Health care utilization and excess costs after pelvic fractures among older people in Germany

Our study demonstrates a strong increase in utilization of inpatient health care and clear excess costs in older people in the first year after pelvic fracture, the latter even after adjustment for several confounders. Excess costs were particularly high in the first few months and mainly attributable to inpatient treatment.

INTRODUCTION

We aimed to estimate health care utilization and excess costs in patients aged minimum 60 years up to 1 year after pelvic fracture compared to a population without pelvic fracture.

METHODS

In this retrospective population-based observational study, we used routine data from a large statutory health insurance (SHI) in Germany. Patients with a first pelvic fracture between 2008 and 2010 (n=5685, 82% female, mean age 80±9 years) were frequency matched with controls (n=193,159) by sex, age at index date, and index month. We estimated health care utilization and mean total direct costs (SHI perspective) with 95% confidence intervals (CIs) using BCA bootstrap procedures for 52 weeks before and after the index date. We calculated cost ratios (CRs) in 4-week intervals after the index date by fitting mixed two-part models including adjustment for possible confounders and repeated measurement. All analyses were further stratified for men/women, in-/outpatient-treated, and major/minor pelvic fractures.

RESULTS

Health care utilization and mean costs in the year after the index date were higher for cases than for controls, with inpatient treatment being particularly pronounced. CRs (95% CIs) decreased from 10.7 (10.2-11.1) within the first 4 weeks to 1.3 (1.2-1.4) within week 49-52. Excess costs were higher for inpatient than for outpatient-treated persons (CRs of 13.4 (12.9-13.9) and 2.3 (2.0-2.6) in week 1-4). In the first few months, high excess costs were detected for both persons with major and minor pelvic fracture.

CONCLUSION

Pelvic fractures come along with high excess costs and should be considered when planning and allocating health care resources.

Time spent on self-management by people with diabetes: results from the population-based KORA survey in Germany

AIMS

Time needed for health-related activities in people with diabetes is assumed to be substantial, yet available data are limited. Time spent on self-management and associated factors was analysed using cross-sectional data from people with diagnosed diabetes enrolled in a population-based study.

METHODS

Mean total time spent on self-management activities was estimated using a questionnaire for all participants with diagnosed diabetes in the KORA FF4 study (n = 227, 57% men, mean age 69.7, sd 9.9 years). Multiple two-part regression models were fitted to evaluate associated factors. Multiple imputation was performed to adjust for bias due to missing values.

RESULTS

Some 86% of participants reported spending time on self-management activities during the past week. Over the entire sample, a mean of 149 (sd 241) min/week were spent on self-management-activities. People with insulin or oral anti-hyperglycaemic drug treatment, better diabetes education, HbA_1c 48 to < 58 mmol/mol (6.5% to < 7.5%) or lower quality of life, spent more time on self-management activities. For example, people without anti-hyperglycaemic medication invested 66 min/week in self-management, whereas those taking insulin and oral anti-hyperglycaemic drugs invested 269 min/week (adjusted ratio 4.34, 95% confidence interval 1.85-10.18).

CONCLUSIONS

Time spent on self-management activities by people with diabetes was substantial and varied with an individual's characteristics. Because of the small sample size and missing values, the results should be interpreted in an explorative manner. Nevertheless, time needed for self-management activities should be routinely considered because it may affect diabetes self-care and quality of life.

The Boehringer Ingelheim employee study (Part 2): 10-year cardiovascular diseases risk estimation

BACKGROUND

Cardiovascular disease (CVD) may cause an economic burden to companies, but CVD risk estimations specific to working populations are lacking.

AIMS

To estimate the 10-year CVD risk in the Boehringer Ingelheim (BI) employee cohort and analyse the potential effect of hypothetical risk reduction interventions.

METHODS

We estimated CVD risk using the Framingham (FRS), PROCAM (PRS) and Reynolds (RRS) risk scores, using cross-sectional baseline data on BI Pharma employees collected from 2005 to 2011. Results were compared using Fisher's exact and Wilcoxon tests. The predictive ability of the score estimates was assessed using receiver-operating characteristics analyses.

RESULTS

Among the 4005 study subjects, we estimated 10-year CVD risks of 35% (FRS), 9% (PRS) and 6% (RRS) for men and 10% (FRS), 4% (PRS) and 1% (RRS) for women. One hundred and thirty-four (6%) men and 111 (6%) women employees had current CVD. The best predictors of prevalent CVD were the FRS and the RRS for men [area-under-the-curve 0.62 (0.57-0.67) for both]. A hypothetical intervention that would improve systolic blood pressure, HbA1c (for diabetes), C-reactive protein, triglycerides and total and high-density lipoprotein cholesterol by 10% each would potentially reduce expected CVD cases by 36-41% in men and 30-45% in women, and if smoking cessation is incorporated, by 39-45% and 30-55%, respectively, depending on the pre-intervention risk score.

CONCLUSIONS

There was a substantial risk of developing CVD in this working cohort. Occupational health programmes with lifestyle interventions for high-risk individuals may be an effective risk reduction measure.

[Diagnostic accuracy of a standardized carbohydrate-rich breakfast compared to an oral glucose tolerance test in occupational medicine]

BACKGROUND

Increasing prevalence of type 2 diabetes mellitus is not only a problem for the health care system but also impairs working environment. In order to reduce costs by illness and early retirement and the development of diabetic complications occupational medicine is important for early diabetes detection. However, the diagnostic gold standard, oral glucose tolerance test (oGTT), is rarely accepted. Aim of our investigation was to evaluate diagnostic accuracy of a standardizable and cost-effective test-breakfast in comparison to oGTT which might be accepted in workplace.

METHODS

During a workplace health promotion program diagnostic accuracy (sensitivity and specificity) of a test-breakfast (index test) was analyzed in a random-cross-over-design with healthy volunteers in comparison to an oGTT (reference test).

RESULTS

278 subjects participated and rated the health promotion program to be useful (99%). 74% stated that they preferred the test-breakfast in contrast to the oGTT. Both screening methods showed comparable plasma glucose and insulin curves. The plasma glucose levels measured capillary and venously during test-breakfast and oGTT were very consistent. Differences were only seen for the 2 h plasma glucose values in the fully adjusted model. The test-breakfast demonstrated high sensitivity and specificity for diabetes diagnosis compared to the reference test with highly comparable results, i. e. 8 persons (2,9%) newly diagnosed with diabetes by the test-breakfast vs. 7 (2,5%) by oGTT.

CONCLUSION

A test-breakfast seems to be a useful first screening instrument to increase the compliance of occupational health promotions and might improve early diabetes diagnosis.

[Effect of Evidence-Based Risk Information on "Informed Choice" in Colorectal Cancer Screening: Randomised Controlled Trial]

Evidence-based information is a prerequisite for informed choice. We compared the effect of evidence-based information on colorectal cancer screening with standard information in a randomised controlled trial. The primary endpoint was informed choice. We randomised 1,577 people insured by a large German statutory health insurance scheme, the Gmünder Ersatzkasse (GEK). The evidence-based information significantly increased informed choices: 44.0% vs. 12.8%; (difference 31.2%, 99% CI 25.7-36.7%; P<0.001).

Diabetes incidence does not differ between subjects with and without high depressive symptoms--5-year follow-up results of the Heinz Nixdorf Recall Study

AIMS

Cross-sectional studies have consistently reported evidence for an association between diabetes and depressive disorders. However, only limited prospective studies have examined this association, reporting conflicting results. In a population-based cohort study, we compared cumulative incidences of diabetes between participants with and without high depressive symptoms.

METHOD

We analysed the 5-year follow-up data from the German Heinz Nixdorf Recall study of 3547 participants without diabetes at baseline [mean age 58.8 (sd 7.6) years, 47.5% male]. Depressive symptoms were defined using the Centre for Epidemiologic Studies Depression scale (cut point ≥ 17). Diabetes (diagnosed or previously undetected) was identified by self-reported physician-diagnosed diabetes, medication and high blood glucose levels. We estimated 5-year cumulative incidences with 95% confidence intervals and fitted multiple logistic regression models to calculate the odds ratios, adjusted for age, sex, physical activity, smoking, living with or without partner, and educational level.

RESULTS

The cumulative incidence of diabetes was 9.2% (95% CI 6.3-12.8) in participants with high depressive symptoms at baseline and 9.0% (95% CI 8.0-10.0) in participants without these symptoms. The age- and sex-adjusted odds ratio of diabetes in participants with depressive symptoms compared with those without was 1.13 [95% CI 0.77-1.68; fully adjusted 1.11 (95% CI 0.74-1.65)]. These results did not substantially change in several additional sensitivity analyses.

CONCLUSION

Our study did not show a significantly increased risk of developing diabetes in individuals with high depressive symptoms compared with those without high depressive symptoms during a 5-year follow-up period.

Blood glucose testing and primary prevention of Type 2 diabetes-evaluation of the effect of evidence-based patient information: a randomized controlled trial

AIMS

To compare the effect of our newly developed online evidence-based patient information vs. standard patient information about sub-threshold elevated blood glucose levels and primary prevention of diabetes on informed patient decision making.

METHODS

We invited visitors to the cooperating health insurance company, Techniker Krankenkasse, and the German Diabetes Center websites to take part in a web-based randomized controlled trial. The population after randomization comprised 1120 individuals aged between 40 and 70 years without known diabetes, of whom 558 individuals were randomly assigned to the intervention group receiving evidence-based patient information, and 562 individuals were randomly assigned to the control group receiving standard information from the Internet. The primary endpoint was acquired knowledge of elevated blood glucose level issues and the secondary outcomes were attitude to metabolic testing, intention to undergo metabolic testing, decisional conflict and satisfaction with the information.

RESULTS

Overall, knowledge of elevated glucose level issues and the intention to undergo metabolic testing were high in both groups. Participants who had received evidence-based patient information, however, had significantly higher knowledge scores. The secondary outcomes in the evidence-based patient information subgroup that completed the 2-week follow-up period yielded significantly lower intention to undergo metabolic testing, significantly more critical attitude towards metabolic testing and significantly higher decisional conflict than the control subgroup (n=466). Satisfaction with the information was not significantly different between both groups.

CONCLUSIONS

Evidence-based patient information significantly increased knowledge about elevated glucose levels, but also increased decisional conflict and critical attitude to screening and treatment options. The intention to undergo metabolic screening decreased. Future studies are warranted to assess uptake of metabolic testing and satisfaction with this decision in a broader population of patients with unknown diabetes.

Inpatient and outpatient health care utilization of children and adolescents with type 1 diabetes before and after introduction of DRGs

OBJECTIVE

To analyze the frequency and length of hospital stays as well as the frequency of diabetes-associated outpatient visits of children and adolescents with type 1 diabetes before and after the introduction of DRGs (diagnosis-related groups) in German hospitals.

METHODS

For this prospective cohort study, data from 2000 (before introduction of DRGs) to 2008 (after introduction) was extracted from the German diabetes documentation software DPV. Incidence rates of hospitalizations, length of hospital stays as well as the incidence rates of outpatient visits of 21,502 children and adolescents were estimated. The associations between the target parameters and DRG introduction, age, sex, diabetes duration, calendar year and migration background were estimated using generalized linear mixed models.

RESULTS

Incidence of hospitalization was 0.45 (95% CI 0.44-0.45) per person-year (PY), mean number of hospital days 2.77/PY (95% CI: 2.76-2.79). Children had 5.3 (95% CI: 5.3-5.3) outpatient visits per PY on average. The number of hospital stays, inpatient days, and outpatient visits decreased significantly between 2000 and 2008. Time of introduction of DRGs was related to a significant rise in the number of hospital stays and outpatient visits (p<0.05). There was no significant relation to the number of hospital days. Compared with children younger than eleven years of age, 11- to 14-year-old children had significantly more, adolescents older than 14 years significantly less hospital stays (RR 1.2, 95% CI: 1.14-1.23 and 0.92, 95%, CI: 0.87-0.97, respectively). Migration background was significantly associated with worse results for all analyzed target variables (RR 1.21 for hospital stays, 1.26 for hospital days, 1.07 number of outpatient visits).

CONCLUSIONS

The introduction of DRGs in the care of patients with pediatric diabetes mellitus resulted in a leveling of the reduction of the number of outpatient visits and hospital stays. Especially adolescents at the age of puberty and patients from families with migration background seem to require particular attention in health care.

Prevalence of lipohypertrophy in insulin-treated diabetic patients and predisposing factors

In a cross-sectional study the frequency of insulin-induced lipohypertrophy at injection sites was assessed in 223 type 1 and 56 type 2 diabetic patients. 64 (28.7%) of the subjects with type 1 diabetes, but only 2 (3.6%) of those with type 2 diabetes presented clinical evidence of lipohypertrophy. In every second affected type 1 diabetic patient lipohypertrophy developed within 2 years after starting insulin therapy. The occurrence of lipohypertrophy was independent of the insulin source and mode of therapy. In a multivariate logistic regression analysis young age, low body mass index, abdominal injection site and, particularly, missing rotation of injection site were significant independent risk factors for the presence of insulin-induced lipohypertrophy. Avoidance of such areas led to a partial or full remission of tissue swellings in 6 of 11 cases under observation for one year. In conclusion, lipohypertrophy is still a frequent complication of insulin therapy. To prevent such local skin reactions insulin-treated patients should be more intensively trained to regularly change injection sites.

Trend of hip fracture incidence in Germany 1995-2004: a population-based study

We analyzed hip fracture incidence trends in Germany 1995-2004, using national hospital discharge register. Crude incidences per 100,000 increased from 121.2 (95% CI 120.5-121.9) in 1995 to 140.9 (140.2-141.7) in 2004. Age-sex-adjusted annual incidence ratios showed a statistically significant, but only slight increase (1.01, p<0.01), compared to higher rises in the past. Trends differed markedly with sex, age, and regions.

INTRODUCTION

Data concerning actual trends of the hip fracture incidence and differences for sex, age, and region are limited. We analyzed hip fracture incidence trends in Germany 1995-2004, using the national hospital discharge register. Crude incidences per 100,000 increased from 121.2 (95% CI 120.5-121.9) in 1995 to 140.9 (140.2-141.7) in 2004. Age-sex-adjusted annual incidence ratios showed a statistically significant, but only slight increase (1.01, p<0.01), compared to higher rises in the past. Trends differed markedly with sex, age, and regions.

METHODS

Analysis of annual hip fracture incidences using the national hospital discharge register. Estimate of age-sex-adjusted changes was found by using Poisson regression (incidence rate ratios, IRR).

RESULTS

The number of patients with at least one hospital admission for hip fracture increased (1995: n=99,141; 2004: n=116,281). Crude incidences per 100,000 were 121.2 (95% confidence interval 120.5-121,9) and 140.9 (140.2-141.7), respectively. The age-sex-adjusted hip fracture incidence increased statistically significantly, but only slightly (IRR per year: 1.01; 1.00-1.01; IRR 1995-2004: 1.05, p<0.01). In men aged 40 years or older, incidences increased. In women, there was a tendency of a decrease up to 74 years of age, but also a significant increase in higher age groups. In people 0-39 years, the incidence declined markedly (IRR 1995-2004, men 0.74; 0.69-0.79, women 0.62; 0.55-0.69, both p<0.01). The increase was significantly higher in Eastern compared to Western Germany (interaction: p=0.002), and differences between East and West decreased.

CONCLUSIONS

In contrast to earlier years, the hip fracture incidence in Germany 1995-2004 increased only slightly, with a decline in younger people, but increases in older ages, particularly in men. Regional differences decreased.

Cost comparison analysis: pentaerythrithyl tetranitrate (PETN) and isosorbide dinitrate (ISDN) prescribed to diabetic patients in primary care practices in Germany

INTRODUCTION

Both pentaerythrithyltetranitrate (Pentalong, PETN) and isosorbide dinitrate (ISDN) are commonly used in the therapy of ischemic heart disease (IHD). However, little is known about the therapeutic patterns in diabetic patients and no comparative data are available regarding the prescription costs of these two substances. Thus, the aim of this investigation was to compare the costs for PETN and ISDN therapy in diabetic patients in primary care.

MATERIAL AND METHODS

All continuously treated patients aged > or = 40 years with diabetes (anti-diabetic agents) and IHD or angina pectoris (ICD codes) and newly started on PETN or ISDN therapy (index date) in the period 2000-2005 were selected from a database containing data from 400 practices throughout Germany (Disease Analyzer, IMS Health). Prescriptions costs for PETN and ISDN, as well as costs for cardiovascular comedication, were determined for the period 183 days before and after the index date, and that changes in costs after the index date were calculated. Differences in costs between the two groups were evaluated using multivariate regression, adjusting for age, sex and comorbidity. Patients in Eastern (n = 137, age 71 +/- 10 years, 55% male) and Western Germany (n = 212, age 73 +/- 9 years, 50% male) were analyzed separately since there is a longer history of PETN use in Eastern Germany.

RESULTS

Significantly more patients were treated with PETN in Eastern Germany (61 vs. 11%, p < 0.05). The patient groups treated with PETN and ISDN differed with respect to sex and comorbidity. PETN therapy was more expensive than ISDN therapy in both German regions (adjusted cost differences were 10 and 17 Euro). However, when comedication was taken into account, a smaller cost increase after the index date was observed in the PETN group than in the ISDN group (non-significant cost savings of 43 and 52 Euro after adjustment for Western and Eastern Germany, respectively).

CONCLUSION

PETN therapy tends to produce a saving in costs compared to ISDN therapy in diabetic patients when costs for comedication are taken into account and after adjustment for age and comorbidity. The prescription patterns in Eastern and Western Germany and the patient characteristics of those receiving PETN and ISDN differed, indicating differences in patients selection and prescribing by physicians in the two regions.

Prescription of insulin glargine in primary care practices in Germany

BACKGROUND

New classes of antidiabetic medications have been introduced, but details of their use are not well known. The aim was to assess prescription patterns and dosing for insulin glargine (market launch: 6/2000) in primary care patients.

METHODS

Computerized data on prescriptions (Disease Analyzer, 6/1999 to 8/2003) from 277 general and internal medicine practices throughout Germany were analysed (67,402 diabetic patients; 340 incident glargine (age: 67+/-12 years) and 378 incident NPH users (66+/-11 years).

RESULTS

Diabetes prevalence in the practices increased over the three-year period (5.1% to 6.2%). The highest increase was observed for insulin treated patients (+29%), followed by diet (+21%) and oral antidiabetics (+19%). Premixed insulin (short-acting insulin and NPH) remained constant as largest insulin group. A continuous increase of short-acting insulin analogues was found (+70%). Long-acting insulin analogues (glargine) increased threefold. Glargine was more often prescribed in combination with oral antidiabetics than NPH (76% vs 49%; p<0.05). Only about a quarter received short-acting insulin (NPH: 61%; p<0.05). The cumulative annual dose was higher among NPH users (geometric mean; NPH: 7971 IU; glargine: 5719 IU) (p<0.01), which persisted after adjusting for age, sex, and morbidity (p<0.01).

CONCLUSIONS

Diabetes prevalence continuously increased in German primary care practices from 1999 to 2003. The largest increase was found for insulin treatment, in particular, for short and long-acting insulin analogues. Insulin glargine was more often prescribed in combination with oral agents, whereas NPH insulin was more frequently prescribed with short-acting insulin, indicating different prescription patterns in primary care.

The prognostic value of the C-reactive protein levels in HD patients with death risk from infection

AIMS

Infection is considered the second leading cause of death in dialysis patients with end-stage renal disease (ESRD). However, infection prevalence as primary cause of death still seems to be underreported in the literature. We investigated the role of C-reactive protein (CRP) levels shortly before death as predictor of dying from an infection as primary cause of death in this patient group.

METHOD

Between January 1997 through March 2006, we defined the primary causes of death in 231 of the 481 incident patients in our single-center study, who died during this time and assessed the overall prevalence of infection at different predefined CRP cutpoints (between 2 and 300 mg/l). By means of an adjusted multiple logistic regression model, we calculated the odds ratio of (log) CRP for death in 346 survivors and non-survivors with available CRP levels within 5 days of death. In the 96 non-survivors (i.e. cases) of this group, the association of (log) CRP and causes of death was determined by the multiple linear regression model.

RESULTS

Infection as a primary cause of death was initially diagnosed in 42% of the 231 non-survivors by standard parameters and clinically. However, the rate of patients possibly dying from this disease increased accordingly when also including cases without any clinical infection signs but with CRP values higher than a given cutpoint (between 2 and 300 mg/l), e.g. when including all cases with CRP cutpoints higher than 100 mg/l, overall prevalence of infection as cause of death increases to 57% (95% CI = 51-64%). Infection was significantly associated with higher CRP levels compared with cardiac death (p < 0.001), with an odds ratio of log CRP for death of 5.4 (95% CI = 3.8-7.7).

CONCLUSIONS

Prevalence of infection as primary cause of death in ESRD patients may be even higher than currently stated in the literature. Therefore, to reduce mortality, infections should be further avoided and controlled in the future.

Clinical and cost-effectiveness of primary prevention of Type 2 diabetes in a 'real world' routine healthcare setting: model based on the KORA Survey 2000

AIMS

To analyse the clinical and cost-effectiveness of the primary prevention of Type 2 diabetes in a 'real world' routine healthcare setting using population-based data (KORA Survey in Augsburg, Germany, total population approximately 600,000).

METHODS

Decision analytic model, time horizon 3 years.

INTERVENTIONS

Staff education, targeted screening and lifestyle modification or metformin in people aged 60-74 years with a body mass index of > or = 24 kg/m(2) and prediabetic status (fasting glucose 5.3-6.9 mmol/l and 2-h post load glucose 7.8-11.0 mmol/l) (target population approximately 72,500), according to the Diabetes Prevention Program trial.

MAIN OUTCOME MEASURES

Cases of Type 2 diabetes prevented, cost (Euro), incremental cost-effectiveness ratios (ICERs).

RESULTS

Under model assumptions, 14 908 people in the target population would develop diabetes if there was no intervention, 184 cases would be avoided with lifestyle intervention and 42 cases with metformin intervention. From the perspective of statutory health insurance and society, costs for lifestyle modification were 856,507 euro (574,241 pounds) and 4,961,340 euro (3,326,307 pounds), respectively, and for metformin 797,539 euro (534,706 pounds) and 1,335,204 euro(895,181 pounds). Up to 5% of the costs were due to staff education and up to 36% to screening. Lifestyle was more cost effective than metformin. ICERs for lifestyle vs. 'no intervention' were 4664 euro (3127 pounds) and 27,015 euro (18,112 pounds) per case prevented from the statutory health insurance and societal perspective.

CONCLUSIONS

Total cost and cost per case of diabetes avoided was high. Staff education and screening had a considerable impact. In view of the low participation in a routine healthcare setting, with both strategies only a small number of cases of diabetes would be prevented. Before implementing the programme, efforts should be made to improve patient participation in order to achieve better clinical and cost-effectiveness of the prevention of Type 2 diabetes in 'real world' clinical practice.

Prevalence of impaired glucose regulation in German school-leaving students

The increase in prevalence of obesity in childhood and adolescence appears to be followed by a rise of type 2 diabetes (T2D) cases in youth. Studies from the United States indicated that more than 1 in 10 adolescents may have disturbed glucose metabolism and that ethnicity and socioeconomic status are major determinants of (pre) diabetes prevalence. Since data for European countries are rare, we conducted a cross-sectional survey in 721 school-leaving boys and girls (mean age 15.5 years) in Düsseldorf (Germany). In our population from a predominantly low socioeconomic background, a total of 2.5% had impaired fasting glucose, impaired glucose tolerance or T2D. Hence, our study does not confirm the alarming data from high-risk US. American populations, but, nevertheless provides evidence for the necessity of public health interventions aiming at primary prevention of obesity and T2D in children and adolescents.

The metabolic syndrome sensitizes leukocytes for glucose-induced immune gene expression

Definitions of the metabolic syndrome (MetS) include obesity, dyslipidemia, elevated levels of fasting blood glucose, and blood pressure as criteria, but it is also known that the MetS is associated with chronic, subclinical inflammation. Hyperglycemia (fasting and postprandial) may be important in exacerbating this proinflammatory state. We aimed to assess the impact of oral glucose challenge and in vitro glucose-stimulation on gene expression and secretion of inflammatory parameters in peripheral blood leukocytes and to investigate whether presence of the MetS could "prime" leukocytes to up-regulate proinflammatory markers in response to glucose. Using quantitative real-time PCR, we could show that the expression of intercellular adhesion molecule 1 (ICAM-1), tumor necrosis factor alpha (TNF-alpha), and interleukin 6 (IL-6) significantly increased in peripheral blood leukocytes from "MetS" subjects (n=39) compared to "no MetS" subjects (n=35) 2 h after an oral glucose tolerance test (ICAM-1 +52%, TNF-alpha +107%, and IL-6 +38%) and also in vitro after 72 h cultivation in high-glucose medium (ICAM-1 +74%, TNF-alpha +71%, and IL-6 +44%). Using ELISA and Luminex technique, we further observed a trend towards increased immune mediator concentrations in the corresponding cell culture supernatants from MetS patients (ICAM-1 +21%, TNF-alpha +31%, and IL-6 +175%). Thus, the MetS may support peripheral inflammation by sensitizing leukocytes to up-regulate proinflammatory markers in response to glucose, which in turn increases the risk for type-2 diabetes mellitus and cardiovascular disease.

Differential association of adiponectin with cardiovascular risk markers in men and women? The KORA survey 2000

BACKGROUND

In men, high adiponectin concentrations were related to a lower risk of myocardial infarction, whereas no association with cardiovascular events was found in women.

OBJECTIVE

To investigate sex differences in the associations of adiponectin with cardiovascular risk factors.

DESIGN

Cross-sectional population-based KORA Survey 2000 in Southern Germany using the same study methods for cardiovascular risk factors as the former WHO MONICA project.

PARTICIPANTS

A total of 697 men and 657 women, aged 55-74 years. Glucose tolerance status was assessed by oral glucose tolerance tests.

RESULTS

Adiponectin (geometric mean, interquartile range; microg/ml) levels were significantly higher in women (11.1; 8.5-14.9) than in men (7.1; 5.2-9.6) (P<0.05). In univariate analyses, HDL-cholesterol and age were significantly positively correlated with adiponectin in both sexes. Negative correlations were observed with BMI, waist circumference, fasting and postchallenge glucose, insulin, HOMA-IR, HbA1c, triglycerides, uric acid and CRP (P<0.01). In sex-specific multivariate regression, age and HDL-cholesterol were independently positively, and fasting insulin and 2-h glucose were negatively related to adiponectin in both sexes. Uric acid was significantly inversely related to adiponectin in women only (sex interaction: P=0.02). Exploratory sex-specific factor analysis of adiponectin and the core components of the metabolic syndrome yielded four similar factors. Adiponectin loaded negatively on the 'lipids' factor in both sexes.

CONCLUSION

The associations of adiponectin with cardiovascular risk factors showed a similar pattern in both sexes, except for uric acid. This small sex difference may not explain previous conflicting results on the association of adiponectin with cardiovascular events in men and women.

Incremental prescription and drug costs during the years preceding diabetes diagnosis in primary care practices in Germany

INTRODUCTION

To evaluate incremental drug prescription costs before diabetes diagnosis in primary care patients in Germany.

MATERIAL AND METHODS

Based on 400 primary care practices throughout Germany (Disease Analyzer, IMS Health, Frankfurt, Germany), we selected only patients receiving continuous treatment (age >or= 40 years) and ascertained drug prescriptions and costs up to 6 years before diabetes was diagnosed. For control, we selected age- and sex-matched nondiabetics (n = 6,294 pairs, age 65.5 +/- 10.5 years, 44 % male). We evaluated incremental prescriptions and costs by calculating differences and ratios between patients with and without a diabetes diagnosis. We also evaluated predictors of cost differences using multivariate regression models. The data used for the evaluation was taken from the period 1993 to 2002.

RESULTS

The mean number of prescriptions in the year preceding diagnosis in men and women increased 15 % and 19 %, respectively (p < 0.001). Prescription costs were 21 % (men) and 28 % (women) higher in subjects who were destined to receive a diabetes diagnosis (269 and 264 Euros per person) compared to controls (p < 0.001). Incremental prescriptions and costs were already present six years preceding diagnosis. Cardiovascular drugs had the largest impact, accounting for about two-thirds of incremental prescriptions and costs. Women had higher numbers of prescriptions and costs, however, differences and ratios were comparable to men. Incremental costs were higher in patients with private compared to statutory health insurance, and in Western compared to Eastern Germany.

DISCUSSION

Numbers of prescriptions and costs in primary care patients with future diabetes diagnosis in Germany were already increased six years before clinical detection, reflecting increased cardiovascular risk even before clinical diabetes diagnosis.

Selective contribution of diabetes and other cardiovascular risk factors to cardiac autonomic dysfunction in the general population

Both cardiac autonomic dysfunction adn cardiovascular risk factors are related to and excess risk of mortality. We sought to determine whether the major cardiovascular risk factors are associated with diminished heart rate variability (HRV), prolonged QTc interval, or increased QT dispersion (QTD). Male (n = 1030) and female (n = 957) subjects, aged 55-74 years, who participated in the population-based MONICA Augsburg survey 1989/90 were assessed for the presence of cardiovascular risk factors such as diabetes, hypertension, obesity, dyslipidemia, smoking, and low physical activity. Lowest quartiles for time domain indexes of HRV (SD of R-R intervals [SDNN], max-min difference), QTc > 440 ms, and QTD > 60 ms determined from 12-lead resting ECG were used as cutpoints. In men, after adjustment for age and alcohol consumption, significant independent determinants for the lowest quartiles of SDNN were diabetes, obesity, and smoking. Independent contributors to prolonged QTc were hypertension, obesity, smoking, and low physical activity, whereas for increased QTD it was only hypertension. In women, diabetes was the only contributor to low SDNN, and hypertension was the only determinant of prolonged QTc. In conclusion, diabetes is the primary determinant of reduced HRV in the general population, while hypertension is the primary contributor to prolonged QTc in both sexes. However, obesity and smoking contribute to autonomic dysfunction in men but not women. Thus, a selectivity and sex-related differences exist among the various cardiovascular risk factors as to their influence on autonomic dysfunction.

[Quality of care and extent of complications in a population-based sample of patients with type 2 diabetes mellitus. The KORA Survey 2000]

BACKGROUND AND OBJECTIVE

The aim of this study was to analyse health care processes and outcomes in type 2 diabetes in a representative population sample of persons, aged 25-74 years, in the region of Augsburg, Germany.

PATIENTS AND METHODS

Based on the KORA Survey 2000, indicators of health care services and outcomes were analysed for all study subjects with known type 2 diabetes (n=149; 80 males (54%)) , mean age 62 +/- 9 years; total random population sample: 4,261 persons). Means and prevalences were calculated, including 95% confidence intervals (CI). Associated factors were analysed using multivariate regression models.

RESULTS

57% of the patients had not received adequate drug treatment concerning hypertension and 43% concerning hypercholesterolemia. 63% (CI: 54-70 %) and 38% (CI: 30-47%), respectively, reported that their eyes or feet had been examined during the past 12 months. 47% (CI: 39-56%) had been instructed about their diabetes. 69% (CI: 61-76%) of the subjects did not know the term "HbA(1c)", the proportion being higher among subjects without diabetes education or those of a low social status. 13% (CI: 8-20%) of the subjects had been told by their medical practitioner that they had a retinopathy, 5% (CI: 2- 10%) a foot ulcer, 19% (CI: 12-28%) proteinuria. Two persons were blind, one had been on renal dialysis, and 5% (CI: 2-10%) had undergone amputation of a limb. 6% (3-12%) had at least one of the end-stage diabetic complications. The mean HbA(1c) was 7.2 +/- 1.6%, significantly higher in those with a diabetes for >10 years.

CONCLUSIONS

The population-based data regarding indicators of type 2 diabetes care processes and outcome in a defined region in Germany show that the treatment of hypertension and hypercholesterolemia was highly inappropriate, as was the frequency of medical control investigations. The high proportion of subjects who did not know the term "HbA(1c)" was striking, particularly among those of a low social status. A significant proportion had severe late complications. The mean HbA(1c), however, was better than had been reported in some previous German practice-based studies.

High prevalence of undiagnosed impaired glucose regulation and diabetes mellitus in patients scheduled for an elective coronary angiography

BACKGROUND

Impaired glucose regulation (IGR) and diabetes mellitus (DM) are amongst the main risk factors for developing coronary heart disease (CHD). The aim of this study was to investigate previously unknown glucose metabolism disorder in patients scheduled for an elective coronary angiography.

METHODS

A total of 141 patients scheduled for coronary angiography without signs of acute myocardial ischemia or previous history of a glucose metabolism disorder were prospectively included in the study. An oral glucose tolerance test (OGTT) was performed in each patient.

RESULTS

IGR was diagnosed in 40.4% (95% confidence interval 32.3-49.0) and undetected DM in 22.7% (16.1-30.5) of patients undergoing an elective coronary angiography. Depending on the severity of CHD, the percentage of IGR and DM increased up to 45.3% (34.6-56.5) and 26.7% (17.8-37.4) in the subgroup with the need of percutaneous angioplasty, while the corresponding proportions in the group without CHD were 30.3% (15.6-48.7) and 12.1% (3.4-28.2). The percentage of undiagnosed DM increased with the number of epicardial vessels involved. Using the recommended fasting plasma glucose value of > or = 126 mg/dl for the diagnosis of DM, we would have missed 71.9% of the patients with undiagnosed DM. If all patients with a fasting plasma glucose of > or = 90 mg/dl had been subjected to OGTT, 93.8% of DM would have been identified.

CONCLUSIONS

Prevalences of DM and IGR are higher than expected in patients with CHD. An OGTT should be considered for all patients with a fasting plasma glucose > or = 90 mg/dl undergoing a coronary angiography.

Inflammation and type 2 diabetes: results from KORA Augsburg

Type 2 diabetes is associated with a systemic low-grade inflammation. First data provided by cross-sectional studies from as early as the 1960s demonstrated elevated systemic levels of glycoproteins and acute-phase reactants and increased leukocyte counts in type 2 diabetes patients. Subsequently, prospective studies showed that elevated concentrations of several acute-phase proteins and cytokines are predictive of later type 2 diabetes. Immune gene variants in man and in animal models were found to affect insulin resistance and diabetes incidence. Antidiabetic treatment by medication, diet or physical activity results in a significant decrease of systemic immune mediator concentrations. Immunological analyses of the KORA Survey S4 (1999/2001) allowed us to show that levels of circulating acute-phase proteins like CRP and of IL-6 are highly correlated and associated not only with overt type 2 diabetes, but already with impaired glucose tolerance (IGT) pointing out a role of these mediators in the pathogenesis of type 2 diabetes. On the contrary, TNFalpha was neither coregulated with CRP nor associated with diabetes status. Our study therefore shows that type 2 diabetes is accompanied by a non-random and differential upregulation of components of the innate immunity and suggests that this inflammatory condition is involved in the aetiology of the disease. Future work will extend the range of analysed immune mediators to chemokines and will also investigate the association of immune markers with indices of obesity to elucidate the relevance of this traditional risk factor for low-grade inflammation.

Cost-Effectiveness of Type 2 Diabetes Screening: Results from Recently Published Studies

Type 2 diabetes screening is recommended by various international diabetes associations. We conducted a literature research to identify and describe systematically recently published cost effectiveness analyses (CEA) for type 2 diabetes screening. Three analyses were included. One of them was conducted in Germany, based on the data of the KORA survey S4 (1999/2001). Two studies came from the US. The German as well as one of the US studies evaluated cost per detected diabetic case as main outcome. In contrast to the US study, the German study considered incomplete participation in the screening programs as baseline case. HbA1 c testing combined with the oral glucose tolerance test (OGTT) was more expensive than OGTT or fasting glucose testing, but also most effective in detecting cases, due to high participation in this screening strategy. The second US study investigated the lifetime cost effectiveness of type 2 diabetes screening, based on a Markov model to calculate cost per quality-adjusted life year (QALY). Effectiveness data were derived from two large intervention studies in clinically diagnosed (not identified by screening) diabetic subjects. The authors conclude that type 2 diabetes screening is cost effective, in particular targeted screening in elderly hypertensive subjects. Diabetes screening may be cost effective. However, the effectiveness of early detection and treatment of type 2 diabetes has not yet been shown, and data regarding the course of early detected diabetes are lacking so far. In the future, the most important question is whether type 2 diabetes screening and early treatment is effective with respect to clinical outcomes.

Sex differences in the associations of socioeconomic status with undiagnosed diabetes mellitus and impaired glucose tolerance in the elderly population: the KORA Survey 2000

BACKGROUND

Sex differences in the associations of socioeconomic status (SES) with prevalence of undiagnosed diabetes mellitus, impaired glucose tolerance (IGT) and known risk factors of type 2 diabetes mellitus were investigated in an elderly population.

METHODS

Oral glucose tolerance tests were carried out in 1354 randomly selected subjects (697 men, 657 women) aged 55-74 years in the population-based KORA Survey 2000, Augsburg, Germany. Odds ratios (ORs) and 95% confidence intervals (CIs) for undiagnosed diabetes or IGT by education, occupation and income were estimated using logistic regression controlling for age, waist circumference, blood pressure, triglycerides, physical activity, smoking and alcohol intake.

RESULTS

All three SES variables were significantly inversely related to body mass index, waist circumference and low physical activity in women (P < 0.05). In men, these associations were weaker or absent. Using the lowest category as reference, occupational status was significantly associated with undiagnosed diabetes in women (adjusted OR 0.5; 95% CI 0.3-0.8) after controlling for risk factors in multivariate regression. The OR was also reduced with higher income in women (adjusted OR, diabetes: 0.7; 95% CI 0.5-1.03). Among men, no significant relations of the SES indicators with unknown diabetes were observed. However, the odds of having IGT was lower with higher occupational status in men (adjusted OR 0.7; 95% CI 0.5-0.9).

CONCLUSIONS

Undiagnosed type 2 diabetes was related to low SES defined by occupation or income in women only. In men, low occupational status was independently associated with higher IGT risk. Educational level was not related to glucose disorders in both sexes in the elderly population.

The Diabetes Epidemic in the Elderly Population in Western Europe: Data from Population-Based Studies

Valid epidemiologic data on type 2 diabetes in the elderly population are scarce in the European Region despite its enormous human and economic burden. The aim was to assess population-based data on type 2 diabetes and impaired glucose regulation (IGR) from surveys carried out in Western Europe since 1990 using oral glucose tolerance tests, and to discuss the possible impact of risk factors on geographic variation, in particular, obesity and physical activity. In the decade below 60 years of age, about 10 % of the population had known or newly diagnosed diabetes in European surveys. In the age group 70 to 79 years, average total diabetes prevalence was about one quarter. IGR prevalences also increased with age, reaching a maximum of 25 % (men) to 30 % (women) above 70 years of age. There was a wide variation of total diabetes prevalence in the elderly population in Western European countries, however, without clear geographical pattern. Whereas age- and sex-specific prevalences for total diabetes in the German KORA Survey S4 (1999/2001) (Augsburg) were comparable to the European average, IGR prevalences were higher in Augsburg (60-69 years: KORA: men: 30.2 %, women: 22.4 % Europe: men: 21.2 %, women: 19.0 %). Thus, there is a huge reservoir for future diabetes cases in the elderly population in Germany. Differences at the population level were found for obesity, nutrition, and sedentary lifestyle in Western Europe. Comparative studies on the predictive values of obesity, physical activity, and nutrition and possible interactions with genetic markers in European populations are of interest in the future.

Association of humoral immunity to human Hsp60 with the IL-6 gene polymorphism C-174G in patients with type 2 diabetes and controls

The relationship between humoral immunity to hsp60 and type 2 diabetes along with other relevant metabolic, inflammatory and immunogenetic variables was studied in 76 non-diabetic and 74 diabetic persons aged 55-74 years selected from the population-based KORA Survey 2000. Antibodies to human hsp60 were measured in serum samples by ELISA. Hsp60 antibodies were detected in all but two individuals in a considerable range of titres (22-1,856 AU/ml). There was no significant association to age and sex, or to key clinical or metabolic parameters (BMI, WHR, HbA1c, total cholesterol, LDL cholesterol, HDL cholesterol, systolic and diastolic blood pressure, albumin, uric acid) or immunological parameters (CRP, IL-6, sIL-6R, TNFalpha, sTNFalpha R60, sTNFalpha R80). Analysis of antibody-positive individuals revealed an association between hsp60 antibodies and diabetes at borderline significance (p = 0.047), which was lost when the two antibody-negative individuals were included. Genetic analyses indicated that this association was significant in carriers of the C allele of the IL-6 promoter region polymorphism at nucleotide -174 (p = 0.02), but not in GG genotype carriers. We conclude that humoral immunity to human hsp60 may be enhanced in those diabetic patients carrying the -174C allele of the IL-6 gene. This finding may contribute to an understanding of the relationship between the -174C allele and increased risk of atherosclerosis.

Postmarketing surveillance of adverse drug reactions: a correlational study approach using multiple data sources

The authors performed a correlational study on nationwide spontaneous adverse drug reaction (ADR) reports related to the antioxidant thioctic acid (Thioctacid; ASTA Medica) in Germany from April 1992 to March 1995. Thioctacid was predominantly utilized by general practitioners and internists for treatment of diabetic neuropathy. The total number of treated patients was estimated using a nationwide drug prescription database (MediPlus, IMS: 362 general practitioners and internists) and pharmacy drug sales data. All Thioctacid prescriptions in MediPlus were assessed and the mean cumulative dosage/patient/year was calculated. Then, the total number of Thioctacid patients in Germany was estimated: N=nationwide pharmacy sales (kg)/mean cumulative dosage/patient (kg). From April 1992 to March 1995, 78 patients with 112 ADRs were notified on spontaneous reports. There was a decreasing number of ADR reports per year (32 to 21 patients/year). In parallel, the estimated total numbers of treated patients/year also decreased from 426,658 to 304,155 (p<0.05). Poisson regression models were fitted including incident cases with ADR and the number of patients per year for each of the 3 years. No significant secular trend of ADR (p=0.91) and no impact of mean cumulative dosages was observed in the models. There were also no changes in the pattern of ADR (e.g. skin reactions, gastrointestinal complaints). This study suggests that a combination of spontaneous reporting systems with prescription drug databases and pharmacy sales data may be a useful tool to perform rapid postmarketing monitoring of ADR.

Direct Costs of Pediatric Diabetes Care in Germany and Their Predictors

INTRODUCTION

Cost-of-illness study to evaluate diabetes-related direct costs for the care of diabetic children and adolescents in Germany from the perspective of the statutory health insurance.

MATERIAL AND METHODS

For all continuously treated patients < 20 years of age from 89 pediatric departments (n = 6437, 52 % male, mean age 12.5 [SD 3.8], diabetes duration 5.2 [3.3] years), diabetes-related hospitalization, ambulatory care, insulin management, glucose self measurement, and treatment with antihypertensive drugs in 2000 were ascertained, as well as metabolic control (HbA1c). Costs per patient-year were calculated in Euros (EUR) based on year 2000 prices. Using multivariate regression, the associations between costs and age, sex, diabetes duration, and metabolic control were evaluated.

RESULTS

Mean total costs per patient-year were EUR 2611 (interquartile range 1665 - 2807). Blood glucose self measurement, hospitalization, and insulin accounted for 37 %, 26 %, and 21 % of the costs, respectively, followed by ambulatory care (9 %), injection equipment and glucagon sets (7 %), and treatment with antihypertensive drugs (0.1 %). The total costs were significantly increased for higher age, longer diabetes duration, and higher HbA1c (p < 0.01). The costs for hospitalization were significantly associated with pubertal age (10 - 14 years) and poor metabolic control (HbA1c SDS > 5) (p < 0.001). Based on the present estimations, the total direct costs for the care of all diabetic subjects in Germany < 20 years would be EUR 66.8 (95 % CI 65.4 - 68.1) million in 2000.

DISCUSSION

Among the direct medical costs of childhood diabetes, the highest economic burden was due to glucose self measurement, hospitalization, and insulin. The costs were considerably higher in adolescents with poor metabolic control, especially the costs for hospitalization. Outpatient education programs in pediatric diabetes care, in particular targeting children with poor metabolic control, should be encouraged, including their evaluation with respect to cost and effectiveness.

Effect of the angiotensin II receptor blocker candesartan on fibrinolysis in patients with mild hypertension

AIM

Impaired fibrinolysis is frequently observed in patients with the metabolic syndrome. Aim of the study was to examine the short-term effect of angiotensin II receptor blockade on the fibrinolytic system.

METHODS

Seventy-four patients with mild hypertension were randomly assigned to a 7-day treatment period with either 16 mg candesartan cilexetil or placebo. Several variables of the fibrinolytic system such as plasminogen activator inhibitor-1 (PAI-1) antigen and activity, tissue plasminogen activator (t-PA) antigen and activity as well as circulating t-PA/PAI-1 complexes were determined.

RESULTS

At baseline, the body mass index but not blood pressure was positively associated with PAI-1 antigen (r=0.314, p<0.01) and PAI-1 activity (r=0.425, p<0.01) but negatively with t-PA activity (r=-0.187, p < 0.05). A 7-day treatment with 16 mg candesartan cilexetil resulted in a significant greater reduction of diastolic blood pressure (-10.3 +/- 10.8 mmHg vs.-5.8 +/- 8.5 mmHg, p=0.03). However, there was no significant effect of candesartan on all parameters of the fibrinolytic system under investigation, i.e. circulating PAI-1 antigen, PAI-1 activity, t-PA antigen, t-PA activity and t-PA/PAI-1 complexes. Furthermore, candesartan did not affect the characteristic circadian pattern of the variables of the fibrinolytic system.

CONCLUSION

We conclude that short-term blockade of the angiotensin II receptor subtype 1 with candesartan does not have an impact on fibrinolysis in patients with mild hypertension.

Genetic variation of the platelet- surface integrin GPIIb-IIIa (PIA1/A2-SNP) shows a high association with Type 2 diabetes mellitus

AIMS/HYPOTHESIS

The gene encoding the beta(3)-subunit (GPIIIa) of the platelet alpha(2)beta(3)-integrin (fibrinogen receptor) shows a polymorphism PlA1/A2 with the A2 allele putatively associated with an increased risk of acute ischaemic events. This study investigated whether Type 2 diabetes as a particular macrovascular risk factor associates with the thrombogenic PIA2 genotype.

METHODS

The PlA genotype was determined in 112 consecutive Type 2 diabetic patients additionally classified according to the presence of macrovascular disease. Forty-four non-diabetic patients with angiografically documented cardiovascular disease (CAD/ AMI) and a further 59 non-diabetic subjects with no angiografical signs of CAD were investigated as genomic background control (n=103). PIA-genotyping was carried out by standard restriction fragment length analysis (RFLA) of PCR amplified lymphocyte template DNA.

RESULTS

The overall allelic PlA2- prevalence accounted to 34.8% (39/112) in diabetic patients as compared to 14.6% (15/103) in non-diabetic patients [OR 3.1 (1.6-6.1), p<0.01]. This odds ratio increased to 7.0 (2.5-19.7), (p<0.01) in subjects free of criteria of macrovascular disease. In non-diabetic control subjects without CAD there was an allelic PIA2 frequency of 10.2% (6/59) as compared to 20.5% (9/44) in patients with CAD and a history of AMI being less than either diabetes subgroup. The PIA2 prevalence in the subgroup of diabetes patients with macrovascular complications did not differ from the respective value in patients without macrovascular disease. [29.0% (20/69) vs. 44.2% (19/43)].

CONCLUSION/INTERPRETATION

This study confirms a trendwise association of PlA2 with severe coronary artery disease, but rather suggests an even stronger, highly significant association with the metabolic condition of Type 2 diabetes mellitus. This justifies the speculation that pathways dependent on the platelet alpha(2)beta(3) integrin physiology could be implicated in the pathogenesis of Type 2 diabetes which lends further support to the "common soil" hypothesis of diabetes and vascular disease.

High prevalence of undiagnosed diabetes mellitus in Southern Germany: target populations for efficient screening. The KORA survey 2000

AIMS/HYPOTHESIS

To estimate the prevalence of undiagnosed diabetes mellitus, impaired glucose tolerance (IGT) and impaired fasting glucose (IFG), and their relations with cardiovascular risk factors in the general population aged 55 to 74 years in Southern Germany.

METHODS

Oral glucose tolerance tests were carried out in a random sample of 1353 subjects aged 55 to 74 years participating in the KORA (Cooperative Health Research in the Region of Augsburg) Survey 2000. Prevalences of glucose tolerance categories (1999 WHO criteria) were adjusted for sample probabilities. The numbers needed to screen (NNTS) to identify one person with undiagnosed diabetes were estimated from age-adjusted logistic regression models.

RESULTS

Sample design-based prevalences of known and unknown diabetes, IGT, and IFG were 9.0%, 9.7%, 16.8%, 9.8% in men, and 7.9%, 6.9%, 16.0%, 4.5% in women, respectively. In both sexes, participants with undiagnosed diabetes had higher BMI, waist circumference, systolic blood pressure, triglycerides, uric acid, and lower HDL-cholesterol than normoglycaemic subjects. A combination of abdominal adiposity, hypertension, and parental diabetes in men resulted in a NNTS of 2.9 (95%CI: 2.0-4.6). In women, the combination of increased triglycerides, hypertension and parental diabetes history yielded a NNTS of 3.2 (95%CI: 2.2-5.1).

CONCLUSION/INTERPRETATION

About 40% of the population aged 55 to 74 years in the Augsburg region have disturbed glucose tolerance or diabetes. Half of the total cases with diabetes are undiagnosed. Cardiovascular risk factors worsen among glucose tolerance categories, indicating the need for screening and prevention. Screening for undiagnosed diabetes could be most efficient in individuals with abdominal adiposity (men), hypertriglyceridaemia (women), hypertension, and parental diabetes history.

Health-related quality of life in subjects with functional bowel disorders in Germany

OBJECTIVES

A low health-related quality of life (HRQL) was reported in subjects with functional bowel disorders (FBD). The aim of the present study was to investigate the association between HRQL and FBD within a three year period in a population-based sample in Germany.

DESIGN

A panel-study based on an age- and sex-stratified random sample of subjects aged 21 - 80 years in Düsseldorf, Germany (about 500,000 population).

METHODS

The presence of FBD, in particular lower abdominal pain, was assessed annually over a three year period using a postal questionnaire. With the last questionning, HRQL was assessed using the Medical Outcome Short Form (SF36) in 305 subjects responding all three questionnaires (49 % males, mean age (SD) 54 (15) years). HRQL was analyzed based on SF36 scores and component summary scores, adjusted for age and sex using regression models.

RESULTS

Twenty-eight percent (28 %; 95 % confidence interval 23 - 33 %) of the respondents reported FBD in at least one year of the study period. HRQL was significantly lower in study subjects with FBD in all scores compared to subjects without any FBD during observation time and compared to the German general population. No significant differences between subjects with persistent and those with intermittent FBD could be evaluated.

CONCLUSIONS

Subjects with FBD within a three-year period had impaired HRQL compared to subjects without FBD and the general population in Germany. HRQL seemed to be less impaired than in subjects with IBS from the UK and the US.

Undiagnosed diabetes mellitus among patients with prior myocardial infarction

OBJECTIVE

To determine the prevalence of undiagnosed diabetic subjects in a group of long-term myocardial infarction (MI) survivors and to investigate their cardiovascular risk factors and medical care.

METHODS

Glucose tolerance (OGTT WHO 1985), cardiovascular risk factors (blood pressure, lipids, urinary albumin), and primary medical care during the previous year were assessed among 244 patients without previously known diabetes (mean age +/- SD: 70.5 +/- 6.9 yrs; 75% males; time since incident infarction: 6.5 years (median), inter-quartile range: 4-9 years) from the population-based MONICA myocardial infarction registry in Augsburg (Germany).

RESULTS

Proportion of undiagnosed diabetes among MI registry patients was 29/244, 12% (95%CI: 8-17%); impaired glucose tolerance was found in 27% (22-34%). Using fasting glucose according to ADA 1997 criteria, 11% (7-16%) had diabetes and 17% (12-22%) impaired fasting glucose. MI registry patients with newly detected diabetes (WHO or ADA) showed a more adverse risk factor profile (higher triglycerides, lower HDL-cholesterol, increased urinary albumin) than subjects with normal glucose tolerance after controlling for possible confounders (age, sex, time since MI, antihypertensive and lipid-lowering medication). No significant differences were observed for self-reported medical care during the previous year among diabetic compared to non-diabetic subjects (number of physician visits and basic investigations).

CONCLUSIONS

There was a high prevalence of undiagnosed diabetes mellitus among the selected elderly long-term MI survivors. Because mortality rate after MI has been previously shown to be increased in diabetic patients, screening for glucose intolerance appears to be as essential as for standard cardiovascular risk factors.

Impaired glucose tolerance is associated with increased serum concentrations of interleukin 6 and co-regulated acute-phase proteins but not TNF-alpha or its receptors

AIMS/HYPOTHESIS

A population-based sample was studied to define immune abnormalities in individuals at risk of Type II (non-insulin-dependent) diabetes mellitus because of impaired glucose tolerance.

METHODS

A total of 1653 individuals aged 55 to 74 years participated in a population based survey in Southern Germany (KORA Survey 2000). Those without a history of diabetes were subjected to an OGTT. Randomly selected subjects with IGT ( n=80) were compared with non-diabetic control subjects ( n=77) and patients with Type II diabetes ( n=152) of the same population-based sample after matching for age and sex. Immune parameters were analysed in serum with rigidly evaluated ELISA.

RESULTS

Serum pro-inflammatory cytokine interleukin 6 (IL-6) concentrations were higher in subjects with IGT and Type II diabetes than in the control subjects (median 1.8 and 2.5 vs 0.8 pg/ml, p<0.0001). Soluble IL-6 receptors potentiate IL-6 bioactivity and their concentrations were mildly increased in Type II diabetes ( p<0.05). These immune changes seem relevant because IL-6 dependent acute-phase proteins C-reactive protein, serum amyloid A protein and fibrinogen were also increased in IGT and Type II diabetes. Circulating concentrations of TNF-alpha and its two receptors sTNF-R60 and sTNF-R80 were not increased in IGT subjects compared with the control subjects.

CONCLUSION/INTERPRETATION

Our study shows systemic up-regulation of selected inflammatory mediators in patients with Type II diabetes and IGT. The pattern observed is non-random and fits with an IL-6 associated rather than TNF-alpha associated response.