T.o the Editors:
糖尿病是结核病(TB)的已知风险因素,群体和地理区域的研究表明,在共有糖尿病中,开发TB的风险显着增加了TB的风险[1]。建议风险是由于与糖尿病相关的高血糖激活潜伏的TB感染。因此,特别关注频繁的环境中同时糖尿病和结核病的发展流行病学。格陵兰因纽特人之间的糖尿病患病率高(10%),增加[2]。同时,结核病发病率仍然很高,估计每10万人180例表明正在进行的TB传输[3.]。T.he aim of this study was to quantify the effect of diabetes on TB development among the Greenland Inuit.
我们进行了回顾性的队列研究。学习参与者包括参加两种以前进行的横断面研究的种族因纽特人,其中评估了糖尿病状态;因金过渡研究中的健康(Ihit)[4.]格陵兰岛人口研究(B99)[2]。Ihit和B99中的所有研究参与者都是从民事登记系统(CRS)中的随机选择,以代表整个格陵兰人口。CRS为格陵兰岛的所有公民提供出生时的独特识别号,促进所有公共登记处的人追查。CRS标识符在国家结核所登记册中启用了学习参与者的后续行动。该研究得到了格陵兰州的伦理审查。
以前未诊断患有糖尿病(98%)的参与者经历了标准口服葡萄糖耐量试验(OGTT)。如果先前被诊断出患有糖尿病或禁食和2小时血糖水平≥7mmol·L,则参与者分类为糖尿病-1≥11.1mmol-1, 分别。测量体重和高度,并计算体重指数(BMI)。从CRS数据确定参与者的年龄和性别。居住地,分为城镇或结算,同样来自CRS登记处。
结核病是格陵兰岛的强制性通知疾病,医生诊断的所有事件案件都记录在国家TB寄存器中[5.]。对于本研究,从国家TB寄存器中检索研究参与者中记录的所有事件结核病;然而,只有在研究中记录糖尿病评估后的结核病病例。
Diabetes status, age, sex, place of residence and BMI retrieved from B99 and IHIT were linked to the National TB register and the death register by the CRS number. Participants were followed from entry into either B99 or IHIT until TB diagnosis, death/emigration or December 31 2010, whichever came first. The incidence rate ratios (RRs) for developing TB according to diabetes status were estimated by log-linear Poisson regression, using the logarithm of person years as offset. The RRs were adjusted for BMI, age, sex and place of residence in a multivariate regression analyses. To evaluate the robustness of our results, we also estimated the crude estimate using exact Poisson regression with mid-p confidence intervals (CIs). This only led to a minor widening of the confidence interval. Level of significance was set at 5%. All analyses were performed in SAS version 9.2 (SAS Institute, Cary, NC, USA).
共有3,012名研究参与者被鉴定为因纽特人并在CRS中登记,其中276中被排除在进一步的分析中,以便不符合纳入标准(先前的TB(n = 257)和缺少样品日期(n = 19))。分析中包含2,736个。平均随访时间为4.97年。大约44%的男性(整个格陵兰为49%),中位年龄为45岁(四分位数:37-56 YRS)(格陵兰(四分位数)40年代(四分位数范围:30-50 YRS))。BMI中位数是25.6千克·米-2(interquartile range: 22.5–29.5 kg·m-2) and 74% lived in towns.
共有281名(10.3%)参与者患有糖尿病,11(0.4%)在随访期间与TB注册。与没有糖尿病的参与者相比,未经调整的TB发病率为糖尿病的参与者比较高2.66倍(table 1)。然而,调整年龄,性别,BMI和居住地的居住地只需要增加11.7的RR(P <0.01)。高BMI和女性对开发TB的风险有保护作用。
本研究是我们的知识,第一项研究探索和量化糖尿病对在因纽特人群中发展结核病的风险的研究。目前的研究发现,由于在调整年龄,性别,居住地和BMI时,在与Inuit的情况下,与Inuites相对于因纽特人,TB发生率为11.7倍。本研究的结果是根据类似研究的总体,评估糖尿病和TB之间的联系。然而,本研究中的RR的大小高于大多数研究中鉴定的风险。因此,来自墨西哥的前瞻性研究发现,在没有糖尿病的人的人中,糖尿病的人群中的TB速率七倍增加了[6.]。T.he link between diabetes and TB was also explored in indigenous populations; thus Moriet al。[7.], found diabetes to be more frequent in Oglala Sioux Indians diagnosed with TB compared with Indians without TB (odds ratio 5.2).
S.urprisingly, a study of TB risk factors recently conducted in Greenland, could not identify diabetes as a risk factor for TB [8.]。然而,糖尿病在该研究中自我报告,因此受到报告的主要报告,因为估计70%的格陵兰糖尿病患者不知道他们的糖尿病[2]。此外,研究人口包括混合的因纽特人/丹麦种族。丹麦的研究发现,活性结核病的一项目标比率为1.18(95%CI 0.96-1.45),其诊断为糖尿病[9.];我们研究的差异很可能是由于丹麦的潜伏结核病风险的风险很低,而格陵兰[10.]。
一种djusting for age, sex, BMI and place of residence entailed a dramatic increase in the RR due to the strong association between BMI and TB, and between sex and TB. The apparent strengthening of risk estimates after confounder adjustment has been found in similar studies [1那7.]。T.he seemingly protective effect of a higher BMI is in accordance with studies suggesting underweight to be a substantial risk factor for active TB [8.]。Nonetheless, it is also plausible that persons with advanced TB symptoms (e.g.广泛的减肥)更有可能寻求医疗注意力,因此更常用于TB。然而,低BMI也可能是更先进的糖尿病的表达,因此,更长的未知糖尿病持续时间。众所周知,女性中的结核病发病率降低,这也是根据本研究中的发现[8.]。同样,生活在城镇的参与者比生活在定居点的参与者的参与者的较低者,与一项研究一致,在定居点生活是TB的危险因素[8.]。
一种major strength of the present study is the longitudinal study design allowing the calculation of RR and thus assessing the temporal order of the association of diabetes and TB. Furthermore, as diabetes is unknown in an estimated 70% of diabetes cases in Greenland [2[来自OGTT的糖尿病评估是一种实质性的强度。同样,TB病例被医疗专业人员诊断,并在国家TB寄存器中注册前进行微生物学证实。
此外,由于在IHIT和B99的学习进入点对糖尿病的评估,糖尿病暴露的持续时间没有考虑。因此,未知的糖尿病可能促进了确诊糖尿病诊断前的结核病发生,低估了糖尿病对结核病发育风险的影响。此外,可能在本研究中未调整的未测量的混淆可能会考虑糖尿病对开发结核病风险的一些影响。
糖尿病的贡献仍然被广泛忽视了TB预防努力[1]。In this sample of Greenland Inuit where both HIV and undernutrition remain uncommon, the risk of developing TB was markedly higher in persons with co-existing diabetes than in persons without. The very high risk associated with diabetes suggests potential reduction in the Greenland TB incidence rates through incorporating diabetes control and prevention in TB prevention schemes. However, the validity of the results should be confirmed in a larger sample size, preferentially by applying longer follow-up time to the study cohort.
一种cknowledgments
T.he present study received funding from the Commission of Scientific Research in Greenland (Nuuk, Greenland). The B99 and IHIT studies were funded by the Danish Medical Research Council and Karen Elise Jensen's Foundation.
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- ©ERS 2012