Reply to: Diabetes and risk of Parkinson's disease.
Reply to: Diabetes and risk of Parkinson's disease.
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回复：糖尿病和帕金森病的风险。
DOI：
10.1002/mds.25208
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发表时间：
2013
期刊：
影响因子：
--
通讯作者：
Ascherio,Alberto
中科院分区：
文献类型：
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作者：
Palacios,Natalia;Ascherio,Alberto
我们感谢 Cereda 等人。感谢将我们的研究纳入他们在《运动障碍》杂志上发表的关于糖尿病和帕金森病 (PD) 的最新荟萃分析中。在原始荟萃分析发表时，只有 4 项前瞻性研究可用，纳入我们的调查后，PD 病例数量从原始荟萃分析中的 3284 例大幅增加到更新版本中的 3940 例。总体而言，这一增加将糖尿病的汇总相对风险估计值从 1.37（95% 置信区间 [CI]，1.21-1.55）更改为 1.25（95% CI，1.03-1.55），但研究之间存在显着异质性。一个关键问题是：这种异质性的根源是什么？本荟萃分析中包含的研究之间的一个重要区别是 PD 确定方法。那些依赖登记数据（Hu 等人）2 或未经证实的自我报告（Driver 等人）3 的研究可能将血管性帕金森病患者纳入为帕金森病偶发病例。 Xu 等人的研究减少了来自这一来源的潜在偏差，4 他们能够从约三分之二的 PD 病例的治疗神经科医生处获得确认，而 Simon 等人的研究中，5 和 Palacios 等人 1 的研究将这一来源的潜在偏差降至最低，其中仅包括经神经科医生确认的 PD 病例。血管性帕金森病可能有助于解释这样一个事实：糖尿病与帕金森病之间的关联性最强的国家是芬兰（Hu 等人）2，该国心血管疾病的发病率相对较高。另一个重要的区别是残余混杂。例如，仅在 Simon 等人 5 和 Palacios 等人中实施了针对吸烟行为变化的调整； 1 在其余的研究中，如果糖尿病患者比非糖尿病患者更有可能在随访期间戒烟（PD 的负面危险因素）6-8，则糖尿病和 PD 之间可能会出现虚假的正相关关系。最后，失访可能会导致偏差——因为 Xu 等人研究的队列中只有约 63% 的参与者。对 PD 调查的回应显示，糖尿病患者较高的回应率可能会导致糖尿病与 PD 之间出现虚假的正相关。正如 Cereda 等人。承认，在荟萃分析中不可能考虑到这些差异。因此，应谨慎考虑荟萃分析的结果。对报告糖尿病与帕金森病之间呈正相关的研究结果进行仔细分析，进一步怀疑这种相关性是否真正反映了糖尿病患者帕金森病风险的增加。报告这种正相关的美国两项研究在帕金森病发病前患糖尿病的时间方面存在冲突。徐等人。美国国立卫生研究院和 AARP（前身为美国退休人员协会）(NIH-AARP) 队列中发现，与糖尿病相关的 PD 风险总体增加，但大多数人
We thank Cereda et al. for including our study1 in their updated meta-analysis of diabetes and Parkinson disease (PD) published in Movement Disorders. There were only 4 prospective studies available at the time of publication of the original meta-analysis and inclusion of our investigation substantially increased the number of PD cases from 3284 in the original meta-analysis to 3940 in the updated version. Overall, this addition changed the pooled relative risk estimate for diabetes from 1.37 (95% confidence interval [CI], 1.21–1.55) to 1.25 (95% CI, 1.03–1.55), but with significant heterogeneity between studies. A key question is: what are the sources of this heterogeneity? An important difference among the studies included in this meta analysis are the methods of PD ascertainment. Those studies that relied on register data (Hu et al.) 2 or unconfirmed self-report (Driver et al.), 3 may have included as incident PD cases individuals with vascular Parkinsonism. The potential bias from this source was reduced in the study by Xu et al., 4 who were able to obtain confirmation from the treating neurologist of about two-thirds of the incident PD cases, and minimized in the studies by Simon et al., 5 and Palacios et al., 1 which included only neurologist-confirmed incident PD cases. Vascular parkinsonism may contribute to explain the fact that the strongest association between diabetes and PD was found in Finland (Hu et al.), 2 which has relatively high rates of cardiovascular disease. Another important difference is residual confounding. For example, adjustment for changes in smoking behavior was only implemented in Simon et al., 5 and Palacios et al.; 1 in the remaining studies, a spurious positive association between diabetes and PD could have resulted if individuals with diabetes were more likely to quit smoking (a negative risk factor for PD) 6–8 during the follow-up than those without diabetes. Finally, losses to follow-up may contribute to bias—because only about 63% of the participants in the cohort studied by Xu et al. responded to the PD survey, a higher response rate among diabetics could induce a spurious positive association between diabetes and PD. As Cereda et al. acknowledge, it is not possible to take these differences into account in the meta-analysis. The results from the meta-analysis should therefore be considered with caution.A close analysis of the results of the studies that report a positive association between diabetes and PD raises further doubt on whether such association truly reflects an increased PD risk among diabetics The 2 US studies that reported a positive association are in conflict as to the timing of diabetes prior to onset of PD. Xu et al. found an overall increased risk of PD associated with diabetes within the National Institutes of Health and AARP (formerly the American Association of Retired Persons)(NIH-AARP) cohort, but most of