Impact of COVID-19 and non-COVID-19 hospitalised pneumonia on longer term cardiovascular mortality in people with type 2 diabetes: A nationwide prospective cohort study from Scotland

OBJECTIVEIn this study we examine whether hospitalized coronavirus disease 2019 (COVID-19) pneumonia increases long-term cardiovascular mortality more than other hospitalized pneumonias in people with type 2 diabetes and aim to quantify the relative cardiovascular disease (CVD) mortality risks associated with COVID-19 versus non-COVID-19 pneumonia.RESEARCH DESIGN AND METHODSWith use of the SCI-Diabetes register, two cohorts were identified: individuals with type 2 diabetes in 2016 and at the 2020 pandemic onset. Hospital and death records were linked for determination of pneumonia exposure and CVD deaths. Poisson regression estimated rate ratios (RRs) for CVD death associated with both pneumonia types, with adjustment for confounders. Median follow-up durations were 1,461 days (2016 cohort) and 700 days (2020 cohort).RESULTSThe adjusted RR for CVD death following non-COVID-19 pneumonia was 5.51 (95% CI 5.31–5.71) prepandemic and 7.3 (6.86–7.76) during the pandemic. For COVID-19 pneumonia, the RR was 9.13 (8.55–9.75). Beyond 30 days post pneumonia, the RRs converged, to 4.24 (3.90–4.60) for non-COVID-19 and 3.35 (3.00–3.74) for COVID-19 pneumonia, consistent even with exclusion of prior CVD cases.CONCLUSIONSHospitalized pneumonia, irrespective of causal agent, marks an increased risk for CVD death immediately and over the long-term. COVID-19 pneumonia poses a higher CVD death risk than other pneumonias in the short-term, but this distinction diminishes over time. These insights underscore the need for including pneumonia in CVD risk assessments, with particular attention to the acute impact of COVID-19 pneumonia

Risk of cardiovascular disease and total mortality in adults with type 1 diabetes: Scottish registry linkage study

<p>Background: Randomized controlled trials have shown the importance of tight glucose control in type 1 diabetes (T1DM), but few recent studies have evaluated the risk of cardiovascular disease (CVD) and all-cause mortality among adults with T1DM. We evaluated these risks in adults with T1DM compared with the non-diabetic population in a nationwide study from Scotland and examined control of CVD risk factors in those with T1DM.</p> <p>Methods and Findings: The Scottish Care Information-Diabetes Collaboration database was used to identify all people registered with T1DM and aged ≥20 years in 2005–2007 and to provide risk factor data. Major CVD events and deaths were obtained from the national hospital admissions database and death register. The age-adjusted incidence rate ratio (IRR) for CVD and mortality in T1DM (n = 21,789) versus the non-diabetic population (3.96 million) was estimated using Poisson regression. The age-adjusted IRR for first CVD event associated with T1DM versus the non-diabetic population was higher in women (3.0: 95% CI 2.4–3.8, p<0.001) than men (2.3: 2.0–2.7, p<0.001) while the IRR for all-cause mortality associated with T1DM was comparable at 2.6 (2.2–3.0, p<0.001) in men and 2.7 (2.2–3.4, p<0.001) in women. Between 2005–2007, among individuals with T1DM, 34 of 123 deaths among 10,173 who were <40 years and 37 of 907 deaths among 12,739 who were ≥40 years had an underlying cause of death of coma or diabetic ketoacidosis. Among individuals 60–69 years, approximately three extra deaths per 100 per year occurred among men with T1DM (28.51/1,000 person years at risk), and two per 100 per year for women (17.99/1,000 person years at risk). 28% of those with T1DM were current smokers, 13% achieved target HbA1c of <7% and 37% had very poor (≥9%) glycaemic control. Among those aged ≥40, 37% had blood pressures above even conservative targets (≥140/90 mmHg) and 39% of those ≥40 years were not on a statin. Although many of these risk factors were comparable to those previously reported in other developed countries, CVD and mortality rates may not be generalizable to other countries. Limitations included lack of information on the specific insulin therapy used.</p> <p>Conclusions: Although the relative risks for CVD and total mortality associated with T1DM in this population have declined relative to earlier studies, T1DM continues to be associated with higher CVD and death rates than the non-diabetic population. Risk factor management should be improved to further reduce risk but better treatment approaches for achieving good glycaemic control are badly needed.</p&gt

Use of personalised risk-based screening schedules to optimise workload and sojourn time in screening programmes for diabetic retinopathy:A retrospective cohort study

Background: National guidelines in most countries set screening intervals for diabetic retinopathy (DR) that are insufficiently informed by contemporary incidence rates. This has unspecified implications for interval disease risks (IDs) of referable DR, disparities in ID between groups or individuals, time spent in referable state before screening (sojourn time), and workload. We explored the effect of various screening schedules on these outcomes and developed an open-access interactive policy tool informed by contemporary DR incidence rates. Methods and findings: Scottish Diabetic Retinopathy Screening Programme data from 1 January 2007 to 31 December 2016 were linked to diabetes registry data. This yielded 128,606 screening examinations in people with type 1 diabetes (T1D) and 1,384,360 examinations in people with type 2 diabetes (T2D). Among those with T1D, 47% of those without and 44% of those with referable DR were female, mean diabetes duration was 21 and 23 years, respectively, and mean age was 26 and 24 years, respectively. Among those with T2D, 44% of those without and 42% of those with referable DR were female, mean diabetes duration was 9 and 14 years, respectively, and mean age was 58 and 52 years, respectively. Individual probability of developing referable DR was estimated using a generalised linear model and was used to calculate the intervals needed to achieve various IDs across prior grade strata, or at the individual level, and the resultant workload and sojourn time. The current policy in Scotland—screening people with no or mild disease annually and moderate disease every 6 months—yielded large differences in ID by prior grade (13.2%, 3.6%, and 0.6% annually for moderate, mild, and no prior DR strata, respectively, in T1D) and diabetes type (2.4% in T1D and 0.6% in T2D overall). Maintaining these overall risks but equalising risk across prior grade strata would require extremely short intervals in those with moderate DR (1–2 months) and very long intervals in those with no prior DR (35–47 months), with little change in workload or average sojourn time. Changing to intervals of 12, 9, and 3 months in T1D and to 24, 9, and 3 months in T2D for no, mild, and moderate DR strata, respectively, would substantially reduce disparity in ID across strata and between diabetes types whilst reducing workload by 26% and increasing sojourn time by 2.3 months. Including clinical risk factor data gave a small but significant increment in prediction of referable DR beyond grade (increase in C-statistic of 0.013 in T1D and 0.016 in T2D, both p < 0.001). However, using this model to derive personalised intervals did not have substantial workload or sojourn time benefits over stratum-specific intervals. The main limitation is that the results are pertinent only to countries that share broadly similar rates of retinal disease and risk factor distributions to Scotland. Conclusions: Changing current policies could reduce disparities in ID and achieve substantial reductions in workload within the range of IDs likely to be deemed acceptable. Our tool s

Being a quantitative interviewer: qualitatively exploring interviewers' experiences in a longitudinal cohort study

<p>Abstract</p> <p>Background</p> <p>Many studies of health outcomes rely on data collected by interviewers administering highly-structured (quantitative) questionnaires to participants. Little appears to be known about the experiences of such interviewers. This paper explores interviewer experiences of working on a longitudinal study in New Zealand (the Prospective Outcomes of injury Study - POIS). Interviewers administer highly-structured questionnaires to participants, usually by telephone, and enter data into a secure computer program. The research team had expectations of interviewers including: consistent questionnaire administration, timeliness, proportions of potential participants recruited and an empathetic communication style. This paper presents results of a focus group to qualitatively explore with the team of interviewers their experiences, problems encountered, strategies, support systems used and training.</p> <p>Methods</p> <p>A focus group with interviewers involved in the POIS interviews was held; it was audio-recorded and transcribed. The analytical method was thematic, with output intended to be descriptive and interpretive.</p> <p>Results</p> <p>Nine interviewers participated in the focus group (average time in interviewer role was 31 months). Key themes were: 1) the positive aspects of the quantitative interviewer role (i.e. relationships and resilience, insights gained, and participants' feedback), 2) difficulties interviewers encountered and solutions identified (i.e. stories lost or incomplete, forgotten appointments, telling the stories, acknowledging distress, stories reflected and debriefing and support), and 3) meeting POIS researcher expectations (i.e. performance standards, time-keeping, dealing exclusively with the participant and maintaining privacy).</p> <p>Conclusions</p> <p>Interviewers demonstrated great skill in the way they negotiated research team expectations whilst managing the relationships with participants. Interviewers found it helpful to have a research protocol in place in the event of sensitive situations - this appeared to alleviate the pressure on interviewers to carry the burden of responsibility. Interviewers are employed to scientifically gather quantitative data, yet their effectiveness relies largely on their humanity. We propose that the personal connection generated between the interviewers and participants was important, and enabled successful follow-up rates for the study. The enjoyment of these relationships was crucial to interviewers and helped balance the negative aspects of their role. Our results suggest that experienced quantitative interviewers endeavour, as do many qualitative researchers, to carefully and respectfully negotiate the requirements of the interview within a relationship they form with participants: being sensitive to the needs of participants and respectful of their wishes - and establishing an ethical relationship.</p

Incidence of Hospitalization for Heart Failure and Case-Fatality Among 3.25 Million People With and Without Diabetes Mellitus

Background: Recent clinical trials of new glucose-lowering treatments have drawn attention to the importance of hospitalisation for heart failure as a complication of diabetes. However, the epidemiology is not well described, particularly for type 1 diabetes. We examined the incidence and case-fatality of heart failure hospitalisations in the entire population aged 30 and older resident in Scotland during 2004 to 2013. Methods: Date and type of diabetes diagnosis were linked to heart failure hospitalisations and deaths using the national Scottish registers. Incidence rates and case-fatality were estimated in regression models (quasi-Poisson and logistic regression respectively). All estimates are adjusted for age, sex, socio-economic status and calendar-year. Results: Over the 10-year period of the study, among 3.25 million people there were 91,429, 22,959 and 1,313 incident heart failure events among those without diabetes, with type 2, and type 1 diabetes respectively. The crude incidence rates of heart failure hospitalisation were therefore 2.4, 12.4 and 5.6 per 1000 person-years for these three groups. Heart failure hospitalisation incidence was higher in people with diabetes, regardless of type, than in people without. Relative differences were smallest for older men, in whom the difference was nonetheless large (men aged 80, rate ratio 1.78; 95% CI 1.45 to 2.19). Rates declined similarly, by 0.2% per calendar-year, in people with type 2 diabetes and without diabetes. Rates fell faster, however, in those with type 1 diabetes (2.2% per calendar-year, RR for type 1/calendar-year interaction 0.978; 95% CI 0.959 to 0.998). 30-day case-fatality was similar among people with type 2 diabetes and without diabetes, but was higher in type 1 diabetes for men (OR 0.96; 95% CI 0.95 to 0.96) and women (OR 0.98; 95% CI 0.97 to 0.98). Case-fatality declined over time for all groups (3.3% per calendar-year, OR per calendar-year 0.967; 95% CI 0.961 to 0.973). Conclusions: Despite falling incidence, particularly in type 1 diabetes, heart failure remains around 2-fold higher than in people without diabetes, with higher case-fatality in those with type 1 diabetes. These findings support the view that heart failure is an under-recognised and important complication in diabetes, particularly for type 1 disease

Factors associated with stillbirth in women with diabetes

Aims/hypothesis: Stillbirth risk is increased in pregnancy complicated by diabetes. Fear of stillbirth has major influence on obstetric management, particularly timing of delivery. We analysed population-level data from Scotland to describe timing of stillbirths in women with diabetes and associated risk factors. Methods: A retrospective cohort of singleton deliveries to mothers with type 1 (n = 3778) and type 2 diabetes (n = 1614) from 1 April 1998 to 30 June 2016 was analysed using linked routine care datasets. Maternal and fetal characteristics, HbA1c data and delivery timing were compared between stillborn and liveborn groups. Results: Stillbirth rates were 16.1 (95% CI 12.4, 20.8) and 22.9 (95% CI 16.4, 31.8) per 1000 births in women with type 1 (n = 61) and type 2 diabetes (n = 37), respectively. In women with type 1 diabetes, higher HbA1c before pregnancy (OR 1.03 [95% CI 1.01, 1.04]; p = 0.0003) and in later pregnancy (OR 1.06 [95% CI 1.04, 1.08]; p &lt; 0.0001) were associated with stillbirth, while in women with type 2 diabetes, higher maternal BMI (OR 1.07 [95% CI 1.01, 1.14]; p = 0.02) and pre-pregnancy HbA1c (OR 1.02 [95% CI 1.00, 1.04]; p = 0.016) were associated with stillbirth. Risk was highest in infants with birthweights &lt;10th centile (sixfold higher born to women with type 1 diabetes [n = 5 stillbirths, 67 livebirths]; threefold higher for women with type 2 diabetes [n = 4 stillbirths, 78 livebirths]) compared with those in the 10th–90th centile (n = 20 stillbirths, 1685 livebirths). Risk was twofold higher in infants with birthweights &gt;95th centile born to women with type 2 diabetes (n = 15 stillbirths, 402 livebirths). A high proportion of stillborn infants were male among mothers with type 2 diabetes (81.1% vs 50.5% livebirths, p = 0.0002). A third of stillbirths occurred at term, with highest rates in the 38th week (7.0 [95% CI 3.7, 12.9] per 1000 ongoing pregnancies) among mothers with type 1 diabetes and in the 39th week (9.3 [95% CI 2.4, 29.2]) for type 2 diabetes. Conclusions/interpretation: Maternal blood glucose levels and BMI are important modifiable risk factors for stillbirth in diabetes. Babies at extremes of weight centiles are at most risk. Many stillbirths occur at term and could potentially be prevented by change in routine care and delivery policies

Ethnic differences in Glycaemic control in people with type 2 diabetes mellitus living in Scotland

Background and Aims: Previous studies have investigated the association between ethnicity and processes of care and intermediate outcomes of diabetes, but there are limited population-based studies available. The aim of this study was to use population-based data to investigate the relationships between ethnicity and glycaemic control in men and women with diabetes mellitus living in Scotland.&lt;p&gt;&lt;/p&gt; Methods: We used a 2008 extract from the population-based national electronic diabetes database of Scotland. The association between ethnicity with mean glycaemic control in type 2 diabetes mellitus was examined in a retrospective cohort study, including adjustment for a number of variables including age, sex, socioeconomic status, body mass index (BMI), prescribed treatment and duration of diabetes.&lt;p&gt;&lt;/p&gt; Results: Complete data for analyses were available for 56,333 White Scottish adults, 2,535 Pakistanis, 857 Indians, 427 Chinese and 223 African-Caribbeans. All other ethnic groups had significantly (p&#60;0.05) greater proportions of people with suboptimal glycaemic control (HbA1c &#62;58 mmol/mol, 7.5%) compared to the White Scottish group, despite generally younger mean age and lower BMI. Fully adjusted odds ratios for suboptimal glycaemic control were significantly higher among Pakistanis and Indians (1.85, 95% CI: 1.68–2.04, and 1.62,95% CI: 1.38–1.89) respectively.&lt;p&gt;&lt;/p&gt; Conclusions: Pakistanis and Indians with type 2 diabetes mellitus were more likely to have suboptimal glycaemic control than the white Scottish population. Further research on health services and self-management are needed to understand the association between ethnicity and glycaemic control to address ethnic disparities in glycaemic control.&lt;p&gt;&lt;/p&gt

The effect of dapagliflozin on glycaemic control and other cardiovascular disease risk factors in type 2 diabetes mellitus:a real-world observational study

Aims/hypothesis: Dapagliflozin, a sodium–glucose cotransporter 2 (SGLT2) inhibitor, is indicated for improving glycaemic control in type 2 diabetes mellitus. Whether its effects on HbA1c and other variables, including safety outcomes, in clinical trials are obtained in real-world practice needs to be established. Methods: We used data from the comprehensive national diabetes register, the Scottish Care Information-Diabetes (SCI-Diabetes) collaboration database, available from 2004 to mid-2016. Data within this database were linked to mortality data from the General Registrar, available from the Information Services Division (ISD) of the National Health Service in Scotland. We calculated crude within-person differences between pre- and post-drug-initiation values of HbA1c, BMI, body weight, systolic blood pressure (SBP) and eGFR. We used mixed-effects regression models to adjust for within-person time trajectories in these measures. For completeness, we evaluated safety outcomes, cardiovascular disease events, lower-limb amputation and diabetic ketoacidosis, focusing on cumulative exposure effects, using Cox proportional hazard models, though power to detect such effects was limited. Results: Among 8566 people exposed to dapagliflozin over a median of 210 days the crude within-person change in HbA1c was −10.41 mmol/mol (−0.95%) after 3 months’ exposure. The crude change after 12 months was −12.99 mmol/mol (−1.19%) but considering the expected rise over time in HbA1c gave a dapagliflozin-exposure-effect estimate of −15.14 mmol/mol (95% CI −15.87, −14.41) (−1.39% [95% CI −1.45, −1.32]) at 12 months that was maintained thereafter. A drop in SBP of −4.32 mmHg (95% CI −4.84, −3.79) on exposure within the first 3 months was also maintained thereafter. Reductions in BMI and body weight stabilised by 6 months at −0.82 kg/m2 (95% CI −0.87, −0.77) and −2.20 kg (95% CI −2.34, −2.06) and were maintained thereafter. eGFR declined initially by −1.81 ml min−1 [1.73 m]−2 (95% CI −2.10, −1.52) at 3 months but varied thereafter. There were no significant effects of cumulative drug exposure on safety outcomes. Conclusions/interpretation: Dapagliflozin exposure was associated with reductions in HbA1c, SBP, body weight and BMI that were at least as large as in clinical trials. Dapagliflozin also prevented the expected rise in HbA1c and SBP over the period of study