Protection From Retinopathy and Other Complications in Patients With Type 1 Diabetes of Extreme Duration: The Joslin 50-Year Medalist Study

Objective: To assess complication prevalence and identify protective factors in patients with diabetes duration of $\geq$50 years. Characterization of a complication-free subgroup in this cohort would suggest that some individuals are protected from diabetes complications and allow identification of endogenous protective factors. Research Design and Methods: Cross-sectional, observational study of 351 U.S. residents who have survived with type 1 diabetes for $\geq$50 years (Medalists). Retinopathy, nephropathy, neuropathy, and cardiovascular disease were assessed in relation to HbA$_{1c}$, lipids, and advanced glycation end products (AGEs). Retrospective chart review provided longitudinal ophthalmic data for a subgroup. Results: A high proportion of Medalists remain free from proliferative diabetic retinopathy (PDR) (42.6%), nephropathy (86.9%), neuropathy (39.4%), or cardiovascular disease (51.5%). Current and longitudinal (the past 15 years) glycemic control were unrelated to complications. Subjects with high plasma carboxyethyl-lysine and pentosidine were 7.2-fold more likely to have any complication. Of Medalists without PDR, 96% with no retinopathy progression over the first 17 years of follow-up did not experience retinopathy worsening thereafter. Conclusions: The Medalist population is likely enriched for protective factors against complications. These factors might prove useful to the general population with diabetes if they can be used to induce protection against long-term complications. Specific AGE combinations were strongly associated with complications, indicating a link between AGE formation or processing with development of diabetic vasculopathy

Disparities Between Teleretinal Imaging Findings and Patient-reported Diabetic Retinopathy Status and Followup Eye Care Interval: A 10-year Prospective study

Objective: To assess self-reported awareness of diabetic retinopathy (DR) and concordance of eye examination follow-up compared to findings from concurrent retinal images. Research Design and Methods: Prospective observational 10-year study of 26,876 consecutive patients with diabetes that underwent retinal imaging during an endocrinology visit. Awareness and concordance was evaluated using questionnaires and retinal imaging. Results: Awareness information and gradable images were available in 25,360 patients (94.3%). Severity of DR by imaging: no DR 14,317(56.5%); mild DR 6,805(26.8%), vision-threatening DR (vtDR) 4,238(16.7%). Patients did not report being aware of any prior DR in 96.7%, 88.5% and 54.9% (no,mild,vtDR). When DR was present, reporting no prior DR was associated with shorter diabetes duration, milder DR, last eye exam >1 year prior, no dilation, no scheduled appointment, and less specialized provider (all P<0.001). Among patients with vtDR, 41.2%, 58.1% and 64.2% did not report being aware of any DR and follow-up was concordant with current DR severity in 66.7%, 41.3% and 25.4% (P<0.001) when prior examination was performed by a retina specialist, non-retina ophthalmologist, or optometrist (P<0.001). Conclusions: Substantial discrepancies exist between DR presence, patient awareness and concordance of follow-up across all DR severity levels. These discrepancies are present across all eye care provider types with the magnitude influenced by provider type. Thus, patient self-report should not be relied upon to reflect DR status. Modification of medical care and education models may be necessary to enhance retention of ophthalmic knowledge in patients with diabetes and assure accurate communication between all health care providers.</p

Glycemic Control and Urinary Tract Infections in Women with Type 1 Diabetes: Results from the DCCT/EDIC

PurposeWe examined the relationship between glycemic control and urinary tract infections in women with type 1 diabetes mellitus.Materials and methodsWomen enrolled in the Epidemiology of Diabetes Interventions and Complications study, the observational followup of the Diabetes Control and Complications Trial, were surveyed to assess the rate of physician diagnosed urinary tract infections in the preceding 12 months. The relationship between glycated hemoglobin levels and number of urinary tract infections in the previous 12 months was assessed using a multivariable Poisson regression model.ResultsA total of 572 women were evaluated at year 17. Mean age was 50.7 ± 7.2 years, mean body mass index was 28.6 ± 5.9 kg/m(2), mean type 1 diabetes duration was 29.8 ± 5.0 years and mean glycated hemoglobin was 8.0% ± 0.9%. Of these women 86 (15.0%) reported at least 1 physician diagnosed urinary tract infection during the last 12 months. Higher glycated hemoglobin levels were significantly associated with number of urinary tract infections such that for every unit increase (1%) in recent glycated hemoglobin level, there was a 21% (p=0.02) increase in urinary tract infection frequency in the previous 12 months after adjusting for race, hysterectomy status, urinary incontinence, sexual activity in the last 12 months, peripheral and autonomic neuropathy, and nephropathy.ConclusionsThe frequency of urinary tract infections increases with poor glycemic control in women with type 1 diabetes. This relationship is independent of other well described predictors of urinary tract infections and suggests that factors directly related to glycemic control may influence the risk of lower urinary tract infections