Ethnicity, race, and baseline retinopathy correlates in the veterans affairs diabetes trial

Longitudinal Trends and Disparities in Diabetic Retinopathy Within an Aggregate Health Care Network

Importance

Diabetic retinopathy (DR) is a leading cause of blindness in the US, warranting updates on its prevalence and incidence in the setting of advancements in diabetic care over recent years.

Objective

To determine recent trends in DR prevalence stratified by baseline demographics to identify those populations at greater risk.

Design, Setting, and Participants

This was a cross-sectional epidemiologic evaluation conducted using deidentified data from the large federated TriNetX Analytics health research network composed of 56 health care organizations in the US. Patients from 2015 to 2022 who had an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code of type 1 DR (T1DR) or type 2 DR (T2DR) were included in this analysis. Patients were further stratified by age cohorts (20-29 years, 30-39 years, 40-49 years, 50-59 years, 60-69 years, and 70 years or older), race and ethnicity, and sex.

Main Outcomes and Measures

Prevalence per 100 000 patients and prevalence odds ratios (ORs) were calculated in Microsoft Excel and Posit (formerly RStudio).

Results

A total of 359 126 patients with T1DR or T2DR (mean [SD] age, 67 [14] years; 52% female) were included in this study between January 1, 2015, and December 21, 2022. T1DR increased in prevalence from 2015 to 2022, with T1DR increasing 1.15-fold affecting 70.4 patients per 100 000 in 2022. T2DR increased 1.07-fold affecting 461.7 patients per 100 000 in 2022. For T1DR, the cohort aged 20 to 39 years had the most substantial increase at 4.7 and 1.96 fold. Overall, White males had the largest prevalence ORs of T1DR at 1.41 (95% CI, 1.36-1.47) compared with White females (reference group). In T2DR, patients aged 20 to 39 years again had a 2.5- and 1.6-fold prevalence increase from 2015 to 2022. Regardless of age group, Hispanic males demonstrated larger prevalence OR at 4.08 (95% CI, 3.97-4.19) compared with White females followed by Hispanic females at 2.49 (95% CI, 2.42-2.56), Black males at 2.23 (95% CI, 2.17-2.29), and Black females at 2.00 (95% CI, 1.95-2.05).

Conclusion and Relevance

The prevalence of both T1DR and T2DR increased in this network from 2015 to 2022, with individuals aged 20 to 39 years showing large increases. Additionally, T2DR was associated with greater increases in both Hispanic and Black communities. These findings support DR screening in young adults and for T2DR interventions specifically designed for racial and ethnic minoritized patients most affected by disease. Future investigations are warranted to further investigate these trends among young adults.

Visual Acuity Outcomes and Complications after Intraocular Lens Exchange: An IRIS® Registry (Intelligent Research in Sight) Analysis

PURPOSE

To assess risk factors for worse visual acuity (VA) outcomes after intraocular lens (IOL) exchange, and the most common postsurgical complications.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Eyes from patients 18 years of age and older in the IRIS® Registry (Intelligent Research in Sight) that underwent IOL exchange in the United States between 2013 and 2019.

METHODS

Vision improvement compared with baseline was determined at 1 year after surgery. A multivariable generalized estimating equation model adjusting for demographic factors and baseline vision was used to identify factors associated with VA worse than 20/40 at 1 year.

MAIN OUTCOME MEASURES

Visual outcomes and postoperative complications after lens exchange.

RESULTS

A total of 46 063 procedures (n = 41 925 unique patients) were included in the analysis. Overall, VA improved from a mean ± standard deviation (SD) of 0.53 ± 0.58 logarithm of the minimum angle of resolution (logMAR; Snellen equivalent, 20/70) before surgery to a mean ± SD of 0.31 ± 0.40 logMAR (Snellen equivalent, 20/40) at 1 year. Among eyes with VA recorded at both baseline and 1 year after surgery, 60.5% achieved VA of 20/40 or better at 1 year. Vision of worse than 20/40 at 1 year was associated with greater age (odds ratio [OR], 1.16 per 5-year increase; 95% confidence interval [CI], 1.14-1.18) and higher logMAR baseline VA (OR, 1.14 per 0.1-logMAR increase; 95% CI, 1.14-1.15), as well as Black or African American (OR, 1.96; 95% CI, 1.68-2.28), Hispanic (OR, 1.82; 95% CI, 1.59-2.08), and Asian (OR, 1.48; 95% CI, 1.21-1.81) race or ethnicity versus White race, Medicaid (OR, 1.78; 95% CI, 1.40-2.25) versus private insurance, smoking history (OR, 1.22; 95% CI, 1.11-1.35), and concurrent anterior (OR, 1.65; 95% CI, 1.51-1.81) and posterior (OR, 1.53; 95% CI, 1.41-1.66) vitrectomy versus no vitrectomy. Female sex was associated with better VA at 1 year. At 1 year, epiretinal membrane (10.9%), mechanical lens complication (9.4%), and dislocation of the replacement lens (7.1%) were the most common complications.

CONCLUSIONS

In this large national cohort, the annual number of IOL exchanges rose steadily over time. Vision improved in 60.2% of patients; worse visual outcomes were associated with greater age, worse baseline vision, Black race, Hispanic ethnicity, Medicaid insurance, smoking, and concurrent vitrectomy. Epiretinal membrane was the most common complication.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Diabetic Macular Edema Is Predictive of Renal Failure in Patients With Diabetes Mellitus and Chronic Kidney Disease

CONTEXT

Chronic hyperglycemia in patients with diabetes mellitus (DM) causes retinal damage and leakage, resulting in vision loss. Although diabetic retinopathy (DR) and diabetic kidney disease (DKD) are usually correlated, the relationship between diabetic macular edema (DME) and DKD remains unknown.

OBJECTIVE

To assess whether DME presence can predict renal failure in patients with DM and chronic kidney disease (CKD).

METHODS

This retrospective cohort study used data from 120 healthcare organizations in the TriNetX network. Electronic medical records of approximately 90 million patients were reviewed. The study population was classified into DME and non-DME cohorts. Primary and secondary outcomes were new-onset end-stage renal disease (ESRD) and all-cause mortality, respectively. Covariate factors were incorporated to reduce confounding effects.

RESULTS

Before matching, the DME cohort used more medication and had poorer renal function and blood sugar control than the non-DME cohort. Subsequently, the 2 groups were well-matched in demographics, socioeconomic status, lifestyle, comorbidities, and medication usage. The DME cohort had a significantly higher risk of ESRD, dialysis, and renal transplantation than the non-DME cohort. Subgroup analyses showed consistent results irrespective of follow-up duration, initial estimated glomerular filtration rate, or glycated hemoglobin levels. Additionally, the DME cohort had a lower risk of all-cause mortality than the non-DME cohort.

CONCLUSION

Statistically significant 5-year increased risks of ESRD, dialysis, and renal transplantation were observed in patients with concurrent DME. Therefore, close monitoring and follow-up of the renal function in DM patients with DME are necessary and strongly recommended.

Comparison of corneal tomographic parameters between Hispanic and non-Hispanic patients

PURPOSE

To compare corneal tomographic parameters between Hispanic White and non-Hispanic White patients using Pentacam data.

METHODS

This retrospective study evaluated preoperative Pentacam data from 641 patients 50 years or older who underwent surgery for senile cataract and self-identified as Hispanic or non-Hispanic White. Patients of non-White race or multiethnic groups, or a history of surgery, trauma, or any abnormality of the cornea or anterior segment were excluded. Cornea and anterior segment parameters, as measured with Pentacam, were then compared between Hispanics and non-Hispanics.

RESULTS

There were 352 Hispanic White and 289 non-Hispanic White patients. These included 231 men and 410 women, with a mean age of 69.5 ± 8.2 years. There were no significant differences between Hispanics and non-Hispanics in front or back keratometry or amount of front astigmatism. However, Hispanics had a greater amount of back astigmatism (0.36 ± 0.19 vs 0.32 ± 0.17 diopter, P = 0.04). Moreover, there was a statistically significant difference in front steep axis of the left eyes between Hispanics and non-Hispanics (97.8 ± 47.9 vs 108.2 ± 48.9 deg, P = 0.01), and a marginally significant difference in front steep axis of the right eyes (81.0 ± 48.2 vs 73.5 ± 49.9 deg, P = 0.06). Hispanics also had a lower vertex pachymetry (548.1 ± 34.5 vs 553.4 ± 37.4 μm, P = 0.04) and a smaller anterior chamber volume (134.7 ± 39.0 vs 146.1 ± 39.9 mm3, P < 0.001).

CONCLUSIONS

There are some differences in cornea and anterior segment parameters between Hispanics and non-Hispanics 50 years or older who underwent surgery for senile cataract. However, such differences may not be clinically significant.

Diverse Research Teams and Underrepresented Groups in Clinical Studies

Importance

Several ophthalmic diseases disproportionately affect racial and ethnic minority patients, yet most clinical trials struggle to enroll cohorts that are demographically representative of disease burden; some barriers to recruitment include time and transportation, language and cultural differences, and fear and mistrust of research due to historical abuses. Incorporating diversity within the research team has been proposed as a method to increase trust and improve engagement among potential study participants.

Objective

To examine how demographic factors of potential research participants and personnel may be associated with patient consent rates to participate in prospective ophthalmic clinical studies.

Design, Setting, and Participants

This retrospective cohort study included patients from an urban, academic hospital who were approached for consent to participate in prospective ophthalmic clinical studies conducted between January 2015 and December 2021.

Main Outcomes and Measures

Multivariable logistic regression assessing associations between patient and research personnel demographics and rates of affirmative consent to participate was used.

Results

In total, 1380 patients (mean [SD] age, 58.6 [14.9] years; 50.3% male) who were approached for consent to participate in 10 prospective ophthalmic clinical studies were included. Of prospective patients, 566 (43.5%) were Black; 327 (25.1%), Hispanic or Latino; 373 (28.6%), White; 36 (2.8%), other race and ethnicity; and 78 (5.8%) declined to answer. Black patients (odds ratio [OR], 0.32; 95% CI, 0.24-0.44; P < .001) and Hispanic or Latino patients (OR, 0.31; 95% CI, 0.20-0.47; P < .001) were less likely to consent compared with White patients. Patients with lower socioeconomic status were less likely to consent than patients with higher socioeconomic status (OR, 0.43; 95% CI, 0.33-0.53; P < .001). Concordance between patient and research staff race and ethnicity was associated with increased odds of affirmative consent (OR, 2.72; 95% CI, 1.99-3.73; P < .001).

Conclusions and Relevance

In this cohort study, patients from underrepresented racial and ethnic groups and those with lower socioeconomic status were less likely to participate in ophthalmic clinical studies. Concordance of race and ethnicity between patients and research staff was associated with improved participant enrollment. These findings underscore the importance of increasing diversity in clinical research teams to improve racial and ethnic representation in clinical studies.

Geographic variation in diabetic retinopathy screening within the Veterans Health Administration

AIMS

Diabetic retinopathy (DR) remains the leading cause of vision impairment among working-age adults in the United States. The Veterans Health Administration (VA) supplemented its DR screening efforts with teleretinal imaging in 2006. Despite its scale and longevity, no national data on the VA's screening program exists since 1998. Our objective was to determine the influence of geography on diabetic retinopathy screening adherence.

METHODS

Setting: VA national electronic medical records.

STUDY POPULATION

A national cohort of 940,654 veterans with diabetes (defined as two or more diabetes ICD-9 codes (250.xx)) without a history of DR.

EXPOSURES

125 VA Medical Center catchment areas, demographics, comorbidity burden, mean HbA1c levels, medication use and adherence, as well as utilization and access metrics.

MAIN OUTCOME MEASURE

Screening for diabetic retinopathy within the VA medical system within a 2-year period.

RESULTS

Within a 2-year time frame 74 % of veterans without a history of DR received retinal screenings within the VA system. After adjustment for age, gender, race-ethnic group, service-connected disability, marital status, and the van Walraven Elixhauser comorbidity score, the prevalence of DR screening varied by VA catchment area with values ranging from 27 % to 86 %. These differences persisted after further adjusting for mean HbA1c level, medication use and adherence as well as utilization and access metrics.

CONCLUSIONS

The wide variability in DR screening across 125 VA catchment areas indicates the presence of unmeasured determinants of DR screening. These results are relevant to clinical decision making in DR screening resource allocation.

FLUORESCENCE LIFETIME IMAGING OPHTHALMOSCOPY IN PATIENTS WITH MACULAR TELANGIECTASIA TYPE 2 WITH AND WITHOUT DIABETES

PURPOSE

Macular telangiectasia type 2 (MacTel) is a vision-altering retinal disease with a high prevalence of diabetes. Differences between patients with MacTel with and without diabetes were investigated using fluorescence lifetime imaging ophthalmoscopy (FLIO).

METHODS

Eighty-six patients with MacTel (59 ± 12 years) were included. 40 patients (46%) did not have diabetes, 16 patients (19%) were prediabetic, and 30 patients (35%) were diabetic. Of these, seven had diabetic retinopathy. 18 diabetic patients without MacTel and 42 age-matched healthy controls were included. FLIO lifetimes (FLTs) were obtained in short (SSC, 498-560 nm) and long (LSC, 560-720 nm) spectral channels from different areas of interest using a Heidelberg Engineering FLIO.

RESULTS

Fundus autofluorescece lifetimes did not show significant differences when comparing diabetic with nondiabetic MacTel eyes (MacTel zone, SSC, diabetic: 243 ± 65 ps; nondiabetic: 232 ± 51 ps; P = 1.0; LSC, diabetic: 327 ± 66 ps; nondiabetic: 309 ± 54 ps; P = 0.582). Longitudinal changes were similarly unrelated to diabetes status. A nonsignificant trend of increased FLT progression with higher body mass index was found. Fundus autofluorescece lifetimes in diabetic patients without MacTel were significantly shorter within the MacTel zone and longer in the periphery compared with diabetic patients with MacTel.

CONCLUSION

Although MacTel has a high prevalence of diabetes, FLTs from the MacTel zone are unrelated to diabetes. Fluorescence lifetime imaging ophthalmoscopy retains diagnostic abilities in patients with MacTel even in the presence of prediabetes, diabetes, and advanced diabetic retinopathy. The lack of diabetic FLT changes in the periphery of diabetic patients with MacTel is an interesting finding that needs further investigation.

In a Large Healthcare System in the Bronx, Teleretinal Triaging Was Found to Increase Screening and Healthcare Access for an Underserved Population with a High Incidence of T2DM and Retinopathy

The early treatment of diabetic retinopathy (DR) prevents vision-threatening proliferative retinopathy (PDR) and macular edema (DME). Our study evaluates telemedicine (teleretinal) screening for DR in an inner-city healthcare network with a high ethnic diversity and disease burden. Fundus photographs were obtained and graded in a centralized reading center between 2014 and 2016. Patients with positive screenings were referred to a retina specialist. An analysis of sensitivity and specificity and a subgroup analysis of prevalence, disease severity, and follow-up adherence were conducted. In 2251 patients, the '1-year' and 'Overall' follow-ups were 35.1% and 54.8%, respectively. Severe grading, male gender, and age were associated with better follow-up compliance. The DR, PDR, and DME prevalence was 24.9%, 4.1%, and 5.9%, respectively, and was significantly associated with HbA1c. The sensitivity and specificity for DR, PDR, and DME were 70% and 87%, 87% and 75%, and 37% and 95%, respectively. No prevalence differences were noted between ethnicities. Annual diabetic eye exam adherence increased from 55% to 85% during the study period. Teleretinal triaging is sensitive and specific for DR and improved diabetic eye exam compliance for underserved populations when integrated into large healthcare networks. The adherence to follow-up recommendations was better among older patients and among those with more severe retinopathy.

Gene Set Enrichment Analsyes Identify Pathways Involved in Genetic Risk for Diabetic Retinopathy

To identify functionally related genes associated with diabetic retinopathy (DR) risk using gene set enrichment analyses applied to genome-wide association study meta-analyses.

METHODS

We analyzed DR GWAS meta-analyses performed on 3246 Europeans and 2611 African Americans with type 2 diabetes. Gene sets relevant to 5 key DR pathophysiology processes were investigated: tissue injury, vascular events, metabolic events and glial dysregulation, neuronal dysfunction, and inflammation. Keywords relevant to these processes were queried in 4 pathway and ontology databases. Two GSEA methods, Meta-Analysis Gene set Enrichment of variaNT Associations (MAGENTA) and Multi-marker Analysis of GenoMic Annotation (MAGMA), were used. Gene sets were defined to be enriched for gene associations with DR if the P value corrected for multiple testing (Pcorr) was <.05.

RESULTS

Five gene sets were significantly enriched for numerous modest genetic associations with DR in one method (MAGENTA or MAGMA) and also at least nominally significant (uncorrected P < .05) in the other method. These pathways were regulation of the lipid catabolic process (2-fold enrichment, Pcorr = .014); nitric oxide biosynthesis (1.92-fold enrichment, Pcorr = .022); lipid digestion, mobilization, and transport (1.6-fold enrichment, P = .032); apoptosis (1.53-fold enrichment, P = .041); and retinal ganglion cell degeneration (2-fold enrichment, Pcorr = .049). The interferon gamma (IFNG) gene, previously implicated in DR by protein-protein interactions in our GWAS, was among the top ranked genes in the nitric oxide pathway (best variant P = .0001).

CONCLUSIONS

These GSEA indicate that variants in genes involved in oxidative stress, lipid transport and catabolism, and cell degeneration are enriched for genes associated with DR risk. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Disparities in Eye Care Utilization During the COVID-19 Pandemic

PURPOSE

To assess the relationship between telemedicine utilization and sociodemographic factors among patients seeking eye care.

DESIGN

Comparative utilization analysis.

METHODS

We reviewed the eye care utilization patterns of a stratified random sample of 1720 patients who were seen at the University of Michigan Kellogg Eye Center during the height of the COVID-19 pandemic (April 30 to May 25, 2020) and their odds of having a video, phone, or in-person visit compared with having a deferred visit. Associations between independent variables and visit type were determined using a multinomial logistic regression model.

RESULTS

Older patients had lower odds of having a video visit (P = .007) and higher odds of having an in-person visit (P = .023) compared with being deferred, and in the nonretina clinic sample, older patients still had lower odds of a video visit (P = .02). Non-White patients had lower odds of having an in-person visit (P < .02) in the overall sample compared with being deferred, with a similar trend seen in the retina clinic. The mean neighborhood median household income was $76,200 (±$33,500) and varied significantly (P < .0001) by race with Blacks having the lowest estimated mean income.

CONCLUSION

Disparities exist in how patients accessed eye care during the COVID-19 pandemic with older patients-those for whom COVID-19 posed a higher risk of mortality-being more likely to be seen for in-person care. In our affluent participant sample, there was a trend toward non-White patients being less likely to access care. Reimbursing telemedicine solely through broadband internet connection may further exacerbate disparities in eye care.

Teleophthalmology and Inequities in Diabetic Eye Disease at Safety Net Hospitals

Introduction: Teleophthalmology has emerged as a convenient and cost-effective intervention to increase access to screening for diabetic retinopathy (DR), a disease that disproportionately affects socially disadvantaged communities. However, a few studies have directly compared the detection of eye disease by teleophthalmology between socially and geographically diverse communities. This study compared the rates and severity of diabetic eye disease, as detected by teleophthalmology, between safety net and non-Safety Net Hospitals (non-SNHs). Methods: Retrospective chart review of patients screened for DR at county Safety Net Hospitals (SNHs) and non-SNHs in 150 cities and 30 states. The rates of DR, macular edema, suspected cataract, suspected glaucoma, and suspected age-related macular degeneration were compared. Relative risk and severity of disease in the county SNH population were calculated. Images were graded by the same group of IRIS readers, who used at least one image per eye with a 45° field centered between the optic disc and the macula. Participants with ungradable screening images were excluded. Results: Ninety-four thousand three hundred twenty-nine participants were screened for eye disease from September 1, 2016 to August 31, 2017. Among the screened participants (54% female; mean [SD] age, 58.7 [12.9] years), overall disease detection was 31% in the county SNH population and 23.6% in the non-SNH population. Compared with the non-SNH population, the county SNH population was twice as likely to screen positive for three or more concurrent eye conditions (1.2% vs. 0.7%) and had increased prevalence of DR (20.2% vs. 16.2%), macular edema (4.9% vs. 3.4%), suspected glaucoma (9.1% vs. 4.3%), suspected cataract (9.6% vs. 4.8%), and proliferative DR (2.1% vs. 1.0%). Conclusions: Increased diabetic eye disease prevalence and severity among people seen at SNHs highlights the need for continued resources to screen, treat, and manage disease. Teleophthalmology continues to be an important tool in efforts to mitigate health inequities and address barriers faced by underserved communities.

Prevalence of diabetic retinopathy in self-reported diabetics among various ethnic groups and associated risk factors in North-East India: A hospital-based study

Purpose:

To describe the prevalence and severity of diabetic retinopathy (DR) among different ethnic groups of North-East India and to study the associated risk factors.

Methods:

In this hospital based cross sectional study 7,133 individuals among the age group of 20-79 years, attending the OPD, were screened for presence of Diabetes Mellitus (DM) (HbA1c >7% or previously diagnosed). Among them, 780 (10.94%) had diabetes; they were evaluated for presence of any retinopathy (based on fundus photograph and fluorescein angiography), its grade (based on International DR severity scale), and risk factors. DR patients were further grouped into different ethnicities (Assamese, Bengali, minor tribes, and other immigrants).

Results:

Of the 780 patients with diabetes, 58 patients had type 1 DM and 722 patients had type 2 DM. The overall prevalence of DR was 30.0% with vision-threatening retinopathy and maculopathy being 10.00% and 4.49%, respectively. The prevalence of retinopathy range was the highest in the immigrants’ group (50.00% among type 1 DM and 44.93% among type 2 DM) and lowest in the tribal's groups (16.67% among type 1 DM and 22.35% among type 2 DM). The risk factors showing significant association with DR were longer diabetes duration, older age, family history of diabetes, higher HbA1c level, associated hypertension, hypertriglyceridemia, and pregnancy state (P value <0.05).

Conclusion:

Every third patient with diabetes had some form of DR with Vision Threatening DR (VTDR) affecting every tenth patient. There was also a wide variation in the prevalence of DR among ethnic groups and this difference could not be attributed to variation in the known measurable risk factors among different ethnic groups, thus signifying the role of ethnicity in occurrence and severity of DR.

Racial and ethnic differences in foveal avascular zone in diabetic and nondiabetic eyes revealed by optical coherence tomography angiography

Purpose

The purpose of this study was to examine whether racial and ethnic differences in retinal microvasculature are detectable with quantitative measures derived from optical coherence tomography angiography (OCTA).

Methods

OCTA scans and fundus photography were obtained in 447 eyes from 271 patients with and without diabetes between April and October 2018. Fundus photos were graded by the hospital reading center for diabetic retinopathy (DR) severity. Eight OCTA parameters relating to the foveal avascular zone (FAZ), superficial vascular perfusion, and deep vascular perfusion were analyzed for significant differences between race and ethnicity groups, self-reported by patients and organized according to National Center for Health Statistics groupings. Multiple regression was then used to adjust estimates for possible confounding by age, gender, hypertension, and last hemoglobin A1c level.

Results

Significant differences in FAZ area were found between white and non-white patients. After adjustment, the differences between white and all non-white groups were statistically significant (p<0.05) among patients with mild to moderate DR. In those without diabetes, the Hispanic and Asian groups had significantly larger FAZ areas (p<0.005) than NH white patients. In those with mild to moderate non-proliferative diabetic retinopathy (NPDR), NH Black, Hispanic, and Asian patients also had significantly larger FAZ areas than NH white patients (p<0.005).

Conclusion

Significant differences in FAZ area exist among different racial and ethnic groups. These results highlight the importance of considering and further studying race and ethnicity in OCTA analyses of the retinal microvasculature.

Ethnic Disparities in the Development of Sight-Threatening Diabetic Retinopathy in a UK Multi-Ethnic Population with Diabetes: An Observational Cohort Study

There is little data on ethnic differences in incidence of DR and sight threatening DR (STDR) in the United Kingdom. We aimed to determine ethnic differences in the development of DR and STDR and to identify risk factors of DR and STDR in people with incident or prevalent type II diabetes (T2DM). We used electronic primary care medical records of people registered with 134 general practices in East London during the period from January 2007-January 2017. There were 58,216 people with T2DM eligible to be included in the study. Among people with newly diagnosed T2DM, Indian, Pakistani and African ethnic groups showed an increased risk of DR with Africans having highest risk of STDR compared to White ethnic groups (HR: 1.36 95% CI 1.02-1.83). Among those with prevalent T2DM, Indian, Pakistani, Bangladeshi and Caribbean ethnic groups showed increased risk of DR and STDR with Indian having the highest risk of any DR (HR: 1.24 95% CI 1.16-1.32) and STDR (HR: 1.38 95% CI 1.17-1.63) compared with Whites after adjusting for all covariates considered. It is important to optimise prevention, screening and treatment options in these ethnic minority groups to avoid health inequalities in diabetes eye care.

Social determinants of health and their impact on rates of postoperative complications among patients undergoing vertical sleeve gastrectomy

BACKGROUND

Vertical sleeve gastrectomy is one of the most common bariatric procedures worldwide, but the impact of social determinants of health on postoperative outcomes for this procedure has not been well characterized. The objective of this study was to analyze the impact that social determinants of health have on postoperative outcomes after vertical sleeve gastrectomy.

METHOD

This was a population-based study using the MARINER-15 database, an all-payer claims database. The primary endpoint of this study was the development of any complication, including cardiac complication, acute kidney injury, deep vein thrombosis, wound complication, hematoma, pneumonia, pulmonary embolism, transfusion, or urinary tract infection within 60 days, 30- and 90-day all-cause mortality, or readmission within 30 or 90 days in patients undergoing vertical sleeve gastrectomy procedures.

RESULTS

Individuals in the social determinants of health cohort had a significantly longer length of stay when compared with those without social determinants of health (3.07 days vs 1.582 days, P < .001). These patients were more likely to develop any complication within 60 days after surgery (hazard ratio 1.20, 95% confidence interval 1.03-1.40) but were less likely to return for readmission within 30 and 90 days (hazard ratio 0.80, 95% confidence interval 0.66-0.96; hazard ratio 0.85 95% confidence interval 0.72-0.99).

CONCLUSION

Vertical sleeve gastrectomy is an effective treatment for morbid obesity and its associated comorbidities. Although patients with social determinants of health are more likely to develop any of the analyzed postoperative complications within 60 days, they are less likely to return for readmission, highlighting the importance of focused follow-up and other measures to avoid lapses in care and eliminate further barriers to care in this population.

Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review

Background

Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients.

Methods

The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed.

Results

Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients’ race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies.

Conclusions

Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01209-w.

Cocoa olein glycerolysis with lipase

In this paper we present the valorization of cocoa olein obtained from the acid fat-splitting of soapstocks. The aim is to develop a solvent free process (enzymatically catalyzed) to maximize the production of a final product with high content of monoglycerides (MAG) and diglycerides (DAG). The effect of the enzyme dose, glycerol content, reaction times as well as the modification of the raw material and pressure were studied. The yield of the reaction increased up to 90-95% when using a vacuum of 2-3 mbar at 65 °C, enough to evaporate the water which is generated as a by-product, an enzyme dose of 1% and molar ratio oil:glycerol of 1:2. The highest yield in terms of MAG and DAG production was obtained by starting from a raw material which was rich in free acidity (FFA), rendering oil with 33.4 and 44.2% MAG and DAG, respectively. Short reaction times (6-8 h) were observed compared to previously reported results (24 h).

Functional imaging of mitochondria in retinal diseases using flavoprotein fluorescence

Mitochondria are critical for cellular energy production and homeostasis. Oxidative stress and associated mitochondrial dysfunction are integral components of the pathophysiology of retinal diseases, including diabetic retinopathy (DR), age-related macular degeneration, and glaucoma. Within mitochondria, flavoproteins are oxidized and reduced and emit a green autofluorescence when oxidized following blue light excitation. Recently, a noninvasive imaging device was developed to measure retinal flavoprotein fluorescence (FPF). Thus, oxidized FPF can act as a biomarker of mitochondrial dysfunction. This review article describes the literature surrounding mitochondrial FPF imaging in retinal disease. The authors describe the role of mitochondrial dysfunction in retinal diseases, experiments using FPF as a marker of mitochondrial dysfunction in vitro, the three generations of retinal FPF imaging devices, and the peer-reviewed publications that have examined FPF imaging in patients. Finally, the authors report their own study findings. Goals were to establish normative reference levels for FPF intensity and heterogeneity in healthy eyes, to compare between healthy eyes and eyes with diabetes and DR, and to compare across stages of DR. The authors present methods to calculate a patient's expected FPF values using baseline characteristics. FPF intensity and heterogeneity were elevated in diabetic eyes compared to age-matched control eyes, and in proliferative DR compared to diabetic eyes without retinopathy. In diabetic eyes, higher FPF heterogeneity was associated with poorer visual acuity. In conclusion, while current retinal imaging modalities frequently focus on structural features, functional mitochondrial imaging shows promise as a metabolically targeted tool to evaluate retinal disease.

Visual Impairment Is More Common in Parkinson's Disease and Is a Risk Factor for Poor Health Outcomes

BACKGROUND

Visual impairment is associated with hip fracture, depression, anxiety, and dementia in the general population, and many causes of visual impairment are preventable or treatable with early detection. However, the prevalence, outcomes, and healthcare utilization patterns associated with visual impairment have not been examined in Parkinson's disease (PD).

METHODS

We performed a cross-sectional analysis of all Medicare beneficiaries with complete data in 2014 and longitudinal analysis of beneficiaries with PD from 2010 to 2014. We used diagnosis and procedure codes to identify PD, visual impairment, eye exams, hip fracture, and neuropsychiatric disorders. We compared the prevalence of visual impairment using logistic regression and used Cox proportional hazards regression to examine visual impairment and incident hip fracture, depression, anxiety, dementia, and death. We also examined the frequency of eye exams in PD using repeated-measures logistic regression.

RESULTS

Among 26,209,997 Medicare beneficiaries in 2014, visual impairment was significantly more prevalent in PD (1.7%) than non-PD (0.71%) (adjusted odds ratio, 1.60; 95% confidence interval [CI], 1.56-1.65). In a longitudinal cohort of 542,224 Medicare beneficiaries with PD, less than 60% had a yearly eye exam. Visual impairment associated with increased hazard of depression (hazard ratio [HR], 1.23; 95% CI, 1.14-1.32), anxiety (HR, 1.34; 95% CI, 1.24-1.43), dementia (HR, 1.28; 95% CI, 1.21-1.36), and death (HR, 1.49; 95% CI, 1.44-1.55).

CONCLUSION

Visual impairment is more common in PD than the general population and is associated with negative PD-related outcomes. Understanding the mechanisms for these relationships is important for guiding future interventions to improve health outcomes in PD. © 2020 International Parkinson and Movement Disorder Society.

Retinopathy develops at similar glucose levels but higher HbA1c levels in people with black African ancestry compared to white European ancestry: evidence for the need to individualize HbA1c interpretation

AIMS

To examine the association of HbA_1c and glucose levels with incident diabetic retinopathy according to black African or white European ancestry.

METHODS

In this retrospective cohort study of 202 500 US Veterans with diabetes (2000-2014), measures included HbA_1c , outpatient random serum/plasma glucose, and incident retinopathy [conversion from negative to ≥2 positive evaluations (ICD-9 codes), without a subsequent negative].

RESULTS

At baseline, the study population had a mean age of 59.3 years, their mean BMI was 31.9 kg/m² , HbA_1c level was 57 mmol/mol (7.4%) and glucose level was 8.8 mmol/l, and 77% were of white European ancestry (white individuals) and 21% of black African ancestry (black individuals). HbA_1c was 0.3% higher in black vs white individuals (P < 0.001), adjusting for baseline age, sex, BMI, estimated glomerular filtration rate (eGFR), haemoglobin, and average systolic blood pressure and glucose. Over 11 years, incident retinopathy occurred in 9% of black and 7% of white individuals, but black individuals had higher HbA_1c , glucose, and systolic blood pressure (all P < 0.001); adjusted for these factors, incident retinopathy was reduced in black vs white individuals (P < 0.001). The population incidence of retinopathy (7%) was associated with higher mean baseline HbA_1c in individuals with black vs white ancestry [63 mmol/mol (7.9%) vs 58 mmol/mol (7.5%); P < 0.001)], but with similar baseline glucose levels (9.0 vs 9.0 mmol/l; P = 0.660, all adjusted for baseline age, sex and BMI).

CONCLUSIONS

Since retinopathy occurs at higher HbA_1c levels in black people for a given level of average plasma glucose, strategies may be needed to individualize the interpretation of HbA_1c measurements.

A Randomized Controlled Trial to Increase Diabetic Retinopathy Screening by a Community-Based Health Insurance Plan in Central Texas - 2017

PURPOSE

Diabetic retinopathy is a leading cause of blindness worldwide. In the United States, the prevalence of diabetic retinopathy is 26% - 33%. Providing preventive care to individuals with diabetes is important to prevent microvascular complications in the eye. This study reports on the results of a randomized controlled trial to determine how using specific cues to action combined with the provision of a free eye exam might positively influence the rate of diabetic retinopathy screening among individuals with diabetes.

METHODS

Individuals were eligible to participate in this campaign if they had a diagnosis of type 2 diabetes or were prescribed a diabetes drug, were members of the health insurance plan during the intervention period and had no evidence of receiving a retinal eye exam prior to the campaign period. The six-week campaign period started on September 19, 2017 and ended on October 31, 2017. A total of 1,454 individuals with type 2 diabetes were randomly assigned to a control group or to one of three intervention groups. Each intervention group included the provision of a free eye exam.

RESULTS

A total of 148 (10.1%) individuals obtained a retinal eye exam during the six-week campaign period with 38 persons (6.8%) in the control group, 38 (15.3%) in the incentive group, 41 (16.5%) in the education group, and 31 (12.4%) in the incentive and education group. Individual intervention comparisons with the referent group yielded statistical significance using the adjusted pairwise alpha of P = .008 for the incentive group (RR = 2.08; 95% CI, 1.36-3.19; P =.0006) and for the education group (RR = 2.23; 95% CI, 1.47-3.39; P =.0001), but not in the incentive plus education group (RR = 1.73; 95% CI, 1.10-2.73; P =.017).

CONCLUSION

This study supports the use of targeted cues to action combined with the provision of a free eye exam to increase the rates of diabetic retinopathy screening among individuals with diabetes who have health insurance coverage under the Affordable Care Act in a Central Texas population.

Differences in macular capillary parameters between healthy black and white subjects with Optical Coherence Tomography Angiography (OCTA)

Purpose

To investigate if there are differences in macular capillaries between black and white subjects using optical coherence tomography angiography (OCTA) and identify potential factors underlying the epidemiologically-based higher vulnerability of black populations to diabetic retinopathy (DR).

Methods

This prospective, observational cross-sectional study included 93 eyes of 47 healthy subjects with no medical history and ocular history who self-identified as black or white and were matched for age, sex, refractive error, and image quality. Subjects underwent OCTA imaging (RTVue-XR Avanti) of the superficial (SCP) and deep (DCP) capillary plexuses and choriocapillaris. AngioAnalytics was used to analyze vessel density (VD) and choriocapillaris % blood flow area (BFA) in the 1mm-diameter fovea, parafovea, and 3mm-diameter circular area including the fovea and parafovea (3x3mm image). Foveal avascular zone (FAZ) was also analyzed. Linear mixed models were used to evaluate for differences between the study groups.

Results

Compared to the white subjects in this study, black subjects were found to have: lower foveal VD in the SCP (p<0.05); lower VD in the parafovea and in the 3x3mm image in the DCP (p<0.05); larger FAZ in SCP and DCP (p<0.05); and decreased choriocapillary BFA in the area underlying the fovea, parafovea, and 3x3mm image (p<0.05).

Conclusion

In our study, our black subjects had decreased macular capillary vasculature compared to matched white subjects, even in early adulthood and the absence of any systemic or ocular conditions. To our knowledge, this is the first report showing that retinal and choriocapillary vascular differences may contribute to racial disparities in vulnerability to DR.

Genome-wide association study for proliferative diabetic retinopathy in Africans

Proliferative diabetic retinopathy (PDR) is a sight-threatening complication of diabetes that is associated with longer duration of diabetes and poor glycemic control under a genetic susceptibility background. Although GWAS of PDR have been conducted in Europeans and Asians, none has been done in continental Africans, a population at increased risk for PDR. Here, we report a GWAS of PDR among Africans. PDR cases (n = 64) were T2D patients with neovascularization in the retina and/or retinal detachment. Controls (n = 227) were T2D patients without listed eye complications despite high risk (T2D duration ≥10 years and fasting blood glucose >169 mg/dl). Replication was assessed in African Americans enrolled in the ARIC study. We identified 4 significant loci: WDR72, HLA-B, GAP43/RP11-326J18.1, and AL713866.1. At WDR72 the most strongly associated SNPs were rs12906891 (MAF = 0.071; p = 9.68 × 10-10; OR = 1.46, 95% CI [1.30,1.64]) and rs11070992 (MAF = 0.14; p = 4.23 × 10⁻⁸; OR = 1.28, 95%CI [1.17–1.40]). rs11070992 replicated in African Americans (p = 0.04). Variants in this gene have been associated with diabetic retinopathy, glycemic control, revascularization, and kidney disease.

Outcomes of vitrectomy for diabetic tractional retinal detachment in Chicago's county health system

PURPOSE

To examine outcomes of 23-gauge (23G) pars plana vitrectomy (PPV) for complex diabetic tractional retinal detachment (TRD) in Chicago's Cook County Health and Hospitals System (CCHHS).

MATERIALS AND METHODS

This is a retrospective noncomparative study of diabetic TRD cases that underwent PPV at CCHHS. Primary retinal reattachment rate, visual function, and postoperative complications were analyzed.

RESULTS

Sixty nine consecutive cases were included. Primary reattachment and final attachment were achieved in 68/69 eyes (98.6%). Secondary retinal detachment was noted in 1 eye (1.4%). Vitreous hemorrhage requiring repeat PPV developed in 5 eyes (7.2%) and reoperation due to other complications was required in 4/69 eyes (5.8%). Perfluoropropane (C3F8) gas tamponade was used in 91.3% of eyes and silicone oil in 8.7% of eyes. Mean LogMAR visual acuity significantly improved from 1.84 ± 0.61 to 0.93 ± 0.66, (P<0.0001). Vision was stabilized or improved in 66 eyes (95.7%). Visual acuity of 20/200 or better was achieved in 49/69 eyes (71.0%) and 20/50 or better in 16/69 eyes (23.2%).

CONCLUSIONS

Even in patients with severe and advanced diabetic TRD pathology and unique demographics as seen in CCHHS, modern vitrectomy techniques can provide excellent anatomical and visual outcomes.

Blindness and Visual Impairment in the Medicare Population: Disparities and Association with Hip Fracture and Neuropsychiatric Outcomes

Purpose: Vision loss has been associated with negative health outcomes, but population-level data on vision loss are lacking, and there are limited data on low vision-associated outcomes among women, minorities, and older age groups. The objective of this study was to determine the prevalence of vision loss in a nationally representative sample of older US adults and examine its association with hip fracture, depression, anxiety, and dementia. Methods: Cross-sectional analysis of Medicare claims data from 2014. Blindness and low vision, hip fracture, depression, anxiety, and dementia were identified using Chronic Condition Warehouse indicator variables based on ICD-9 and CPT codes. Multivariable logistic regression models were built to examine whether sociodemographic factors were associated with vision loss and to determine the relationships between vision loss and hip fracture and neuropsychiatric outcomes. Results: The prevalence of low vision in the Medicare population was 994/100,000 and increased significantly with age, Black (1,854/100,000) or Hispanic (2,862/100,000) race/ethnicity, female gender (1,181/100,000), and Medicaid eligibility (2,975/100,000). After adjusting for relevant comorbidities, low vision was significantly associated with hip fracture (adjusted odds ratio [AOR] 2.54, 95% CI: 2.52-2.57), depression (AOR 3.99, 95% CI: 3.97-4.01), anxiety (AOR 2.93, 95% CI: 2.91-2.95), and dementia (AOR 3.91, 95% CI: 3.88-3.93). Conclusion: Blindness and low vision are common in older Americans, especially among racial and ethnic minorities and lower income individuals, and associated with hip fracture, depression, anxiety, and dementia. The prevention and treatment of vision loss may reduce health disparities and negative health outcomes in the aging population.

Prevalence of and Risk Factors for Diabetic Retinopathy in a Rural Chinese Population: The Yangxi Eye Study

Purpose

To investigate the prevalence and determinants of diabetic retinopathy (DR) among older adults in rural Southern China.

Methods

Using random cluster sampling, persons aged 50 years or older were randomly selected in rural Yangxi County, Guangdong Province, China. All participants underwent a standardized interview, fundus photography, and point of service glycosylated hemoglobin A1c (HbA1c) testing. Diabetes mellitus (DM) was diagnosed based on confirmed medical history or HbA1c ≥6.5%. Fundus photographs were graded for DR and diabetic macular edema (DME) based on the United Kingdom National Diabetic Eye Screening Program guidelines. Prevalence of and risk factors for DR and vision-threatening diabetic retinopathy (VTDR) were evaluated.

Results

Among 5825 subjects who participated (90.7% response rate) in the Yangxi Eye Study, 562 (9.6%) were diagnosed with DM, including 79 (14.1%) known and 483 new (85.9%) cases. Among DM cases, 476 (84.7%) had gradable fundus photos. The prevalence of any DR and VTDR were 8.19% (95% confidence interval [CI] 5.9-11.0) and 5.25% (95% CI 3.43-7.66), respectively. These figures were 23.9% and 12.7% for known and 5.43% and 3.95% for new DM cases. Risk factors for any DR were higher HbA1c level (OR [odds ratio] per unit 1.34, P < 0.001), longer duration of DM (OR per year = 2.29, P < 0.001) and having previously undergone cataract surgery (OR 4.11, P < 0.030).

Conclusions

Our study found a lower prevalence of DR among adults 50 years and older than in previously reports. Perhaps this difference can be explained by the short duration of most cases.

Blood pressure, antihypertensive medication use, and risk of erectile dysfunction in men with type I diabetes

OBJECTIVE

To gain insight into the effect of blood pressure on the pathophysiology of diabetic erectile dysfunction, we determined the onset, severity and treatment of hypertension and risk of incident erectile dysfunction in men with type I diabetes.

METHODS

This prospective cohort study included 692 men without prevalent erectile dysfunction in the Epidemiology of Diabetes Interventions and Complications study. Erectile dysfunction was assessed yearly for 16 years with a single question querying presence of impotence. Multivariable cox proportional hazards models examined associations of hypertension variables with risk for incident erectile dysfunction.

RESULTS

Over 7762 person-years of follow-up, 337 of 692 men reported incident erectile dysfunction representing an unadjusted rate of 43.4 cases per 1000 person-years. Risk of erectile dysfunction significantly increased with each 10 mmHg of SBP elevation for those not taking antihypertensive medications, after adjustment for age, cigarette smoking and HbA1c levels [relative risk (RR) = 1.21, 95% CI = 1.04-1.41]. This relationship disappeared among those reporting antihypertensive medication use (RR = 0.96, 95% CI = 0.84-1.10) and the interaction between SBP and medication use was statistically significant (P = 0.02). Antihypertensive medication did not confer any reduction of erectile dysfunction risk, with similar rates across all measures of blood pressure and hypertension.

CONCLUSION

Among men with type 1 diabetes not using antihypertensive medications, higher SBP is associated with increased risk of developing erectile dysfunction. These findings provide evidence to support further investigation into the potential benefit of early blood pressure control on risk of erectile dysfunction in men with diabetes regardless of age, blood pressure level, or glycemic control.

Self-Reported Type 2 Diabetes and Diabetes-Related Eye Disease in Jews and Arabs in Israel

Prevalence rates of diabetes and its complications may be higher in minorities. We assessed these rates in Jews and Arabs living in Israel. Data were pooled from the first and second Israeli national health interview surveys. 9625 Jews and 2401 Arabs participated in the analysis. The age adjusted rate of self-reported diabetes was 10.7 % among Arabs and 5.7 % among Jews [odds ratio (OR) 2.14, 95 % confidence interval 1.77-2.60]. After adjustment for risk factors the OR decreased to 1.28 (95 % CI 1.04-1.59). The rate of self-reported diabetes-related eye disease was 37.6 % among Arabs with diabetes and 18.3 % among Jews (OR 2.69, 95 % CI 1.84-3.93). After adjustment the odds among Arabs were still double that of Jews (OR 2.26, 95 % CI 1.44-3.56). Self-reported type 2 diabetes and diabetes-related eye disease were higher among Arabs. Multi-disciplinary and cultural sensitive approach is required in order to improve diabetes care among the Arab population.

Diabetic Retinopathy: Focus on Minority Populations

Diabetic retinopathy is a major cause of blindness in the United States. With rise of the epidemic of obesity and diabetes in the USA and around the globe, serious and common diabetic complications are evolving as a major public health problem, particularly among minority populations. These populations are disproportionately affected by diabetes and 2-3 times more likely to develop visually significant complications. In this highly illustrated review article, we discuss the diabetic epidemic, highlighting the biology and the pathophysiologic mechanisms of this disorder on the anatomy of the eye. We also discuss the risk factors and the implications for minority populations. For the health care providers, we provide cutting edge information and imminently relevant information to help evaluate, manage, and know when to refer their patients to a specialist in ophthalmology to quell the tide of the epidemic.

Glucose targets for preventing diabetic kidney disease and its progression

BACKGROUND

Diabetes is the leading cause of end-stage kidney disease (ESKD) around the world. Blood pressure lowering and glucose control are used to reduce diabetes-associated disability including kidney failure. However there is a lack of an overall evidence summary of the optimal target range for blood glucose control to prevent kidney failure.

OBJECTIVES

To evaluate the benefits and harms of intensive (HbA1c < 7% or fasting glucose levels < 120 mg/dL versus standard glycaemic control (HbA1c ≥ 7% or fasting glucose levels ≥ 120 mg/dL for preventing the onset and progression of kidney disease among adults with diabetes.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register up to 31 March 2017 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials evaluating glucose-lowering interventions in which people (aged 14 year or older) with type 1 or 2 diabetes with and without kidney disease were randomly allocated to tight glucose control or less stringent blood glucose targets.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and risks of bias, extracted data and checked the processes for accuracy. Outcomes were mortality, cardiovascular complications, doubling of serum creatinine (SCr), ESKD and proteinuria. Confidence in the evidence was assessing using GRADE. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes.

MAIN RESULTS

Fourteen studies involving 29,319 people with diabetes were included and 11 studies involving 29,141 people were included in our meta-analyses. Treatment duration was 56.7 months on average (range 6 months to 10 years). Studies included people with a range of kidney function. Incomplete reporting of key methodological details resulted in uncertain risks of bias in many studies. Using GRADE assessment, we had moderate confidence in the effects of glucose lowering strategies on ESKD, all-cause mortality, myocardial infarction, and progressive protein leakage by kidney disease and low or very low confidence in effects of treatment on death related to cardiovascular complications and doubling of serum creatinine (SCr).For the primary outcomes, tight glycaemic control may make little or no difference to doubling of SCr compared with standard control (4 studies, 26,874 participants: RR 0.84, 95% CI 0.64 to 1.11; I2= 73%, low certainty evidence), development of ESKD (4 studies, 23,332 participants: RR 0.62, 95% CI 0.34 to 1.12; I2= 52%; low certainty evidence), all-cause mortality (9 studies, 29,094 participants: RR 0.99, 95% CI 0.86 to 1.13; I2= 50%; moderate certainty evidence), cardiovascular mortality (6 studies, 23,673 participants: RR 1.19, 95% CI 0.73 to 1.92; I2= 85%; low certainty evidence), or sudden death (4 studies, 5913 participants: RR 0.82, 95% CI 0.26 to 2.57; I2= 85%; very low certainty evidence). People who received treatment to achieve tighter glycaemic control probably experienced lower risks of non-fatal myocardial infarction (5 studies, 25,596 participants: RR 0.82, 95% CI 0.67 to 0.99; I2= 46%, moderate certainty evidence), onset of microalbuminuria (4 studies, 19,846 participants: RR 0.82, 95% CI 0.71 to 0.93; I2= 61%, moderate certainty evidence), and progression of microalbuminuria (5 studies, 13,266 participants: RR 0.59, 95% CI 0.38 to 0.93; I2= 75%, moderate certainty evidence). In absolute terms, tight versus standard glucose control treatment in 1,000 adults would lead to between zero and two people avoiding non-fatal myocardial infarction, while seven adults would avoid experiencing new-onset albuminuria and two would avoid worsening albuminuria.

AUTHORS' CONCLUSIONS

This review suggests that people who receive intensive glycaemic control for treatment of diabetes had comparable risks of kidney failure, death and major cardiovascular events as people who received less stringent blood glucose control, while experiencing small clinical benefits on the onset and progression of microalbuminuria and myocardial infarction. The adverse effects of glycaemic management are uncertain. Based on absolute treatment effects, the clinical impact of targeting an HbA1c < 7% or blood glucose < 6.6 mmol/L is unclear and the potential harms of this treatment approach are largely unmeasured.

Racial and Ethnic Differences in Satisfaction with Care Coordination Among VA and non-VA Medicare Beneficiaries

Purpose: Patients who have multiple sources of care are at risk for fragmented and uncoordinated care, which can lead to poorer outcomes. Veteran Medicare beneficiaries who use the Veterans Health Administration (VHA) system (VA users), particularly racial/ethnic minorities, often have complex medical conditions that may require care from multiple sources, leaving them especially vulnerable to the effects of fragmented care. We examined racial/ethnic differences in the level of satisfaction with care coordination among Medicare beneficiaries, comparing those who do and do not use the VHA healthcare system. Methods: We conducted a retrospective, pooled, cross-sectional study of Medicare beneficiaries using the 2009-2011 Medicare Current Beneficiary Survey. The outcomes are self-reported satisfaction with care items related to three dimensions of care coordination: (1) integrated care, (2) care continuity, and (3) follow-up care. We present descriptive statistics and use generalized linear models to examine racial/ethnic differences across VA and non-VA users, after accounting for other demographic characteristics, health status, functional limitations, insurance coverage, and geographic variation. Results: VA users are more likely to be very satisfied with receiving both integrated and follow-up care compared with non-VA users. Despite the existence of significant racial/ethnic disparities in the likelihood of being very satisfied with receiving well-coordinated care in the larger Medicare population, racial/ethnic minority VA users are just as likely as White non-Hispanics to be very satisfied with receiving well-coordinated care. Conclusions: Future research should continue to study care coordination among VA users and reasons for preferring the VA over other healthcare systems, especially among racial/ethnic minority groups.

Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers

OBJECTIVE

To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference.

STUDY SETTING/DATA COLLECTION

Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053).

STUDY DESIGN

We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group-Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self-reported hypoglycemic events. We used the Blinder-Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non-English language groups.

PRINCIPAL FINDINGS

After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients.

CONCLUSIONS

Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients.

The association analysis polymorphism of CDKAL1 and diabetic retinopathy in Chinese Han population

AIM

To identify the contribution of CDKAL1 to the development of diabetic retinopathy (DR) in Chinese population.

METHODS

A case-control study was performed to investigate the genetic association between DR and polymorphic variants of CDKAL1 in Chinese Han population with type 2 diabetes mellitus (T2DM). A well-defined population with T2DM, consisting of 475 controls and 105 DR patients, was recruited. All subjects were genotyped for the genetic variant (rs10946398) of CDKAL1. Genotyping was performed by iPLEX technology. The association between rs10946398 and T2DM was assessed by univariate and multivariate logistic regression (MLR) analysis.

RESULTS

There were significant differences in C allele frequencies of rs10946398 (CDKAL1) between control and DR groups (45.06% versus 55.00%, P<0.05). The rs10946398 of CDKAL1 was found to be associated with the increased risk of DR among patients with diabetes.

CONCLUSION

Our findings suggest that rs10946398 of CDKAL1 is independently associated with DR in a Chinese Han population.

Risk Factors for Proliferative Diabetic Retinopathy in African Americans with Type 2 Diabetes

PURPOSE

To assess personal and demographic risk factors for proliferative diabetic retinopathy in African Americans with type 2 diabetes.

METHODS

In this prospective, non-interventional, cross-sectional case-control study, 380 African Americans with type 2 diabetes were enrolled. Participants were recruited prospectively and had to have either: (1) absence of diabetic retinopathy after ≥10 years of type 2 diabetes, or (2) presence of proliferative diabetic retinopathy when enrolled. Dilated, 7-field fundus photographs were graded using the Early Treatment Diabetic Retinopathy Study scale. Covariates including hemoglobin A1C (HbA1C), blood pressure, height, weight and waist circumference were collected prospectively. Multivariate regression models adjusted for age, sex and site were constructed to assess associations between risk factors and proliferative diabetic retinopathy.

RESULTS

Proliferative diabetic retinopathy was associated with longer duration of diabetes (odds ratio, OR, 1.62, p < 0.001), higher systolic blood pressure (OR 1.65, p < 0.001) and insulin use (OR 6.65, p < 0.001) in the multivariate regression analysis. HbA1C was associated with proliferative diabetic retinopathy in the univariate analysis (OR 1.31, p = 0.002) but was no longer significant in the multivariate analysis.

CONCLUSIONS

In this case-control study of African Americans with type 2 diabetes, duration of diabetes, systolic hypertension and insulin use were strong risk factors for the development of proliferative diabetic retinopathy. Interestingly, HbA1C did not confer additional risk in this cohort.

African Ancestry Analysis and Admixture Genetic Mapping for Proliferative Diabetic Retinopathy in African Americans

PURPOSE

To examine the relationship between proportion of African ancestry (PAA) and proliferative diabetic retinopathy (PDR) and to identify genetic loci associated with PDR using admixture mapping in African Americans with type 2 diabetes (T2D).

METHODS

Between 1993 and 2013, 1440 participants enrolled in four different studies had fundus photographs graded using the Early Treatment Diabetic Retinopathy Study scale. Cases (n = 305) had PDR while controls (n = 1135) had nonproliferative diabetic retinopathy (DR) or no DR. Covariates included diabetes duration, hemoglobin A1C, systolic blood pressure, income, and education. Genotyping was performed on the Affymetrix platform. The association between PAA and PDR was evaluated using logistic regression. Genome-wide admixture scanning was performed using ANCESTRYMAP software.

RESULTS

In the univariate analysis, PDR was associated with increased PAA (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.16-1.59, P = 0.0002). In multivariate regression adjusting for traditional DR risk factors, income and education, the association between PAA and PDR was attenuated and no longer significant (OR = 1.21, 95% CI = 0.59-2.47, P = 0.61). For the admixture analyses, the maximum genome-wide score was 1.44 on chromosome 1.

CONCLUSIONS

In this largest study of PDR in African Americans with T2D to date, an association between PAA and PDR is not present after adjustment for clinical, demographic, and socioeconomic factors. No genome-wide significant locus (defined as having a locus-genome statistic > 5) was identified with admixture analysis. Further analyses with even larger sample sizes are needed to definitively assess if any admixture signal for DR is present.

P-selectin Plasma Levels and Genetic Variant Associated With Diabetic Retinopathy in African Americans

PURPOSE

To report the prevalence and risk factors for retinopathy in African Americans with impaired fasting glucose (IFG) and type 2 diabetes in the Jackson Heart Study and to determine if P-selectin plasma levels are independently associated with retinopathy in this population.

DESIGN

Prospective, cross-sectional observational study.

METHODS

setting: Community-based epidemiologic study.

STUDY POPULATION

Total of 629 patients with type 2 diabetes and 266 participants with impaired fasting glucose.

OBSERVATION PROCEDURES

Bilateral, 7-field fundus photographs were scored by masked readers for diabetic retinopathy (DR) level. Covariate data including P-selectin plasma levels and genotypes were collected in a standardized fashion.

MAIN OUTCOME MEASURES

Association between risk factors, including P-selectin plasma levels and genotypes, and retinopathy.

RESULTS

The prevalences of any retinopathy among participants with IFG and type 2 diabetes were 9.4% and 32.4%, respectively. Among those with type 2 diabetes, in multivariate models adjusted for age, sex, and other traditional risk factors, higher P-selectin levels were associated with any DR (odds ratio = 1.11, 95% confidence interval = 1.02-1.21, P = .02) and proliferative DR (odds ratio = 1.23, 95% confidence interval = 1.03-1.46, P = .02). To further investigate the relationship between P-selectin and DR, we examined the association between P-selectin genotype and DR. Minor allele homozygotes for the variant rs6128 were less likely to develop DR (P after Bonferroni correction = 0.03).

CONCLUSIONS

Both serologic and genetic data show an association between P-selectin and DR in the Jackson Heart Study. If confirmed in other studies, this association may provide insight into the pathogenesis of retinopathy.

Associations Between Diabetes and Cognitive Function in Socioeconomically Diverse African American and White Men and Women

OBJECTIVES

To examine whether race and poverty (income <125% of the federal poverty limit), modifies associations between diabetes and cognition in a biracial, urban-dwelling sample.

METHODS

Cross-sectional data for 2066 participants (mean age = 47.6 years, 56.8% women, 56.2% African American, 38.6% below poverty) from the first wave of the Healthy Aging in Neighborhoods of Diversity across the Life Span study were used for analyses. Eleven tests measured cognitive function. Interactions among diabetes, race, and poverty status with cognition were assessed in multiple regression analyses.

RESULTS

Significant interactions among diabetes, race, and poverty status were observed. Among African Americans below poverty, diabetic individuals performed lower than nondiabetic individuals on California Verbal Learning Test Free Recall Short Delay (z = -0.444 [0.123] versus z = -0.137 [0.045]) and Long Delay (z = -0.299 [0.123] versus z = -0.130 [0.045]), Digit Span Backward (z = -0.347 [0.109] versus z = -0.072 [0.041]), and the Brief Test of Attention (z = -0.452 [-0.099] versus z = -0.099 [0.047]), and higher on Category Fluency (z = 0.114 [0.117] versus z = -0.118 [0.044]). No consistent differences between diabetic and nondiabetic individuals were found for African American and white participants above poverty.

CONCLUSIONS

Diabetes was associated with poorer verbal memory, working memory, and attention among African Americans living in poverty. Diabetic African Americans below poverty may have increased risk of cognitive deficit at a younger age. Improving health literacy, doctor-patient communication, and multidisciplinary medical care for impoverished individuals may reduce differences. Additional research is needed to clarify mechanisms underlying these associations.

A genome-wide association study for diabetic retinopathy in a Japanese population: potential association with a long intergenic non-coding RNA

Elucidation of the genetic susceptibility factors for diabetic retinopathy (DR) is important to gain insight into the pathogenesis of DR, and may help to define genetic risk factors for this condition. In the present study, we conducted a three-stage genome-wide association study (GWAS) to identify DR susceptibility loci in Japanese patients, which comprised a total of 837 type 2 diabetes patients with DR (cases) and 1,149 without DR (controls). From the stage 1 genome-wide scan of 446 subjects (205 cases and 241 controls) on 614,216 SNPs, 249 SNPs were selected for the stage 2 replication in 623 subjects (335 cases and 288 controls). Eight SNPs were further followed up in a stage 3 study of 297 cases and 620 controls. The top signal from the present association analysis was rs9362054 in an intron of RP1-90L14.1 showing borderline genome-wide significance (P_met = 1.4×10⁻⁷, meta-analysis of stage 1 and stage 2, allele model). RP1-90L14.1 is a long intergenic non-coding RNA (lincRNA) adjacent to KIAA1009/QN1/CEP162 gene; CEP162 plays a critical role in ciliary transition zone formation before ciliogenesis. The present study raises the possibility that the dysregulation of ciliary-associated genes plays a role in susceptibility to DR.

Genetics in diabetic retinopathy: current concepts and new insights

There is emerging evidence which indicates the essential role of genetic factors in the development of diabetic retinopathy (DR). In this regard it should be highlighted that genetic factors account for 25-50% of the risk of developing DR. Therefore, the use of genetic analysis to identify those diabetic patients most prone to developing DR might be useful in designing a more individualized treatment. In this regard, there are three main research strategies: candidate gene studies, linkage studies and Genome-Wide Association Studies (GWAS). In the candidate gene approach, several genes encoding proteins closely related to DR development have been analyzed. The linkage studies analyze shared alleles among family members with DR under the assumption that these predispose to a more aggressive development of DR. Finally, Genome-Wide Association Studies (GWAS) are a new tool involving a massive evaluation of single nucleotide polymorphisms (SNP) in large samples. In this review the available information using these three methodologies is critically analyzed. A genetic approach in order to identify new candidates in the pathogenesis of DR would permit us to design more targeted therapeutic strategies in order to decrease this devastating complication of diabetes. Basic researchers, ophthalmologists, diabetologists and geneticists should work together in order to gain new insights into this issue.

Intravitreal bevacizumab (Avastin) for persistent new vessels in diabetic retinopathy (IBEPE study): 1-year results

PURPOSE

To evaluate the effect of intravitreal bevacizumab on area of fluorescein leakage from active new vessels (NVs) and on best-corrected visual acuity in patients with actively leaking NV associated with diabetic retinopathy unresponsive to panretinal photocoagulation.

METHODS

A prospective open-label study of diabetic patients with actively leaking NV refractory to panretinal photocoagulation and best-corrected visual acuity worse than 20/40. Ophthalmic evaluation, including fluorescein angiography, was performed at baseline and at Weeks 1, 6, 12, 24, and 48 after intravitreal bevacizumab (1.5 mg/0.06 mL) injection. After Week 12, patients could receive additional intravitreal bevacizumab injections pro re nata, per the discretion of the treating ophthalmologist. Main outcome measures include change from baseline (at each study visit) in total area of fluorescein leakage from active NV and change from baseline in best-corrected visual acuity.

RESULTS

Fifteen consecutive patients were included, and 12 completed the study. Mean ± SEM fluorescein leakage was 27.7 ± 6.2 mm at baseline and was significantly lower at all visits post injection; at Week 6, no leakage was observed (P = 0.0001). The mean ± SEM logarithm of minimum angle of resolution best-corrected visual acuity improved from 0.90 ± 0.11 at baseline to 0.70 ± 0.12 at Week 48 (P = 0.0449). Throughout the 48-week study period, patients received a mean of 2.16 injections.

CONCLUSION

With 1-year follow-up, treatment with intravitreal bevacizumab was associated with reduced fluorescein leakage from persistent NV and improved visual acuity in patients with diabetic retinopathy unresponsive to panretinal photocoagulation.

Tromsø eye study: prevalence and risk factors of diabetic retinopathy

PURPOSE

To determine the prevalence of visual impairment, retinopathy and macular oedema, and assess risk factors for retinopathy in persons with diabetes.

METHODS

The present study included 514 participants with diabetes aged 46-87 years from the Tromsø Eye Study, a sub-study of the population-based Tromsø Study in Norway. Visual acuity was measured using an auto-refractor. Retinal images from both eyes were graded for retinopathy and macular oedema. We collected data on risk factor exposure from self-report questionnaires, clinical examinations, laboratory measurements and case note reviews. Regression models assessed the cross-sectional relationship between potential risk factors and diabetic retinopathy.

RESULTS

The prevalence of visual impairment (corrected Snellen visual acuity <20/60 in the better-seeing eye) was 1.6%. The prevalence of diabetic retinopathy was 26.8% and macular oedema 3.9%. In a multivariable logistic regression model, retinopathy was associated with longer diabetes duration (odds ratio, OR 1.07, 95% CI 1.03-1.11), insulin use (OR 2.14, 95% CI 1.19-3.85), nonfasting glucose (OR 1.07, 95% CI 1.00-1.15) and microalbuminuria (OR 1.89, 95% CI 1.28-2.81). Sub-group analyses showed association between retinopathy and even low levels of microalbuminuria (1.16 mg/mmol).

CONCLUSION

The findings suggest that low levels of microalbuminuria may be a useful risk predictor for identifying individuals with diabetes at high risk of retinopathy. The study confirms previous findings that insulin use, longer diabetes duration and higher levels of blood glucose are associated with retinopathy in persons with diabetes. The prevalence of diabetic retinopathy was similar as reported in other studies.

Diabetic retinopathy and its risk factors at the university hospital in Jamaica

PURPOSE

To determine the frequency of diabetic retinopathy and its risk factors in diabetic patients attending the eye clinic at the University Hospital of the West Indies (UHWI).

MATERIALS AND METHODS

This was a prospective cohort study of diabetic outpatients attending the Eye Clinic at the UHWI. Data were collected on age, gender, type of diabetes mellitus (DM), type of diabetic retinopathy, other ocular diseases, visual acuity, blood glucose and blood pressure.

RESULTS

There were 104 patients (208 eyes) recruited for this study. There were 58.6% (61/104) females (mean age 53.6 ± 11.9 years) and 41.4% (43/104) males (mean age 61.7 ± 12.1 years). Type II DM was present in 68.3% (56% were females) of the patients and Type I DM was present in 31.7% (69.7% were females). Most patients (66%) were compliant with their diabetic medications. The mean blood glucose was 11.4 ± 5.3 mmol/L. Elevated blood pressure (<130/80) was present in 82.7% of patients. The mean visual acuity was 20/160 (logMAR 0.95 ± 1.1). The frequency of diabetic retinopathy was 78%; 29.5% had background retinopathy, and 50.5% of eyes had proliferative diabetic retinopathy (PDR) of which 34% had tractional retinal detachments. The odds ratio of developing PDR was 1.88 (95% confidence intervals (CI): 1.02-3.3) for Type I DM compared to 0.74 (95% CI: 0.55-0.99) for Type II DM. PDR was more prevalent in females (χ(2), P = 0.009) in both Type I and II DM.

CONCLUSIONS

Jamaica has a high frequency of PDR which is more common in Type I diabetics and females. This was associated with poor glucose and blood pressure control.

Epidemiological issues in diabetic retinopathy

There is currently an epidemic of diabetes in the world, principally type 2 diabetes that is linked to changing lifestyle, obesity, and increasing age of the population. Latest estimates from the International Diabetes Federation (IDF) forecasts a rise from 366 million people worldwide to 552 million by 2030. Type 1 diabetes is more common in the Northern hemisphere with the highest rates in Finland and there is evidence of a rise in some central European countries, particularly in the younger children under 5 years of age. Modifiable risk factors for progression of diabetic retinopathy (DR) are blood glucose, blood pressure, serum lipids, and smoking. Nonmodifiable risk factors are duration, age, genetic predisposition, and ethnicity. Other risk factors are pregnancy, microaneurysm count in an eye, microaneurysm formation rate, and the presence of any DR in the second eye. DR, macular edema (ME), and proliferative DR (PDR) develop with increased duration of diabetes and the rates are dependent on the above risk factors. In one study of type 1 diabetes, the median individual risk for the development of early retinal changes was 9.1 years of diabetes duration. Another study reported the 25 year incidence of proliferative retinopathy among population-based cohort of type 1 patients with diabetes was 42.9%. In recent years, people with diabetes have lower rates of progression than historically to PDR and severe visual loss, which may reflect better control of glucose, blood pressure, and serum lipids, and earlier diagnosis.

No ethnic differences in the association of glycated hemoglobin with retinopathy: the national health and nutrition examination survey 2005-2008

OBJECTIVE

Current recommendations for the use of hemoglobin A(1c) (HbA(1c)) in diabetes screening and diagnosis aim to identify those at greatest risk for diabetic microvascular complications. However, there is current controversy regarding the clinical implications of ethnic differences in HbA(1c) values. The objective of this study was to determine whether the association between HbA(1c) and retinopathy differs by ethnic group in a representative sample of U.S. adults.

RESEARCH DESIGN AND METHODS

The study was a cross-sectional analysis of 2,945 non-Hispanic white, 1,046 non-Hispanic black, and 1,231 Hispanic American participants aged ≥40 years from the 2005-2008 National Health and Nutrition Examination Survey.

RESULTS

Among nondiabetic adults, the mean HbA(1c) was 5.5% in non-Hispanic whites, 5.7% in non-Hispanic blacks, and 5.6% in Hispanic Americans. Among those with diagnosed diabetes, mean HbA(1c) was 6.9% in non-Hispanic whites, 7.5% in non-Hispanic Blacks, and 7.7% in Hispanic Americans. Overall, non-Hispanic blacks had the highest prevalence of retinopathy. In multivariable logistic models, HbA(1c) clinical categories were strongly associated with prevalent retinopathy. However, the magnitude of the association did not differ by ethnic group (all P values for interaction ≥ 0.7). Similar results were observed with HbA(1c) modeled continuously (per one percentage point) and stratified by diabetes status (all P for interactions > 0.3).

CONCLUSIONS

We observed no ethnic differences in the association of HbA(1c) with retinopathy. These data do not support ethnic-specific cut points for HbA(1c) for diagnosis or screening of diabetes mellitus.