Epidemiology of diabetes mellitus among First Nations and non-First Nations adults

Background

First Nations people in Canada experience a disproportionate burden of type 2 diabetes mellitus. To increase our understanding of this evolving epidemic, we compared the epidemiology of diabetes between First Nations and non-First Nations adults in Saskatchewan from 1980 to 2005.

Methods

We used administrative databases to perform a population-based study of diabetes frequency, incidence and prevalence in adults by ethnic background, year, age and sex.

Results

We identified 8275 First Nations and 82 306 non-First Nations people with diabetes from 1980 to 2005. Overall, the incidence and prevalence of diabetes were more than 4 times higher among First Nations women than among non-First Nations women and more than 2.5 times higher among First Nations men than among non-First Nations men. The number of incident cases of diabetes was highest among First Nations people aged 40–49 , while the number among non-First Nations people was greatest in those aged 70 or more years. The prevalence of diabetes increased over the study period from 9.5% to 20.3% among First Nations women and from 4.9% to 16.0% among First Nations men. Among non-First Nations people, the prevalence increased from 2.0% to 5.5% among women and from 2.0% to 6.2% among men. By 2005, almost 50% of First Nations women and more than 40% of First Nations men aged 60 or older had diabetes, compared with less than 25% of non-First Nations men and less than 20% of non-First Nations women aged 80 or older.

Interpretation

First Nations adults are experiencing a diabetes epidemic that disproportionately affects women during their reproductive years. This ethnicity-based pattern suggests diverse underlying mechanisms that may include differences in the diabetogenic impact of gestational diabetes.The global epidemic of type 2 diabetes mellitus disproportionately affects indigenous and developing populations.¹ Although genotypic variants related to energy balance may underlie this epidemic,² the rapid emergence of type 2 diabetes in genetically diverse populations worldwide is most likely caused by environmental factors. Increasing rates of type 2 diabetes among Canada’s First Nations people, for example, parallel an epidemic of overweight and obesity that has coincided with socio-cultural disruption and a loss of traditional lifestyles.³In Saskatchewan in 1937, diabetes was not detected among the 1500 First Nations people who underwent a tuberculosis survey.⁴ By 1990, almost 10% of the province’s First Nations adults had diabetes;⁵ by 2006, the proportion was over 20%,⁶ while it remained at about 6% in the general population.^5,6 Although an increased prevalence of diabetes among First Nations people has also been documented in other Canadian provinces,³ only recently have consistent diabetes case definitions applied to health care system administrative databases been used to compare differences between large populations of First Nations and non-First Nations people.^7–9We sought to describe the epidemiology of diabetes in Saskatchewan from 1980 to 2005. We reasoned that finding ethnicity-based differences in trends and patterns of type 2 diabetes over the longest period reported for a Canadian jurisdiction would help to clarify the underlying mechanisms behind known disparities and translate into more effective diabetes prevention and management initiatives.     

Income-related differences in mortality among people with diabetes mellitus

Background

Mortality has declined substantially among people with diabetes mellitus over the last decade. Whether all income groups have benefited equally, however, is unclear. We examined the impact of income on mortality trends among people with diabetes.

Methods

In this population-based, retrospective cohort study, we compared changes in mortality from Apr. 1, 1994, to Mar. 31, 2005, by neighbourhood income strata among people with diabetes aged 30 years or more in the province of Ontario, Canada.

Results

Overall, the annual age- and sex-adjusted mortality declined, from 4.05% in 1994/95 (95% confidence interval [CI] 3.98%–4.11%) to 2.69% in 2005/06 (95% CI 2.66%–2.73%). The decrease was significantly greater in the highest income group (by 36%) than in the lowest income group (by 31%; p < 0.001). This trend was most pronounced in the younger group (age 30–64 years): the mortality rate ratio widened by more than 40% between the lowest and highest income groups, from 1.12 to 1.59 among women and from 1.14 to 1.60 among men. Income had a much smaller effect on mortality trends in the older group, whose drug costs are subsidized: the income-related difference rose by only 0.9% over the study period.

Interpretation

Mortality declined overall among people with diabetes from 1994 to 2005; however, the decrease was substantially greater in the highest income group than in the lowest, particularly among those aged 30–64 years. These findings illustrate the increasing impact of income on the health of people with diabetes even in a publicly funded health care setting. Further studies are needed to explore factors responsible for these income-related differences in mortality.The number of people with diabetes mellitus has increased dramatically over the last 20 years^1,2 and is estimated to double to about 366 million by 2030.³ Diabetes is associated with a 2-fold increase in mortality, with the majority of deaths attributed to cardiovascular causes.⁴ However, survival among people with diabetes has improved substantially over the last decade,^1,5,6 in part because of better diabetes care and a reduction in cardiovascular events.⁶Income is a well-known predictor of survival.^7,8 Even in Canada, where much of health care is universally funded, income-based inequities in health and access to care remain.^9–12 Although income-related differences in all-cause mortality have decreased since the advent of provincially subsidized health care in Canada,^8,9 the income gap may be increasing for certain causes of death, including those related to diabetes.⁸ The shift to more complex medical care involving a greater number of drug therapies has resulted in improved diabetes-related outcomes overall.¹³ However, patients in lower-income groups may not have benefited from advances in diabetes care as much as more affluent patients have because of the financial burden of out-of-pocket expenses for such medications and diabetes supplies.We conducted a population-based study to examine income-related differences in mortality from 1994 to 2005 among people with diabetes.     

Association of macrosomia with perinatal and postneonatal mortality among First Nations people in Quebec

Background

High prevalence of infant macrosomia (up to 36%, the highest in the world) has been reported in some First Nations communities in the Canadian province of Quebec and the eastern area of the province of Ontario. We aimed to assess whether infant macrosomia was associated with elevated risks of perinatal and postneonatal mortality among First Nations people in Quebec.

Methods

We calculated risk ratios (RRs) of perinatal and postneonatal mortality by birthweight for gestational age, comparing births to First Nations women (n = 5193) versus women whose mother tongue is French (n = 653 424, the majority reference group) in Quebec 1991–2000.

Results

The prevalence of infant macrosomia (birthweight for gestational age > 90th percentile) was 27.5% among births to First Nations women, which was 3.3 times (confidence interval [CI] 3.2–3.5) higher than the prevalence (8.3%) among births to women whose mother tongue is French. Risk ratios for perinatal mortality among births to First Nations women were 1.8 (95% CI 1.3–2.5) for births with weight appropriate for gestational age, 4.1 (95% CI 2.4–7.0) for small-for-gestational-age (< 10th percentile) births and < 1 (not significant) for macrosomic births compared to births among women whose mother tongue is French. The RRs for postneonatal mortality were 4.3 (95% CI 2.7–6.7) for infants with appropriate-for-gestational-age birthweight and 8.3 (95% CI 4.0–17.0) for infants with macrosomia.

Interpretation

Macrosomia was associated with a generally protective effect against perinatal death, but substantially greater risks of postneonatal death among births to First Nations women in Quebec versus women whose mother tongue is French.A trend toward higher birthweights has emerged in recent decades.^1–3 Reflected in this trend is a rise in the prevalence of infant macrosomia, commonly defined as either a birthweight greater than 4000 g or a birthweight for gestational age greater than the 90th percentile relative to a fetal growth standard.^4–8 Maternal obesity, impaired glucose tolerance and gestational diabetes mellitus are important risk factors for infant macrosomia^9,10 and are known to afflict a much higher proportion of people in Aboriginal populations than in the general population.^11–14 This is true especially for Aboriginal populations in which a traditional lifestyle has changed to a less physically active, modern lifestyle in recent decades. A high prevalence of infant macrosomia (up to 36%, which, to the best of our knowledge, is the highest in the world) has been reported in some First Nations communities of Quebec and eastern Ontario in Canada.^15–17 However, little is known about the implications of this high prevalence for perinatal and infant health of First Nations people in these regions. We examined whether infant macrosomia was associated with increased risk for perinatal and postneonatal death among First Nations infants in Quebec.     

Fracture risk among First Nations people: a retrospective matched cohort study

Background

Canadian First Nations people have unique cultural, socioeconomic and health-related factors that may affect fracture rates. We sought to determine the overall and site-specific fracture rates of First Nations people compared with non-First Nations people.

Methods

We studied fracture rates among First Nations people aged 20 years and older (n = 32 692) using the Manitoba administrative health database (1987–1999). We used federal and provincial sources to identify ethnicity, and we randomly matched each First Nations person with 3 people of the same sex and year of birth who did not meet this definition of First Nations ethnicity (n = 98 076). We used a provincial database of hospital separations and physician billing claims to calculate standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for each fracture type based on a 5-year age strata.

Results

First Nations people had significantly higher rates of any fracture (age- and sex-adjusted SIR 2.23, 95% CI 2.18–2.29). Hip fractures (SIR 1.88, 95% CI 1.61–2.14), wrist fractures (SIR 3.01, 95% CI 2.63–3.42) and spine fractures (SIR 1.93, 95% CI 1.79–2.20) occurred predominantly in older people and women. In contrast, craniofacial fractures (SIR 5.07, 95% CI 4.74–5.42) were predominant in men and younger adults.

Interpretation

First Nations people are a previously unidentified group at high risk for fracture.Most of the epidemiologic data describing fractures have been derived from white populations,¹ although it is known that there is ethnic variation in the epidemiology of fractures.^2,3,4 Canadian First Nations people are known to suffer from a heavy burden of medical and social problems that may affect fracture rates.⁵ To date, however, there have been no satisfactory studies of fracture rates among North American Aboriginal groups. We sought to determine the overall and site-specific fracture rates of First Nations people compared with non-First Nations people in Manitoba.     

Rates and outcomes of diabetic end-stage renal disease among registered native people in Saskatchewan.

OBJECTIVE: To determine the rates and outcomes of diabetic end-stage renal disease (ESRD) among registered native people and non-native people in Saskatchewan. DESIGN: Retrospective population-based study using data from the Canadian Organ Replacement Registry. SETTING: Saskatchewan. PATIENTS: All patients with diabetic ESRD diagnosed between Jan. 1, 1981, and Dec. 31, 1990. MAIN OUTCOME MEASURES: Incidence rates of diabetic ESRD in the general population, rates of diabetic ESRD among patients with diabetes mellitus, nature of initial dialysis treatment, length of survival from start of dialysis, cause of death and renal transplant rates. RESULTS: The 10-year incidence rates of diabetic ESRD were higher among all age groups among registered native people than among non-native people. The overall relative risk ratio for native people was 16.2. When a higher prevalence of diabetes among native people was taken into account, native diabetic people were still seven times as likely as non-native diabetic people to manifest diabetic ESRD. The median survival from start of dialysis was under 2 years in both groups, but more native people died of stroke and more non-native people died of heart disease. Non-native diabetic people were more likely than native diabetic people to receive renal transplants. CONCLUSIONS: Although the overall incidence of diabetic ESRD in Saskatchewan is increasing, registered native people have a disproportionate risk for this serious complication.     

Differing myocardial response to a single session of hemodialysis in end-stage renal disease with and without type 2 diabetes mellitus and coronary artery disease

The ninth edition of the congress of the European Association of Echocardiography (EAE) (former working group of Echocardiography) held in Florence has just finished with a great success of participant attendance (2.842) and abstract submissions. Hot topics at EuroEcho 9 were: 1-live 3-dimensional echocardiography and surgical decision making; in pediatric cardiology; in resynchronization therapy 2- stress echocardiography beyond wall motion: from valve diseases to contractility to coronary flow reserve to diastolic function; 3- pulmonary cardiogenic interstitial thickening recognized by ultrasonic lung comets; 4- the "proven clinical inefficacy" of the many technologies sold as breakthrough: color kinesis, tissue characterization, strain rate, tissue Doppler, applied to stress echocardiography.     

Monitoring,treatment and control of blood glucose and lipids in Ontario First Nations people with diabetes

BACKGROUND:Indigenous people worldwide are disproportionately affected by diabetes and its complications. We aimed to assess the monitoring, treatment and control of blood glucose and lipids in First Nations people in Ontario.METHODS:We conducted a longitudinal population-based study using administrative data for all people in Ontario with diabetes, stratified by First Nations status. We assessed age- and sex-specific rates of completion of recommended monitoring for low-density lipoprotein (LDL) and glycated hemoglobin (A_1c) from 2001/02 to 2014/15. We used data from 2014/15 to conduct a cross-sectional analysis of rates of achievement of A_1c and LDL targets and use of glucose-lowering medications.RESULTS:The study included 22 240 First Nations people and 1 319 503 other people in Ontario with diabetes. Rates of monitoring according to guidelines were 20%–50% for A_1c and 30%–70% for lipids and were lowest for younger First Nations men. The mean age- and sex-adjusted A_1c level was higher among First Nations people than other people (7.59 [95% confidence interval (CI) 7.57 to 7.61] v. 7.03 [95% CI 7.02 to 7.03]). An A_1c level of 8.5% or higher was observed in 24.7% (95% CI 23.6 to 25.0) of First Nations people, compared to 12.8% (95% CI 12.1 to 13.5) of other people in Ontario. An LDL level of 2.0 mmol/L or less was observed in 60.3% (95% CI 59.7 to 61.6) of First Nations people, compared to 52.0% (95% CI 51.1 to 52.9) of other people in Ontario. Among those aged 65 or older, a higher proportion of First Nations people than other Ontarians were using insulin (28.1% v. 15.1%), and fewer were taking no medications (28.3% v. 40.1%).INTERPRETATION:As of 2014/15, monitoring and achievement of glycemic control in both First Nations people and other people in Ontario with diabetes remained suboptimal. Interventions to support First Nations patients to reach their treatment goals and reduce the risk of complications need further development and study.

Diabetes and its related complications are major contributors to morbidity and mortality worldwide.^1–3 Indigenous populations in Canada and around the world are disproportionately affected by diabetes owing to the complex relations among colonization, social disadvantage, stress, trauma and metabolic health.^4–7 In addition to our own work showing persistently higher rates of peripheral vascular disease, stroke, cardiac disease, renal dysfunction and ophthalmologic complications in Ontario First Nations,^8–12 other Canadian and international studies also showed higher complication rates in diverse Indigenous populations.^6,7,13–15Glycemic control is fundamental to the management of diabetes and the prevention of complications.¹⁶ Glycated hemoglobin (A_1c) is a reliable way to estimate the average level of glucose in the blood.¹⁷ Since A_1c levels higher than 7.0% have been associated with an increased risk of microvascular complications,^18–20 treatment guidelines suggest A_1c should be measured every 3–6 months to ensure that glycemic goals are being met or maintained.²¹ Since people with diabetes also have an elevated risk for cardiovascular disease,^22–24 management and control of cardiovascular risk factors, particularly lipids such as low-density lipoprotein (LDL) cholesterol, are also important.^25–27 Guidelines further recommend that a full lipid profile be measured every 1–3 years, depending on cardiovascular risk, and suggest that LDL be consistently less than 2.0 mmol/L.²⁸ Control of A_1c and lipids has been shown to be associated with reduced morbidity and mortality in patients with diabetes.^18,29–32One possible reason for the high burden of complications among Indigenous people with diabetes may be failure to achieve control of these 2 key clinical parameters. We examined differences between Status First Nations people with diabetes in Ontario and all other Ontario residents with diabetes in rates of monitoring of A_1c and lipids, achievement of targets for A_1c and LDL outlined in clinical guidelines, and patterns of medication use to help attain these targets.     

Risk of mortality in patients with end-stage renal disease: the role of malnutrition and possible therapeutic implications

The mortality rate of dialysis patients is still considerably high. Beside the traditional risk factors, specific uremia-related risk factors are identified. Among them, hypoalbuminemia and malnutrition have a strong association to mortality in chronic dialysis patients. Various studies document a strong relation between reduced calorie and protein uptake and mortality in uremic patients. Several factors responsible for malnutrition in dialysis patients have been identified. These factors may be dialysis-associated, due to intercurrent illnesses or are associated with uremic complications (e.g. hyperparathyroidism, anemia, acidosis, etc.). Malnutrition is treatable and can be avoided by several means. Beside the increase in the dose of dialysis and adequate protein and calorie intake, intradialytic nutrition is an additional choice. The combination with specific drugs (e.g. growth hormone) may potentiate the success of the modified treatment modalities, particularly in patients who need nutritional support during an intercurrent illness. Further studies are required to measure the impact of for example growth hormone supplementation on mortality rate and quality of life in malnourished patients on chronic dialysis.     

Effect of end-stage renal disease and diabetes on zinc and copper status

The aim of this study was to compare the nutritional status of zinc and copper in patients with and without diabetes submitted to chronic hemodialysis. Thirty-three patients with type 2 diabetes (DM group), 30 nondiabetic patients (NDM group), and 20 healthy individuals (control group) were studied. Plasma, erythrocyte, and urinary zinc and plasma copper were obtained from atomic absorption spectrophotometry and ceruloplasmin by immunonephelometry. The anthropometric parameters were similar among the groups. Plasma zinc was lower and erythrocyte zinc was higher in the DM and NDM groups in relation to the control group. No difference in urinary zinc was observed comparing the groups. Plasma copper was higher in the DM group when compared to the NDM and control groups. Ceruloplasmin was similar in the three groups. Serum urea was a positive independent determinant of plasma zinc concentrations. The determinants of erythrocyte zinc were MAMC midarm nuscle circumference and Kt/V dialysis adequacy. The determinants of plasma copper concentration were serum creatinine and serum glucose. The results of this study demonstrate an alteration in the distribution of zinc of patients with chronic kidney disease (CKD) independently of the presence of DM. Also, the status of copper seems not to be influenced by CKD, but only by the metabolic derangements associated with diabetes.     

Differential distribution of muscle and skin sympathetic nerve activity in patients with end-stage renal disease

End-stage renal disease (ESRD) is characterized by resting sympathetic overactivity. Baseline muscle sympathetic nerve activity (MSNA), which is governed by baroreflexes and chemoreflexes, is elevated in ESRD. Whether resting skin sympathetic nerve activity (SSNA), which is independent from baroreflex and chemoreflex control, is also elevated has never been reported in renal failure. The purpose of this study was to determine whether sympathetic overactivity of ESRD is generalized to include the skin distribution. We measured sympathetic nerve activity to both muscle and skin using microneurography in eight ESRD patients and eight controls. MSNA was significantly (P = 0.025) greater in ESRD (37.3 +/- 3.6 bursts/min) when compared with controls (23.1 +/- 4.4 bursts/min). However, SSNA was not elevated in ESRD (ESRD vs. controls, 17.6 +/- 2.2 vs. 16.1 +/- 1.7 bustst/min, P = 0.61). Similar results were obtained when MSNA was quantified as bursts per 100 heartbeats. We report the novel finding that although sympathetic activity directed to muscle is significantly elevated, activity directed to skin is not elevated in ESRD. The differential distribution of sympathetic outflow to the muscle vs. skin in ESRD is similar to the pattern seen in other disease states characterized by sympathetic overactivity such as heart failure and obesity.     

Hospitalization for heart disease, stroke, and diabetes mellitus among Indian-born persons: a small area analysis

Background

We set out to describe the risk of hospitalization from heart disease, stroke, and diabetes among persons born in India, all foreign-born persons, and U.S.-born persons residing in New York City.

Methods

We examined billing records of 1,083,817 persons hospitalized in New York City during the year 2000. The zip code of each patient's residence was linked to corresponding data from the 2000 U.S. Census to obtain covariates not present in the billing records. Using logistic models, we evaluated the risk of hospitalization for heart disease, stroke and diabetes by country of origin.

Results

After controlling for covariates, Indian-born persons are at similar risk of hospitalization for heart disease (RR = 1.02, 95% confidence interval 1.02, 1.03), stroke (RR = 1.00, 95% confidence interval, 0.99, 1.01), and diabetes mellitus (RR = 0.96 95% confidence interval 0.94, 0.97) as native-born persons. However, Indian-born persons are more likely to be hospitalized for these diseases than other foreign-born persons. For instance, the risk of hospitalization for heart disease among foreign-born persons is 0.70 (95% confidence interval 0.67, 0.72) and the risk of hospitalization for diabetes is 0.39 (95% confidence interval 0.37, 0.42) relative to native-born persons.

Conclusions

South Asians have considerably lower rates of hospitalization in New York than reported in countries with national health systems. Access may play a role. Clinicians working in immigrant settings should nonetheless maintain a higher vigilance for these conditions among Indian-born persons than among other foreign-born populations.     

Partial characterization of the molecular nature of collagen-linked fluorescence: Role of diabetes and end-stage renal disease

Collagen-linked fluorescence at excitation/emission 370/440 nm has widely been used as a marker for advanced glycation in studies of aging, diabetic complications, and end-stage renal disease (ESRD). Diagnostic devices measuring skin autofluorescence at this wavelength revealed an association between fluorescence and cardiovascular morbidity and mortality. We now report the presence of a major fluorophore (LW-1) in human skin collagen which increases with age, diabetes, and ESRD. It has a molecular weight of 623.2 Da, a UV maximum at 348 nm, and involves a lysine residue in an aromatic ring. LW-1 could not be synthesized using traditional glycation chemistry suggesting a complex mechanism of formation, perhaps related to hypoxia since elevated levels were also found in nondiabetic individuals with chronic lung disease.     

Risk of end-stage renal disease associated with gout: a nationwide population study

Introduction

We explored the risk of end-stage renal disease (ESRD) among gout patients in a representative cohort in Taiwan.

Methods

The primary database used was the Taiwan National Health Insurance Research Database. Subjects older than 20 years without ESRD, coronary heart disease, or stroke were included in the study. The case definition of gout in the present study was gout diagnosis and medical treatment for gout. An ESRD case was defined by the presence of chronic renal failure necessitating long-term renal replacement therapy. Multivariate Cox proportional hazards models were used to evaluate the risk of ESRD among gout patients.

Results

The analysis included data of 656,108 patients who were followed up for a mean of 8.0 years. Among them, 19,963 (3.0%) patients had gout. At the end of 2008, 2,377 individuals (gout, n = 276; non-gout, n = 2,101) had ESRD, and 861 individuals (gout, n = 77, 27.9%; non-gout, n = 521, 24.8%) died due to ESRD. The rates of incidence of ESRD were 1.73 and 0.41 cases per 1,000 patient-years in the gout and non-gout groups. After adjustment for age, sex, and history of diabetes mellitus and/or hypertension, gout was associated with a hazard ratio (HR) of 1.57 for ESRD (95% confidence interval [CI], 1.38-1.79; P < 0.001). In patients with ESRD, the adjusted HR for death in patients with gout was 0.95 (0.74-1.23, P = 0.71), which was similar to the HR obtained in patients without gout.

Conclusions

Gout is associated with an increased hazard for development of ESRD.     

Incidence and causes of end-stage renal disease among Aboriginal children and young adults

Background:

Although Aboriginal adults have a higher risk of end-stage renal disease than non-Aboriginal adults, the incidence and causes of end-stage renal disease among Aboriginal children and young adults are not well described.

Methods:

We calculated age- and sex-specific incidences of end-stage renal disease among Aboriginal people less than 22 years of age using data from a national organ failure registry. Incidence rate ratios were used to compare rates between Aboriginal and white Canadians. To contrast causes of end-stage renal disease by ethnicity and age, we calculated the odds of congenital diseases, glomerulonephritis and diabetes for Aboriginal people and compared them with those for white people in the following age strata: 0 to less than 22 years, 22 to less than 40 years, 40 to less than 60 years and older than 60 years.

Results:

Incidence rate ratios of end-stage renal disease for Aboriginal children and young adults (age < 22 yr, v. white people) were 1.82 (95% confidence interval [CI] 1.40–2.38) for boys and 3.24 (95% CI 2.60–4.05) for girls. Compared with white people, congenital diseases were less common among Aboriginal people aged less than 22 years (odds ratio [OR] 0.56, 95% CI 0.36–0.86), and glomerulonephritis was more common (OR 2.18, 95% CI 1.55–3.07). An excess of glomerulonephritis, but not diabetes, was seen among Aboriginal people aged 22 to less than 40 years. The converse was true (higher risk of diabetes, lower risk of glomerulonephritis) among Aboriginal people aged 40 years and older.

Interpretation:

The incidence of end-stage renal disease is higher among Aboriginal children and young adults than among white children and young adults. This higher incidence may be driven by an increased risk of glomerulonephritis in this population.Compared with white Canadians, Aboriginal Canadians have a higher prevalence of end-stage renal disease,^1,2 which is generally attributed to their increased risk for diabetes. However, there has been limited investigation of the incidence and causes of end-stage renal disease among Aboriginal children and young adults. Because most incident cases of diabetes are identified in middle-aged adults, an excess risk of end-stage renal disease in young people would not be expected if the high risk of diabetes is responsible for higher overall rates of end-stage renal disease among Aboriginal people. About 12.3% of children with end-stage renal disease in Canada are Aboriginal,³ but only 6.1% of Canadian children (age < 19 yr) are Aboriginal.^4,5A few reports suggest that nondiabetic renal disease is common among Aboriginal populations in North America.^2,6–8 Aboriginal adults in Saskatchewan are twice as likely as white adults to have end-stage renal disease caused by glomerulonephritis,^7,8 and an increased rate of mesangial proliferative glomerulonephritis has been reported among Aboriginal people in the United States.^6,9 These studies suggest that diabetes may be a comorbid condition rather than the sole cause of kidney failure among some Aboriginal people in whom diabetic nephropathy is diagnosed using clinical features alone.We estimated incidence rates of end-stage renal disease among Aboriginal children and young adults in Canada and compared them with the rates seen among white children and young adults. In addition, we compared relative odds of congenital renal disease, glomerulonephritis and diabetic nephropathy in Aboriginal people with the relative odds of these conditions in white people.     

Prevalence and determinants of diabetes mellitus among Iranian patients with chronic liver disease

BACKGROUND: Alterations in carbohydrate metabolism are frequently observed in cirrhosis. We conducted this study to define the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in Iranian patients with chronic liver disease (CLD), and explore the factors associated with DM in these patients. METHODS: One hundred and eighty-five patients with CLD were enrolled into the study. Fasting plasma glucose and two-hour plasma glucose were measured in patients' sera. DM and IGT were diagnosed according to the latest American Diabetes Association criteria. RESULTS: The subjects included 42 inactive HBV carriers with a mean age of 42.2 +/- 12.0 years, 102 patients with HBV or HCV chronic hepatitis with a mean age of 41.2 +/- 10.9 years, and 41 cirrhotic patients with a mean age of 52.1 +/- 11.4 years. DM and IGT were diagnosed in 40 (21.6%) and 21 (11.4%) patients, respectively. Univariate analysis showed that age (P = 0.000), CLD status (P = 0.000), history of hypertension (P = 0.007), family history of DM (P = 0.000), and body mass index (BMI) (P = 0.009) were associated with DM. Using Multivariate analysis, age (OR = 4.7, 95%CI: 1.8-12.2), family history of DM (OR = 6.6, 95%CI: 2.6-17.6), chronic hepatitis (OR = 11.6, 95%CI: 2.9-45.4), and cirrhosis (OR = 6.5, 95%CI: 2.4-17.4) remained as the factors independently associated with DM. When patients with cirrhosis and chronic hepatitis were analyzed separately, higher Child-Pugh's score in cirrhotic patients (OR = 9.6, 95%CI: 1.0-88.4) and older age (OR = 7.2, 95%CI: 1.0-49.1), higher fibrosis score (OR = 59.5, 95%CI: 2.9-1211.3/ OR = 11.9, 95%CI: 1.0-132.2), and higher BMI (OR = 30.3, 95%CI: 3.0-306.7) in patients with chronic hepatitis were found to be associated with higher prevalence of DM. CONCLUSIONS: Our findings indicate that patients with cirrhosis and chronic hepatitis are at the increased risk of DM occurrence. Older age, severe liver disease, and obesity were associated with DM in these patients.     

Secular decline in mortality from coronary heart disease in adults with diabetes mellitus: cohort study

Objective To examine trends in fatal coronary heart disease in adults with and without diabetes.Design Cohort study.Setting Two surveys of the Nord-Trøndelag health study (HUNT), a population based study in Norway.Participants 74 914 men and women from the first survey (1984-6) and 64 829 from the second survey (1995-7).Main outcome measure Age specific mortality from coronary heart disease among adults with and without diabetes during two consecutive nine year follow-up periods.Results A total of 2623 men and 1583 women died from coronary heart disease. Mortality rates were substantially lower during the most recent follow-up period: among men aged 70-79 without diabetes, deaths per 1000 person years declined from 16.38 to 8.79 (reduction 48%, 95% confidence interval 39% to 55%) and among women aged 70-79 from 6.84 to 2.68 (62%, 52% to 70%). Among the same age group with diabetes, deaths per 1000 person years in men declined from 38.97 to 17.89 (54%, 32% to 69%) and in women from 28.15 to 11.83 (59%, 37% to 73%). The reduction was more noticeable in age groups younger than 70 at baseline, and less pronounced among people aged 80 or more. Mortality from coronary heart disease was more than twofold higher in people with than without diabetes, with a slightly stronger association in women. The difference in mortality by diabetes status remained almost unchanged from the first to the second survey.Conclusion The strong general reduction in mortality rates from coronary heart disease from the first to the second follow-up period also benefited people with diabetes, but the more than twofold higher mortality from coronary heart disease associated with diabetes persisted over time.     

Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease

Background

Atrial electrical remodeling has been shown to influence the outcome the outcome following cardioversion of atrial fibrillation (AF) in experimental studies. The aim of the present study was to find out whether a non-invasively measured atrial fibrillatory cycle length, alone or in combination with other non-invasive parameters, could predict sinus rhythm maintenance after cardioversion of AF.

Methods

Dominant atrial cycle length (DACL), a previously validated non-invasive index of atrial refractoriness, was measured from lead V1 and a unipolar oesophageal lead prior to cardioversion in 37 patients with persistent AF undergoing their first cardioversion.

Results

32 patients were successfully cardioverted to sinus rhythm. The mean DACL in the 22 patients who suffered recurrence of AF within 6 weeks was 152 ± 15 ms (V1) and 147 ± 14 ms (oesophagus) compared to 155 ± 17 ms (V1) and 151 ± 18 ms (oesophagus) in those maintaining sinus rhythm (NS). Left atrial diameter was 48 ± 4 mm and 44 ± 7 mm respectively (NS). The optimal parameter predicting maintenance of sinus rhythm after 6 weeks appeared to be the ratio of the lowest dominant atrial cycle length (oesophageal lead or V1) to left atrial diameter. This ratio was significantly higher in patients remaining in sinus rhythm (3.4 ± 0.6 vs. 3.1 ± 0.4 ms/mm respectively, p = 0.04).

Conclusion

In this study neither an index of atrial refractory period nor left atrial diameter alone were predictors of AF recurrence within the 6 weeks of follow-up. The ratio of the two (combining electrophysiological and anatomical measurements) only slightly improve the identification of patients at high risk of recurrence of persistent AF. Consequently, other ways to asses electrical remodeling and / or other variables besides electrical remodeling are involved in determining the outcome following cardioversion.