pproximately 347 million persons worldwide have diabetes mellitus. 1,2 The Centers for Disease Control and Prevention estimates that 25.8 million persons (8.3% of the US population) had diabetes in 2010. 3 Substantial racial/ ethnic differences in the prevalence of diabetes in the United States have also been noted. National estimates report that, in persons aged 20 years or older in the United States, 14.2% of American Indians and Alaskan natives, 12.6% of non-Hispanic blacks, 11.8% of Hispanics, 8.4% of Asian Americans, and 7.1% of non-Hispanic whites have received a diagnosis of diabetes. 3 Diabetic eye disease is a leading cause of vision loss in persons aged 20 to 74 years. 4 Of the visually disabling conditions in persons with diabetic eye disease, diabetic macular edema (DME), left untreated, is a common cause of vision loss. 5 It affects central vision and can lead to decline in vision ranging from slight visual blurring to blindness, substantially affecting independence and quality of life. 6,7 At least since the 1980s and until 2010, focal/grid laser photocoagulation was the standard of care for treating macular edema, reducing the risk of vision loss, and increasing the possibility of vision gain compared with no treatment. 8 More recently, in phase II and III trials of ranibizumab and aflibercept and phase II trials of bevacizumab, intravitreal injections of antivascular endothelial growth factor agents have been shown to be superior to focal/ grid laser photocoagulation in decreasing the risk of vision loss and increasing the possibility of vision gain. [9][10][11][12][13][14] In planning the IMPORTANCE Diabetic macular edema (DME) is a leading cause of vision loss in persons with diabetes mellitus. Although there are national estimates for the prevalence of diabetic retinopathy and its risk factors among persons with diabetes, to our knowledge, no comparable estimates are available for DME specifically.OBJECTIVES To estimate the prevalence of DME in the US population and to identify associated risk factors. DESIGN, SETTING, AND PARTICIPANTSA cross-sectional analysis of 1038 participants aged 40 years or older with diabetes and valid fundus photographs in the 2005 to 2008 National Health and Nutrition Examination Survey. MAIN OUTCOMES AND MEASURESThe overall prevalence of DME and its prevalence according to age, race/ethnicity, and sex. RESULTSOf the 1038 persons with diabetes analyzed for this study, 55 had DME, for an overall weighted prevalence of 3.8% (95% CI, 2.7%-4.9%) or approximately 746 000 persons in the US 2010 population aged 40 years or older. We identified no differences in the prevalence of DME by age or sex. Multivariable logistic regression analysis showed that the odds of having DME were higher for non-Hispanic blacks than for non-Hispanic whites (odds ratio [OR], 2.64; 95% CI, 1.19-5.84; P = .02). Elevated levels of glycosylated hemoglobin A 1c (OR, 1.47; 95% CI, 1.26-1.71 for each 1%; P < .001) and longer duration of diabetes (OR, 8.51; 95% CI, 3.70-19.54 for Ն10 vs <10 yea...
The high estimated prevalence of burnout among EMS professionals represents a significant concern for the physical and mental well-being of this critical healthcare workforce. Further, the strong association between burnout and variables that negatively impact the number of available EMS professionals signals an important workforce concern that warrants further prospective investigation.
Objectives We evaluated the cross-sectional association between race and hysterectomy prevalence in a population-based cohort of US women and investigated participant characteristics associated with racial differences. Methods The cohort consisted of 1863 Black and White women in the Coronary Artery Risk Development in Young Adults (CARDIA) study from 2000 to 2002 (years 15 and 16 after baseline). We used logistic regression to examine unadjusted and multivariable adjusted odds ratios. Results Black women demonstrated greater odds of hysterectomy compared with White women (odds ratio [OR]=3.52; 95% confidence interval [CI]=2.52, 4.90). Adjustment for age, educational attainment, perceived barriers to accessing medical care, body mass index, polycystic ovarian syndrome, tubal ligation, depressive symptoms, age at menarche, and geographic location minimally altered the association (OR=3.70; 95% CI=2.44, 5.61). In a subset of the study population, those with directly imaged fibroids, the association was minimally attenuated (OR=3.47; 95% CI=2.23, 5.40). Conclusions In both unadjusted and multivariable adjusted models, Black women, compared with White women, had increased odds of hysterectomy that persisted despite adjustment for participant characteristics. The increased odds are possibly related to decisions to undergo hysterectomy.
Objective-We evaluated age and coronary heart disease (CHD) as potential moderators of the effects of 17-estradiol on vascular endothelial function in postmenopausal women. Methods and Results-In a double-blind crossover design, 100 postmenopausal women aged 50 to 80 years were randomized to each of 3 transdermal patches, releasing 17-estradiol (0.05 mg/d), 17-estradiol (0.05 mg/d)ϩ norethindrone acetate (NETA, 0.14 mg/d), and placebo. Flow-mediated dilation (FMD) and response to 400 g sublingual glyceryl trinitrate (GTN-D) were assessed approximately 18 hours after patch placement. Age, but not CHD, moderated the FMD response to treatment (Pϭ0.01). For women in their fifties, the estradiol patch was associated with improved FMD (7.69Ϯ4.79%) compared with placebo (4.81Ϯ5.97%, PϽ0.05), but the estradiolϩnorethindrone patch response (5.81Ϯ4.85%) was not significantly different from placebo. Women in their sixties and seventies showed no alterations in FMD response to either active patch. GTN-D response declined with advancing age (PϽ0.01), with women in their seventies exhibiting blunted GTN-D response compared with younger women. Conclusions-The cardiovascular benefits of natural estrogen supplementation on vascular endothelial function may be dependent on postmenopausal age, with improved vascular function evident only in the early postmenopausal years. Short-term FMD response to estradiol might help stratify individual differences in risks versus benefits of HRT.
Obesity is a strong risk factor for developing endometrial cancer and cardiovascular disease (CVD); consequently, understanding CVD mortality among endometrial cancer survivors is important. We analyzed Surveillance, Epidemiology and End Results Program data for 157,496 endometrial cancer cases diagnosed between 1988 and 2012. We calculated standardized mortality ratios (SMRs) for CVD and all-cause mortality comparing endometrial cancer cases and general population women. We categorized women into one of three prognostic groups (excellent, intermediate and poor) based on tumor characteristics. Cumulative incidence function curves were plotted to visualize absolute mortality risk in the presence of competing risks. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression for cause-specific mortality. Deaths were as follows: endometrial cancer 40.6%, CVD 20.5%, other cancers 18.7% and other causes 20.3%. Women with endometrial cancer were more likely to die from CVD (age-adjusted SMR = 8.8, 95% CI = 8.7-9.0) and all causes (age-adjusted SMR = 15.9, 95% CI = 15.8-16.0) compared to general population women. In case-only analyses, higher CVD mortality was associated with older age, Black ethnicity and lack of surgical treatment. Poor prognosis cancers (non-endometrioid histology and late stage) were related to higher mortality from each cause, with the highest HRs observed for endometrial cancer-specific mortality. Among women diagnosed with excellent prognosis tumors (endometrioid, well-differentiated and early stage), absolute risk of CVD mortality surpassed endometrial cancer-specific mortality 5 years after diagnosis. Women diagnosed with common forms of endometrial cancer have a high CVD burden. After diagnosis, cardiovascular health should be emphasized for these women to reduce mortality.
In the present study, we compared changes in risk factors for cardiovascular disease (CVD) before and after natural menopause (NM), hysterectomy with at least 1 ovary conserved (HOC), or hysterectomy with bilateral oophorectomy (HBSO). Data were obtained from women 18-30 years of age who were enrolled in the Coronary Artery Risk Development in Young Adults Study (1985-2011). Piecewise linear mixed models were used to examine changes in CVD risk factors from baseline to the index visit (the first visit after the date of NM or hysterectomy) and after index visit until the end of follow-up. During 25 years of follow-up, 1,045 women reached menopause (for NM, n = 588; for HOC, n = 304; and for HBSO, n = 153). At baseline, women with either type of hysterectomy had less favorable values for CVD risk factors. When comparing the annual rates of change of all CVD risk factors from baseline until the index visit to those from the index visit to the end of follow-up, we saw a small increase in rate of change for high-density lipoprotein cholesterol (β = 0.28 mg/dL; P = 0.002) and a decrease for triglycerides (β =-0.006 mg/dL; P = 0.027) for all groups. Hysterectomy was not associated with risk factors for CVD after accounting for baseline values. However, antecedent young-adult levels of CVD risk factors were strong predictors of levels of postmenopausal risk factors.
OBJECTIVEDiabetes and hypertension often co-occur and share risk factors. Hypertension is known to predict diabetes. However, hyperglycemia also may be independently associated with future development of hypertension. We investigated glycated hemoglobin (HbA1c) as a predictor of incident hypertension.RESEARCH DESIGN AND METHODSWe conducted a prospective analysis of 9,603 middle-aged participants in the Atherosclerosis Risk in Communities Study without hypertension at baseline. Using Cox proportional hazards models, we estimated the association between HbA1c at baseline and incident hypertension by two definitions 1) self-reported hypertension during a maximum of 18 years of follow-up and 2) measured blood pressure or hypertension medication use at clinic visits for a maximum of 9 years of follow-up.RESULTSWe observed 4,800 self-reported and 1,670 visit-based hypertension cases among those without diagnosed diabetes at baseline. Among those with diagnosed diabetes at baseline, we observed 377 self-reported and 119 visit-based hypertension cases. Higher baseline HbA1c was associated with an increased risk of hypertension in subjects with and without diabetes. Compared with nondiabetic adults with HbA1c <5.7%, HbA1c in the prediabetic range (5.7–6.4%) was independently associated with incident self-reported hypertension (hazard ratio 1.14 [95% CI 1.06–1.23]) and visit-detected hypertension (1.17 [1.03–1.33]).CONCLUSIONSWe observed that individuals with elevated HbA1c, even without a prior diabetes diagnosis, are at increased risk of hypertension. HbA1c is a known predictor of incident heart disease and stroke. Our results suggest that the association of HbA1c with cardiovascular risk may be partially mediated by the development of hypertension.
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