-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE
Diabetes Control and Complications Trial/Epidemiology of Diabetes Intervention and Complications analyses demonstrated that intensive insulin therapy was inversely associated with incident hypertension. We thus sought to confirm these observations and, given sex differences in other type 1 diabetes complications and risk factors, assessed whether any such associations differ by sex.RESEARCH DESIGN AND METHODS
Participants of a prospective cohort of childhood-onset type 1 diabetes, free of hypertension at study entry (baseline mean age, 28 years; diabetes duration, 19 years), were selected for study (n = 510). Hypertension incidence was defined as blood pressure >140/90 mmHg or use of hypertension medications in two consecutive visits. Intensive insulin therapy was defined as three or more injections (or pump) and four or more glucose tests daily. Baseline predictors of hypertension were examined using Cox proportional hazards models. Models with time-dependent updated means of baseline significant variables were also constructed.RESULTSHypertension incidence over 18 years of follow-up was marginally higher in men than in women (43.2 vs. 35.4%, P = 0.07). A significant interaction was noted between sex and HbA(1c), and separate models were constructed by sex. Multivariably, elevated HbA(1c) was a significant predictor only in men (hazard ratio 1.48 [95% CI 1.28-1.71]). In time-dependent models, although a significant effect of HbA(1c) was also seen in women (1.21 [1.00-1.46]), the effect of glycemic control on hypertension development remained stronger in men (1.59 [1.29-1.97], P interaction <0.0001).CONCLUSIONS
Although hyperglycemia is a risk factor for hypertension, its effect is stronger in men compared with women with type 1 diabetes.
Diabetes care 09/2012; · 8.09 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Few studies have examined stroke risk in type 1 diabetes mellitus (T1DM). Stroke incidence, predictors, and survival were thus explored in this study. Pittsburgh Epidemiology of Diabetes Complications (EDC) Study participants (n = 658) with childhood-onset T1DM were followed biennially for 18 years. Baseline (1986-1988) mean age and diabetes duration were 28 and 19 years respectively. Stroke incidence and type was determined via survey or physician interview and, when possible, confirmed with medical or autopsy records. During follow-up, 31 (4.7%) strokes occurred (21 ischaemic, 8 haemorrhagic, 2 unclassified) in participants of mean age = 40.2 years (range 23-60). In exploratory multivariable Cox modelling, diabetes duration, systolic blood pressure (SBP), non-high density lipoprotein cholesterol (non-HDLc), white blood cells (WBC), and pulse significantly predicted ischaemic stroke. Adding overt nephropathy (ON) (hazard ratio = 4.4, 95% CI, 1.5-12.4) to the model replaced SBP. Participant survival after stroke was 80.6%, 45.2%, and 9.6% at 1, 5, and 10 years, respectively, and significantly worse after haemorrhagic stroke (p = 0.03). These risk factors merit careful evaluation and management to prevent stroke in T1DM, which occurs at least 20 years earlier than in the general.
Diabetes & Vascular Disease Research 04/2012; · 2.12 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Recent data suggest that highly elevated high-density lipoprotein cholesterol (HDL-C) may not always protect against cardiovascular disease. To what degree this is true in type 1 diabetes is unknown, although cardiovascular risk is increased despite elevated mean HDL-C.
To reassess the association between HDL-C and its subfractions with coronary artery disease (CAD) in childhood-onset type 1 diabetes.
Epidemiology of Diabetes Complications study participants free of CAD at baseline (301 men, 298 women; mean age, 27.1 and diabetes duration, 18.9 years) were studied. CAD was defined as angina, ischemic electrocardiogram changes, confirmed myocardial infarction, angiographic stenosis ≥50%, revascularization, or CAD death. Cholesterol in the HDL fraction and HDL3 cholesterol subfraction was measured enzymatically after precipitation with heparin/manganese and dextran sulfate, respectively.
During 18 years of follow-up, 29.5% of men and 25.5% of women developed CAD. Although a linear decrease in incidence was observed with increasing HDL-C concentration in men, incidence increased in women at less than 47 mg/dL and greater than 80 mg/dL. These patterns largely reflected the HDL3 cholesterol-CAD association. After multivariable adjustment, the linear, inverse, HDL-C/CAD association persisted in men (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.94-0.99); in women, the U-shaped relationship lost significance. HDL3 cholesterol remained multivariably associated with CAD in both men (linear association, P = .03) and women (HR 2.31 (95% CI 1.31-4.08) and HR 1.80 (95% CI 1.01-3.23) for the lowest and highest versus the middle quintiles, respectively).
The increased CAD risk in women for an HDL-C >80 mg/dL in type 1 diabetes merits further study. Gender specificity could not be determined as only two men had HDL-C >80 mg/dL.
Journal of Clinical Lipidology 09/2011; 5(5):387-94. · 1.58 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Kidney disease in patients with type 1 diabetes historically has been believed to be more prevalent in men. Because recent data do not reflect this pattern, we evaluated whether a sex difference persists.
Prospective cohort study.
We used 18-year follow-up data from the Pittsburgh Epidemiology of Diabetes Complications Study (n = 788; baseline mean age, 27 years; diabetes duration, 19 years).
Sex and diagnosis interval (1950-1964 or 1965-1980).
Cumulative incidences of macroalbuminuria (albumin excretion rate >200 μg/min) and end-stage renal disease (ESRD; kidney failure, dialysis, or transplant) were evaluated at 20, 25, and 30 years of diabetes duration. To address potential survival bias, death certificate information was included in determining ESRD for those who died before baseline (n = 145). Analyses were stratified by diagnosis year (1950-1964 or 1965-1980). OTHER MEASUREMENTS: Kidney disease risk factor information was available.
A significant interaction was noted between sex and diagnosis cohort for ESRD incidence by 25 (P = 0.002) and 30 (P < 0.001) years' duration. Thus, within the 1950-1964 cohort (210 men and 180 women), ESRD incidence was higher in men compared with women by 25 (30.6% vs 18.0%, respectively) and 30 (43.4% vs 24.6%, respectively) years' duration of type 1 diabetes. However, in the 1965-1980 cohort (260 men and 283 women), the incidence was higher in women (7.6% vs 13.8% by 25 years [P = 0.04] and 13.7% vs 21.0% by 30 years' duration [P = 0.09] in men vs women, respectively). Results were similar for macroalbuminuria.
Study participants were not followed up from the onset of diabetes; thus, risk-factor data from that period are lacking.
Our data suggest that the male excess of type 1 diabetic kidney disease cases observed in the earlier cohort has been eliminated in the younger cohort. The reason for this dramatic change presently is unclear, but should be addressed in subsequent studies.
American Journal of Kidney Diseases 08/2011; 58(4):565-73. · 5.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Socioeconomic status (SES) as a risk factor for mortality in type 1 diabetes (T1D) has not been adequately studied prospectively.
Complete clinical and SES (income, education, occupation) data were available for 317 T1D participants in the Pittsburgh Epidemiology of Diabetes Complications Study within 4 years of age 28 (chosen to maximize income, education, and occupational potential, and to minimize the SES effect of advanced diabetes complications). Vital status was determined as of 1/1/2008.
Over a median 16 years of follow-up, 34 (10.7%) deaths occurred (standardized mortality ratios [SMRs] = 4.1, 95% confidence interval [CI]: 2.7-5.5). SMRs did not differ from the general population for those in the highest education and income groups, whereas in those with low SES, SMRs were increased. Mortality rates were three times lower for individuals with a college degree versus without a college degree (p = 0.004) and nearly four times lower for the highest income versus lower income groups (p = 0.04). In Cox models adjusting for diabetes duration and sex, education was the only SES measure predictive of mortality (hazard ratio [HR] = 3.0, 95% CI: 1.2-7.8), but lost significance after adjusting for HbA(1c), non-HDL cholesterol, hypertension, and microalbuminuria (HR = 2.1, 95% CI: 0.8-5.6).
The strong association of education with mortality in T1D is partially mediated by better glycemic, lipid, and blood pressure control.
Annals of epidemiology 05/2011; 21(5):367-73. · 2.95 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To understand the effect of socioeconomic status (SES) on the risk of complications in type 1 diabetes (T1D), we explored the relationship between SES and major diabetes complications in a prospective, observational T1D cohort study.
Complete data were available for 317 T1D persons within 4 years of age 28 (ages 24-32) in the Pittsburgh Epidemiology of Diabetes Complications Study. Age 28 was selected to maximize income, education, and occupation potential and to minimize the effect of advanced diabetes complications on SES.
The incidences over 1 to 20 years' follow-up of end-stage renal disease and coronary artery disease were two to three times greater for T1D individuals without, compared with those with a college degree (p < .05 for both), whereas the incidence of autonomic neuropathy was significantly greater for low-income and/or nonprofessional participants (p < .05 for both). HbA(1c) was inversely associated only with income level. In sex- and diabetes duration-adjusted Cox models, lower education predicted end-stage renal disease (hazard ratio [HR], 2.9; 95% confidence interval [95% CI], 1.1-7.7) and coronary artery disease (HR, 2.5, 95% CI, 1.3-4.9), whereas lower income predicted autonomic neuropathy (HR, 1.7; 95% CI, 1.0-2.9) and lower-extremity arterial disease (HR, 3.7; 95% CI, 1.1-11.9).
These associations, partially mediated by clinical risk factors, suggest that lower SES T1D individuals may have poorer self-management and, thus, greater complications from diabetes.
Annals of epidemiology 05/2011; 21(5):374-81. · 2.95 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This discussion of increased cardiovascular risk in patients with type 1 diabetes reviews recent data concerning glycemia and the role of glycemic control in type 1 diabetes, as well as observations of an association with haptoglobin genotype and coronary artery disease events. This genetic predisposition also leads to oxidative damage and appears to be associated with profound high-density lipoprotein dysfunction. This article also briefly discusses recent data on general cardiovascular risk factors and provides updated comments concerning the association of coronary artery disease with other diabetes complications, especially renal disease.
Current Diabetes Reports 02/2010; 10(1):48-54. · 2.50 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Given the paucity of data in type 1 diabetes concerning lipoprotein-associated phospholipase A( 2) (Lp-PLA(2)), we examined its prospective relationship with coronary artery disease (CAD), as well as the effect of modification by C-reactive protein (CRP) and haptoglobin genotype, in individuals with type 1 diabetes who are at an increased risk for CAD due to also having macroalbuminuria (n=96). Although Lp-PLA(2) activity was univariately predictive of CAD (HR=1.54 per SD, p=0.009), this relationship was not significant after covariate adjustment (p=0.59). There was a significant interaction between Lp-PLA(2) and CRP (p=0.02), i.e. those with both markers greater than the median level were more likely to have a CAD event than those persons with low levels of both (HR=2.89, p=0.06). When stratified by haptoglobin genotype, Lp-PLA(2) was predictive of CAD in persons with the 2/1 (HR=2.40, p=0.05), but not 2/2 (HR=0.66, p=0.27), genotype. The association between Lp-PLA(2) activity and CAD differs by CRP and haptoglobin genotype in this group of persons with type 1 diabetes and macroalbuminuria.
Diabetes & Vascular Disease Research 01/2010; 7(1):47-55. · 2.12 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Although coronary artery disease (CAD) is the leading cause of death in type 1 diabetes (T1D), the mechanisms responsible for the greatly increased risk are poorly understood. In particular, the role of glycaemic control is controversial with one study suggesting it predicts CAD mortality but not incidence. In this analysis, of the Pittsburgh Epidemiology of Diabetes Complications study cohort of T1D, we examine whether risk factors differ for CAD morbidity and mortality, with a specific focus on HbA1c and insulin dose. Participants (n=592) were followed for 18 years for incident non-fatal and fatal CAD. Cox stepwise regression was used to determine the independent risk factors for non-fatal and fatal CAD. Mean age and diabetes duration at study baseline were 29 and 20 years, respectively. There were 109 incident non-fatal and 48 fatal CAD events. Baseline HbA(1C) was an independent risk factor for fatal CAD, along with duration of diabetes and albuminuria. In contrast, baseline lower insulin dose was strongly predictive of non-fatal CAD, as was lower renal function, higher diastolic blood pressure, and lipids. HbA(1C) predicts CAD mortality while lower insulin dose and standard CAD risk factors predict CAD morbidity.
Diabetes & Vascular Disease Research 10/2009; 6(4):223-30. · 2.12 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Haptoglobin (Hp) binds free Hb, inhibiting Hb-induced oxidative damage. As oxidative stress has been associated with microvascular complications, we evaluated the relationship between Hp genotype and microalbuminuria, macroalbuminuria, end-stage renal disease (ESRD), and early renal function decline in type 1 diabetes.
Participants from the Epidemiology of Diabetes Complications Study with DNA available were studied for the incidence of microalbuminuria (albumin excretion rate [AER] 20-200 microg/min), macroalbuminuria (AER >200 microg/min), ESRD (renal dialysis or transplantation), and renal function decline (a decline > or =30 ml/min per 1.73 m(2) from baseline estimated [by the Cockcroft-Gault equation] glomerular filtration rate [eGFR] in those with baseline eGFR >60 ml/min per 1.73 m(2)).
The proportions with the Hp 2/2, 2/1, and 1/1 genotype were 43.4, 44.4, and 12.1%, respectively. During 18 years of follow-up, the incidence of eGFR decline, microalbuminuria, macroalbuminuria, and ESRD was 42.0, 40.5, 16.7, and 12.2%, respectively. No significant univariate differences were observed by Hp genotype. However, in multivariable Cox models, an approximately twofold increased risk was observed for the Hp 2/2 compared with the Hp 1/1 genotype for eGFR decline (hazard ratio 1.79 [95% CI 1.06-3.00]) and ESRD (2.74 [1.17-6.45]); no significant associations were observed for microalbuminuria or macroalbuminuria.
These data suggest that although Hp genotype is not associated with albuminuria per se, it may be an independent determinant of early renal function decline and progression to ESRD. Understanding these apparent contradictory findings may provide further insight into the pathogenesis of renal disease in type 1 diabetes.
Diabetes 08/2009; 58(12):2904-9. · 8.29 Impact Factor
-
Kidney International 02/2009; 75(1):121. · 6.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: It has been suggested that adiponectin has antiatherogenic, anti-inflammatory, and insulin-sensitizing properties. However, studies in humans have reported inverse as well as positive associations between adiponectin concentrations and disease states. This Commentary discusses the apparent conflict in the literature.
Kidney International 10/2008; 74(5):549-51. · 6.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Haptoglobin is a plasma protein that binds free hemoglobin, thereby inhibiting hemoglobin-induced oxidative damage. We investigated the association between the haptoglobin genotype and the incidence of coronary artery disease (CAD) in a cohort of individuals with childhood-onset type 1 diabetes.
Participants from the Epidemiology of Diabetes Complications Study who were free of CAD at study entry and had DNA available were selected (n = 453, mean age 27.1 years, and diabetes duration 18.8 years). CAD was defined as angina, ischemic electrocardiogram, myocardial infarction confirmed by Q-waves on electrocardiogram or hospital records, angiographic stenosis >50%, or revascularization.
The proportions of the cohort with the haptoglobin 1/1, 2/1, and 2/2 genotypes were 11.5, 41.3, and 47.2%, respectively. During 18 years of follow-up, there were 135 (29.8%) incident CAD events. Univariately, the proportion of CAD events increased from 15.4 to 28.3 and 34.6% for haptoglobin 1/1, 2/1, and 2/2, respectively (P = 0.02, P-trend = 0.007). Cumulative incidence (including 33 baseline prevalent cases) also increased from 24.1 to 32.3 and 39.1%, respectively (P = 0.07, P-trend = 0.02). In Cox proportional hazards models adjusting for traditional CAD risk factors, the haptoglobin 2/2 genotype was associated with increased CAD incidence compared with the haptoglobin 1/1 genotype (hazard ratio [HR] 2.21, 95% CI 1.05-4.65, P = 0.04). Although the risk associated with the haptoglobin 2/1 genotype did not reach significance (1.78, 0.84-3.79, P = 0.13), there remained a significant trend across the three groups (P = 0.03).
These data support the hypothesis that the haptoglobin genotype influences cardiovascular risk in type 1 diabetes.
Diabetes 07/2008; 57(6):1702-6. · 8.29 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The authors compared postpartum adiponectin levels among women with prior pregnancy-induced disturbances and assessed their association with homeostasis model assessment for insulin resistance (HOMA-IR), the metabolic syndrome (MS), and the Framingham risk score (FRS). Women delivering in 1998 through 2001 and who had gestational diabetes mellitus (n=22), gestational hypertension (n=32), or preeclampsia (n=34) were examined 1 to 2 years after delivery and were grouped-matched to controls (n=29) by age and prepregnancy body mass index. HOMA-IR was increased, adiponectin values were decreased, and there was a higher MS prevalence in women with prior gestational diabetes mellitus (all P<.05). Adiponectin levels were inversely related to HOMA-IR (r=-0.45; P<.0001) and FRS (r=-0.25; P=.007), and a significant trend for decreasing adiponectin values with increased number of MS components was noted (P trend <.0001). Adiponectin concentration remained a significant correlate of FRS and MS irrespective of pregnancy history; a concentration <10.5 microg/mL provided the optimal cutoff to distinguish those with or without MS. Thus, a lower postpartum adiponectin concentration identifies women at increased cardiovascular risk regardless of pregnancy history.
Preventive Cardiology 01/2008; 11(2):106-15.
-
[show abstract]
[hide abstract]
ABSTRACT: Coronary artery disease (CAD), a leading cause of death in type 1 diabetes (T1D), often occurs two or more decades earlier in this population compared to the population without diabetes. Although CAD generally increases with adiposity, this association is unclear in T1D. In this study, we examined associations of adiposity with coronary artery calcium (CAC) in 315 individuals with T1D. Mean age and diabetes duration were 42 and 34 years, respectively, at study entry. CAC, visceral adiposity (VAT) and subcutaneous adiposity (SAT) were determined by electron beam tomography; and BMI and waist circumference (WC) were determined. The presence of CAC was positively associated with VAT, SAT and BMI in men (p<0.05) and with all four adiposity measures in women (p<0.05) after adjustment for age and other traditional cardiovascular risk factors. However, after adjustment, the degree of CAC was not associated with any of the four adiposity measures, with the exception of SAT in women. Women in the lowest tertile of SAT had more CAC than those in the second tertile (p<0.016). Adiposity was positively associated with the presence of CAC, but the relationship with its severity was either inverse or non-existent. This double-edged association emphasises the complex relationship between adiposity and cardiovascular risk in diabetes.
Diabetes & Vascular Disease Research 01/2008; 4(4):332-9. · 2.12 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Coronary artery calcium (CAC) has been previously associated with atherosclerotic plaque disease and coronary events. Thus, identifying predictors of CAC progression may provide new insights for early risk-factor intervention and subsequent reduction of the rates of more severe atherosclerotic disease. The aim of this study was to identify risk factors for CAC progression and evaluate whether risk-factor change was related to CAC progression in a cohort of patients with type 1 diabetes mellitus (DM). Participants in the Pittsburgh EDC Study, a prospective investigation of childhood-onset type 1 DM, who underwent 2 electron beam tomographic screenings 4 years apart were selected for study (n = 222). CAC was calculated using the Agatston method of scoring, and progression was defined as an increase >2.5 in the square root-transformed CAC score. Adjusting for DM duration and initial CAC score, body mass index (BMI; odds ratio [OR] 1.13, 95% confidence interval [CI] 1.01 to 1.26), non-high-density lipoprotein cholesterol (OR 1.01, 95% CI 1.003 to 1.03), and albumin excretion rate (OR 1.30, 95% CI 1.03 to 1.63) were associated with CAC progression. When considering change in risk factors, an increase in BMI (OR 1.38, 95% CI 1.10 to 1.72) was also associated with CAC progression after adjustment. In conclusion, in this cohort with type 1 DM, in addition to baseline BMI, non-high-density lipoprotein cholesterol, albumin excretion rate, and all known coronary artery disease risk factors, weight gain further added to the prediction of CAC progression. Thus, weight control, in addition to lipid and renal management, may help retard atherosclerosis progression in persons with type 1 DM.
The American Journal of Cardiology 11/2007; 100(10):1543-7. · 3.37 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The sensitivity of albuminuria in predicting loss of kidney function has been questioned. We determined the sequence of kidney disease stages (microalbuminuria, macroalbuminuria, low estimated glomerular filtration rate [eGFR], and end-stage renal disease [ESRD]) and characterized those without albuminuria before a low eGFR.
The Pittsburgh Epidemiology of Diabetes Complications Study is a prospective cohort investigation of childhood-onset type 1 diabetes.
480 study participants with eGFR greater than 60 mL/min/1.73 m(2) (mean age, 27 years; diabetes duration, 19 years at study entry) were prospectively followed up for 16 years.
Low eGFR was defined as creatinine clearance less than 60 mL/min/1.73 m(2) from timed urine collections; microalbuminuria, as albumin excretion rate between 20 to 200 microg/min (30 to 300 mg/24 h); macroalbuminuria, as albumin excretion rate greater than 200 microg/min (>300 mg/24 h); and ESRD, as dialysis or renal transplantation.
The 33 of 480 individuals (7%) who developed ESRD had prior albuminuria. 71 of 480 (15%) individuals developed low eGFR. 66 of 71 (93%) had prior/concurrent albuminuria, and 5 of 71 (7%) did not. Incident low eGFR values in the 5 patients were: (1) 54, (2) 58, (3) 59, (4) 59.7, and (5) 59.8 mL/min/1.73 m(2). 3 of 5 (60%; patients 1, 4, and 5) subsequently developed albuminuria. Final eGFRs in the 5 patients were: (1) 94, (2) 86, (3) 60, (4) 65, and (5) 54 mL/min/1.73 m(2), respectively.
GFR and insulin sensitivity were not measured, but estimated. Incident decreased eGFR in patients without preceding/concurrent albuminuria may be caused by misclassification or a temporary eGFR decrease.
Moderately decreased eGFR may occur rarely in patients with type 1 diabetes without preceding albuminuria.
American Journal of Kidney Diseases 11/2007; 50(5):721-32. · 5.43 Impact Factor
-
Diabetes care 09/2007; 30(8):1995-7. · 8.09 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The metabolic syndrome has been shown to confer an increased risk of cardiovascular disease in both the general and type 2 diabetic populations, but few studies have assessed the metabolic syndrome in type 1 diabetic patients. In a type 1 diabetic cohort, we assessed the prevalence and value of the metabolic syndrome in improving the prediction of major complication outcomes compared with its components and a surrogate measure of insulin resistance, estimated glucose disposal rate (eGDR).
A total of 514 (78%) subjects participating in the Pittsburgh Epidemiology of Diabetes Complications Study with complete 12-year follow-up clinical data were classified by baseline metabolic syndrome status according to three definitions: those of the National Cholesterol Education Program Adult Treatment Panel III (modified by the American Heart Association), the International Diabetes Federation (IDF), and the World Health Organization (WHO). The complication outcomes included coronary artery disease, renal failure, diabetes-related death, and the aggregate of these three major outcomes of diabetes (MOD).
Metabolic syndrome prevalence ranged from 8% (IDF) to 21% (WHO). All definitions showed reasonable specificity (> or = 83%) for each outcome, while the WHO definition had the highest sensitivity for all outcomes except renal failure, for which eGDR was most sensitive. However, the components of each definition predicted better than the overall syndrome. Microalbuminuria was clearly the strongest predictor of all individual measures, yielding hazard ratios of 9 and 6 for mortality and MOD, respectively.
Though the three metabolic syndrome classifications predict major complication outcomes in type 1 diabetes, their individual components predict better. Of the variables studied, including HbA1, microalbuminuria appears to be the best single predictor of MOD.
Diabetes care 05/2007; 30(5):1248-54. · 8.09 Impact Factor
-
Diabetes Care 03/2007; 30(2):448; author reply 448-9. · 8.09 Impact Factor
