RESUMO
This study aimed to investigate the association between dietary magnesium intake and all-cause mortality among diabetic retinopathy (DR) patients. In this retrospective cohort study, data of 1,034 DR patients were extracted from the National Health and Nutrition Examination Survey (NHANES) (1999-2018). Dietary magnesium data were obtained from two 24-hour dietary recall interviews, and categorized into quartiles. Potential confounders were selected using weighted univariate Cox regression models. Weighted univariate and multivariate Cox regression models were used to explore the association between dietary magnesium intake and all-cause mortality in DR patients. The results were presented with hazard ratios (HRs) and 95% confidence intervals (CIs). Associations were further explored for subgroups related to age, gender, cardiovascular disease, and chronic kidney disease. Our study included 1,034 DR patients, of whom 438 (42.36%) died. The mean age of all patients was 63.26 (0.51) years old, with a median follow-up time of 75.00 months. Higher magnesium intake was associated with lower all-cause mortality risk (HR=0.58, 95% CI: 0.38-0.88) in DR patients. The association remained for those aged <65 years (HR=0.35, 95% CI: 0.15-0.81), male patients (HR=0.48, 95% CI: 0.27-0.84), patients without chronic kidney disease (HR=0.43, 95% CI: 0.23-0.82), and patients with a history of cardiovascular disease (HR=0.63, 95% CI: 0.39-1.02). DR patients with adequate magnesium intake exhibited a lower incidence of all-cause mortality. Further studies are needed to validate our findings and explore the optimal strategy for magnesium supplementation in DR patients.
Assuntos
Retinopatia Diabética , Magnésio , Inquéritos Nutricionais , Humanos , Masculino , Feminino , Magnésio/administração & dosagem , Estudos Retrospectivos , Pessoa de Meia-Idade , Retinopatia Diabética/mortalidade , Retinopatia Diabética/epidemiologia , Dieta , Idoso , Estudos de CoortesRESUMO
Background and Objectives: This study aimed to investigate the relationship between the systemic immune inflammation (SII) index and the development of micro and macro complications and mortality within the first year and the following three years in type 2 diabetic retinopathy patients. Materials and Methods: The retrospective study included 523 type 2 diabetic retinopathy patients seen in the endocrinology outpatient clinic of our hospital between January and December 2019. Their demographic and clinical characteristics were analyzed using descriptive statistics. The normal distribution of quantitative data was assessed by the Shapiro-Wilk test. Mann-Whitney U, McNemar-Chi-square, and Cochran's Q tests were used to analyze the SII values and complication rates over time. An ROC analysis determined the sensitivity and specificity of SII. A multiple linear regression analysis examined the relationship between variables and SII, while Spearman's test assessed the correlation between CRP and SII. p < 0.05 was accepted as significant. Results: The mean age of patients was 63.5 ± 9.3 years, with mean SII values of 821.4 ± 1010.8. Higher SII values were significantly associated with acute-chronic renal failure, peripheral arterial disease, and hospitalization rates in both the first year and the following three years (p < 0.05 for all). Significant cut-off values for SII were found for micro- and macrovascular complications and death within the first year (p < 0.05 for all). The ROC curve analysis identified an optimal SII cut-off value of >594.0 for predicting near-term (1-year) complications and mortality, with a sensitivity of 73.8% and specificity of 49.4% (area under the ROC curve: 0.629, p = 0.001). Multiple linear regression indicated that smoking of at least 20 pack-years had a significant positive effect on SII. The Spearman test showed a weak positive correlation between SII and CRP. Conclusions: High SII values predict both early and late acute-chronic renal failure, peripheral arterial disease, and hospitalizations in patients with type 2 diabetic retinopathy. The study also shows that high SII values may predict microvascular and macrovascular complications of type 2 DM and mortality risk in the early period in patients with type 2 diabetic retinopathy. In addition, comorbidities and inflammatory habits, such as long-term smoking, should be considered in the clinical use of SII.
Assuntos
Diabetes Mellitus Tipo 2 , Retinopatia Diabética , Inflamação , Humanos , Pessoa de Meia-Idade , Masculino , Feminino , Retinopatia Diabética/mortalidade , Estudos Retrospectivos , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/mortalidade , Diabetes Mellitus Tipo 2/sangue , Idoso , Inflamação/sangue , Seguimentos , Curva ROC , MorbidadeRESUMO
PURPOSE: To evaluate the dynamic transitions in diabetic retinopathy (DR) severity over time and associated risk factors in an Asian population with diabetes. DESIGN: Longitudinal cohort study METHODS: We analyzed data from 9481 adults in the Singapore Integrated Diabetic Retinopathy Screening Program (2010-2015) with linkage to death registry. A multistate Markov model adjusted for age, sex, systolic blood pressure (SBP), diabetes duration, HbA1c, and body mass index (BMI) was applied to estimate annual transition probabilities between four DR states (no, mild, moderate, and severe/proliferative) and death, and the mean sojourn time in each state. RESULTS: The median assessment interval was 12 months, with most patients having 3 assessments. Annual probabilities for DR progression (no-to-mild, mild-to-moderate and moderate-to-severe/proliferative) were 6.1 %, 7.0 % and 19.3 %, respectively; and for regression (mild-to-no, moderate-to-mild and severe-to-moderate) were 55.4 %, 17.3 % and 4.4 %, respectively. Annual mortality rates from each DR state were 1.2 %, 2.0 %, 18.7 %, and 30.0 %. The sojourn time in each state were 8.2, 0.8, 0.8 and 2.2 years. Higher HbA1c and SBP levels were associated with progression of no-mild and mild-moderate DR, and diabetes duration with no-to-mild and moderate-to-severe/proliferative DR. Lower HbA1c levels were associated with regression from mild-to-no and moderate-to-mild, and higher BMI with mild-to-no DR. CONCLUSIONS: Our results suggest a prolonged duration (â¼8 years) in developing mild DR, with faster transitions (within a year) from mild or moderate states. Moderate/above DR greatly increases the probability of progression and death as compared to mild DR/below. HbA1c was associated with both progression as well as regression.
Assuntos
Retinopatia Diabética , Progressão da Doença , Humanos , Retinopatia Diabética/mortalidade , Masculino , Feminino , Pessoa de Meia-Idade , Singapura/epidemiologia , Fatores de Risco , Idoso , Hemoglobinas Glicadas/metabolismo , Adulto , Seguimentos , Diabetes Mellitus Tipo 2/complicações , Povo Asiático , Estudos LongitudinaisRESUMO
To evaluate the effect of diabetic retinopathy (DR) status or severity on all-cause and cause-specific mortality among diabetic older adults in the United States using the most recent National Health and Nutrition Examination Survey (NHANES) follow-up mortality data. The severity of DR was graded according to the Early Treatment Diabetic Retinopathy Study (ETDRS) grading scale. Multiple covariate-adjusted Cox proportional hazards regression models, Fine and Gray competing risk regression models, and propensity score matching (PSM) methods were used to assess the risk of all-cause and cause-specific mortality in individuals with diabetes. All analyses adopted the weighted data and complex stratified design approach proposed by the NHANES guidelines. Time to death was calculated based on the time between baseline and date of death or December 31, 2019, whichever came first. Ultimately 1077 participants, representing 3,025,316 US non-hospitalized individuals with diabetes, were included in the final analysis. After a median follow-up of 12.24 years (IQR, 11.16-13.49), 379 participants were considered deceased from all-causes, with 43.90% suffering from DR, including mild DR (41.50%), moderate to severe DR (46.77%), and proliferative DR (PDR) (67.21%). DR was associated with increased all-cause, cardiovascular disease (CVD) and diabetes mellitus (DM)-specific mortality, which remained consistent after propensity score matching (PSM). Results of DR grading assessment suggested that the presence of mild, moderate to severe NPDR was significantly associated with increased risk of all-cause and CVD-specific mortality, while the presence and severity of any DR was associated with increased DM-specific mortality, with a positive trend. The presence of DR in elderly individuals with diabetes is significantly associated with the elevated all-cause and CVD mortality. The grading or severity of DR may reflect the severity of cardiovascular disease status and overall mortality risk in patients with diabetes.
Assuntos
Retinopatia Diabética , Inquéritos Nutricionais , Humanos , Retinopatia Diabética/mortalidade , Masculino , Feminino , Idoso , Estados Unidos/epidemiologia , Causas de Morte , Idoso de 80 Anos ou mais , Pessoa de Meia-Idade , Fatores de Risco , Modelos de Riscos Proporcionais , Diabetes Mellitus/mortalidadeRESUMO
A frequently addressed issue in clinical trials is the comparison of censored paired survival outcomes, for example, when individuals were matched based on their characteristics prior to the analysis. In this regard, a proper incorporation of the dependence structure of the paired censored outcomes is required and, up to now, appropriate methods are only rarely available in the literature. Moreover, existing methods are not motivated by the strive for insights by means of an easy-to-interpret parameter. Hence, we seek to develop a new estimand-driven method to compare the effectiveness of two treatments in the context of right-censored survival data with matched pairs. With the help of competing risks techniques, the so-called relative treatment effect is estimated. This estimand describes the probability that individuals under Treatment 1 have a longer lifetime than comparable individuals under Treatment 2. We derive hypothesis tests and confidence intervals based on a studentized version of the estimator, where resampling-based inference is established by means of a randomization method. In a simulation study, we demonstrate for numerous sample sizes and different amounts of censoring that the developed test exhibits a good power. Finally, we apply the methodology to a well-known benchmark data set from a trial with patients suffering from diabetic retinopathy.
Assuntos
Simulação por Computador , Retinopatia Diabética , Humanos , Análise de Sobrevida , Retinopatia Diabética/mortalidade , Retinopatia Diabética/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , Estatísticas não Paramétricas , Modelos Estatísticos , Intervalos de ConfiançaRESUMO
Purpose: To assess the impact of retinopathy and systemic vascular comorbidities on the all-cause mortality in a representative U.S. sample. Methods: A total of 5703 participants (≥40 years old) from the 2005-2008 National Health and Nutrition Examination Survey. The Early Treatment Diabetic Retinopathy Study grading scale was used to evaluate the retinopathy status. Systemic vascular comorbidities included diabetes mellitus (DM), high blood pressure (HBP), chronic kidney disease (CKD) and cardiovascular disease (CVD). Time to death was calculated as the time from baseline to either the date of death or censoring (December 31st, 2015), whichever came first. Risks of mortality were estimated using Cox proportional hazards models after adjusting for confounders and vascular comorbidities. Results: After a median follow-up of 8.33 years (IQR: 7.50-9.67 years), there were 949 (11.8%) deaths from all causes. After adjusting for confounders, the presence of retinopathy predicted higher all-cause mortality (hazard ratio (HR), 1.41; 95% confidence interval (CI), 1.08-1.83). The all-cause mortality among participants with both retinopathy and systemic vascular comorbidities including DM (HR, 1.72; 95% CI, 1.21-2.43), HBP (HR, 1.47; 95% CI, 1.03-2.10), CKD (HR, 1.73; 95% CI, 1.26-2.39) and CVD (HR, 1.92; 95% CI, 1.21-3.04) was significantly higher than that among those without either condition. When stratified by diabetic or hypertension status, the co-occurrence of retinopathy and CKD or CVD further increased the all-cause mortality compared to those without either condition. Conclusions: The co-occurrence of retinopathy and systemic vascular conditions predicted a further increase in the risk of mortality. More extensive vascular risk factor assessment and management are needed to detect the burden of vascular pathologies and improve long-term survival in individuals with retinopathy.
Assuntos
Angiopatias Diabéticas/mortalidade , Retinopatia Diabética/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/mortalidade , Causas de Morte , Diabetes Mellitus/mortalidade , Feminino , Seguimentos , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais , Insuficiência Renal Crônica/mortalidade , Medição de Risco , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Multiple modifiable risk factors for late complications in patients with diabetic kidney disease (DKD), including hyperglycemia, hypertension and dyslipidemia, increase the risk of a poor outcome. DKD is associated with a very high cardiovascular risk, which requires simultaneous treatment of these risk factors by implementing an intensified multifactorial treatment approach. However, the efficacy of a multifactorial intervention on major fatal/non-fatal cardiovascular events (MACEs) in DKD patients has been poorly investigated. METHODS: Nephropathy in Diabetes type 2 (NID-2) study is a multicentre, cluster-randomized, open-label clinical trial enrolling 395 DKD patients with albuminuria, diabetic retinopathy (DR) and negative history of CV events in 14 Italian diabetology clinics. Centres were randomly assigned to either Standard-of-Care (SoC) (n = 188) or multifactorial intensive therapy (MT, n = 207) of main cardiovascular risk factors (blood pressure < 130/80 mmHg, glycated haemoglobin < 7%, LDL, HDL and total cholesterol < 100 mg/dL, > 40/50 mg/dL for men/women and < 175 mg/dL, respectively). Primary endpoint was MACEs occurrence by end of follow-up phase. Secondary endpoints included single components of primary endpoint and all-cause death. RESULTS: At the end of intervention period (median 3.84 and 3.40 years in MT and SoC group, respectively), targets achievement was significantly higher in MT. During 13.0 years (IQR 12.4-13.3) of follow-up, 262 MACEs were recorded (116 in MT vs. 146 in SoC). The adjusted Cox shared-frailty model demonstrated 53% lower risk of MACEs in MT arm (adjusted HR 0.47, 95%CI 0.30-0.74, P = 0.001). Similarly, all-cause death risk was 47% lower (adjusted HR 0.53, 95%CI 0.29-0.93, P = 0.027). CONCLUSION: MT induces a remarkable benefit on the risk of MACEs and mortality in high-risk DKD patients. Clinical Trial Registration ClinicalTrials.gov number, NCT00535925. https://clinicaltrials.gov/ct2/show/NCT00535925.
Assuntos
Albuminúria/terapia , Anti-Hipertensivos/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Nefropatias Diabéticas/terapia , Retinopatia Diabética/terapia , Estilo de Vida Saudável , Hipoglicemiantes/uso terapêutico , Hipolipemiantes/uso terapêutico , Comportamento de Redução do Risco , Idoso , Albuminúria/diagnóstico , Albuminúria/mortalidade , Anti-Hipertensivos/efeitos adversos , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Nefropatias Diabéticas/diagnóstico , Nefropatias Diabéticas/mortalidade , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/mortalidade , Dieta Hipossódica , Exercício Físico , Feminino , Humanos , Hipoglicemiantes/efeitos adversos , Hipolipemiantes/efeitos adversos , Itália , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The prognostic importance of several hematological parameters has been scarcely investigated in type 2 diabetes. So, we aimed to evaluate their prognostic importance for development of complications in a cohort of type 2 diabetes. METHODS: In a prospective study, 689 individuals with type 2 diabetes had blood red cell, platelet and leukocyte parameters obtained at baseline. Multivariate Cox analyses examined the associations between several hematological parameters (including neutrophyl-to-lymphocyte, lymphocyte-to-monocyte, platelet-to-lymphocyte, and monocyte-to-HDL ratios) and the occurrence of microvascular (retina, renal and peripheral neuropathy) and cardiovascular complications (total cardiovascular events [CVEs], and major adverse CVEs [MACEs]), and all-cause and cardiovascular mortality. Improvements in risk discrimination were assessed by C-statistics and Integrated Discrimination Improvement (IDI) index. RESULTS: During a median follow-up of 10.5 years, 212 patients had a CVE (174 MACEs), 264 patients died (131 cardiovascular deaths); 206 had a renal, 161 a retinopathy and 179 patients had a neuropathy outcome. In multivariate-adjusted analyses, the lymphocytes count and lymphocyte-to-monocyte ratio were protective (hazard ratios [HRs]: 0.77 and 0.72, respectively), whereas the neutrophyl-to-lymphocyte and platelet-to-lymphocyte ratios were associated with increased risks (HRs: 1.19 and 1.17) for all-cause mortality. For cardiovascular mortality, the monocytes count, the neutrophyl-to-lymphocyte and monocyte-to-HDL ratios were associated with increased risks and the lymphocyte-to-monocyte ratio was protective. Higher lymphocyte-to-monocyte ratio was protective for renal failure outcome. However, none of them improved risk discrimination. CONCLUSIONS: Low lymphocytes count and leukocyte ratios that mainly included lymphocytes were predictors of macrovascular complications and mortality in individuals with type 2 diabetes. However, they did not improve risk prediction over traditional risk factors.
Assuntos
Plaquetas , Diabetes Mellitus Tipo 2/sangue , Angiopatias Diabéticas/sangue , Eritrócitos , Leucócitos , Idoso , Brasil/epidemiologia , Causas de Morte , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidade , Angiopatias Diabéticas/diagnóstico , Angiopatias Diabéticas/mortalidade , Nefropatias Diabéticas/sangue , Nefropatias Diabéticas/diagnóstico , Nefropatias Diabéticas/mortalidade , Neuropatias Diabéticas/sangue , Neuropatias Diabéticas/diagnóstico , Neuropatias Diabéticas/mortalidade , Retinopatia Diabética/sangue , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/mortalidade , Contagem de Eritrócitos , Feminino , Humanos , Contagem de Linfócitos , Linfócitos , Masculino , Pessoa de Meia-Idade , Contagem de Plaquetas , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
OBJECTIVE: To assess whether the presence of microvascular complications modifies the effect of intensive glucose reduction on long-term outcomes in patients with type 2 diabetes. PATIENTS AND METHODS: Using ACCORD and ACCORDION study data, we investigated the risk of the primary outcome (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death) or death in relation to the prerandomization type and extent of microvascular complications. Interaction terms were fitted in survival models to estimate the risk of both outcomes across levels of an overall microvascular disease score (range 0 to 100) and its individual components: diabetic nephropathy, retinopathy, and neuropathy. RESULTS: During a mean follow-up of 7.7 years, 1685 primary outcomes and 1806 deaths occurred in 9405 participants. The outcome-specific microvascular score was ≤30 in 97.9% of subjects for the primary outcome and in 98.5% for death. For participants with scores of 0 and 30, respectively, the 10-year absolute risk difference between intensive glucose control and standard treatment ranged from -0.8% (95% CI, -2.6, 1.1) to -3.0% -7.1, 1.1) for the primary outcome and from -0.5% (-2.1, 1.1) to 0.7% (-4.2, 5.6) for mortality. Retinopathy was associated with the largest effects, with a 10-year absolute risk difference of -6.5% (-11.1 to -2.0) for the primary outcome and -3.9% (-7.8 to 0.1) for mortality. CONCLUSION: This hypothesis-generating study identifies diabetic retinopathy as predictor of the beneficial effect of intensive glucose control on the risk of cardiovascular disease and possibly death. Further long-term studies are required to confirm these findings.
Assuntos
Doenças Cardiovasculares/etiologia , Diabetes Mellitus Tipo 2/complicações , Angiopatias Diabéticas/complicações , Doenças Cardiovasculares/mortalidade , Diabetes Mellitus Tipo 2/mortalidade , Diabetes Mellitus Tipo 2/terapia , Angiopatias Diabéticas/mortalidade , Retinopatia Diabética/complicações , Retinopatia Diabética/mortalidade , Feminino , Controle Glicêmico/mortalidade , Controle Glicêmico/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
This study investigates the associations between sodium intake and diabetes complications in a nationwide cohort of elderly Japanese patients with type 2 diabetes aged 65-85. Data from 912 individuals regarding their dietary intake at baseline is analyzed and assessed by the Food Frequency Questionnaire based on food groups. Primary outcomes are times to diabetic retinopathy, overt nephropathy, cardiovascular disease (CVD), and all-cause mortality during six years. We find that mean sodium intake in quartiles ranges from 2.5 g to 5.9 g/day. After adjustment for confounders, no significant associations are observed between sodium intake quartiles and incidence of diabetes complications and mortality, except for a significant trend for an increased risk of diabetic retinopathy (p = 0.039). Among patients whose vegetable intake was less than the average of 268.7 g, hazard ratios (HRs) for diabetic retinopathy in patients in the second, third, and fourth quartiles of sodium intake compared with the first quartile were 0.87 (95% CI, 0.31-2.41), 2.61 (1.00-6.83), and 3.70 (1.37-10.02), respectively. Findings indicate that high sodium intake under conditions of low vegetable intake is associated with an elevated incidence of diabetic retinopathy in elderly patients with type 2 diabetes.
Assuntos
Complicações do Diabetes/mortalidade , Diabetes Mellitus Tipo 2/mortalidade , Retinopatia Diabética/mortalidade , Sódio na Dieta/análise , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Complicações do Diabetes/etiologia , Diabetes Mellitus Tipo 2/complicações , Retinopatia Diabética/etiologia , Inquéritos sobre Dietas , Feminino , Humanos , Incidência , Japão/epidemiologia , Masculino , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Sódio na Dieta/efeitos adversosRESUMO
Objective: This study aimed to compare cause-specific mortality rates in patients with type 2 diabetes with and without various vascular complications. Methods: In Japanese hospitals, we followed up 30 834 patients with a mean age of 64.4 (standard deviation [SD]: 11.1) years. Patients were followed up from 2003 to 2007 for a median of 7.5 (interquartile range: 6.1-9.7) years. We calculated cause-specific mortality rates (number of deaths/1000 person-years) and confounder-adjusted hazard ratios in patients with macrovascular disease and in those with diabetic nephropathy, neuropathy and retinopathy, allowing for overlap of complications. Results: All-cause mortality rate was highest (51.4) in the nephropathy group, followed by the macrovascular disease group (45.2), the neuropathy group (39.5), the retinopathy group (38.7) and the nonvascular complication group (18.1). In the nephropathy group, morality rates of ischaemic heart, cerebrovascular, and infectious diseases and cancer were also highest among the groups. However, the cancer mortality rate was similar among the vascular complication groups. Relative to the nonvascular complication group, covariate-adjusted hazard ratios for ischaemic heart and cerebrovascular disease mortality were triple to quadruple in the macro- and microvascular complication groups. All-cause mortality rates rose exponentially according to age. Conclusion: Highest risks of all-cause, cancer, and ischaemic heart, infectious, and cerebrovascular disease mortality were determined in Japanese patients with diabetic nephropathy. Although cancer is the primary cause of death in Japanese patients with diabetes, cancer mortality rates are similar among those with and without vascular complications.
Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/mortalidade , Causas de Morte , Transtornos Cerebrovasculares/epidemiologia , Transtornos Cerebrovasculares/mortalidade , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/mortalidade , Angiopatias Diabéticas/epidemiologia , Angiopatias Diabéticas/mortalidade , Fatores Etários , Idoso , Estudos de Coortes , Comorbidade , Nefropatias Diabéticas/epidemiologia , Nefropatias Diabéticas/mortalidade , Neuropatias Diabéticas/epidemiologia , Neuropatias Diabéticas/mortalidade , Retinopatia Diabética/epidemiologia , Retinopatia Diabética/mortalidade , Feminino , Seguimentos , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-IdadeRESUMO
AIMS/HYPOTHESIS: This study explored the impact of ethnicity on time-to-clinic, time-to-treatment and rates of vision loss in people referred to hospital with diabetic eye disease. METHODS: A survival analysis was performed on all referrals from an inner-city diabetic eye screening programme to a tertiary hospital eye service between 1 October 2013 and 31 December 2017. Exclusion criteria were failure to attend hospital, distance visual acuity in both eyes too low to quantify with the Early Treatment Diabetic Retinopathy Study (ETDRS) letter chart and treatment received prior to referral. Demographic and screening grade data were collected at the point of referral. Small-area statistics and census data were used to calculate indices of multiple deprivation. The main outcome measures were time taken from the date of referral for an individual to achieve the following: (1) attend the first hospital clinic appointment; (2) receive the first macular laser, intravitreal anti-vascular endothelial growth factor injection or pan-retinal photocoagulation treatment, in either eye; and (3) lose at least ten ETDRS letters of distance visual acuity, in either eye. RESULTS: Of 2062 referrals, 1676 individuals were included. Mean age (± SD) was 57.6 ± 14.7 years, with 52% male sex and 86% with type 2 diabetes. The ethnicity profile was 52% Black, 30% White, 10% Asian and 9% mixed/other, with similar disease severity at the time of referral. Time-to-clinic was significantly longer for Asian people than for Black people (p = 0.03) or White people (p = 0.001). Time-to-treatment was significantly longer for Black people than for White people (p = 0.02). Social deprivation did not significantly influence time-to-treatment. There were no significant differences in the rates of vision loss between ethnic groups. CONCLUSIONS/INTERPRETATION: Black people wait longer for hospital eye treatment compared with their White counterparts. The reasons for this delay in treatment warrant further investigation.
Assuntos
Povo Asiático , População Negra , Retinopatia Diabética/etnologia , Retinopatia Diabética/terapia , Tempo para o Tratamento , Transtornos da Visão/etnologia , Transtornos da Visão/terapia , População Branca , Adulto , Idoso , Retinopatia Diabética/mortalidade , Retinopatia Diabética/fisiopatologia , Feminino , Conhecimentos, Atitudes e Prática em Saúde/etnologia , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/etnologia , Humanos , Londres/epidemiologia , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Prevalência , Encaminhamento e Consulta , Medição de Risco , Fatores de Risco , Determinantes Sociais da Saúde/etnologia , Fatores Socioeconômicos , Fatores de Tempo , Resultado do Tratamento , Saúde da População Urbana/etnologia , Transtornos da Visão/mortalidade , Transtornos da Visão/fisiopatologia , Acuidade VisualRESUMO
BACKGROUND: The prognostic significance of diabetic retinopathy (DR) for cardiovascular diseases (CVD) remained unclear. Therefore, we performed this meta-analysis to assess whether DR predicted CVD mortality in diabetic patients. METHODS: We searched PubMed, Embase, Web of Science and Cochrane Library for cohort studies reporting the association of DR and CVD mortality. Then we pooled the data for analysis. RESULTS: After screening the literature, 10 eligible studies with 11,239 diabetic subjects were finally included in quantitative synthesis. The pooled risk ratio (RR) of DR, mild DR, and severe DR for CVD mortality was 1.83 (95% confidence interval (CI): 1.42, 2.36; p < 0.001), 1.13 (95% CI 0.81, 1.59; p = 0.46), and 2.26 (1.31, 3.91; p = 0.003), respectively, compared to those without DR. In type 2 DM, the patients with DR had a significantly higher CVD mortality (RR: 1.69; 95% CI 1.27, 2.24; p < 0.001). Subgroup analysis also showed a significantly higher CVD mortality in DR according to various regions, study design, data source, and follow-up period (all RR > 1; all P values < 0.05). Data from 2 studies showed no significant correlation of DR and CVD mortality in diabetic patients receiving cardiovascular surgery (RR: 2.40; 95% CI 0.63, 9.18; P = 0.200). CONCLUSIONS: DR is a risk marker of cardiovascular death, and severe DR predicts a doubled mortality of CVD in diabetes. These findings indicate the importance of early identification and management of diabetic patients with DR to reduce the risk of death.
Assuntos
Doenças Cardiovasculares/mortalidade , Retinopatia Diabética/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/diagnóstico , Causas de Morte , Retinopatia Diabética/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND: Microangiopathy in type 2 diabetes (T2D) is associated with cardiovascular disease (CVD), but most relevant studies were performed > 10 years ago. CVD risk factor management has since improved. The aim of this study was to determine whether diabetic retinopathy (DR) and its severity increases stroke and myocardial infarction (MI) risk in a contemporary cohort. METHODS: Fremantle Diabetes Study Phase II participants with T2D had DR graded from fundus photography at baseline between 2008 and 2011. Subsequent hospitalizations and mortality for MI or stroke were ascertained through validated data linkage to end-2016. Cox regression modelling identified predictors of first stroke and MI including DR presence and severity. RESULTS: The 1521 participants with T2D and known DR status (mean age 65.6 years, 52.1% males, median diabetes duration 9.0 years) were followed for a mean of 6.6 years. After excluding those with prior MI/stroke, there were 126 incident MIs among 1393 eligible participants and 53 incident strokes in 1473 eligible participants, respectively. Moderate non-proliferative DR (NPDR) or worse was significantly and independently associated with an increased risk of incident stroke (adjusted hazard ratio 2.55 (95% CI 1.19, 5.47), p = 0.016). Retinopathy presence and severity increased the risk of incident MI in unadjusted models (p ≤ 0.001), but these associations were no longer statistically significant after adjusting for other risk factors. CONCLUSIONS: Moderate NPDR or worse was associated with an increased risk of first stroke in Australians with T2D. Intensified CVD risk factor management should be considered for patients with at least moderate NPDR.
Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Retinopatia Diabética/epidemiologia , Infarto do Miocárdio/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidade , Diabetes Mellitus Tipo 2/terapia , Retinopatia Diabética/diagnóstico , Retinopatia Diabética/mortalidade , Retinopatia Diabética/terapia , Feminino , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Austrália Ocidental/epidemiologiaRESUMO
BACKGROUND: Microvascular complications (MC) have been claimed to increase the risk for cardiovascular disease in diabetic subjects. However, the effect of MC burden on the risk of major vascular outcomes and all-cause mortality in type 1 diabetes is still poorly explored. We evaluated the relationship between microvascular complications burden and incidence of major cardiovascular events and all-cause mortality in subjects with type 1 diabetes. METHODS: We recruited 774 participants with type 1 diabetes in a single-center observational study over a follow-up of 10.8 ± 2.5 years. Hazard ratios (HR) for cardiovascular outcomes and all-cause death associated with microvascular complications were determined by unadjusted and adjusted Cox regression analysis. RESULTS: Out of 774 individuals, 54.9% had no-MC, 32.3% 1 MC, 9.7% 2 MC and 3.1% 3 MC. A total of 54 deaths (7.0%) occurred. Death rate increased from no-MC 2.1% (Ref) to 1 MC 7.2% (HR 3.54 [95% CI 1.59-7.87]), 2 MC 14.7% (HR 6.41 [95% CI 2.65-15.49]) and 3 MC 66.7% (HR 41.73 [95% CI 18.42-94.57], p < 0.0001). After adjustments, HRs were: 1 MC 2.05 (95% CI 0.88-4.76), 2 MC 1.98 (95% CI 0.75-5.21), 3 MC 7.02 (95% CI 2.44-20.20, p = 0.002). Forty-nine subjects (6.7%) had at least one cardiovascular event, and cumulative incidence went from no-MC 2.2% (Ref) to 1 MC 5.0%; (HR 2.27 [95% CI 0.96-5.38]), 2 MC 26.8% (HR 12.88 [95% CI 5.82-28.50]) and 3 MC 40.9% (HR 29.34 [95% CI 11.59-74.25], p < 0.0001). Upon adjustments, HRs were: 1 MC 1.59 (95% CI 0.65-3.88), 2 MC 4.33 (95% CI 1.75-10.74), 3 MC 9.31 (95% CI 3.18-27.25, p < 0.0001). Thirty-five individuals (4.8%) had at least one coronary event, which cumulative incidence increased with MC burden (p < 0.0001). CONCLUSIONS: In type 1 diabetes, microvascular complications burden increases in an independent dose-dependent manner the risk of major cardiovascular outcomes and all-cause mortality. The presence and number of microvascular complications should be considered in stratifying overall cardiovascular risk in type 1 diabetes.
Assuntos
Diabetes Mellitus Tipo 1/mortalidade , Nefropatias Diabéticas/mortalidade , Neuropatias Diabéticas/mortalidade , Retinopatia Diabética/mortalidade , Adulto , Idoso , Causas de Morte , Estudos Transversais , Diabetes Mellitus Tipo 1/diagnóstico , Nefropatias Diabéticas/diagnóstico , Neuropatias Diabéticas/diagnóstico , Retinopatia Diabética/diagnóstico , Feminino , Seguimentos , Humanos , Incidência , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
Survival models incorporating random effects to account for unmeasured heterogeneity are being increasingly used in biostatistical and applied research. Specifically, unmeasured covariates whose lack of inclusion in the model would lead to biased, inefficient results are commonly modeled by including a subject-specific (or cluster-specific) frailty term that follows a given distribution (eg, gamma or lognormal). Despite that, in the context of parametric frailty models, little is known about the impact of misspecifying the baseline hazard or the frailty distribution or both. Therefore, our aim is to quantify the impact of such misspecification in a wide variety of clinically plausible scenarios via Monte Carlo simulation, using open-source software readily available to applied researchers. We generate clustered survival data assuming various baseline hazard functions, including mixture distributions with turning points, and assess the impact of sample size, variance of the frailty, baseline hazard function, and frailty distribution. Models compared include standard parametric distributions and more flexible spline-based approaches; we also included semiparametric Cox models. The resulting bias can be clinically relevant. In conclusion, we highlight the importance of fitting models that are flexible enough and the importance of assessing model fit. We illustrate our conclusions with two applications using data on diabetic retinopathy and bladder cancer. Our results show the importance of assessing model fit with respect to the baseline hazard function and the distribution of the frailty: misspecifying the former leads to biased relative and absolute risk estimates, whereas misspecifying the latter affects absolute risk estimates and measures of heterogeneity.
Assuntos
Modelos Estatísticos , Análise de Sobrevida , Retinopatia Diabética/mortalidade , Retinopatia Diabética/terapia , Humanos , Método de Monte Carlo , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Tamanho da Amostra , Neoplasias da Bexiga Urinária/tratamento farmacológico , Neoplasias da Bexiga Urinária/mortalidadeRESUMO
OBJECTIVE: To estimate the association between (1) visual impairment (VI) and (2) eye disease and 6-year mortality risk within a cohort of elderly Kenyan people. DESIGN, SETTING AND PARTICIPANTS: The baseline of the Nakuru Posterior Segment Eye Disease Study was formed from a population-based survey of 4318 participants aged ≥50 years, enrolled in 2007-2008. Ophthalmic and anthropometric examinations were undertaken on all participants at baseline, and a questionnaire was administered, including medical and ophthalmic history. Participants were retraced in 2013-2014 for a second examination. Vital status was recorded for all participants through information from community members. Cumulative incidence of mortality, and its relationship with baseline VI and types of eye disease was estimated. Inverse probability weighting was used to adjust for non-participation. PRIMARY OUTCOME MEASURES: Cumulative incidence of mortality in relation to VI level at baseline. RESULTS: Of the baseline sample, 2170 (50%) were re-examined at follow-up and 407 (10%) were known to have died (adjusted risk of 11.9% over 6 years). Compared to those with normal vision (visual acuity (VA) ≥6/12, risk=9.7%), the 6-year mortality risk was higher among people with VI (<6/18 to ≥6/60; risk=28.3%; risk ratio (RR) 1.75, 95% CI 1.28 to 2.40) or severe VI (SVI)/blindness (<6/60; risk=34.9%; RR 1.98, 95% CI 1.04 to 3.80). These associations remained after adjustment for non-communicable disease (NCD) risk factors (mortality: RR 1.56, 95% CI 1.14 to 2.15; SVI/blind: RR 1.46, 95% CI 0.80 to 2.68). Mortality risk was also associated with presence of diabetic retinopathy at baseline (RR 3.18, 95% CI 1.98 to 5.09), cataract (RR 1.26, 95% CI 0.95 to 1.66) and presence of both cataract and VI (RR 1.57, 95% CI 1.24 to 1.98). Mortality risk was higher among people with age-related macular degeneration at baseline (with or without VI), compared with those without (RR 1.42, 95% CI 0.91 to 2.22 and RR 1.34, 95% CI 0.99 to 1.81, respectively). CONCLUSIONS: Visual acuity was related to 6-year mortality risk in this cohort of elderly Kenyan people, potentially because both VI and mortality are related to ageing and risk factors for NCD.
Assuntos
Oftalmopatias/mortalidade , Transtornos da Visão/mortalidade , Idoso , Catarata/mortalidade , Retinopatia Diabética/mortalidade , Feminino , Seguimentos , Humanos , Quênia/epidemiologia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores de RiscoRESUMO
PURPOSE: To estimate prevalence and severity of diabetic retinopathy (DR) among U.S. adults with diabetes and with or without chronic kidney disease (CKD), and assess associated risk of mortality. DESIGN: Cross-sectional study with national survey data. METHODS: The cohort included adults ≥40 years old with diabetes in the National Health and Nutrition Examination Surveys (NHANES) 2005-2008. Vital status was determined through December 31, 2011. We defined diabetes as hemoglobin A1c ≥6.5% or self-report and CKD by urinary albumin/creatinine ≥30 mg/g or glomerular filtration rate <60 mL/min/1.73 m2. The main outcomes were DR and mortality. RESULTS: Prevalence of DR was 27.8% (95% CI 24.3-31.7), 36.2% (95%CI 30.1-42.7), and 23.4% (95% CI 19.2-28.1), overall, with and without CKD. Prevalence of vision-threatening DR was 4.2% (95% CI 3.2-5.5), 8.2% (95% CI 5.4-12.2), and 2.0% (95% CI 1.2-3.5), respectively. In a multivariable adjusted model, DR was positively but nonsignificantly associated with CKD (OR = 1.1, 95% CI 0.7-1.7), was 40% higher per 1% increase in hemoglobin A1c (OR = 1.4, 95% CI 1.1-1.6), was 30% higher per 5 years additional diabetes duration (OR = 1.3, 95% CI 1.1-1.5), was 30% higher per 10 mm Hg increase in systolic blood pressure (OR = 1.3, 95% CI 1.1-1.5), and was 6-fold higher with insulin treatment (OR = 6.2, 95% CI 2.6-14.8). Compared with diabetic participants with neither DR nor CKD, those with DR and CKD had a 3.6-fold (95% CI 1.5-9.1) increased adjusted risk for all-cause mortality. CONCLUSIONS: Over one third of persons with diabetes and CKD had DR. The risk of death was higher with than without CKD and DR. Many of the studied risk factors associated with DR are modifiable.
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Diabetes Mellitus/epidemiologia , Retinopatia Diabética/mortalidade , Insuficiência Renal Crônica/epidemiologia , Idoso , Albuminúria/diagnóstico , Pressão Sanguínea , Creatinina/urina , Estudos Transversais , Diabetes Mellitus/diagnóstico , Retinopatia Diabética/diagnóstico , Feminino , Taxa de Filtração Glomerular , Hemoglobinas Glicadas/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais , Prevalência , Insuficiência Renal Crônica/diagnóstico , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
AIMS/HYPOTHESIS: The role of burden and duration of multiple microvascular complications on mortality rate has not been explored in detail in type 1 diabetes. Taking complication burden and time-updated duration into account we aimed to quantify mortality rate in individuals with and without microvascular complications. METHODS: This observational clinical cohort included 3828 individuals with type 1 diabetes attending the Steno Diabetes Center Copenhagen in 2001-2013. We used information on mortality and detailed clinical measures of microvascular complications from electronic patient records. Poisson models were used to model mortality rates according to complication burden. RESULTS: During 26,665 person-years of follow-up, 503 deaths occurred. Compared with individuals without microvascular complications, the mortality rate ratio was 2.20 (95% CI 1.79, 2.69) for individuals with diabetic kidney disease, 1.72 (95% CI 1.39, 2.12) for individuals with neuropathy and 1.02 (95% CI 0.77, 1.37) for individuals with retinopathy, all adjusted for calendar time (year/month/day), age, duration of diabetes, sex, HbA1c, LDL-cholesterol, BMI, smoking status, systolic blood pressure, use of antihypertensive and lipid-lowering medication, and cardiovascular disease status. In individuals with two complications or more, the risk of mortality did not exceed the combined risk from each individual complication. Mortality rate ratios increased immediately after diagnosis of neuropathy and diabetic kidney disease. Mortality rate ratios were independent of the duration of neuropathy and retinopathy, while the mortality rate associated with diabetic kidney disease reached a stable level after approximately 3 years. CONCLUSIONS/INTERPRETATION: Neuropathy and diabetic kidney disease are strong and independent risk markers of mortality in type 1 diabetes, whereas no evidence of higher mortality rate was found for retinopathy. We found no indication that the mortality risk with multiple complications exceeds the risk conferred by each complication separately. The duration spent with microvascular complications had only a marginal effect on mortality.
Assuntos
Diabetes Mellitus Tipo 1/mortalidade , Diabetes Mellitus Tipo 1/terapia , Microcirculação , Adolescente , Adulto , Anti-Hipertensivos/uso terapêutico , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/mortalidade , Dinamarca , Angiopatias Diabéticas/mortalidade , Nefropatias Diabéticas/mortalidade , Neuropatias Diabéticas/mortalidade , Retinopatia Diabética/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Adulto JovemRESUMO
IMPORTANCE: Five-year survival rates in patients undergoing vitrectomy for diabetic retinopathy (DR) vary from 68% to 95%. No study has been conducted in an Australian population. BACKGROUND: We aimed to determine the survival rates of patients undergoing diabetic vitrectomy in an Australian population. DESIGN: Retrospective audit, tertiary centre hospitals and private practices. PARTICIPANTS: All individuals in South Australia and the Northern Territory who underwent their first vitrectomy for diabetic complications between January 1, 2007 and December 31, 2011. METHODS: An audit of all eligible participants has been completed previously. Survival status as of July 6, 2018 and cause of death were obtained using SA/NT DataLink. Kaplan-Meier survival curves and multivariate cox-regressions were used to analyse survival rates and identify risk factors for mortality. MAIN OUTCOME MEASURES: Five-, seven- and nine-year survival rates. RESULTS: The 5-, 7- and 9-year survival rates were 84.4%, 77.9% and 74.7%, respectively. The most common cause of death was cardiovascular disease. Associated with increased mortality independent of age were Indigenous ethnicity (HR = 2.04, 95% confidence interval [CI]: 1.17-3.57, P = 0.012), chronic renal failure (HR = 1.76, 95% CI: 1.07-2.89, P = 0.026) and renal failure requiring dialysis (HR = 2.32, 95% CI: 1.25-4.32, P = 0.008). CONCLUSIONS AND RELEVANCE: Long-term survival rates after diabetic vitrectomy in Australia are similar to rates reported in other populations. Indigenous ethnicity and chronic renal failure were the most significant factors associated with long-term mortality. This information can guide allocation of future resources to improve the prognosis of these high risk groups.