The incidence of type 1 diabetes in the age group 0-39 years has not increased in Antwerp (Belgium) between 1989 and 2000: evidence for earlier disease manifestation

OBJECTIVE: A worldwide increase in the incidence of childhood type 1 diabetes has been observed. Because in various countries the majority of new type 1 diabetic patients are diagnosed in adulthood, we investigated whether the rising incidence of this disorder in children reflects a global increase in the incidence of diabetes or a shift toward earlier clinical presentation. RESEARCH DESIGN AND METHODS: The incidence of type 1 diabetes presenting before age 40 years was prospectively measured in the Antwerp district over a 12-year period (1989-2000). The completeness of ascertainment was evaluated by the capture-recapture method. Trends in incidence during the study period were analyzed by Poisson regression. RESULTS: The incidence of type 1 diabetes diagnosed before age 40 years remained constant over the 12-year period, averaging 9.9 cases per 100,000 individuals per year. The incidence was similar in both sexes under age 15 years, but a marked male excess was noted for adult-onset disease, in particular after age 20 years, resulting in a male-to-female ratio of 0.9 under age 15 years vs. 1.6 thereafter (P = 0.001). During the 12-year observation period, there was a significant tendency toward increasing incidence under age 15 years at the expense of a decreasing incidence between ages 15 and 40 years (P = 0.025). The annual increase in incidence averaged 1.8% under age 15 years and 5.0% under age 5 years (P = 0.06). CONCLUSIONS: Our results indicate that in Belgium, the increasing incidence of childhood type 1 diabetes-especially for children under age 5 years-is not attributable to a global increase in disease incidence, but rather to earlier clinical manifestation. The results suggest that an environmental factor may preferentially accelerate the subclinical disease process in young diabetes-prone subjects.     

Incidence and prognosis of heart failure in persons with type 2 diabetes compared with individuals without diabetes – a nation-wide study from Finland in 1996–2012

Aims: To quantify the incidence and prevalence of heart failure (HF) in persons with type 2 diabetes (T2DM) and to examine the 1-year survival after the diagnosis of HF.Materials and methods: All cases of HF (n = 295,990) and T2DM in Finland were identified from national electronic health care registers for the period 1996–2012. The annual incidence and prevalence rates of HF and 1-year survival after the first diagnosis of HF were calculated for persons with T2DM and without diabetes using Poisson regression for the event rates.Results: The age-adjusted rate ratio for incident HF among men with T2DM in the age group 35–74 years declined from 3.73 (95% CI, 3.46–4.02) in 1996 to 2.17 (2.04–2.31) in 2012 and among women from 3.90 (3.61–4.22) to 2.36 (2.16–2.58). The multivariate-adjusted hazard ratio of 1-year death after the diagnosis of HF declined from 1.15 (1.11–1.21) to 1.07 (1.05–1.10) from the first to the second half of the study period.Conclusions: Individuals aged <75 years with T2DM had a considerably higher incidence of HF than individuals without diabetes. The prognosis of HF was worse in individuals with T2DM than in individuals without diabetes. However, the gap between the groups had narrowed over time.

Key messages

• The incidence of heart failure is 2–3 times higher among patients under 75 years of age with type 2 diabetes than among individuals without diabetes.
• The prognosis of heart failure patients is worse among patients with type 2 diabetes than it is among patients without diabetes although it is improving.

     

Intentional weight loss and mortality among overweight individuals with diabetes

OBJECTIVE: To estimate the effect of intentional weight loss on mortality in overweight individuals with diabetes. RESEARCH DESIGN AND METHODS: We performed a prospective analysis with a 12-year mortality follow-up (1959-1972) of 4,970 overweight individuals with diabetes, 40-64 years of age, who were enrolled in the American Cancer Society's Cancer Prevention Study I. Rate ratios (RRs) were calculated, comparing overall death rates, and death from cardiovascular disease (CVD) or diabetes in individuals with and without reported intentional weight loss. RESULTS: Intentional weight loss was reported by 34% of the cohort. After adjustment for initial BMI, sociodemographic factors, health status, and physical activity, intentional weight loss was associated with a 25% reduction in total mortality (RR = 0.75; 95% CI 0.67-0.84), and a 28% reduction in CVD and diabetes mortality (RR = 0.72; 0.63-0.82). Intentional weight loss of 20-29 lb was associated with the largest reductions in mortality (approximately 33%). Weight loss >70 lb was associated with small increases in mortality CONCLUSIONS: Intentional weight loss was associated with substantial reductions in mortality in this observational study of overweight individuals with diabetes.     

Effects of ethnicity and nephropathy on lower-extremity amputation risk among diabetic veterans

OBJECTIVE: To describe ethnic differences in the risk of amputation in diabetic patients with diabetic nephropathy. RESEARCH DESIGN AND METHODS: A retrospective cohort study was conducted on a national cohort of diabetic patients who received primary care within the Veterans Affairs (VA) Health Care System. Hospitalizations for lower-limb amputations were established by ICD-9-CM procedure codes. Relative risk of amputation in diabetic patients with and without diabetic nephropathy was determined using Cox proportional hazard modeling for unadjusted and adjusted models. RESULTS: Of the 429,918 subjects identified with diabetes (mean age 64 +/- 11 years, 97.4% male), 3,289 individuals were determined to have had a lower-limb amputation during the study period. Compared with diabetic patients without amputations, amputees were on average older, more likely to belong to a minority group, and were more likely to have received treatment for more comorbid conditions. Asians were more likely to have toe amputations compared with whites or other ethnicities, while Native Americans were more likely to have below-the-knee amputations. Native Americans had the highest risk of amputation (RR 1.74, 95% CI 1.39-2.18), followed by African Americans (RR 1.41, 95% CI 1.34-1.48) and Hispanics (RR 1.28, 95% CI 1.20-1.38) compared with whites. The presence of diabetic nephropathy increased the risk of amputation threefold in all groups. Asian subjects with diabetes had the lowest adjusted relative risk of amputation (RR 0.31, 95% CI 0.19-0.50). CONCLUSIONS: Among diabetic patients, certain ethnic minority individuals have an increased risk of lower-extremity amputation compared with whites. Presence of diabetic nephropathy further increases this risk.     

Differences in diabetes prevalence, incidence, and mortality among the elderly of four racial/ethnic groups: whites, blacks, hispanics, and asians

OBJECTIVE: To examine diabetes prevalence, incidence, and mortality from 1993 to 2001 among fee-for-service Medicare beneficiaries > or = 67 years of age. RESEARCH DESIGN AND METHODS: This study was a retrospective analysis of a 5% random sample of Medicare fee-for-service beneficiaries > or = 65 years of age in each year. RESULTS: In 1993, the prevalence of diabetes among those > or = 67 years of age was 145 cases per 1,000 individuals. By 2001, it was 197/1,000, an increase of 36.0%. The 2001 prevalence among Hispanics (334/1,000) was significantly higher than among blacks (296/1,000), Asians (243/1,000), and whites (184/1,000, P < 0.0001). During the 7-year period the greatest increase in diabetes prevalence was among Asians (68.0%). Between 1994 and 2001, the annual rate of newly diagnosed elderly individuals with diabetes increased by 36.9%. Hispanics had the greatest increase at 55.0%. The mortality rate among individuals with diabetes decreased by approximately 5% between 1994 and 2001 from 92.1/1,000 to 87.2/1,000 (P < 0.001), due to a 6% decrease among whites. No decrease in mortality was seen among elderly individuals without diabetes, it was 55/1,000 in 1994 and 54/1,000 in 2001. CONCLUSIONS: The dramatic increase in the incidence and prevalence of diabetes likely reflect a combination of true increases, as well as changes in the diagnostic criteria and increased interest in diagnosing and appropriately treating diabetes in the elderly. Improved treatment may have had an impact on mortality rates among individuals with diabetes, although they could have been influenced by the duration of diabetes before diagnosis, which has likely decreased. Changes in incidence, prevalence, and mortality in elderly individuals with diabetes need to continue to be monitored.     

Mortality in diabetic and nondiabetic patients after amputations performed from 1990 to 1995: a 5-year follow-up study

OBJECTIVE: To compare survival rates after first amputation between patients with and without diabetes. RESEARCH DESIGN AAND METHODS: We performed a retrospective study of all nontraumatic amputations performed at our center in the years 1990-1995 in patients with (n = 100) and without (n = 151) diabetes. Survival status was assessed from the first amputation until 31 December 2001. RESULTS: Altogether, 61% of the patients with and 54.3% of those without diabetes died 5.2 (4.5-5.8) and 5.3 (4.7-5.9) [mean (95% CI)] years after the first amputation, respectively (P = 0.80). Survival was not different between patients with and without diabetes after controlling for the level (major versus minor) (P = 0.67) or the cause (ischemia versus infection) of amputation (P = 0.72). No sex differences were found for survival in either study group. Independent predictors of mortality in the diabetic group were duration of diabetes (P = 0.05), history of stroke (P = 0.02), and serum creatinine level (P < 0.0001), while in the nondiabetic group independent predictors were history of stroke (P = 0.04), serum creatinine level (P = 0.005), and higher white blood cell count (P = 0.02). The peak incidence of amputations was observed in the decade of 67-76 years of age in both groups. Major amputations were more common among nondiabetic patients in all age-groups. Median hospital stay and postoperative complications were comparable between the two groups. CONCLUSIONS: All-cause mortality is high after an amputation in both diabetic and nondiabetic patients. Mortality rates, hospital stay, and postoperative complications are not different between diabetic and nondiabetic amputees. No modifiable factors, with the exception of nephropathy, were found to improve survival in amputees. Peripheral vascular disease and neuropathy are the main cause of amputations; prevention, therefore, of these complications is warranted to prevent amputations and the subsequent high mortality.     

Factors influencing rehabilitation of arteriosclerotic lower limb amputees

This survey considered 598 arteriosclerotic amputees over a period of 9 years: 267 below-knee; 81 Gritti-Stokes; 195 above-knee; and 55 double amputees. A walking ability index (WAI) ranging from 1 for a normal gait to 6 for inability to walk was determined for these amputees by clinical grading at 3, 6, 9, and 12 months after prosthesis fitting. Amputees with the below-knee operation had better WAI at 3 and more months than those with either Gritti-Stokes or above-knee operations. There was no statistical evidence for a difference between Gritti-Stokes and above-knee operations at any time of assessment of WAI. The 50-59 year-old age group had significantly better WAI at 6, 9, and 12 months than did the 60-69 or 70+ age group, but the 60-69 year-old group was not significantly different from the 70+ age group. On an average, the 78 amputees (14 percent) with ischemic heart disease had a poorer WAI at 6 and more months than did those without it; the 46 amputees (8 percent) with hemiplegia were worse at 12 months than those without hemiplegia; and the 15 amputees (11 percent) with bronchitis were worse at 12 months than those without bronchitis. Double amputees had poorer WAIs at 12 months than those of single amputees.     

Celiac disease and risk of subsequent type 1 diabetes: a general population cohort study of children and adolescents

OBJECTIVE: Earlier studies suggest that children with type 1 diabetes are more likely to have a subsequent diagnosis of celiac disease. However, research is sparse on the risk of subsequent type 1 diabetes in individuals with celiac disease. We sought to determine the risk of subsequent type 1 diabetes diagnosed before the age of 20 years in children and adolescents with celiac disease in a national, general population-based cohort. RESEARCH DESIGN AND METHODS: We identified 9,243 children with a diagnosis of celiac disease in the Swedish national inpatient register between 1964 and 2003. We then identified five reference individuals matched at time of diagnosis for age, calendar year, sex, and county (n = 45,680). Only individuals with >1 year of follow-up after study entry (diagnosis of celiac disease) were included in the analyses. RESULTS: Celiac disease was associated with a statistically significantly increased risk of subsequent type 1 diabetes before age 20 years (hazard ratio 2.4 [95% CI 1.9-3.0], P < 0.001). This risk increase was seen regardless of whether celiac disease was first diagnosed between 0 and 2 (2.2 [1.7-2.9], P < 0.001) or 3 and 20 (3.4 [1.9-6.1], P < 0.001) years of age. Individuals with prior celiac disease were also at increased risk of ketoacidosis or diabetic coma before the age of 20 years (2.3 [1.4-3.9], P = 0.001). CONCLUSIONS: Children with celiac disease are at increased risk of subsequent type 1 diabetes. This risk increase is low considering that 95% of individuals with celiac disease are HLA-DQ2 positive.     

Predicting expenditures for Medicare beneficiaries with diabetes. A prospective cohort study from 1994 to 1996.

OBJECTIVE: To describe health care expenditures and utilization patterns among older adults with diabetes and to examine factors associated with expenditures over a 3-year period. RESEARCH DESIGN AND METHODS: We conducted a prospective cohort study of health care expenditures and utilization by diabetic patients from a random nationwide sample of aged Medicare beneficiaries from 1994 to 1996. All services covered by the Medicare program were examined. Multivariate regression was used to assess the contribution of patient characteristics in 1994 on Part B, inpatient, and total expenditures in 1995 and 1996. RESULTS: Per capita expenditures for beneficiaries with diabetes (n = 169,613) were 1.7 times greater than those for those beneficiaries without diabetes (n = 968,832) in 1994. This ratio remained fairly constant over the 2 years of follow-up. Expenditures for beneficiaries with diabetes were highly skewed. However, few of these individuals remained in the highest expenditure quintile over the 2 years of follow-up. Using multiple regression analysis to adjust for demographic and clinical characteristics, we were able to explain 7% of the variation in total expenditures in 1995 and 6% of the variation in 1996. Using the same model, we were able to explain 10.7% of the variation in Part B expenditures in 1995 and 8% in 1996. CONCLUSIONS: Beneficiaries with diabetes are consistently more expensive than beneficiaries without diabetes. Demographic and clinical factors at baseline are able to predict only a small portion of future expenditures among this population, and the most expensive patients in one year were often not the most expensive in subsequent years. More work is necessary to assure equitable risk adjustment in the calculation of capitation rates for health plans and practitioners who specialize in the care of individuals with diabetes.     

Diabetes is an independent risk factor for in-hospital mortality from acute spontaneous intracerebral hemorrhage

OBJECTIVE: We tested the hypothesis that diabetes is an independent determinant of outcome after intracerebral hemorrhage (ICH). RESEARCH DESIGN AND METHODS: This was a hospital-based prospective study The setting was an acute care 350-bed hospital in the city of Barcelona, Spain. Spontaneous ICH was diagnosed in 229 (11%) of 2,000 consecutive stroke patients included in a prospective stroke registry during a 10-year period. Main outcome measures were frequency of demographic variables, risk factors, clinical events, neuroimaging data, and outcome in ICH patients with and without diabetes. Variables related to vital status at discharge (alive or dead) in the univariate analysis plus age were studied in 4 logistical regression models. RESULTS: A total of 35 patients (15.3%) had diabetes. The overall in-hospital mortality rate was 54.3% in the diabetic group and 26.3% in the nondiabetic group (P < 0.001). Previous cerebral infarction, altered consciousness, sensory symptoms, cranial nerve palsy, multiple topography of the hematoma, intraventricular hemorrhage, and infectious complications were significantly more frequent in diabetic patients than in nondiabetic patients. The presence of diabetes was a significant predictive variable in the model based on demographic variables and cardiovascular risk factors (odds ratio 2.98 [95% CI 1.37-6.46]) and in the models based on these variables plus clinical variables (5.76 [2.01-16.51]), neuroimaging variables (5.59 [1.87-16.691), and outcome data (6.10 [2.04-18.291). CONCLUSIONS: Diabetes is an independent determinant of death after ICH. ICH in diabetic individuals presents some different clinical features compared with ICH in nondiabetic patients.     

Clinical and psychological course of diabetes from adolescence to young adulthood: a longitudinal cohort study

OBJECTIVE: To determine the clinical and psychological course of diabetes through adolescence and the relationship with glycemic control in young adulthood. RESEARCH DESIGN AND METHODS: A longitudinal cohort study of adolescents recruited from the register of the outpatient pediatric diabetes clinic. A total of 76 individuals (43 male patients, 33 female patients) aged 11-18 years completed baseline assessments, and 65 individuals (86%) were reinterviewed as young adults (20-28 years of age). Longitudinal assessments were made of glycemic control (HbA(1c)), weight gain (BMI), and development of complications. Adolescents completed self-report questionnaires to assess emotional and behavioral problems as well as self-esteem. As young adults, psychological state was assessed by the Revised Clinical Interview Schedule and the self-report Brief Symptom Inventory. RESULTS: Mean HbA(1c) levels peaked in late adolescence and were worse in female participants (average 11.1% at 18-19 years of age). The proportion of individuals who were overweight (BMI >25.0 kg/m(2)) increased during the 8-year period from 21 to 54% in female patients and from 2 to 28% in male patients. Serious diabetes-related events included death in one patient and cognitive impairment in two patients. Individuals in whom diabetic complications developed (25% of male patients and 38% of female patients) had significantly higher mean HbA(1c) levels than those without complications (difference 1.9%, 95% CI 1.1-2.7, P < 0.0001). Behavioral problems at baseline were related to higher mean HbA(1c) during the subsequent 8 years (beta = 0.15, SEM (beta) 0.04, P < 0.001, 95% CI 0.07-0.24). CONCLUSIONS: The outcome for this cohort was generally poor. Behavioral problems in adolescence seem to be important in influencing later glycemic control.     

Thyroid autoimmunity in children and adolescents with type 1 diabetes: a multicenter survey

OBJECTIVE: To investigate thyroid autoimmunity in a very large nationwide cohort of children and adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS: Data were analyzed from 17,749 patients with type 1 diabetes aged 0.1-20 years who were treated in 118 pediatric diabetes centers in Germany and Austria. Antibodies to thyroglobulin (anti-TG) and thyroperoxidase (anti-TPO) were measured and documented at least once in 7,097 patients. A total of 49.5% of these patients were boys, the mean age was 12.4 years (range 0.3-20.0 years), and the mean duration of diabetes was 4.5 years (range 0.0-19.5 years). A titer exceeding 100 units/ml or 1:100 was considered significantly elevated. RESULTS: In 1,530 patients, thyroid antibody levels were elevated on at least one occasion, whereas 5,567 were antibody-negative during the observation period. Patients with thyroid antibodies were significantly older (P < 0.001), had a longer duration of diabetes (P < 0.001), and developed diabetes later in life (P < 0.001) than those without antibodies. A total of 63% of patients with positive antibodies were girls, compared with 45% of patients without antibodies (P < 0.001). The prevalence of significant thyroid antibody titers increased with increasing age; the highest prevalence was in the 15- to 20-year age group (anti-TPO: 16.9%, P < 0.001; anti-TG: 12.8%, P < 0.001). Thyroid-stimulating hormone (TSH) levels were higher in patients with thyroid autoimmunity (3.34 microU/ml, range 0.0-615.0 microU/ml) than in control subjects (1.84 microU/ml, range 0.0-149.0 microU/ml) (P < 0.001). Even higher TSH levels were observed in patients with both anti-TPO and anti-TG (4.55 microU/ml, range 0.0-197.0 microU/ml). CONCLUSIONS: Thyroid autoimmunity seems to be particularly common in girls with diabetes during the second decade of life and may be associated with elevated TSH levels, indicating subclinical hypothyroidism.     

High incidence of childhood type 1 diabetes in the Avalon Peninsula, Newfoundland, Canada

OBJECTIVE: The aim of this study was to determine the incidence of type 1 diabetes among children aged 0-14 years in the Avalon Peninsula in the Canadian Province of Newfoundland. RESEARCH DESIGN AND METHODS: This was a prospective cohort study of the incidence of childhood type 1 diabetes in children aged 0-14 years who were diagnosed with type 1 diabetes from 1987 to 2002 on the Avalon Peninsula. Identified case subjects during this time period were ascertained from several sources and verified using the capture-recapture technique. Data were obtained from the only pediatric diabetes treatment center for children living on the Avalon Peninsula. RESULTS: Over the study period, 294 children aged 0-14 years from the Avalon Peninsula were diagnosed with type 1 diabetes. The incidence of type 1 diabetes in this population over the period 1987-2002 inclusive was 35.93 with a 95% CI of 31.82-40.03. The incidence over this period increased linearly at the rate of 1.25 per 100,000 individuals per year. CONCLUSIONS: The Avalon Peninsula of Newfoundland has one of the highest incidences of type 1 diabetes reported worldwide. The incidence increased over the 16-year study period.     

The significant effect of diabetes duration on coronary heart disease mortality: the Framingham Heart Study

OBJECTIVE: The risk of coronary heart disease (CHD) in type 2 diabetes is two- to threefold higher than in the general population, but the effect of diabetes duration on CHD risk has not been well characterized. We hypothesized that duration of diabetes is an important predictor of incident CHD among people with diabetes. RESEARCH DESIGN AND METHODS: The duration of diabetes (fasting glucose > or =126 mg/dl, random glucose > or =200 mg/dl, or use of an oral hypoglycemic agent or insulin) was assessed in participants with diabetes in the original and offspring cohorts of the Framingham Heart Study. Only subjects with diabetes diagnosed between the ages of 30 and 74 years, without a history of ketoacidosis, and free of cardiovascular disease at the baseline evaluation were included. Cox proportional hazards models were used to estimate the hazard ratio of incident CHD events and mortality over a 12-year follow-up period; models were adjusted for known CHD risk factors. RESULTS: Among 588 person-exams with diabetes (mean age 58 +/- 9 years, 56% men), there were 86 CHD events, including 36 deaths. After adjustment for age, sex, and CHD risk factors, the risk of CHD was 1.38 times higher for each 10-year increase in duration of diabetes (95% CI 0.99-1.92), and the risk for CHD death was 1.86 times higher (1.17-2.93) for the same increase in duration of diabetes. CONCLUSIONS: Duration of diabetes increases the risk of CHD death independent of coexisting risk factors. Further research is necessary to understand the pathophysiology of this increased risk.     

Incidence of falls,risk factors for falls,and fall-related fractures in individuals with diabetes and a prior foot ulcer

OBJECTIVE: To describe the incidence of falls, risk factors for falls, and the frequency of fall-related fractures in a cohort of individuals with diabetes and a prior foot ulcer. RESEARCH DESIGN AND METHODS: A total of 400 individuals with diabetes and a prior foot ulcer were recruited from two western Washington State health care organizations and followed prospectively for 2 years. Diabetes, demographic, and health information was collected at baseline, 1 year, and 2 years. Data on falls were collected at baseline, 4 weeks, and every 17 weeks thereafter. Medical records were abstracted to confirm fall-related morbidity. RESULTS: The average age of the study population was 62 years, with 77% male and 23% female. Approximately 32% had fixed foot deformities, 58% had insensate feet, and 76% had comorbid conditions. Of the participants, 252 (64%) reported at least one fall during the 2-year study period. The overall incidence of falls in this cohort was 1.25 falls/person-year (95% CI 1.17-1.33). For the 164 participants (41%) who reported two or more falls, a BMI >/=30 kg/m(2), the presence of one or more comorbid conditions, and insensate feet increased the risk. Two or more falls of any type were associated with a higher fracture risk. Although women were not at significantly greater risk for falls than men, their fracture incidence was 3.6 times higher. CONCLUSIONS: Falls are very common in individuals with diabetes and prior foot ulcers. A small percentage of falls resulted in fractures. The risk of a fall-related fracture was significantly higher in women than in men. Increased attention to falls and fall prevention is indicated for diabetes care providers.     

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.     

Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.

OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population.     

The National Cholesterol Education Program - Adult Treatment Panel III, International Diabetes Federation, and World Health Organization definitions of the metabolic syndrome as predictors of incident cardiovascular disease and diabetes

OBJECTIVE: The clinical value of metabolic syndrome is uncertain. Thus, we examined cardiovascular disease (CVD) and diabetes risk prediction by the National Cholesterol Education Program (NCEP)-Adult Treatment Panel III (ATPIII), International Diabetes Federation, and World Health Organization definitions of the metabolic syndrome. RESEARCH DESIGN AND METHODS: We analyzed the risks associated with metabolic syndrome, the NCEP multiple risk factor categories, and 2-h glucose values in the San Antonio Heart Study (n = 2,559; age range 25-64 years; 7.4 years of follow-up). RESULTS: Both ATPIII metabolic syndrome plus age > or = 45 years (odds ratio 9.25 [95% CI 4.85-17.7]) and multiple (two or more) risk factors plus a 10-year coronary heart disease (CHD) risk of 10-20% (11.9 [6.00-23.6]) had similar CVD risk in men without CHD, as well as CHD risk equivalents. In women counterparts, multiple (two or more) risk factors plus a 10-year CHD risk of 10-20% was infrequent (10 of 1,254). However, either a 10-year CHD risk of 5-20% (7.72 [3.42-17.4]) or ATPIII metabolic syndrome plus age > or = 55 years (4.98 [2.08-12.0]) predicted CVD. ATPIII metabolic syndrome increased the area under the receiver operating characteristic curve of a model containing age, sex, ethnic origin, family history of diabetes, and 2-h and fasting glucose values (0.857 vs. 0.842, P = 0.013). All three metabolic syndrome definitions imparted similar CVD and diabetes risks. CONCLUSIONS: Metabolic syndrome is associated with a significant CVD risk, particularly in men aged > or = 45 years and women aged > or = 55 years. The metabolic syndrome predicts diabetes beyond glucose intolerance alone.