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Diabetes Care 30:e115 2007
DOI: 10.2337/dc07-1493
© 2007 by the American Diabetes Association
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Online Letters: Comments and Responses

Prospective Study of Type 1 and Type 2 Diabetes and Risk of Stroke Subtypes: the Nurses’ Health Study

Response to Tuttolomondo et al.

Mohsen Janghorbani, PHD1,2, Kathryne M. Rexrode, MD3,4 and Giancarlo Logroscino, MD5

1 Department of Epidemiology and Biostatistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
3 Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
4 Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
5 Department of Epidemiology, Harvard School of Public Health, Boston, Masschusetts

Address correspondence to Mohsen Janghorbani, PhD, Department of Epidemiology and Biostatistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: janghorbani{at}yahoo.com

We thank Tuttolomondo et al. (1) for their interest in our study (2). In response, we would like to clarify several points. First, coding of strokes has been ongoing in the Nurses’ Health Study since 1976. We have not had funding to implement coding by TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification (3) but hope to do so in the future. In an internal comparison of coding by Perth criteria (4) versus TOAST, the concordance rate for lacunar infarction was very high (91%); however, a percentage of large artery infarctions as classified by Perth coding criteria was classified as "unknown type" by TOAST criteria due to inconclusive carotid Doppler findings. Thus, it is possible that differences in stroke classification may have lead to slightly higher risk estimates for large artery infarction in our population.

Second, our results are consistent with diabetes being a strong risk factor for lacunar infarction. As shown in Table 2 of the article, incidence rates for lacunar infarction were higher than for large artery infarction among women with type 2 diabetes (50 and 36 per 100,000 person-years, respectively), and risk estimates were also slightly higher for lacunar than large artery infarction (3.6 vs. 2.7 in age-adjusted analyses) compared with women without diabetes.

Third, both fatal and nonfatal infarctions were included, but only first events were considered. Thus, our methods do differ from some hospital-based studies in that only first stroke events were included. As stated in the article, results were similar for confirmed (medical records) and probable (letter or telephone corroboration) cases, thus the combined results were presented (see p. 1731, column 2).

Finally, as suggested by Tuttolomondo et al., it is possible that there are sex differences in the strength of association between diabetes and large artery infarction. Our results are limited to women, and we encourage further sex-specific evaluations of these associations.

Footnotes

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C Section 1734 solely to indicate this fact.

References

  1. Tuttolomondo A, Pinto A, Di Raimondo D, Licata G: Prospective study of type 1 and type 2 diabetes and risk of stroke subtypes: the Nurses’ Health Study (Letter). Diabetes Care 30: e114, 2007. DOI: 10.2337/dc07-1333[Free Full Text]
  2. Janghorbani M, Hu FB, Willett WC, Li TY, Manson JE, Logroscino G, Rexrode KM: Prospective study of type 1 and type 2 diabetes and risk of stroke subtypes: the Nurses’ Health Study. Diabetes Care 30: 1730–1735, 2007[Abstract/Free Full Text]
  3. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd, the TOAST Investigators: Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial: TOAST: Trial of Org 10172 in Acute Stroke Treatment. Stroke 24: 35–41, 1993[Abstract/Free Full Text]
  4. Anderson CS, Jamrozik KD, Burvill PW, Chakera TMH, Johnson GA, Stewart-Wynne EG: Determining the incidence of different subtypes of stroke: results from the Perth Community Stroke Study, 1989–1990. Med J Aust 158: 85–89, 1993[Medline]

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This Article
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