D and waist-to-hip ratio (p = 0.041) in the entire sample and between -880I/D and BMI (p = 0.031), abdominal circumference (p = 0.044), and waist-to-hip ratio (p = 0.041) in a non-obese subsample (BMI < 30 kg/m2, n = 594). The 69I/D variant was observed in only one pedigree and does not appear to segregate with obesity within this pedigree.

DISCUSSION

This study reports newly identified common human sequence variation within the regulatory and coding sequence of NPY. Several variants were observed, and of those tested, the -880I/D promoter region variant may influence body fat patterning in non-obese individuals but does not appear to play a major role in the etiology of common forms of obesity in this population.

Incidence and determinants of mortality and cardiovascular events in diabetes mellitus: a meta-analysis

Patients with diabetes mellitus are at increased risk of developing atherosclerotic disease. The extent of this additional risk and its determinants are not well known, but this information is needed for sample-size estimations in intervention studies. Therefore, a meta-analysis of epidemiologic studies on this subject was performed. Medline was searched from 1966 onwards, including the reference lists of all relevant publications. A total of 27 prospective follow-up studies in the English language that allowed calculation of the unadjusted incidence of one of the predefined outcome events were included. The influence of age, sex, type of diabetes, duration of diabetes, year of study, HbA1c, cholesterol level, blood pressure and smoking on these incidences was studied by means of univariate Poisson regression analysis. Overall total mortality was 2.9% per year (95% CI 2.8-3.0; 27 studies), and for death from all vascular causes was 1.4% per year (95% CI 1.3-1.4; 16 studies). Only two studies were found that reported on the incidence of the composite outcome 'event death from all vascular causes, non-fatal myocardial infarction, or non-fatal stroke'. In univariate analysis, age, year of study, total cholesterol and systolic blood pressure were positively related to total mortality and death from all vascular causes. After adjustment for age, or limiting the analyses to studies in patients with type 2 diabetes only (n = 11), these relationships remained statistically significant. In conclusion, the overall yearly total mortality in diabetes mellitus is 2.9% and for death from all vascular causes is 1.4%. There are few data on the incidence of composite cardiovascular outcome events.

Ionizing radiation and genetic risks. VI. Chronic multifactorial diseases: a review of epidemiological and genetical aspects of coronary heart disease, essential hypertension and diabetes mellitus

This paper provides a broad overview of the epidemiological and genetical aspects of common multifactorial diseases in man with focus on three well-studied ones, namely, coronary heart disease (CHD), essential hypertension (EHYT) and diabetes mellitus (DM). In contrast to mendelian diseases, for which a mutant gene either in the heterozygous or homozygous condition is generally sufficient to cause disease, for most multifactorial diseases, the concepts of genetic susceptibility' and risk factors' are more appropriate. For these diseases, genetic susceptibility is heterogeneous. The well-studied diseases such as CHD permit one to conceptualize the complex relationships between genotype and phenotype for chronic multifactorial diseases in general, namely that allelic variations in genes, through their products interacting with environmental factors, contribute to the quantitative variability of biological risk factor traits and thus ultimately to disease outcome. Two types of such allelic variations can be distinguished, namely those in genes whose mutant alleles have (i) small to moderate effects on the risk factor trait, are common in the population (polymorphic alleles) and therefore contribute substantially to the variability of biological risk factor traits and (ii) profound effects, are rare in the population and therefore contribute far less to the variability of biological risk factor traits. For all the three diseases considered in this review, a positive family history is a strong risk factor. CHD is one of the major contributors to mortality in most industrialized countries. Evidence from epidemiological studies, clinical correlations, genetic hyperlipidaemias etc., indicate that lipids play a key role in the pathogenesis of CHD. The known lipid-related risk factors include: high levels of low density lipoprotein cholesterol, low levels of high density lipoprotein cholesterol, high apoB levels (the major protein fraction of the low density lipoprotein particles) and elevated levels of Lp(a) lipoprotein. Among the risk factors which are not related to lipids are: high levels of homocysteine, low activity of paraoxonase and possibly also elevated plasma fibrinogen levels. In addition to the above, hypertension, diabetes and obesity (which themselves have genetic determinants) are important risk factors for CHD. Among the environmental risk factors are: high dietary fat intake, smoking, stress, lack of exercise etc. About 60% of the variability of the plasma cholesterol is genetic in origin. While a few genes have been identified whose mutant alleles have large effects on this trait (e.g., LDLR, familial defective apoB-100), variability in cholesterol levels among individuals in most families is influenced by allelic variation in many genes (polymorphisms) as well as environmental exposures. A proportion of this variation can be accounted for by two alleles of the apoE locus that increase (&epsi;4) and decrease (&epsi;2) cholesterol levels, respectively. A polymorphism at the apoB gene (XbaI) also has similar effects, but is probably not mediated through lipids. High density lipoprotein cholesterol levels are genetically influenced and are related to apoA1 and hepatic lipase (LIPC) gene functions. Mutations in the apoA1 gene are rare and there are data which suggest a role of allelic variation at or linked LIPC gene in high density lipoprotein cholesterol levels. Polymorphism at the apoA1--C3 loci is often associated with hypertriglyceridemia. The apo(a) gene which codes for Lp(a) is highly polymorphic, each allele determining a specific number of multiple tandem repeats of a unique coding sequence known as Kringle 4. The size of the gene correlates with the size of the Lp(a) protein. The smaller the size of the Lp(a) protein, the higher are the Lp(a) levels. (ABSTRACT TRUNCATED)

Relationship between blood glucose level and mortality in type 2 diabetes mellitus: a systematic review

AIM

To review the relationship between blood glucose level and mortality in patients with Type 2 diabetes mellitus (DM) as reported in the literature.

METHODS

Literature search using Medline Search: January 1966 - April 1998.

KEYWORDS

Diabetes, Non Insulin Dependent, Mortality. Inclusion criteria for papers were: Type 2 DM; follow-up for at least 3 years; glucose or glycated haemoglobin (HbA1c) was used as parameter; published in the form of an article. Additionally all references in the selected articles that dealt with the relationship between blood glucose level and mortality in Type 2 DM were included in the search.

RESULTS

Twenty-seven eligible articles were found. Twenty-three of them showed a positive association: measures of elevated blood glucose concentrations were associated with higher mortality; in 15 out of 23 studies the positive association was statistically significant, in two only for postprandial blood glucose. One study found a nonsignificant negative relationship in a very old population.

CONCLUSION

In the literature there is a positive, but rather weak, association between the measures of blood glucose control and the risk of dying of patients with Type 2 DM. In the six larger studies (more than 100 deceased patients) that used a continuous categorization of glycaemia, the Risk ratio per unit varies from 1.03 to 1.12.

[Increase in mortality associated with the presence of diabetes mellitus in Japanese-Brazilians]

OBJECTIVE

As part of a study involving Japanese migrants, living in a developed city in the state of S. Paulo, Southeastern Brazil, a four-year experience of mortality among diabetic and non-diabetic subjects is described and their respective death rates are compared. In 1993, a cohort of 530 Japanese-Brazilians (236 issei or 1st generation and 294 nisei or 2nd generation) of both sexes, aged 40 from to 79 years old, were identified.

RESEARCH DESIGN AND METHOD

At that time, 91 (17%) were classified as non-insulin-dependent diabetic subjects (NIDDM), 90 (17%) with impaired glucose tolerance (IGT) and 349 (66%) as normal, according to WHO criteria. In 1996, families were questioned with a view detecting the deaths which had occurred among the subjects previously studied. This information, in addition to that from death certificates was used to record the date and the causes of death. Mortality rates for all causes and for specific causes (circulatory and renal diseases) were obtained for the three groups of subjects, by glucose tolerance status. Proportional hazard regression models were used to compare the mortality rates, adjusted for several covariables (gender, age, generation, hypertension, dyslipidemia, obesity and serum creatinine).

RESULTS AND CONCLUSIONS

Crude mortality rate ratios for all causes and specific causes, for NIDDM, and normal subjects were 2.95 (95% CI: 1.10-7.62) and 4.57 (95% CI: 1.31-16.48), respectively. No difference was observed between the crude mortality rate ratio for IGT and normal subjects. After simultaneous adjustments for the covariates, higher mortality rates for specific causes were observed among NIDDM than in the normal subjects (mortality rates ratio: 3.86; 95% CI: 1.11-13.38). These results in Japanese-Brazilians are consistent with previous reports of increased mortality in other diabetic subjects, thus confirming the adverse effect of this metabolic disturbance on mortality among diabetic subjects.

Attitudes and issues in treating Latino patients with type 2 diabetes: views of healthcare providers

The purpose of this study was to explore the concerns of Latino patients with Type 2 diabetes. Focus groups were conducted with healthcare practitioners to chart their perceptions of the issues faced by their Latino patients. One group consisted of professionals working among Mexican American clients in an inner-city clinic; another group was held at an inner-city hospital serving mostly Puerto Rican Americans; and a third group involved providers practicing with more affluent, suburban Mexican Americans. Practitioners agreed that communication with patients was hindered by low reading levels, lack of proficiency in English, and an excessive respect for physicians. Emotional barriers to adequate treatment were often more important than financial concerns, even among low-income patients. Fear of insulin therapy was expressed in Hispanic communities, and folk remedies were commonly used. Because family needs were considered most important, adhering to a treatment regimen might be viewed as self-indulgent. Yet families provided valuable reinforcement and emotional support. Important questions facing Latinos with diabetes were effectively identified using focus groups of healthcare providers.

A 15-year follow-up study of patients with non-insulin-dependent diabetes mellitus (NIDDM) in Osaka, Japan. Factors predictive of the prognosis of diabetic patients

Risk factors related to the prognosis of diabetic patients were studied in a follow-up study of 1939 patients with non-insulin-dependent diabetes mellitus (NIDDM) for a mean observation period of 15 years at our institute. Age at entry into the study was the most powerful risk factor related to the survival of diabetic patients in this study. Moreover, the risk of death, computed in relation to baseline factors, was significantly increased in male patients; in patients with fasting plasma glucose (FPG) levels greater than 140 mg/dl, with hypertension, with diabetic retinopathy or with proteinuria; and in patients treated with an oral hypoglycemic agent of insulin at baseline, even after correction for age. The baseline factors were compared between the groups of patients who were alive and who had died at the end of the follow-up study. Greater age at onset of NIDDM and at entry into the study, higher FPG level, higher systolic and diastolic blood pressure, as well as an increase in the proportion of male patients and in patients with ischemic ECG changes, with diabetic retinopathy, with proteinuria, and with treatment with an oral hypoglycemic agent of insulin, were observed in the group of deceased patients. Furthermore, multiple logistic analysis indicated a significant relationship of age at entry, FPG, hypertension, retinopathy, proteinuria and therapeutic regimen to prognosis. We also found that the baseline factors predictive of prognosis were very different in each age group.

A 15 year follow-up study of patients with non-insulin dependent diabetes mellitus (NIDDM) in Osaka, Japan. Long-term prognosis and causes of death

A 15 year follow-up study of diabetic patients was performed in Osaka, Japan. The subjects studied were 1939 patients with non-insulin dependent diabetes mellitus (NIDDM), of whom 1000 (51.5%) were alive, 880 (45.4%) had died and 59 (3.0%) were untraceable at the end of 1993. The mortality rate per 1000 person-years of the subjects increased from 28.94 in 1960-1984 to 35.74 in 1985-1993, but the ratio of numbers of observed to expected deaths (O/E ratio) declined from 1.77 to 1.52 for the corresponding periods, suggesting an improvement in the prognosis for diabetic patients, with the exception of patients 65 years or over at the time of entry. Cerebro-cardiovascular and renal diseases were major causes of death, accounting for 48.4% of all deaths. In particular, disease of the heart was the cause of death in 20.5% of all deaths, cerebrovascular disease in 14.5% and renal disease in 12.0%. The O/E ratio was 11.30 for renal disease, which was remarkably high. The O/E ratios were 1.48 for malignant neoplasms, 3.02 for cancer of the liver and 2.15 for cancer of the pancreas. In the subjects less than 65 years of age at entry, a significant decrease in the O/E ratio for overall deaths, malignant neoplasms, disease of the heart, cerebrovascular disease and renal disease was observed, but no notable difference in the O/E ratio for ischemic heart disease was found between the periods 1960-1984 and 1985-1993. By contrast, in the case of subjects 65 years or more at entry, the O/E ratios for overall deaths, malignant neoplasms, disease of the heart, ischemic heart disease and cerebrovascular disease increased markedly in the later period, while there was a considerable decline in renal disease indicated during this period. The analysis suggested a structural change in causes of death of Japanese diabetic patients in recent years, with a relative increase in ischemic heart disease and a relative decrease in renal disease.

Dominant risk factors for retinopathy at clinical diagnosis in patients with type II diabetes mellitus

A study of 270 newly presenting, previously untreated, type II diabetic patents revealed that 38 patients (14%) had already developed diabetic retinopathy (DR). Among this group, 26 patients had lesions of background diabetic retinopathy and 12 patients already had maculopathy or preproliferative changes. The aim of this study was to determine the risk factors influencing susceptibility to retinopathy, and to provide an accurate predictive value for diabetic retinopathy from a detailed multiple regression analysis that involved 27 demographic variables and the metabolic and hormonal responses during a meal tolerance test (MTT) at presentation. Compared to the nonretinopaths, the retinopaths had higher fasting plasma glucose levels (FPG) (mean +/- SD) (13.9 +/- 3.1 versus 11.6 +/- 3.2 mmol/L, p < 0.001), lower body-mass index values (BMI) (26.1 +/- 3.8 versus 29.3 +/- 5.0 kg/m2, p < 0.001) and higher plasma urea concentrations (6.0 +/- 1.9 versus 5.3 +/- 1.2 mmol/L, p 0.05). In contrast, gender and levels of blood pressure and other lipid levels did not influence the prevalence of diabetic retinopathy. A multiple regression formula for the prediction of diabetic retinopathy was derived and then used to categorize patients into high-risk and low-risk groups. The retinopaths also had higher HbA1c (p < 0.001), higher plasma glucose are under curve (0-2 h, p < 0.001), lower plasma insulin area under curve (0-22 h, p < 0.001), lower C-peptide area under curve (0-2 h, p < 0.01). They were also leaner (p < 0.001) and older (p < 0.05). However, these variables did not feature significantly in the multiple regression formula. The retinopaths were found to have higher risk probability values (25.1 +/- 11.5 versus 13.1 +/- 10.4%, p < 0.001). In the high risk group, 81.6% of retinopaths were identified. In the low-risk group, 63.8% of nonretinopaths were found. The incidence of diabetic retinopathy in type II diabetic patients at clinical diagnosis was found to be highly related to the degree of hyperglycemia, body-mass index, and to a lesser extent, renal impairment.

A genome-wide search for human non-insulin-dependent (type 2) diabetes genes reveals a major susceptibility locus on chromosome 2

Non-insulin-dependent (type 2) diabetes mellitus (NIDDM) is a common disorder of middle-aged individuals characterized by high blood glucose levels which, if untreated, can cause serious medical complications and lead to early death. Genetic factors play an important role in determining susceptibility to this disorder. However, the number of genes involved, their chromosomal location and the magnitude of their effect on NIDDM susceptibility are unknown. We have screened the human genome for susceptibility genes for NIDDM using non-and quasi-parametric linkage analysis methods in a group of Mexican American affected sib pairs. One marker, D2S125, showed significant evidence of linkage to NIDDM and appears to be a major factor affecting the development of diabetes mellitus in Mexican Americans. We propose that this locus be designated NIDDM1.

Searching for NIDDM susceptibility genes: studies of genes with triplet repeats expressed in skeletal muscle

The expansion of trinucleotide repeats has been associated with late-onset neurodegenerative disorders. Although the genes harbouring the triplet expansions may be widely expressed, the pathological expression of these diseases is restricted to specific tissues. Non-insulin-dependent diabetes mellitus (NIDDM) shares several features with diseases resulting from such dynamic mutations including late-onset and specific but limited sites of tissue pathology-muscle, fat, liver and insulin-secreting pancreatic beta cells. In order to examine the contribution of genes containing polymorphic CAG/CTG repeats to the development of NIDDM, we screened an adult human skeletal muscle cDNA library for expressed sequences containing tandem repeats of CAG and/ or CTG. Ten different loci with polymorphic CAG/ CTG repeats were identified, of which seven had a heterozygosity greater than 0.20. There was no evidence for linkage between these seven loci and NIDDM in a group of affected Mexican-American sib pairs. Nor was there a significant difference in the distribution of alleles between Caucasian patients with NIDDM and normal healthy control subjects or evidence for repeat expansion in diabetic subjects. Thus, muscle genes with polymorphic CAG/CTG repeats do not appear to play a significant role in the development of NIDDM.