Ethnicity Does Not Influence Glycemic Outcomes or Diabetes Remission After Sleeve Gastrectomy or Gastric Bypass in a Multiethnic Asian Cohort

Background

In Asia, metabolic-bariatric surgery (MBS) rates have grown rapidly in parallel with rising prevalence of obesity and type 2 diabetes (T2D).

Objective

The objective of this study was to identify factors that influence glycemic outcomes and diabetes remission 12 months after sleeve gastrectomy (SG) or gastric bypass (GB) in a multiethnic Asian cohort.

Setting

The study’s setting was in a tertiary hospital in Singapore.

Methods

Data from 145 T2D patients who had SG (37%) or GB (63%) and at least 1-year follow-up were analyzed. Diabetes remission was defined as hemoglobin A1c ≤?6.0% without diabetes medications. Analysis involved binary logistic regression to identify predictors and general linear regression for variables associated with glycemic improvement after surgery.

Results

Baseline parameters are as follows: BMI 40.0?±?7.6 kg/m², A1c 8.4?±?1.6%, diabetes duration 9.3 years, ethnic composition: Chinese (51.7%), Malay (23.4%), Indian (20.7%), Others (4.1%). 55.9% achieved diabetes remission at 1 year. Baseline A1c, baseline BMI, and diabetes duration were significant pre-operative factors for remission (cumulative R ²?=?0.334). At 12 months, percentage weight loss was similar after SG (24.1?±?7.4%) and GB (25.4?±?7.4%, p?=?0.31). Greater A1c decrease was seen with GB compared to SG (2.7?±?1.6 vs 2.0?±?1.5%, p?=?0.006), significant even after adjustment for weight loss, age, BMI, baseline A1c, and diabetes duration (p?=?0.033). Weight loss at 12 months also correlated independently with A1c reduction. Ethnicity did not influence weight loss, diabetes remission, or glycemic control after MBS.

Conclusion

Baseline A1c, baseline BMI, and diabetes duration independently predict diabetes remission after MBS. GB is more effective in controlling T2D compared to SG despite similar weight loss, whereas ethnicity does not play a significant role in the multiethnic Asian cohort.

     

Cause-Specific Mortality Trends in a Large Population-Based Cohort With Long-Standing Childhood-Onset Type 1 Diabetes

OBJECTIVE

Little is known concerning the primary cause(s) of mortality in type 1 diabetes responsible for the excess mortality seen in this population.

RESEARCH DESIGN AND METHODS

The Allegheny County (Pennsylvania) childhood-onset (age <18 years) type 1 diabetes registry (n = 1,075) with diagnosis from 1965 to 1979 was used to explore patterns in cause-specific mortality. Cause of death was determined by a mortality classification committee of at least three physician epidemiologists, based on the death certificate and additional records surrounding the death.

RESULTS

Vital status for 1,043 (97%) participants was ascertained as of 1 January 2008, revealing 279 (26.0%) deaths overall (141 females and 138 males). Within the first 10 years after diagnosis, the leading cause of death was acute diabetes complications (73.6%), while during the next 10 years, deaths were nearly evenly attributed to acute (15%), cardiovascular (22%), renal (20%), or infectious (18%) causes. After 20 years'' duration, chronic diabetes complications (cardiovascular, renal, or infectious) accounted for >70% of all deaths, with cardiovascular disease as the leading cause of death (40%). Women (P < 0.05) and African Americans (P < 0.001) have significantly higher diabetes-related mortality rates than men and Caucasians, respectively. Standardized mortality ratios (SMRs) for non–diabetes-related causes do not significantly differ from the general population (violent deaths: SMR 1.2, 95% CI 0.6–1.8; cancer: SMR 1.2, 0.5–2.0).

CONCLUSIONS

The excess mortality seen in type 1 diabetes is almost entirely related to diabetes and its comorbidities but varies by duration of diabetes and particularly affects women and African Americans.Mortality rates for type 1 diabetes are much higher than in the general population in the U.S. and worldwide (1–3). Understanding the primary cause(s) of this excess mortality is essential for developing interventions to decrease mortality rates in type 1 diabetes. This excess mortality has been attributed both to acute diabetes complications as well as to chronic diabetic renal and cardiovascular disease (CVD). Previous reports have shown that renal disease is the principal cause of mortality in the first 20 years of type 1 diabetes; subsequently, CVD predominates (4–6).Only a handful of recent reports address cause-specific mortality in population-based type 1 diabetes cohorts (7–12) and even fewer have long-term follow-up (>15 years) (10,11). A recent Norwegian 20-year follow-up report addressed long-term cause-specific mortality in 1,906 individuals with childhood-onset type 1 diabetes (standardized mortality ratio [SMR] = 4.0) (11) and found that, before age 30 years, acute complications was the leading cause of death in this cohort, whereas, after age 30 years, CVD was predominant, consistent with findings from the large Diabetes U.K. Study (12). The Diabetes U.K. Study classified type 1 diabetes as insulin treatment before age 30 years (n = 23,752), and based on death certificate data alone, found that acute metabolic complications predominated before age 30 years, but again thereafter, CVD becomes the leading cause. Aside from the current study, the Norwegian study is the only other long-term type 1 diabetes study to investigate deaths using available clinical data in addition to death certificate data.Findings from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study suggest that the incidence of end-stage renal disease has declined quite markedly, whereas the incidence of coronary artery disease remains relatively unchanged over 30 years in individuals with type 1 diabetes (13). This is of particular interest, since renal disease is thought to be the major driver of CVD in type 1 diabetes (14).Herein, we explore cause-specific mortality trends by sex, race, and calendar year of diagnosis to determine how type 1 diabetes mortality is changing over time using a large population-based type 1 diabetes cohort in Allegheny County (Pittsburgh), Pennsylvania (diagnosis 1965–1979). Apart from a race-specific analysis where this cohort was combined with the Pittsburgh EDC study, cause-specific mortality has not been formally evaluated in this population since 1985 (15). We specifically examine whether the percentage of renal-related cardiovascular deaths is changing over time as well as other cause-specific patterns.     

Distal Pancreatectomy: Incidence of Postoperative Diabetes

Introduction  Distal pancreatectomy is an accepted and safe procedure for lesions of the body and tail of the pancreas. Limited resections, including central pancreatectomy, have recently been advocated as possible strategies to preserve pancreatic endocrine function. The true rate of diabetes after distal pancreatectomy is not known, but we hypothesize that the risk is nominal. Materials and Methods  We reviewed 125 consecutive patients who underwent distal pancreatectomy between January 1, 1992, and March 31, 2006. Results  Of these 125 patients, 27 (21.6%) had an islet cell tumor, 25 (20%) adenocarcinoma, 24 (18.4%) serous cystic neoplasm, 19 (15.2%) mucinous cystic neoplasm, 11 (8.8%) chronic pancreatitis, and eight (6.4%) intraductal papillary mucinous neoplasm. In addition to the distal pancreatectomy, 105 (84%) of the patients underwent splenectomy and 12 (9.6%) a concomitant liver resection. The median operative time was 232 min and median blood loss 250 cc. Postoperative complications occurred in 44 (35.2%) patients (12% fistula), and there was one death. Fourteen patients had known type 2 diabetes preoperatively. Discussions  With a median follow-up of 21 months, 10 (9%) of previously nondiabetic patients developed new onset diabetes. There was a trend toward increased risk of new onset diabetes among patients with pancreatitis (odds ratio, 2.9). In the absence of pancreatitis, the rate was 7.5%. Length of hospitalization was greater for patients with new onset diabetes (9.4 vs 7.5, P < .05). Neither demographics, diagnosis, nor operative statistics impacted the risk of postoperative diabetes. Conclusion  We conclude that the rate of clinically apparent new onset diabetes after distal pancreatectomy is minimal. Alternative pancreatic resections aimed at preserving pancreatic mass are likely to be unwarranted.     

Assessment of Sex Differences in Fracture Risk Among Patients With Anorexia Nervosa: A Population‐Based Cohort Study Using The Health Improvement Network

Though previous studies have demonstrated an increased fracture risk in females with anorexia nervosa (AN), fracture risk in males is not well characterized. The objective of this study was to examine sex differences in fracture risk and site‐specific fracture incidence in AN. We performed a population‐based retrospective cohort study using The Health Improvement Network (THIN; a large database of anonymized electronic medical records collected at primary care clinics throughout the United Kingdom). The median calendar year for the start of the observation period was 2004–2005. We identified 9239 females and 556 males <60 years of age with AN, and 97,889 randomly selected sex‐, age‐, and practice‐matched participants without eating disorders (92,329 females and 5560 males). Multivariable Cox regression was used to estimate the hazard ratio (HR) for incident fracture. Median age at start of observation was 29.8 years in females and 30.2 years in males. The HR for fracture associated with AN differed by sex and age (interaction p = 0.002). Females with AN had an increased fracture risk at all ages (HR, 1.59; 95% confidence interval [CI], 1.45 to 1.75). AN was associated with a higher risk of fracture among males >40 years of age (HR, 2.54; 95% CI, 1.32 to 4.90; p = 0.005) but not among males ≤40 years. Females with AN had a higher risk of fracture at nearly all anatomic sites. The greatest excess fracture risk was noted at the hip/femur (HR, 5.59; 95% CI, 3.44 to 9.09) and pelvis (HR, 4.54; 95% CI, 2.42 to 8.50) in females and at the vertebrae (HR, 7.25; 95% CI, 1.21 to 43.45) for males with AN. AN was associated with higher incident fracture risk in females across all age groups and in males >40 years old. Sites of highest fracture risk include the hip/femur and pelvis in females and vertebrae in males with AN. © 2016 American Society for Bone and Mineral Research.     

The Incidence of Cancer in a Population‐Based Cohort of Canadian Heart Transplant Recipients

To assess the long‐term risk of developing cancer among heart transplant recipients compared to the Canadian general population, we carried out a retrospective cohort study of 1703 patients who received a heart transplant between 1981 and 1998, identified from the Canadian Organ Replacement Register database. Vital status and cancer incidence were determined through record linkage to the Canadian Mortality Database and Canadian Cancer Registry. Cancer incidence rates among heart transplant patients were compared to those of the general population. The observed number of incident cancers was 160 with 58.9 expected in the general population (SIR = 2.7, 95% CI = 2.3, 3.2). The highest ratios were for non‐Hodgkin's lymphoma (NHL) (SIR = 22.7, 95% CI = 17.3, 29.3), oral cancer (SIR = 4.3, 95% CI = 2.1, 8.0) and lung cancer (SIR = 2.0, 95% CI = 1.2, 3.0). Compared to the general population, SIRs for NHL were particularly elevated in the first year posttransplant during more recent calendar periods, and among younger patients. Within the heart transplant cohort, overall cancer risks increased with age, and the 15‐year cumulative incidence of all cancers was estimated to be 17%. There is an excess of incident cases of cancer among heart transplant recipients. The relative excesses are most marked for NHL, oral and lung cancer.     

Improvements in the Life Expectancy of Type 1 Diabetes: The Pittsburgh Epidemiology of Diabetes Complications Study Cohort

Survival in type 1 diabetes has improved, but the impact on life expectancy in the U.S. type 1 diabetes population is not well established. Our objective was to estimate the life expectancy of the Pittsburgh Epidemiology of Diabetes Complications (EDC) study cohort and quantify improvements by comparing two subcohorts based on year of diabetes diagnosis (1950–1964 [n = 390] vs. 1965–1980 [n = 543]). The EDC study is a prospective cohort study of 933 participants with childhood-onset (aged <17 years) type 1 diabetes diagnosed at Children’s Hospital of Pittsburgh from 1950 to 1980. Mortality ascertainment was censored 31 December 2009. Abridged cohort life tables were constructed to calculate life expectancy. Death occurred in 237 (60.8%) of the 1950–1964 subcohort compared with 88 (16.2%) of the 1965–1980 subcohort. The life expectancy at birth for those diagnosed 1965–1980 was ∼15 years greater than participants diagnosed 1950–1964 (68.8 [95% CI 64.7–72.8] vs. 53.4 [50.8–56.0] years, respectively) (P < 0.0001); this difference persisted regardless of sex or pubertal status at diagnosis. This improvement in life expectancy emphasizes the need for insurance companies to update analysis of the life expectancy of those with childhood-onset type 1 diabetes because weighting of insurance premiums is based on outdated estimates.Several worldwide studies have shown that survival in type 1 diabetes has improved over time (1–9). However, formal assessments of life expectancy of people with type 1 diabetes are relatively rare, and the most recent we found was published in 2001, where Brown et al. (10) reported a life expectancy at birth of 59.7 years in a subset of the Canterbury Diabetes Registry (New Zealand) cohort diagnosed with diabetes when aged younger than 30 years and that began insulin therapy within 12 months of diagnosis. In 1999, Borch-Johnsen (3) reported an increase in life expectancy of 15 years over a 50-year period up to 1982 in a Danish type 1 diabetes cohort. The life expectancy of individuals with type 1 diabetes in the U.S. seems to have been last formally assessed in 1975 by Goodkin (11), who reported that life expectancy in type 1 diabetes (diagnosis age <15 years) was reduced 27 years compared with individuals without diabetes in a life insurance cohort. Using National Health Interview Survey data from 1984 to 2000, however, Narayan et al. (12) estimated that U.S. children diagnosed with diabetes at age 10 years lose an average of ∼19 life-years. Similarly, the estimated life expectancy for people with diabetes was 13 years less than people without diabetes in Ontario, Canada; however, this estimate included type 1 and type 2 diabetes (13).The Pittsburgh Epidemiology of Diabetes Complications (EDC) study cohort provides a unique opportunity to examine mortality and life-expectancy changes over time in a U.S. cohort with long-term (>30 years) follow-up, because the participants were all diagnosed with childhood-onset type 1 diabetes between 1950 and 1980. To determine if, and to what degree, life expectancy has improved, this article compares two subcohorts based on year of type 1 diabetes diagnosis (1950–1964 vs. 1965–1980). We further assess the representativeness of the EDC cohort by comparing the 1965–1980 subcohort with the population-based Allegheny County Type 1 Diabetes Registry (ACR) of childhood-onset type 1 diabetes.     

Posttransplant Diabetes Mellitus: Incidence and Risk Factors

Objective

Posttransplant diabetes mellitus (PTDM) is a common and serious complication of renal transplantation. Estimates of the incidence of PTDM after renal transplantation vary between 2% and 54%. The aim of the present study was to evaluate the incidence and risk factors for PTDM among our renal transplant patients.

Patients and Methods

In this study we evaluated 121 nondiabetic patients with end-stage renal disease (ESRD) who underwent kidney transplantation for the first time at our centers since 2005. All patients received the same protocol of immunosuppressive therapy. PTDM was defined according to the clinical practice recommendations of the American Diabetes Association.

Results

At 12 months following renal transplantation, 9.9% of patients developed PTDM. Patients with PTDM were significantly older (P = .013) and had higher body mass index (P = .001). There were significant differences (P ≤ .05) between PTDM and non-PTDM patients with respect to systolic blood pressure, serum triglycerides (TG), peritoneal dialysis as renal replacement therapy before transplantation, and duration of pretransplant dialysis therapy. Upon multivariate analysis, serum TG, systolic blood pressure, and body mass index were associated with PTDM (P ≤ .05).

Conclusions

The incidence at 12 months of PTDM among our renal transplant recipients was 9.9%. The most important factors associated with PTDM were serum TG, systolic blood pressure, and body mass index.     

Incidence of Post-transplantation Diabetes Mellitus Within 1 Year After Kidney Transplantation and Related Factors in Korean Cohort Study

BackgroundPost-transplantation diabetes mellitus (PTDM) is associated with a higher risk of mortality and graft loss. The reported incidence of PTDM after kidney transplantation (KT) varies from 10% to 74% and varies by country and ethnicity. There are few reports of nationwide cohort studies on PTDM incidence and related factors in Korea. The purpose of this study was to evaluate incidence of PTDM and related factors within 1 year after KT in Korea.MethodsThe KoreaN cohort study for Outcome in patients With Kidney Transplantation (KNOW-KT) enrolled 1080 recipients from July 2012 to August 2016. This study included 723 recipients, excluding 273 patients with pretransplant DM and 84 patients who were lost from follow-up within 1 year after KT.ResultsAmong 723 recipients, 85 (11.8%) recipients were diagnosed and treated with PTDM. Recipient age, HLA mismatches, hemoglobin A1c (HbA1c), waist-hip ratio (WHR), and use of prednisolone were significantly higher in PTDM group than the nondiabetic group. In the multivariable logistic regression analysis, independent risk factors for PTDM were older recipient age, higher WHR, and HbA1c before KT.ConclusionThe incidence of PTDM was 11.8% in a nationwide Korean cohort study. The factors related to the development of PTDM within 1 year after KT were older recipient age and higher WHR, and HbA1c levels before KT. In recipients with high WHR, it is important to control pretransplant abdominal obesity to prevent PTDM after KT.     

Predictors of Fracture While on Treatment With Oral Bisphosphonates: A Population‐Based Cohort Study

Although oral bisphosphonates (BPs) are highly effective in preventing fractures, some patients will fracture while on treatment. We identified predictors of such fractures in a population‐based cohort of incident users of oral BPs. We screened the Sistema d‘Informació per al Desenvolupament de l‘Investigació en Atenció Primària (SIDIAP) database to identify new users of oral BPs in 2006–2007. SIDIAP includes pharmacy invoice data and primary care electronic medical records for a representative 5 million people in Catalonia (Spain). Exclusion criteria were the following: Paget disease; <40 years of age; and any antiosteoporosis treatment in the previous year. A priori defined risk factors included age, gender, body mass index, vitamin D deficiency, smoking, alcohol drinking, preexisting comorbidities, and medications. Fractures were considered if they appeared at least 6 months after treatment initiation. “Fractures while on treatment” were defined as those occurring among participants persisting for at least 6 months and with an overall high compliance (medication possession ratio ≥80%). Fine and Gray survival models accounting for competing risk with therapy discontinuation were fitted to identify key predictors. Only 7449 of 21,385 (34.8%) participants completed >6 months of therapy. Incidence of fracture while on treatment was 3.4/100 person‐years (95% confidence interval [CI], 3.1–3.7). Predictors of these among patients persisting and adhering to treatment included: older age (subhazard ratio [SHR] for 60 to <80 years, 2.18 [95% CI, 1.70–2.80]; for ≥80 years, 2.5 [95% CI, 1.82–3.43]); previous fracture (1.75 [95% CI, 1.39–2.20] and 2.49 [95% CI, 1.98–3.13], in the last 6 months and longer, respectively); underweight, 2.11 (95% CI, 1.14–3.92); inflammatory arthritis, 1.46 (95% CI, 1.02–2.10); use of proton pump inhibitors (PPIs), 1.22 (95% CI, 1.02–1.46); and vitamin D deficiency, 2.69 (95% CI, 1.27–5.72). Even among high compliers, 3.4% of oral BP users will fracture every year. Older age, underweight, vitamin D deficiency, PPI use, previous fracture, and inflammatory arthritides increase risk. Monitoring strategies and/or alternative therapies should be considered for these patients. © 2014 American Society for Bone and Mineral Research.     

Incidence of Venous Thromboembolism After Bariatric Surgery: A Population-Based Cohort Study

Background

The incidence of venous thromboembolism (VTE) after bariatric surgery is uncertain.

Methods

Using the resources of the Rochester Epidemiology Project and the Mayo Bariatric Surgery Registry, we identified all residents of Olmsted County, Minnesota, with incident VTE after undergoing bariatric surgery from 1987 through 2005. Using the dates of bariatric surgery and VTE events, we determined the cumulative incidence of VTE after bariatric surgery by using the Kaplan–Meier estimator. Cox proportional hazards modeling was used to assess patient age, sex, weight, and body mass index as potential predictors of VTE after bariatric surgery.

Results

We identified 396 residents who underwent 402 bariatric operations. The most common operation was an open Roux-en-Y gastric bypass (n?=?228). Eight patients had VTE that developed within 6 months (7 within 1 month) after surgery; five events occurred after hospital discharge but within 1 month after bariatric surgery. The cumulative incidence of VTE at 7, 30, 90, and 180 days was 0.3, 1.9, 2.1, and 2.1 %, respectively (180-day 95 % confidence interval (CI), 0.7–3.6 %). Patient age was a predictor of postoperative VTE (hazard ratio, 1.89 per 10-year increase in age; 95 % CI, 1.01–3.55; P?=?0.05).

Conclusions

In our population-based study, bariatric surgery had a high risk of VTE, especially for older patients. Because most VTE events occurred after hospital discharge, a randomized controlled trial of extended outpatient thromboprophylaxis is warranted in patients undergoing open Roux-en-Y gastric bypass for medically complicated obesity.     

Estimated GFR and Incidence of Major Surgery: A Population-Based Cohort Study

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Clinical Risk Factors for Fracture in Diabetes: A Matched Cohort Analysis

The objective was to determine which individuals with diabetes are at increased risk for fracture. It is unknown whether traditional clinical risk factors (CRFs) can be used in this population to identify individuals at higher risk of fracture. Using the Manitoba Bone Density Program database, we identified 3054 diabetic women and 9151 matched nondiabetic controls. The independent association of specific CRFs with incident osteoporotic fracture risk was assessed separately in those with diabetes and in controls, with subsequent examination of the interaction between diagnosed diabetes and each CRF. Prior major fractures were more prevalent in the diabetic group compared with the nondiabetic group (16.2% vs 14.3%, p < 0.001). During mean 4 yr of observation, 259 (8.5%) of diabetic women and 559 (6.5%) of nondiabetic women experienced an incident major osteoporotic fracture (unadjusted hazard ratio [HR] for diabetes 1.49 [95% confidence interval (CI): 1.28–1.72], p < 0.001; adjusted HR 1.14 [95% CI: 1.10–1.18], p < 0.001). There were no significant differences between the 2 groups in the HRs for incident fracture associated with any of the CRFs studied (all p-for-interaction >0.1). Diabetes is a risk factor for major fracture. The ability of traditional CRFs to predict osteoporotic fractures is not influenced by the diagnosis of diabetes.