Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

A socioeconomic gradient related to type 2 diabetes (T2D) prevalence has been demonstrated in high-income countries. However, there is no evidence of such a socioeconomic gradient regarding diabetes complications. Thus, the aim of this systematic review was to collect data on risk of complications according to socioeconomic status in patients with T2D.

METHODS

PubMed and EMBASE were searched for English-language observational studies evaluating the prevalence or incidence of micro- and macrovascular complications according to individual and geographical socioeconomic status (SES). Observational studies reporting the prevalence and risk of micro- and macrovascular diabetes complications, according to an individual or geographical index of deprivation, were selected, and estimated crude and adjusted risks for each complication were reported.

RESULTS

Among the 28 included studies, most described a clear relationship between SES and diabetes complications, especially retinopathy (in 9 of 14 studies) and cardiopathy (in 8 of 9 studies). Both individual and area-based low SES was associated with an increased risk of complications. However, very few studies adjusted their analyses according to HbA_1c level.

CONCLUSION

Evaluation of SES is necessary for every T2D patient, as it appears to be a risk factor for diabetes complications. However, the available studies are insufficient for gradation of the impact of low socioeconomic level on each of these complications. Regardless, strategies for the improved screening, follow-up and care of high-risk patients should now be implemented.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Incidence and characteristics of lower limb amputations in people with diabetes

AIMS

To estimate the incidence, characteristics and potential causes of lower limb amputations in France.

METHODS

Admissions with lower limb amputations were extracted from the 2003 French national hospital discharge database, which includes major diagnoses and procedures performed during hospital admissions. For each patient, diabetes was defined by its record in at least one admission with or without lower limb amputation in the 2002-2003 databases.

RESULTS

In 2003, 17 551 admissions with lower limb amputation were recorded, involving 15 353 persons, which included 7955 people with diabetes. The crude incidence of lower limb amputation in people with diabetes was 378/100 000 (349/100 000 when excluding traumatic lower limb amputation). The sex and age standardized incidence was 12 times higher in people with than without diabetes (158 vs. 13/100 000). Renal complications and peripheral arterial disease and/or neuropathy were reported in, respectively, 30% and 95% of people with diabetes with lower limb amputation. Traumatic causes (excluding foot contusion) and bone diseases (excluding foot osteomyelitis) were reported in, respectively, 3% and 6% of people with diabetes and lower limb amputation, and were 5 and 13 times more frequent than in people without diabetes.

CONCLUSIONS

We provide a first national estimate of lower limb amputation in France. We highlight its major impact on people with diabetes and its close relationship with peripheral arterial disease/neuropathy and renal complications in the national hospital discharge database. We do not suggest the exclusion of traumatic causes when studying the epidemiology of lower limb amputation related to diabetes, as diabetes may contribute to amputation even when the first cause appears to be traumatic.

Self-monitoring of blood glucose in people with type 1 and type 2 diabetes living in France: the Entred study 2001

OBJECTIVE

To describe the practice of self-monitoring blood glucose (SMBG) testing and to determine factors linked to SMBG in people with diabetes living in France.

METHODS

The 2001 Entred study, a French national survey of people being treated for diabetes, is based on a representative sample of 10,000 adults who claimed reimbursement for oral hypoglycaemic agents and/or insulin in October to December 2001 and who were randomly extracted from the database of the major National Health Insurance System. A questionnaire was mailed to all these people and was returned by 36% of them, who were then classified into three groups: type 1 diabetes (T1D, N=235); type 2 diabetes treated with insulin (iT2D, N=635); and type 2 diabetes treated with oral hypoglycaemic agents (oT2D, N=2689). Factors associated with SMBG were analyzed using logistic regression models with a step-by-step forward approach.

RESULTS

HbA(1c) was greater than or equal to 8% in 42% of people with T1D, 48% of those with iT2D and 21% of those with oTD2. Almost all of those treated with insulin performed SMBG. The frequency of self-monitoring was higher in T1D than in iT2D. In T1D, 58% of people reported they took at least three tests a day, as recommended in guidelines, which was more frequent in those who knew what HbA(1c) meant and in women. In iT2D, 74% reported that they took at least two tests a day, as recommended, and it was more frequent in those who knew what HbA(1c) meant, who reported at least one severe hypoglycaemic episode in 2001 and who received dietary advice from their practitioner. In oT2D, 38% reported using SMBG (six tests a week on average), even though no official recommendation had been provided for these patients. SMBG was also more frequent in patients being treated with multiple oral hypoglycaemic agents, in those who benefited from a waiver of co-payment due to a chronic disease and in those, who had visited a diabetes specialist in 2001, reported they knew what HbA(1c) meant, received dietary advice and reported at least one severe hypoglycaemic episode in 2001 and/or a history of diabetes complications.

CONCLUSION

In France, as per the official recommendations, almost all people on insulin treatment use a SMBG device while, overall, their glucose control remains poor. More than one-third of those with oT2D regularly perform SMBG. In only 3% of people, the regular use of SMBG does not appear to be related to any special needs or events (such as insulin treatment, occurrence of severe hypoglycaemia or chronic complications).

Prevalence of macrovascular complications and cardiovascular risk factors in people treated for diabetes and living in France: the ENTRED study 2001

AIM

The aim of this study is to estimate the prevalence of macrovascular complications and cardiovascular risk factors among people with diabetes living in France and to compare these prevalences with other national estimates.

METHODS

We randomly sampled 10,000 people who received one or more reimbursements for insulin or oral hypoglycaemic treatment from the major national medical insurance system during the period October-December 2001; 3646 of the 10,000 people completed a questionnaire; for a subgroup of 1718 people, their care providers completed a medical questionnaire.

RESULTS

The prevalence of diagnosed macrovascular complications was of 17% according to patients (angina or myocardial infarction, 15%; coronary revascularization, 9%) and of 20% overall, according to physicians (angina or myocardial infarction, 16%; coronary revascularization, 6%; stroke, 5%). Macrovascular complications were more frequent in people with type 2 than type 1 diabetes, reflecting an age effect. The prevalences of cardiovascular risk factors in type 1 and type 2 diabetes were: current smoking, 35 and 14%; overweight, 28 and 42%; obesity, 9 and 36%; blood pressure superior to 130/80 mmHg, 29 and 59%; LDL cholesterol superior or equal to 3.4 mmol/l, 18 and 26%, respectively.

CONCLUSIONS

Compared with other European countries, elevated blood pressure is more frequent in people with diabetes living in France; compared with US estimates, the prevalence of macrovascular complications is lower, glucose control better and blood pressure control poorer in France. These data, observed in a country with widespread access to care and at low cost to the patient, nevertheless demonstrate an urgent need for improving the cardiovascular risk profile of people with type 1 and type 2 diabetes, both with and without macrovascular complications.

[Pre-hospital management of acute coronary syndromes with ST elevation in the Ile-de-France Region: the E-MUST registry]

The E-MUST registry gathers patient data from the emergency ambulance service of the IIe-de-France for acute coronary syndromes with ST elevation seen within 24 hours from onset of symptoms. The parameters include the type of emergency phone call, details relative to the different phase of management, decisions of therapeutic strategy concerning pre-hospital thrombolysis or primary angioplasty and the different factors influencing these decisions. From January 2001 to June 2002, the mean delay from the onset of symptoms and the call-out of the emergency ambulance was 67.5 minutes for the 2584 patients studied. In this group, a pre-hospital decision for coronary revascularisation was taken in 84.3% of cases, pre-hospital thrombolyis started 33 minutes after arrival of the ambulance (32.7% of cases) and primary angioplasty carried out 81 minutes after that arrival (51.6% of cases). Decisions for revascularisation were less common in the elderly and those seen over 6 hours after the onset of symptoms. Pre-hospital management allows decisions concerning coronary reperfusion to be taken more often and earlier in patients with acute coronary syndromes.

Single-dose pharmacokinetics of amprenavir coadministered with grapefruit juice

In this crossover study in 12 healthy volunteers, coadministration of amprenavir (1,200 mg; single dose) with grapefruit juice slightly reduced the maximum concentration of drug in serum (Cmax) compared to administration with water (7.11 versus 9.10 microg/ml), slightly increased the time to Cmax (1.13 versus 0.75 h), and did not affect the area under the concentration-time curve from 0 to 12 h (AUC(0-12)), the AUC(0-infinity), or the concentration at 12 h. Therefore, grapefruit juice does not clinically significantly affect amprenavir pharmacokinetics.

Single-dose pharmacokinetics of amprenavir, a human immunodeficiency virus type 1 protease inhibitor, in subjects with normal or impaired hepatic function

Amprenavir (141W94) is extensively metabolized by P450 cytochromes, specifically, CYP3A4. Because hepatic insufficiency reduces P450-mediated metabolism, the concentrations in plasma of drugs metabolized through this pathway are often increased in subjects with liver disease. Following administration of a single, oral dose of 600 mg of amprenavir, pharmacokinetic parameters were determined for 10 subjects with severe cirrhosis, 10 subjects with moderate cirrhosis, and 10 healthy volunteers. Model-independent methods for determining the area under the plasma concentration-time curve (AUC) from time zero to infinity (AUC(0-infinity)) showed an increase in amprenavir AUC(0-infinity) of 2.5-fold in the group with moderate cirrhosis and 4.5-fold in the group with severe cirrhosis compared with that in the control group of healthy volunteers (P < 0.05). AUC(0-infinity) was linearly related to the severity of liver disease, as assessed by the Child-Pugh score. Of the laboratory data used to calculate the Child-Pugh score, only the mean total bilirubin concentration showed a significant relationship with AUC(0-infinity). The relationship between the total bilirubin concentration and the AUC(0-infinity) of amprenavir was well characterized by a simple E(max) model, suggesting that the total bilirubin concentration may be a useful parameter for predicting the amprenavir AUC in subjects with hepatic insufficiency. Finally, the sera of cirrhotic subjects showed significant decreases in the levels of alpha(1)-acid glycoprotein, the primary plasma binding protein for amprenavir. On the basis of the results of this study, for an exposure equivalent to a clinical dose of 1,200 mg twice daily in subjects without cirrhosis, subjects with Child-Pugh scores of 5 to 8 should receive a twice-daily 450-mg dose of amprenavir, and subjects with Child-Pugh scores of 9 to 15 should receive a twice-daily 300-mg dose of amprenavir.

Diagnosis and treatment of colloid cysts of the third ventricle by stereotactic drainage. Report on eleven cases

Between December 1979 and September 1986, 11 patients with colloid cysts of the third ventricle were operated on by a stereotactic procedure with Talairach's system. Stereoscopic angiography and ventriculographic study allowed for a percutaneous (twist-drill hole diameter: 2.5 mm) stereotactic aspiration of the cysts. The operations were successful, and there were no intraoperative or postoperative mortalities but just mild transient morbidity in three cases. Six cysts were evacuated completely, and five only partially. The mean residual volume was 19% of the initial one. Clinical and anatomical results are presented, and the advantages of this stereotactic procedure are discussed.

Stereotactic aspiration of colloid cysts of the third ventricle. Preliminary report

From January, 1979, to July, 1986, 10 patients (6 females, 4 males; 12-59 years, mean 37) with colloid cysts of the third ventricle were treated by stereotactic aspiration (Talairach's method). Five cysts have been completely aspirated. The mean residual volume of the other 5 was 19% of the initial volume. Clinical symptoms completely cleared in all but one patient. The advantages of the procedure are discussed.