Screening for chronic kidney disease is recommended in people at high risk, but data on the independent and combined associations of estimated glomerular filtration rate (eGFR) and albuminuria with ...all-cause and cardiovascular mortality are limited. To clarify this, we performed a collaborative meta-analysis of 10 cohorts with 266,975 patients selected because of increased risk for chronic kidney disease, defined as a history of hypertension, diabetes, or cardiovascular disease. Risk for all-cause mortality was not associated with eGFR between 60–105ml/min per 1.73m2, but increased at lower levels. Hazard ratios at eGFRs of 60, 45, and 15ml/min per 1.73m2 were 1.03, 1.38 and 3.11, respectively, compared to an eGFR of 95, after adjustment for albuminuria and cardiovascular risk factors. Log albuminuria was linearly associated with log risk for all-cause mortality without thresholds. Adjusted hazard ratios at albumin-to-creatinine ratios of 10, 30 and 300mg/g were 1.08, 1.38, and 2.16, respectively compared to a ratio of five. Albuminuria and eGFR were multiplicatively associated with all-cause mortality, without evidence for interaction. Similar associations were observed for cardiovascular mortality. Findings in cohorts with dipstick data were generally comparable to those in cohorts measuring albumin-to-creatinine ratios. Thus, lower eGFR and higher albuminuria are risk factors for all-cause and cardiovascular mortality in high-risk populations, independent of each other and of cardiovascular risk factors.
Aim/hypothesis
Arginine vasopressin (AVP), the hormone important for maintaining fluid balance, has been shown to cause kidney damage in rodent models of diabetes. We investigated the potential role ...of AVP in the natural course of kidney function decline in diabetes in an epidemiological study.
Methods
Plasma copeptin, a surrogate for AVP, was measured in baseline samples from patients with type 2 diabetes treated in primary care and included in the Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) cohort.
Results
Samples from 1,328 patients were available; 349 were analysed separately because they used renin–angiotensin–aldosterone system inhibition (RAASi), which influences albumin/creatinine ratio (ACR) and estimated (e)GFR. In the other 979 patients (46% men, age 68 years 58–75, ACR 1.8 mg/mmol 0.9–5.7, eGFR 67 ± 14 ml min
−1
1.73 m
−2
) baseline copeptin (5.3 pmol/l 3.2–9.5) was significantly associated with log
e
ACR and eGFR, even after adjustment for sex, age and risk factors for kidney function decline (standardised std β 0.13,
p
< 0.001, std β −0.20,
p
< 0.001 respectively). Follow-up data were available for 756 patients (6.5 years 4.1–9.6). Baseline copeptin was associated with increase in ACR (std β 0.09,
p
= 0.02), but lost significance after adjustment (std β 0.07,
p
= 0.08). Copeptin was associated with a decrease in eGFR after adjustment (std β −0.09,
p
= 0.03). The strength of the association of copeptin with change in eGFR was stronger than that of established risk factors for kidney function decline (e.g. BMI, HbA
1c
). In patients who used RAASi there was a significant association between baseline copeptin and ACR and eGFR, but not with change in ACR and eGFR.
Conclusions/interpretation
In patients with diabetes not using RAASi a higher baseline copeptin concentration is significantly associated with higher baseline ACR and lower eGFR values and with a decline in eGFR during follow-up. This last association is independent of, and stronger than, most traditional risk factors for kidney function decline.
Abstract Purpose 1. To assess health-related quality of life (HRQoL) of adult long term (up to 20 years) and very long term (>20 years) childhood cancer survivors, compared to the HRQoL of an age ...matched Dutch population sample. 2. To evaluate the impact of cancer-related adverse late effects on the functional, psychological and social health of childhood cancer survivors. Method The RAND-36 was used to assess HRQoL in all adult (⩾18 years) survivors who had attended the long-term follow-up clinic since 1995. The survivors were divided into two groups based on the length of follow-up: Group LF (long term follow-up, follow-up ⩽20 years, n = 129) and Group VLF (very long-term follow-up, follow-up >20 years, n = 184). Data on diagnosis, treatment and complications were obtained from medical records. Late effects were graded using the CTCAEv3. Results The RAND-36 was completed by 313 (86.2%) out of 363 eligible patients. Except for higher scores on the subscale Bodily pain, LF patients did not differ significantly on the RAND-36 subscales from the population sample; VLF patients had significant lower scores on the subscales Physical functioning ( P = 0.003), Social functioning, Vitality and General health perception ( P < 0.001). Significantly more VLF patients ( P < 0.001) had severe (grade 3 and 4) late effects (47.8%) compared to LF patients (27.9%). Female gender and especially psycho-social late effects were inversely related to HRQoL. Conclusion Childhood cancer survivors who were diagnosed more than 20 years ago have lower scores on the RAND 36, and have significantly more severe late effects than those diagnosed more recently. Patients with longer follow-up are more likely to become lost to follow-up. Time has come to establish new models of care for adult childhood cancer survivors, which are more flexible and appropriate to the needs of adult childhood cancer survivors.
Background
Patients with diabetes mellitus are at high risk for onychomycosis, which is related to the development of foot ulcers.
Objective
The aim of this study was to evaluate the safety and ...efficacy of the treatment of onychomycosis with local laser therapy.
Methods
In a single‐centre, randomized (1:1), quadruple‐blind, sham‐controlled trial, patients and microbiological confirmation with diabetes mellitus, at risk for developing diabetic foot ulcers (Sims classification score 1, 2) and a clinical suspicion on onychomycosis, were randomized to either four sessions neodymium‐doped yttrium aluminium garnet (Nd‐YAG) 1064 nm laser or sham treatment. The primary outcome was clinical and microbiological cure of onychomycosis after 1‐year follow‐up.
Results
From March 2015 to July 2016, 64 patients were randomized; 63 could be analysed. Trichophyton rubrum was the most detected pathogen. There was no difference in the primary outcome between laser and sham treatment. With the exception of a subungual haematoma in the fifth toenail occurring 2 weeks after laser treatment, the results suggested that treatment with Nd‐YAG 1064 nm laser is safe.
Conclusion
At this moment, there is no evidence of any effect of laser treatment for onychomycosis in patients with diabetes at increased risk for foot ulcers, at least not within 1 year after treatment.
Background: To assess health status and health-related quality of life (HRQoL) in childhood cancer survivors who were not involved in regular long-term follow-up. Patients and methods: One hundred ...and twenty-three long-term survivors, median age 33 (19–50) years, follow-up 27 (9–38) years, were recalled to the long-term follow-up clinic. Most of them were treated in the period 1970–1990. Late effects were graded using the Common Terminology Criteria for Adverse Events, version 3 (CTCAEv3). HRQoL was assessed by RAND-36. Socio-economic factors were compared with data from Statistics Netherlands (CBS). Results: Grade 1–2 late effects were found in 54% of the survivors, grade 3–4 in 39%, two or more late effects in 70% and grade 2–4 previously unknown late effects in 33%. Survivors had significantly lower scores on RAND-36 compared with controls. Conclusions: As nearly 40% of these long-term childhood cancer survivors suffer from moderate to severe late effects and 33% had previously unknown late effects it is worthwhile recalling these patients to follow-up. Where and by whom this follow-up can best be done is still a question that needs to be answered.
To assess the expected precision of HbA1c measurements and the magnitude of HbA1c changes eliciting the advice to change treatment among diabetes care professionals.
A seven-item questionnaire was ...sent to participants through a website. The survey focused on physicians and nurses involved in diabetes care.
In total, 104 physicians, 177 diabetes specialist nurses, and 248 primary care nurses responded to the survey. A large number of the nurses (44%) and only a small number of the physicians (4%) were not aware of the inherent uncertainty of HbA1c results. Nurses considered adjusting therapy based on very small changes in HbA1c whereas physicians in general adhere to 0.5% (5.5 mmol÷mol) as a clinically meaningful cut-off point. After therapy adjustment, a very small (0.1%) or no increase in HbA1c was considered to be significant enough to conclude that glucose regulation has worsened by 49% of the nurses and only 13% of the physicians.
Significant differences exist in the interpretation of changes in HbA1c results between physicians and nurses. Nurses consider therapy changes based on very small changes in HbA1c, whereas physicians preferably agree to the clinically relevant change of 0.5% (5.5 mmol÷mol). Changing therapy based on relatively small changes in HbA1c might lead to undue adjustments in the treatment of patients with diabetes. There is a clear need for more training for all diabetes care professionals about both the clinical significance and accuracy of HbA1c measurements.
Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in children. Studies on costs related to T1DM are scarce and focused primarily on the costs directly related to diabetes. We ...aimed to investigate both the overall healthcare costs and the more specific costs related to the management of diabetes.
This is a retrospective and observational, nationwide cohort study of all Dutch children (aged 0-18 years) with T1DM. Data were collected from the national registry for healthcare reimbursement, in which all Dutch insurance companies combine their reimbursement data. In the Netherlands for all Dutch citizens health care is covered by law and all children are treated by hospital-based paediatricians.
We analysed 6710 children distributed over 81 hospitals: 475 children in 6 university hospitals and 6235 children in 75 general hospitals. Total reimbursement for all children with T1DM over the period 2009 to 2011 was € 167,494,732 corresponding to an annual mean of € 55,831,577 of total costs and € 8326 euros per child. When comparing small (between 26 and 54 patients), medium (57-84 patients) and large (88-248 patients) general hospitals, costs per patient were highest in the hospitals with the highest number of T1DM patients. The costs for devices, secondary care and pharmaceutics had most impact on total expenditures. Over the study period, there was a slight decrease in per person costs.
The overall health expenditure of a child with T1DM is more than € 8000 per patient per annum. Given the move towards more device-intensive multidisciplinary care for these patients, the costs of treating T1DM in children are likely to increase further in the coming years.
Highlights • OH is not related to first fall incidents. • OH is not related to recurrent falling. • Falling is highly prevalent in nursing home residents.
Highlights • OH is highly prevalent in nursing home residents. • No correlation was found between a history of previous falls and OH or orthostatic complaints. • Patients with OH were found to have a ...higher chance of successful rehabilitation compared to patients without OH. • Confirmation of this rather remarkable and counterintuitive finding in other studies is necessary.
Background: To present actual data to estimate prevalence, incidence and mortality of known type 2 diabetes mellitus in all age categories in The Netherlands. Methods: Prospective population-based ...study between 1998 and 2000 in The Netherlands. Baseline population of 155,774 patients, registered with 61 general practitioners participating in the Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC)-study. Results: Age- and sex-adjusted prevalence of type 2 diabetes was 2.2% at baseline and 2.9% after 2 years of follow-up; for women and men it was 3.1 and 2.7% at follow-up, respectively. Patients aged >70 years account for almost 50% of all type 2 diabetes patients. Age- and sex-adjusted mean annual incidence per 10,000 over 3 years was 22.7 overall; for women 23.1 and for men 22.2. Incidence - even though high - decreases after the age of 70 years. The mortality rate was 47.9/1000 and standardised mortality ratio 1.40. Based on these results, the estimated total number of subjects known with type 2 diabetes was 466,000 for The Netherlands in 2000; the number of patients with newly diagnosed diabetes 36,000. Conclusions: Prevalence and incidence rates exceed all estimates regarding known type 2 diabetes for The Netherlands. Elderly patients, aged 70 years and over, account for 50% of the type 2 diabetic population. These results are important for health-care planning.
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