Diabetes screening among immigrants: a population-based urban cohort study

OBJECTIVE

To examine diabetes screening, predictors of screening, and the burden of undiagnosed diabetes in the immigrant population and whether these estimates differ by ethnicity.

RESEARCH DESIGN AND METHODS

A population-based retrospective cohort linking administrative health data to immigration files was used to follow the entire diabetes-free population aged 40 years and up in Ontario, Canada (N = 3,484,222) for 3 years (2004–2007) to determine whether individuals were screened for diabetes. Multivariate regression was used to determine predictors of having a diabetes test.

RESULTS

Screening rates were slightly higher in the immigrant versus the general population (76.0 and 74.4%, respectively; P < 0.001), with the highest rates in people born in South Asia, Mexico, Latin America, and the Caribbean. Immigrant seniors (age ≥65 years) were screened less than nonimmigrant seniors. Percent yield of new diabetes subjects among those screened was high for certain countries of birth (South Asia, 13.0%; Mexico and Latin America, 12.1%; Caribbean, 9.5%) and low among others (Europe, Central Asia, U.S., 5.1–5.2%). The number of physician visits was the single most important predictor of screening, and many high-risk ethnic groups required numerous visits before a test was administered. The proportion of diabetes that remained undiagnosed was estimated to be 9.7% in the general population and 9.0% in immigrants.

CONCLUSIONS

Overall diabetes-screening rates are high in Canada’s universal health care setting, including among high-risk ethnic groups. Despite this finding, disparities in screening rates between immigrant subgroups persist and multiple physician visits are often required to achieve recommended screening levels.Diabetes is a serious chronic disease that is associated with substantial increases in morbidity and mortality and imposes a huge economic burden on society. Although screening for diabetes is increasing in Canada (1), up to one-third of all diabetes subjects are thought to be undiagnosed in the general population in Canada and the U.S., an estimate that may now be out of date (2,3). One significant factor that is likely contributing to increased screening is the rising prevalence of obesity in the population.Early detection and control of diabetes can potentially reduce the heightened risk of cardiovascular morbidity and mortality associated with this disease. People with screen-detected diabetes have an increased risk of heart disease as compared with the general population, and this risk is modifiable with treatment (4–6). In addition, timely screening can prevent the onset of common diabetes-related complications that could be avoided through early detection and treatment (e.g., retinopathy, peripheral neuropathy, and peripheral vascular disease) (7).National guidelines in both the U.S. and Canada recommend that diabetes screening should be performed on those aged 45 years (U.S.) or 40 (Canada) years and over every 3 years, with more frequent or earlier screening for those with additional risk factors, including belonging to a high-risk ethnic group (8,9). Ethnic groups that have been shown to display an elevated risk for diabetes include people of South Asian (10–12), Aboriginal (13), and African-Caribbean descent (2,11). Many of the 250,000 immigrants to Canada every year (14) belong to ethnicities that experience higher rates of diabetes (11) and who therefore should be screened regularly and beginning at a younger age. There is evidence, however, that immigrants may have lower health care utilization (15), which may predispose this group to have lower rates of screening than the Canadian-born population. An important and currently unanswered question, therefore, is whether some ethnic or migrant groups are more likely to be underdiagnosed than others. In this study, we describe the pattern of diabetes screening among recent immigrants to Ontario by looking at screening rates, screening efficiency/yield, predictors of screening, and the burden of undiagnosed diabetes in this population by region of origin.     

Moraxella catarrhalis bacteremia: a 10-year experience

BACKGROUND: Moraxella catarrhalis commonly inhabits the upper respiratory tract and is a cause of acute otitis media and sinusitis in children. It is an infrequent cause of invasive disease. METHODS: We reviewed records of all patients with positive blood cultures for M catarrhalis admitted to our hospital during the 10-year period (1988 through 1997). RESULTS: Eleven cases were identified. Age range was 11 to 32 months. Four (44%) had risk factors for infection, including sickle cell disease (2), acquired immunodeficiency syndrome (AIDS) (1), and leukopenia (1). Upper respiratory symptoms and fever were present in all patients. Ten had acute otitis media, five had sinusitis, and three had pneumonia. All isolates were beta-lactamase producers. Treatment included intravenous cefuroxime (8), cefotaxime (2), and ceftazidime (1), followed by oral amoxicillin/clavulanate or cefuroxime axetil. CONCLUSION: Moraxella catarrhalis bacteremia should be considered in febrile young children with upper respiratory infections and/or acute otitis media especially in those with underlying immune dysfunction.     

Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study

Purpose  

As part of a larger nationwide enquiry into severe maternal morbidity, our aim was to assess the incidence and possible risk factors of obstetric intensive care unit (ICU) admission in the Netherlands.     

Urbanization and place of death for the elderly: a 10-year population-based study

OBJECTIVES: To explore the association between the place of death and the level of urbanization within the communities where the elderly were residing at the time of their death. METHODS: A retrospective, population-based, cross-sectional study set in Taiwan, involving a total of 697,814 eligible deaths occurred between 1995 and 2004, among elderly people (aged 65 years or above). RESULTS: After adjusting for other factors, the multilevel logistic regression analyses showed that home death was associated with lower levels of urbanization; as compared with participants living in the highest urbanization level (level 1), the respective adjusted odds of dying at home were 1.600, 2.769, 3.774, 4.481, 4.003 and 4.717 times for those living in the areas from the second highest to the lowest urbanization levels (levels 2-7). CONCLUSIONS: After adjusting for other socio-demographic, clinical and healthcare factors, the place of death has a significant association with the level of urbanization among the elderly.     

Cardiovascular Risk Attributable to Diabetes in Southern Brazil: A population-based cohort study

OBJECTIVE

To analyze the effect of diabetes on general and cardiovascular disease (CVD) mortality and morbidity in southern Brazil.

RESEARCH DESIGN AND METHODS

A population-based cohort study of 1,091 individuals was conducted. Diabetes was ascertained by medical history. The vital status of 982 individuals and the incidence of events were ascertained during another visit and through hospital records, death certificates, and verbal necropsy with relatives.

RESULTS

The mean ± SD age of participants was 43.1 ± 17 years, and 55.7% were women. The prevalence of diabetes was 4.2%, and the mean follow-up time was 5.3 ± 0.07 years. Mortality was 36.3% and 6.6% in participants with or without diabetes, respectively; the incidence of CVD was 20.8% and 3.0%, with an adjusted hazard ratio of 4.4 (95% CI 2.4–7.9). Diabetic population-attributable risk (PAR) for CVD mortality was 10.1% and 13.1% for total CVD.

CONCLUSIONS

Diabetes is responsible for a large PAR for overall mortality and cardiovascular events in Brazil.Approximately 2.2 million deaths worldwide from ischemic heart disease and stroke were attributed to high levels of blood glucose in 2001 (1). We describe the effect of diabetes on cardiovascular disease (CVD) morbidity and mortality in southern Brazil.     

Diabetes incidence in 0- to 14-year age-group in Italy: a 10-year prospective study

OBJECTIVE: The Registry for Type 1 Diabetes Mellitus in Italy (RIDI) Study Group was established to coordinate the registries of type 1 diabetes in Italy. This report is based on 3,606 children younger than 15 years diagnosed with type 1 diabetes and prospectively registered during 1990-1999 by nine centers, covering >35% of the Italian population. RESEARCH DESIGN AND METHODS: Registries were pooled in four geographic macro-areas: north, central, south, and insular. The completeness of registration was assessed by the capture-recapture method. Poisson regression analysis was used to evaluate temporal trend in incidence. RESULTS: Large variations in incidence were confirmed not only between Sardegna and the mainland but also among peninsular areas. In Sardegna, there was an excess of boys (the boy-to-girl incidence ratio was 1.4). The overall incidence showed average increases of 3.6% (P <0.001) and 3.7% (P <0.001) per year in peninsular Italy and in Sardegna, respectively. Significant increases in incidence rates were found in boys aged 10-14 years (6.7%, 95% CI 0.5-13.3) and in girls aged 5-9 years (6.6%, 0.5-13.1) living in the southern area. The incidence rate also increased in boys aged 10-14 years (5.0%, 0.3-10) and in girls aged 0-4 years (4.9%, 0.8-9.1) living in Sardegna. CONCLUSIONS: Italy is a country with large geographical variations in incidence rates of type 1 diabetes. However, the rates are evenly increasing both in the mainland and Sardegna, suggesting that similar environmental factors are operating over populations that have different genetic backgrounds.     

Diabetes as a predictor of change in functional status among older Mexican Americans: a population-based cohort study

OBJECTIVE: Epidemiological studies have demonstrated that older Mexican Americans are at high risk for type 2 diabetes and its complications. Type 2 diabetes leads to a more rapid decline in functional status among older Mexican Americans with diabetes. This study was designed to examine the impact of diabetes on change in self-reported functional status over a 2-year period among older Mexican Americans with diabetes. RESEARCH DESIGN AND METHODS: We performed a longitudinal analysis with repeated measurements of functional limitations in a cohort of Mexican Americans aged > or =60 years in the Sacramento Area Latino Study on Aging (SALSA). Diabetes was diagnosed on the basis of self-report of physician diagnosis, medication use, and fasting plasma glucose. Functional status was measured by assessment of activities of daily living (ADL) and instrumental activities of daily living (IADL) at baseline and 1 and 2 years. RESULTS: Of 1,789 SALSA participants, 585 (33%) had diabetes at baseline. Diabetic subjects reported 74% more limitations than nondiabetic subjects in ADL (summary score for number of limitations, 0.99 vs. 0.57; P = 0.002) and 50% more limitations in IADL (summary score for number of limitations, 7.83 vs. 5.25; P < 0.0001). The annual rate of increase in limitations of ADL and IADL was 0.046 and 0.033 (log scale) on each scale among diabetic subjects compared with 0.013 and 0.003 (log scale) among nondiabetic subjects (P < 0.0005). Complications of diabetes were found to increase ADL and IADL limitations among diabetic subjects. Longer duration of diabetes was also associated with an increase in ADL and IADL limitations. CONCLUSIONS: There was lower baseline functional status and a more rapid decline in functional status among older Mexican Americans with diabetes versus those without diabetes.     

The impact of statin use on pneumonia risk and outcome: a combined population-based case-control and cohort study

ABSTRACT: INTRODUCTION: The impact of statin use on pneumonia risk and outcome remains unclear. We therefore examined this risk in a population-based case-control study and did a 5-year update of our previous 30-day mortality analyses. METHODS: We identified 70,953 adults with a first-time hospitalization for pneumonia between 1997 and 2009 in Northern Denmark. Ten age- and sex-matched population controls were selected for each pneumonia patient. To control for potential confounders, we retrieved individual-level data on other medications, comorbidities, recent surgery, socioeconomic indicators, influenza vaccination, and other markers of frailty or health awareness from medical databases. We followed all pneumonia patients for 30 days after hospital admission. RESULTS: A total of 7,223 pneumonia cases (10.2%) and 64 523 controls (9.1%) were statin users before admission, corresponding to an age- and sex-matched odds ratio (OR) of 1.17 (95% confidence interval [CI]: 1.14-1.21). After controlling for higher comorbidity and a wide range of other potential confounders, the adjusted OR for pneumonia associated with current statin use dropped to 0.80 (95% CI: 0.77-0.83). Previous statin use was not associated with decreased pneumonia risk (adjusted OR = 0.97, 95% CI: 0.91-1.02). Decreased risk remained significant after further adjustment for frailty and health awareness markers.The prevalence of statin use among Danish pneumonia patients increased from 1% in 1997 to 24% in 2009. Thirty-day mortality following pneumonia hospitalization was 11.3% among statin users versus 15.1% among nonusers. This corresponded to a 27% reduced mortality rate (adjusted hazard ratio = 0.73, 95% CI: 0.67-0.79), corroborating our earlier findings. CONCLUSIONS: Current statin use was associated with both a decreased risk of hospitalization for pneumonia and lower 30-day mortality following pneumonia.     

Four-year prospective evaluation of community-acquired bacteremia: epidemiology, microbiology, and patient outcome.

The objectives of this study were to (1) describe the epidemiology and microbiology of community-acquired bacteremia; (2) determine the crude mortality associated with such infections; and (3) identify independent predictors of mortality. All patients with clinically significant community-acquired bacteremia admitted to a university-affiliated Veterans Affairs medical center from January 1994 through December 1997 were evaluated. During the study period, 387 bacteremic episodes occurred in 334 patients. Staphylococcus aureus, Escherichia coli, and coagulase-negative staphylococci were the most commonly isolated organisms; the most frequent sources were the urinary tract and intravascular catheters. Approximately 14% of patients died. Patient characteristics independently associated with increased mortality included shock (OR 3.7, p = 0.02) and renal failure (OR 4.0, p = 0.003). The risk of death was also higher in those whose source was pneumonia (OR 6.3, p = 0.03) or an intra-abdominal site (OR 10.7, p = 0.02), or if multiple sources were identified (OR 13.4, p = 0.003). Community-acquired bacteremia is often device-related and may be preventable. Strategies that have been successful in preventing nosocomial device-related bacteremia should be adapted to the outpatient setting.     

Acute Pancreatitis in Association With Type 2 Diabetes and Antidiabetic Drugs: A population-based cohort study

OBJECTIVE

Previous observational studies have found an increased risk of acute pancreatitis among type 2 diabetic patients. However, limited information is available on this association and specifically on the role of antidiabetic treatment. Our aim, therefore, was to further assess the risk of acute pancreatitis in adult patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We performed a population-based case-control analysis nested in a cohort of 85,525 type 2 diabetic patients and 200,000 diabetes-free individuals from the general population using data from The Health Improvement Network database. Subjects were followed up to ascertain incident cases of acute pancreatitis.

RESULTS

We identified 419 cases of acute pancreatitis, 243 in the general population and 176 in the diabetes cohort. Incidence rates were 30.1 and 54.0 per 100,000 person-years in the general population and the diabetes cohort, respectively. In the cohort analysis, the adjusted incidence rate ratio of acute pancreatitis in diabetic patients versus that in the general population was 1.77 (95% CI 1.46–2.15). The magnitude of this association decreased with adjustment for multiple factors in the nested case-control analysis (adjusted odds ratio 1.37 [95% CI 0.99–1.89]). Furthermore, we found that the risk of acute pancreatitis was decreased among insulin-treated diabetic patients (0.35 [0.20–0.61]).

CONCLUSIONS

Type 2 diabetes may be associated with a slight increase in the risk of acute pancreatitis. We also found that insulin use in type 2 diabetes might decrease this risk. Further research is warranted to confirm these associations.Acute pancreatitis is defined as an acute inflammatory process of the pancreas. The incidence of acute pancreatitis in the general population shows geographical variation. Incidence rates reported in the literature range between 4 and up to >100 cases per 100,000 person-years in the western world (1–3). Data from western countries suggest that the incidence of acute pancreatitis has been increasing over the last 40 years (3).The reason for this increase is unknown. However, a concurrent trend has been the rapid, worldwide increase in type 2 diabetes and obesity. Several clinical factors associated with type 2 diabetes and obesity are known or putative risk factors for acute pancreatitis (e.g., gallstone disease). Therefore, it can be hypothesized that in type 2 diabetic patients the risk of acute pancreatitis might be higher than that for the general population (2). Studies exploring whether diabetes or antidiabetic treatment may act as risk factors for the development of acute pancreatitis have been limited so far (2,4–6). Three observational studies reported an approximately two- to threefold increased risk of acute pancreatitis among diabetic patients (2,4,5). The purpose of this study was to further assess the risk of acute pancreatitis in association with type 2 diabetic patients and antidiabetic treatment.     

Diabetes and disenrollment in a health maintenance organization setting: a 4-year longitudinal study with a matched cohort.

OBJECTIVE: The increasing enrollment of Medicare beneficiaries in health maintenance organizations (HMOs) in recent years has caused concern about whether HMOs and their providers have created an unfavorable environment for members who are chronically ill. This study was designed to examine whether there are any differences in disenrollment rates among enrollees with diabetes and enrollees without diabetes. RESEARCH DESIGN AND METHODS: This was a 4-year longitudinal follow-up study with a matched cohort. Medicare beneficiaries (aged > or =65 years) with diabetes identified through pharmacy records in 1994 were matched with a comparison group according to age, sex, comorbidities, and type of provider groups in an HMO in California. RESULTS: The overall distribution of the characteristics of members in the diabetic and matched nondiabetic group is almost identical. The matched-pair chi2 tests indicated that there were no statistical differences in disenrollment rates between diabetic and nondiabetic members during all three follow-up periods (P = 0.16-0.85). CONCLUSIONS: We found that the HMO members with diabetes did not disenroll from the HMO at a higher rate than those without diabetes. The findings should alleviate some of the concern that HMOs and their contracted providers have created an unattractive environment for members who have chronic diseases such as diabetes.     

Association between interleukin 23 receptor polymorphism and kidney transplant outcomes: a 10-year Taiwan cohort study

ObjectiveInterleukin 23 receptor (IL-23R) plays a role in the pathogenesis of multiple autoimmune processes. The relationship between allograft outcomes and the IL-23Rvariant genotypes has not been reported on previously. Therefore, we examined the relationship between this genetic polymorphism and kidney transplant outcomes.MethodsThis is an observational cohort study and 422 renal transplant recipients (RTRs) were enrolled. Polymerase chain reaction-restriction fragment length polymorphism was used for the measurement of IL-23R genetic polymorphisms. We used a composite end-point incorporating serum creatinine (SCr) doubling, graft failure and death as the primary outcome. Secondary outcomes included biopsy-proven acute rejection (BPAR), biopsy-proven interstitial fibrosis/tubular atrophy (IF/TA) and individual primary outcome. The risks of developing primary and secondary outcomes were compared between the different IL-23R genotypes and alleles.ResultsWith a mean follow-up of 79.3 ± 28.8 months, 26 patients in the IL-23R genotype AA group and 32 patients in the IL-23R genotype AC/CC group reached the primary outcome (p = 0.061). RTRs who carried the IL-23R AC/CC genotype (aHR 1.78; 95% CI. 1.01–3.12; p = 0.046) and C allele (aHR 1.48; 95% CI. 0.96–2.28; p = 0.075) had a higher risk of developing primary outcome as compared to those with IL-23R AA genotype and A allele, respectively. Moreover, RTRs who carried the IL-23R AC/CC genotype and C allele had a higher risk of developing biopsy-proven IF/TA (p = 0.012; p = 0.012) and SCr doubling (p = 0.024; p = 0.042) as compared to those with IL-23R AA genotype and A allele, respectively. The risk of BPAR, graft failure and death between the IL-23R genotypes and alleles were comparable.ConclusionIL-23R polymorphism may have a potential immuno-modulating role in long-term allograft outcome.     

Diabetes and burns: retrospective cohort study

Burn injuries are often associated with multisystemic complications, even in otherwise healthy individuals. It is therefore intuitive that for the diabetic patient, the underlying pathophysiologic alterations in vascular supply, peripheral neuropathy, and immune function could have a profoundly devastating impact on patient outcome. The effects of diabetes on morbidity and mortality of the burn-injured patient have not been examined in great detail. The purpose of this retrospective study was to compare clinical outcomes between diabetic and nondiabetic burn patients. We reviewed the charts of 181 diabetic (DM) and 190 nondiabetic (nDM) patients admitted with burns between January 1996 and May 2000, matched by sex and date of admission. Burn cause and size, time to presentation, clinical course, and outcomes were evaluated. Because age was a factor, the analysis was done by three age groups: younger than 18 years, 18 to 65 years, and older than 65 years. Of patients 18 to 65 years, 51% (98/191) were diabetic, whereas 84% (81/96) of those older than 65 and only 4% (3/85) of patients younger than 18 were diabetic. Because of the disproportion in numbers of diabetics compared with nondiabetics in the younger than 18 and older than 65 years-old groups, these patients will not be discussed. Diabetics were more likely to incur scald injury from tub or shower water rather than hot fluid spills (33% DM vs 15% nDM; P < or = 0.01), and have a delayed presentation (45 vs 23%; P = 0.00001). There was no difference in total burn size in all groups. Diabetics in the 18 to 65 years group had a higher rate of full-thickness burns (51 vs 31%; P = 0.025), skin grafts (50 vs 28%; P = 0.01) and burn-related procedures (57 vs 32%; P = 0.001), infections (65 vs 51%; P = 0.05), and longer lengths of stay (23 vs 12 days; P = 0.0001). Although there was no statistically significant difference in incidence of specific infections, the rates of cellulitis, wound infection, urinary tract infection, line infection, and osteomyelitis, were consistently higher in the diabetic population. Partial graft slough was 6% in diabetics 18 to 65 years with a 3% regraft rate, whereas nondiabetics had a 1% regraft rate. Comparing diabetics with controlled vs uncontrolled glucose levels, diabetics with uncontrolled glucose had higher rates of infection (72 vs 55%; P < or = 0.025), all burn-related procedures (68 vs 45%; P < or = 0.025), and longer ICU stays (24 vs 10 days; P = 0.048). Mortality rate was 2% for diabetics and for nondiabetics. In summary, presence of diabetes in the burn patient was associated with a worse outcome. A predilection for burn injuries in the diabetic was noted in the older adult population. Deeper burns, delayed presentation, higher rates of infection, graft failure and operations, and longer lengths of stay translate into an increased cost to society both economically and in lives. This data would suggest a need for better burn education for diabetics and health care professionals, recognizing the elderly population as a "high-risk" group. We believe that targeted prevention measures and treatment strategies, emphasizing earlier and more aggressive intervention for this population, may have a favorable effect on morbidity and mortality.     

Gallstone pancreatitis and the effect of cholecystectomy: a population-based cohort study

Although an association between gallstones and pancreatitis has been recognized for almost 100 years, the risk of acute pancreatitis in patients with gallstones and the effect of cholecystectomy on this risk have been unknown. The complete medical records of the 2,583 residents of Rochester, Minnesota, who had gallstones diagnosed between 1950 and 1970 were carefully reviewed to detect the development of acute pancreatitis. Acute pancreatitis developed in only 89 subjects (3.4% of the cohort); however, the relative risk for acute pancreatitis (before cholecystectomy) was increased 14 to 35 times in men and 12 to 25 times in women. The overall age- and sex-adjusted incidence of acute pancreatitis of the members of the cohort before cholecystectomy was 6.3 to 14.8 per 1,000 person-years of follow-up. Cholecystectomy in 1,560 patients without a prior attack of pancreatitis reduced the relative risk to 1.9 and 2.0 for men and women respectively. Of 58 patients who had a cholecystectomy after an attack of acute pancreatitis and underwent follow-up for a median of 15 years postoperatively, only 2 had another attack of acute pancreatitis, and the cause of the pancreatitis was unrelated to gallstones in both. In summary, patients with gallstones have a considerably increased relative risk for acute pancreatitis and, regardless of whether prior attacks of pancreatitis have occurred, cholecystectomy reduces this risk to almost the same level as in the general population. Because the overall incidence of pancreatitis is low, however, performance of cholecystectomy to prevent pancreatitis is indicated only if an attack of acute pancreatitis has already occurred.     

Incidence of Lower-Limb Amputation in the Diabetic and Nondiabetic General Population: A 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations

OBJECTIVE—The purpose of this study was to compare the incidence of vascular lower-limb amputation (LLA) in the diabetic and nondiabetic general population.RESEARCH DESIGN AND METHODS—A population-based cohort study was conducted in a representative Swedish region. All vascular LLAs (at or proximal to the transmetatarsal level) performed from 1997 through 2006 were consecutively registered and classified into initial unilateral amputation, contralateral amputation, or reamputation. The incidence rates were estimated in the diabetic and nondiabetic general population aged ≥45 years.RESULTS—During the 10-year period, LLA was performed on 62 women and 71 men with diabetes and on 79 women and 78 men without diabetes. The incidence of initial unilateral amputation per 100,000 person-years was 192 (95% CI 145–241) for diabetic women, 197 (152–244) for diabetic men, 22 (17–26) for nondiabetic women, and 24 (19–29) for nondiabetic men. The incidence increased from the age of 75 years. Of all amputations, 74% were transtibial. The incidences of contralateral amputation and of reamputation per 100 amputee-years in diabetic women amputees were 15 (7–27) and 16 (8–28), respectively; in diabetic men amputees 18 (10–29) and 21 (12–32); in nondiabetic women amputees 14 (7–24) and 18 (10–28); and in nondiabetic men amputees 13 (6–22) and 24 (15–35).CONCLUSIONS—In the general population aged ≥45 years, the incidence of vascular LLA at or proximal to the transmetatarsal level is eight times higher in diabetic than in nondiabetic individuals. One in four amputees may require contralateral amputation and/or reamputation.Severe peripheral arterial disease indicating critical ischemia has been found in 1.2% of a general population aged ≥60 years (1) and in almost 5% of primary care patients aged ≥65 years (2). It has been reported that one in four diabetic individuals develops peripheral vascular disease that, when severe, may require amputation (3). Estimating the incidence of vascular lower-limb amputation (LLA) in diabetic and nondiabetic individuals can provide important information regarding changes in the incidence over time. This can assist in the planning of preventative care and rehabilitation and facilitate assessment of the effects of interventions, such as arterial reconstruction and amputation at specific levels, and the success of prosthetic rehabilitation (4,5).The reported annual incidence of LLA related to peripheral vascular disease has ranged from approximately 20 to 35 per 100,000 inhabitants (5,6). These incidence rates were usually based on the total population rather than on age-groups of the diabetic or the nondiabetic general population in which severe peripheral vascular disease usually occurs (7). Furthermore, different definitions and incidence estimation methods have been used, and problems of incorrectly registered diagnoses and missing data have been described (3,8). Individuals with diabetes have accounted for less than half of all patients with LLA in studies from Finland and Sweden (5,9) but for as much as two-thirds of patients with LLA in a German general population study (6).Compared with amputations in nondiabetic individuals, amputations due to diabetes have more often involved younger individuals and lower amputation levels (10). Because vascular LLA in diabetic and nondiabetic individuals may differ with regard to patient characteristics, initial amputation level, clinical management, and prognosis (including mortality rates), it is important to study the epidemiology of LLA related to peripheral vascular disease with and without diabetes independently (10). Few population-based studies have estimated the incidence of LLA in the diabetic general population based on validated data concerning the age- and sex-specific prevalence of diabetes at the time of study. Despite the availability of data on amputations (11), the utility of these data to accurately determine the incidence of LLA in the general population may be limited because the data are usually based on hospital discharges, which do not accurately detail procedures performed and concurrent diagnosis of diabetes. Moreover, accurate incidence rates cannot be derived unless the data are related to validated estimates of the sex- and age-specific prevalence of diabetes in the general population.The aim of this population-based cohort study was to estimate the incidence of LLA (at or proximal to the transmetatarsal level) performed for peripheral vascular disease among the diabetic and the nondiabetic general population over a 10-year period, with particular consideration of the rate of reamputation and contralateral amputation.