- Email: [email protected]
Epidemiol-ogy of Diabetes Interventions and Complications Research Group. JAMA 2002;287:2563-2569.
T
YPE 2 DIABETES MELLITUS AFFECTS UP TO 15 MILLION
persons in the United States and is a leading cause of morbidity and mortality. Microvascular processes have been hypothesized to play a role in the pathogenesis of the disease. The retinal arterioles offer an excellent opportunity to explore, noninvasively, the prognostic importance of microvascular disease in type 2 diabetes mellitus. The Atherosclerosis Risk in Communities Study, an ongoing population-based, prospective cohort study in four US communities that began in 1987–1989. Included in this analysis were 7,993 persons aged 49 to 73 years without diabetes, of whom retinal photographs were taken during the third examination (1993–1995). After a median follow-up of 3.5 years, 291 persons (3.6%) had incident diabetes. The incidence of diabetes was higher in persons with lower retinal arteriole-to-venule ratios (AVR) at baseline (2.4%, 3.1%, 4.0%, and 5.2%, from highest to lowest AVR quartile; P for trend ⬍ .001). After controlling for fasting glucose and insulin levels, family history of diabetes, adiposity, physical activity, blood pressure, and other factors, persons in the lowest quartile of AVR were 71% more likely to develop diabetes than those in the highest quartile (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.13–2.57; P for trend ⫽ .002). The association persisted with different diagnostic criteria (OR, 1.92; 95% CI, 1.10 –3.36; P for trend ⫽ .01, using a fasting glucose level of ⱖ 141 mg/dl as a cutoff), and was seen even in people at lower risk of diabetes, including those without a family history of diabetes, without impaired fasting glucose, and with lower measures of adiposity. Retinal arteriolar narrowing is independently associated with a risk of type 2 diabetes mellitus, supporting a microvascular role in the development of clinical diabetes.—Nancy J. Newman *Department of Ophthalmology, National University of Singapore, 10 Kent Ridge Crescent, Singapore 119260. E-mail: [email protected]
●
Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus. Writing Team* for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. JAMA 2002;287:2563–2569.
T
HE MICROVASCULAR COMPLICATIONS OF TYPE 1 DIA-
betes mellitus include diabetic retinopathy and nephropathy. The purpose of this special report was to summarize and integrate the findings of the Diabetes Control and Complications Trial (DCCT), a randomized controlled clinical trial, and the succeeding observational follow-up of the DCCT cohort in the Epidemiology of Diabetes Interventions and Complications (EDIC) study, regarding the effects of intensive treatment on the microvascular complications of type 1 diabetes mellitus. The DCCT proved that intensive treatment reduced the risks of retinopathy, nephropathy, and neuropathy by 35% to VOL. 134, NO. 4
90% compared with conventional treatment. The absolute risks of retinopathy and nephropathy were proportional to the mean glycosylated hemoglobin (HbA1c) level over the follow-up period preceding each event. Intensive treatment was most effective when begun early, before complications were detectable. These risk reductions, achieved at a median HbA1c level difference of 9.1% for conventional treatment vs 7.3% for intensive treatment, have been maintained through 7 years of EDIC, even though the difference in mean HbA1c levels of the two former randomized treatment groups was only 0.4% at 1 year (P ⬍ .001) (8.3% in the former conventional treatment group vs 7.9% in the former intensive treatment group), continued to narrow and became statistically nonsignificant by 5 years (8.1% vs 8.2%, P ⫽ .09). The further rate of progression of complications from their levels at the end of the DCCT remains less in the former intensive treatment group. Thus, the benefits of 6.5 years of intensive treatment extend well beyond the period of its most intensive implementation. Intensive treatment should be started as soon as is safely possible after the onset of type 1 diabetes mellitus and maintained thereafter, aiming for a practicable target HbA1c level of 7.0% or less.—Nancy J. Newman *The Diabetes Control and Complications Trial Research Group, Box NDIC/DCCT, Bethesda, MD 20892.
●
Bilateral orbital signs predict cortical venous drainage in cavernous sinus dural AVMs. Steibel-Kalish H,* Setton A, Berenstein A, Kalish Y, Nimii Y, Kupersmith MJ. Neurology 2002;58:1521–1524.
C
AVERNOUS SINUS DURAL ARTERIOVENOUS MALFOR-
mations (CSdAVM) cause a spectrum of ophthalmic signs and symptoms ranging from a purely ocular or orbital syndrome to less common aggressive neurologic dysfunction due to intracerebral hemorrhages or cerebral venous infarction. Most CSdAVMs have a benign clinical course, but those that drain into cortical veins have an increased risk for neurologic complications. The objective of this study was to determine whether a specific clinical sign predicts cortical venous drainage in CSdAVMs. The records of 118 patients with CSdAVMs were evaluated for the clinical features of the disorder and tested for predictive value of cortical venous drainage. Clinical signs that predicted the presence of cortical venous drainage included bilateral orbital signs (P ⫽ 0.004, OR ⫽ 23.84) and presence of a postauricular bruit (P ⫽ 0.035, odds ratio (OR) ⫽ 23.8). No other clinical sign predicted the presence of cortical venous drainage, including extraocular muscle dysfunction, abducens or oculomotor nerve dysfunction, increased intraocular pressure, venous stasis retinopathy, chroroidal effusion, optic neuropathy, subjective bruit, and objective orbital bruit. The authors concluded that patients who present with or develop bilateral orbital
ABSTRACTS
641
YPE 2 DIABETES MELLITUS AFFECTS UP TO 15 MILLION
persons in the United States and is a leading cause of morbidity and mortality. Microvascular processes have been hypothesized to play a role in the pathogenesis of the disease. The retinal arterioles offer an excellent opportunity to explore, noninvasively, the prognostic importance of microvascular disease in type 2 diabetes mellitus. The Atherosclerosis Risk in Communities Study, an ongoing population-based, prospective cohort study in four US communities that began in 1987–1989. Included in this analysis were 7,993 persons aged 49 to 73 years without diabetes, of whom retinal photographs were taken during the third examination (1993–1995). After a median follow-up of 3.5 years, 291 persons (3.6%) had incident diabetes. The incidence of diabetes was higher in persons with lower retinal arteriole-to-venule ratios (AVR) at baseline (2.4%, 3.1%, 4.0%, and 5.2%, from highest to lowest AVR quartile; P for trend ⬍ .001). After controlling for fasting glucose and insulin levels, family history of diabetes, adiposity, physical activity, blood pressure, and other factors, persons in the lowest quartile of AVR were 71% more likely to develop diabetes than those in the highest quartile (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.13–2.57; P for trend ⫽ .002). The association persisted with different diagnostic criteria (OR, 1.92; 95% CI, 1.10 –3.36; P for trend ⫽ .01, using a fasting glucose level of ⱖ 141 mg/dl as a cutoff), and was seen even in people at lower risk of diabetes, including those without a family history of diabetes, without impaired fasting glucose, and with lower measures of adiposity. Retinal arteriolar narrowing is independently associated with a risk of type 2 diabetes mellitus, supporting a microvascular role in the development of clinical diabetes.—Nancy J. Newman *Department of Ophthalmology, National University of Singapore, 10 Kent Ridge Crescent, Singapore 119260. E-mail: [email protected]
●
Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus. Writing Team* for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. JAMA 2002;287:2563–2569.
T
HE MICROVASCULAR COMPLICATIONS OF TYPE 1 DIA-
betes mellitus include diabetic retinopathy and nephropathy. The purpose of this special report was to summarize and integrate the findings of the Diabetes Control and Complications Trial (DCCT), a randomized controlled clinical trial, and the succeeding observational follow-up of the DCCT cohort in the Epidemiology of Diabetes Interventions and Complications (EDIC) study, regarding the effects of intensive treatment on the microvascular complications of type 1 diabetes mellitus. The DCCT proved that intensive treatment reduced the risks of retinopathy, nephropathy, and neuropathy by 35% to VOL. 134, NO. 4
90% compared with conventional treatment. The absolute risks of retinopathy and nephropathy were proportional to the mean glycosylated hemoglobin (HbA1c) level over the follow-up period preceding each event. Intensive treatment was most effective when begun early, before complications were detectable. These risk reductions, achieved at a median HbA1c level difference of 9.1% for conventional treatment vs 7.3% for intensive treatment, have been maintained through 7 years of EDIC, even though the difference in mean HbA1c levels of the two former randomized treatment groups was only 0.4% at 1 year (P ⬍ .001) (8.3% in the former conventional treatment group vs 7.9% in the former intensive treatment group), continued to narrow and became statistically nonsignificant by 5 years (8.1% vs 8.2%, P ⫽ .09). The further rate of progression of complications from their levels at the end of the DCCT remains less in the former intensive treatment group. Thus, the benefits of 6.5 years of intensive treatment extend well beyond the period of its most intensive implementation. Intensive treatment should be started as soon as is safely possible after the onset of type 1 diabetes mellitus and maintained thereafter, aiming for a practicable target HbA1c level of 7.0% or less.—Nancy J. Newman *The Diabetes Control and Complications Trial Research Group, Box NDIC/DCCT, Bethesda, MD 20892.
●
Bilateral orbital signs predict cortical venous drainage in cavernous sinus dural AVMs. Steibel-Kalish H,* Setton A, Berenstein A, Kalish Y, Nimii Y, Kupersmith MJ. Neurology 2002;58:1521–1524.
C
AVERNOUS SINUS DURAL ARTERIOVENOUS MALFOR-
mations (CSdAVM) cause a spectrum of ophthalmic signs and symptoms ranging from a purely ocular or orbital syndrome to less common aggressive neurologic dysfunction due to intracerebral hemorrhages or cerebral venous infarction. Most CSdAVMs have a benign clinical course, but those that drain into cortical veins have an increased risk for neurologic complications. The objective of this study was to determine whether a specific clinical sign predicts cortical venous drainage in CSdAVMs. The records of 118 patients with CSdAVMs were evaluated for the clinical features of the disorder and tested for predictive value of cortical venous drainage. Clinical signs that predicted the presence of cortical venous drainage included bilateral orbital signs (P ⫽ 0.004, OR ⫽ 23.84) and presence of a postauricular bruit (P ⫽ 0.035, odds ratio (OR) ⫽ 23.8). No other clinical sign predicted the presence of cortical venous drainage, including extraocular muscle dysfunction, abducens or oculomotor nerve dysfunction, increased intraocular pressure, venous stasis retinopathy, chroroidal effusion, optic neuropathy, subjective bruit, and objective orbital bruit. The authors concluded that patients who present with or develop bilateral orbital
ABSTRACTS
641