bluuebunny/crossref_metadata_2025 huggingface dataset:
Enhancement of Insulin Sensitivity Contributes to Polychlorinated Biphenyl-126–Induced Hepatic Steatosis and Injury
Authors: WANG XIN
Published: June 2018

Background: In the last decades, the prevalence of diabetes and related diseases of metabolic disorders has a dramatic increase. The global prevalence of diabetes and its related diseases is closely associated with the exposure to polychlorinated biphenyls (PCBs).

Aim: To investigate the the effect of PCB-126 on glucose/lipid metabolism and hepatic steatosis and to elucidate the molecular mechanisms.

Methods: C57BL/6J mice were orally administrated with PCB-126 (1.5 mg/kg) twice in a week with or without the injection of GDC-0941 (1 mg/kg) before the administration of PCB-126. The experimental period was two weeks.

Results: PCB-126 significantly decreased fasting blood glucose level, reduced glucose levels in the glucose and insulin tolerance tests, indicating that PCB-126 treatment increased insulin sensitivity in mice. In addition, PCB-126 exposure resulted in a significant increase in hepatic lipid content, as reflected by biochemical determination, Oil Red O staining and Bodipy staining. Using transmission electron microscope, we observed that PCB-126 increased the number and size of lipid droplets in liver tissues. We showed that injection of GDC-0941, an inhibitor of insulin signaling, slightly inhibited the effect of PCB-126 on glucose levels and glucose and insulin tolerance. Although GDC-0941 did not significantly affect the content of triglyceride in liver of PCB-126-treated mice, the size of hepatic lipid droplet was significantly reduced by GDC-0941, as evidence by Bodipy staining and observation under transmission electron microscope. Moreover, PCB-126-induced expression of aryl hydrocarbon receptor and lipogenesis-related regulators, such as sterol regulatory element-binding protein 1, was inhibited by GDC-0941.

Conclusion: The data suggest that enhancement of insulin sensitivity contributes to PCB-126-induced hepatic steatosis and injury.

Disclosure

X. Wang: None.
The Validity and Reliability of Japanese Version of the Diabetes Distress Scale for Adult Patients with Type 2 Diabetes
Authors: MATSUMOTO HIROHIDE , OKAZAKI KENTARO , OYA TOSHIKI , TAKAHASHI NORIYUKI , SUEMATSU MINA
Published: June 2018

Diabetes related distress is common for patients with type 2 diabetes (T2D), which exacerbates glycemic control through negative effects on emotional and physical well-being and self-care behaviors. Diabetes Distress Scale (DDS) is a widely used instrument to measure diabetes related distress. The aim of this study was to develop the Japanese version of the DDS (DDS-J) and examine its psychometric properties. DDS-J was developed conceptually equivalent to the original English version by forward and backward translations and adjustments of inappropriate terms. The investigation was conducted in 132 (mean age 64.5 years, 67.4% male, mean duration 14.2 years, mean HbA1c 7.7%) T2D patients at outpatient department of 2 hospitals in Aichi, Japan from February to March 2017. Cronbach’s α was used to assess reliability, and factor analysis to analyze validity. The 5-item World Health Organization Well-Being Index (WHO-5) and Patient Health Questionnaire-9 (PHQ-9) scale were adopted to evaluate the criteria-related validity. The scores of DDS-J, WHO-5 and PHQ-9 were calculated, then their relationship analyzed using Pearson correlation analysis. Four factors of regimen-related distress (RD), emotional burden (EB), physician-related distress (PD), and diabetes-related interpersonal distress (ID) were extracted by exploratory factor analysis. This factor structure was the same as the original. The overall Cronbach’s α was 0.91, while ones for RD, EB, PD, and ID were 0.86, 0.87, 0.73 and 0.86, respectively. The total DDS-J score was 24.4±18.7, WHO-5 15.3±5.4 and PHQ-9 3.5±4.4. The total DDS-J score showed a weak but significant correlation with WHO-5 (r=-0.376, p<0.01) and PHQ-9 (r=0.425, p<0.01).

In conclusion, DDS-J have good validity and reliability, and can be used as an effective tool to assess diabetes related distress of Japanese adult T2D patients. Furthermore, diabetes related distress is associated with well-being and depression in the studied patients.

Disclosure

H. Matsumoto: None. K. Okazaki: Advisory Panel; Self; Eli Lilly and Company. Research Support; Self; Taisho Pharmaceutical Co., Ltd.. Speaker's Bureau; Self; Ono Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Corporation, Novo Nordisk A/S, Astellas Pharma US, Inc., Takeda Development Center Asia, Pte. Ltd., Terumo Medical Corporation, MSD K.K., Sanwa Kagaku Kenkyusho Co., Ltd.. Other Relationship; Self; Aichi prefecture government and Nagoya city government. T. Oya: None. N. Takahashi: Other Relationship; Self; Archie prefecture government and Nagoya city government. M. Suematsu: Other Relationship; Self; Aichi prefecture government and Nagoya city government.
Depression and Anxiety Associated with Complications after Foot and Ankle Surgery in Diabetic Patients—Comparison with a Nondiabetic Population
Authors: KIRBY KRISTIN , HOBIZAL KIMBERLEE , SHEPHERD RENEE , WIZE TRESA
Published: June 2018

The purpose of this study is to evaluate and compare the complications rates in diabetic patients with a history of depression and anxiety than those without diabetes following foot and ankle surgery. Diabetes and a diagnosis of depression have shown to increase post-surgical complication rates in other specialities including cardiothoracic surgery and plastic surgery. 1patients who were surgically treated by one surgeon at one hospital with foot and ankle conditions were retrospectively reviewed, identifying 28 patients with diabetes, 14 diabetic patients with depression, 1 with anxiety and 2 with both depression and anxiety. In comparison, there were 78 patients without diabetes identified and of those 78 subjects, 22 had depression, 3 with anxiety and 9 with both depression and anxiety. The primary outcomes evaluated were the rates of post-surgical complications and glycemic control. Diabetes, depression and anxiety was confirmed by diagnosis history and treatment. Most common complications included superficial soft tissue infection (SSI) and incisional dehiscence/delayed healing. Diabetic patients with a history of depression and anxiety had a 1.8 times higher likelihood to develop a post-surgical complication. Patients with diabetes with a history of a psychological disorder showed a complication rate of 28%. The complication rate associated with a psychological disorder without diabetes was 15%. In the 1patients, a psychological disorder was noted in 60% of the diabetic patient cases and for the group without diabetes was noted to be 43.5%. The mean HgbA1c of the 28 diabetic patients without complications included a mean of 6.5.

The presence of depression and anxiety in a diabetic patient negatively impacts the outcomes of patients undergoing foot and ankle surgery resulting in a higher likelihood of post-surgical complications in compared to those without diabetes.

Disclosure

K. Kirby: None. K. Hobizal: None. R. Shepherd: None. T. Wize: None.
Comparison of Microbiological Results of Two Bone Sampling Methods in Diabetic Foot Osteomyelitis—Debridement vs. Operation
Authors: ZOU MENGCHEN , HU PING , PAN YANLING , LUO XANGRONG , JIANG YA , XUE YAO-MING , CAO YING , GAO FANG
Published: June 2018

The purpose of this study is to compare the microbiological results of debridement bone samples with those of corresponding results of operation bone samples for patients with diabetic foot osteomyelitis, using 16s rRNA high-throughput sequencing approach. We prospectively recruited 24 diabetic foot patients with osteomyelitis, and obtained 9 bone samples during surgery(Ds-Group) and 16 bone samples from debridement(Dd-Group). We compared the differences between debridement and operation procedures based on microbiological study of bone samples via 16s rRNA sequencing, using Ion PGM™ System Sequencer. It was obvious that microbes in Ds-Group, with narrower distribution, were more stable in alpha and beta diversity analysis. As for genera, totally 14 dominant genera were separated, and the average of Ds-Group and Dd-Group were respectively 10.44 and 9.44, with no statistically significant difference(P>0.05). Halomonas spp. and Prevotella spp. were the predominant genera of Ds-Group and Dd-Group respectively. Ds-Group had significant more Anaerococcus spp., Dialister spp. and Pseudomonas spp. than Dd-Group(P<0.05), but less Halomonas spp. and Nesterenkonia spp. than Dd-Group(P<0.05). There were no difference in other dominant genera, such as Bacteroides spp., Finegoldia spp., Fusobacterium spp., Parvimonas spp., Prevotella spp., Proteus spp., Staphylococcus spp., Streptococcus spp. and Veillonella spp.(P>0.05). We might draw a conclusion that though surgical operation was a little bit more accurate than debridement, microbiological study of bone samples from debridement could be capable enough for the diagnosis and treatment guidance of diabetic foot osteomyelitis.

Disclosure

M. Zou: None. P. Hu: None. Y. Pan: None. X. Luo: None. Y. Jiang: None. Y. Xue: None. Y. Cao: None. F. Gao: None.
Maternal and Paternal Exercise Regulates Offspring Metabolic Health and Beta-Cell Phenotype
Authors: ZHENG JIA , WAGNER ANA B.A. , PRINCE NOAH B. , SO KAWAI , MUL JORAM , DIRICE ERCUMENT , HIRSHMAN MICHAEL F. , STANFORD KRISTIN I. , KULKARNI ROHIT , GOODYEAR LAURIE J.
Published: June 2018

Maternal and paternal environment are critical factors in determining risk for obesity and diabetes in offspring. Maternal exercise in mice can prevent the detrimental effects of maternal high-fat feeding on offspring metabolic health, whereas the effects of paternal exercise on offspring are less clear. Little is also known about the effects of maternal or paternal exercise on offspring beta cells, a major factor in glucose homeostasis. We determined the effects of maternal, paternal and maternal+paternal exercise on offspring glucose tolerance and beta cell morphology. Male sires were housed ± running wheels for 3 weeks before breeding (4.4±0.8 km/day) and dams were housed ± running wheels for 2 weeks before breeding (8.4±0.5 km/day) and during gestation (4.7±0.5 km/day). All male and female breeders were fed a high-fat diet. Four groups of male offspring were studied: both parents sedentary (Sed); maternal exercise only (Mat Ex); paternal exercise only (Pat Ex); maternal+paternal exercise (Mat+Pat Ex) (n=5-8 litters/group). Offspring were sedentary and separate cohorts were studied at weaning, 52, and 80 weeks. Post-weaning, offspring were fed a chow diet. There was no effect of parental exercise on offspring glucose tolerance at weaning. At 52 weeks, offspring of exercised parents had ∼25% lower fasting blood glucose concentrations vs. Sed (all p<0.01), and glucose tolerance was improved in Mat Ex (33%), Pat Ex (35%), and Mat+Pat Ex (50%) vs. Sed (p<0.001). Mat Ex, Pat Ex and Mat+Pat Ex had decreased beta cell size (40%) and mass (40%), whereas islet size and density were only decreased in offspring from Mat+Pat Ex parents (28% and 40%, respectively). Older offspring (80 weeks) from all three parental exercise treatments displayed improved glucose tolerance (p<0.05). Maternal and paternal exercise in high-fat fed parents has profound positive effects on offspring glucose tolerance during adulthood and older age that may be linked to adaptations in the endocrine pancreas.

Disclosure

J. Zheng: None. A.B.A. Wagner: None. N.B. Prince: None. K. So: None. J. Mul: None. E. Dirice: None. M.F. Hirshman: None. K.I. Stanford: None. R. Kulkarni: None. L.J. Goodyear: None.
Microstructure Dysfunction May Be More Severe in Diabetes than in Peripheral Arterial Disease—A MRI Diffusion Tensor Imaging Study
Authors: EDALATI MASOUD , SORENSEN CHRISTOPHER J. , HASTINGS MARY , ZAYED MOHAMED A. , MUELLER MICHAEL J. , ZHENG JIE
Published: June 2018

Aim: This study aims to assess the changes in water molecule diffusion properties during exercise of calf muscles in nondiabetes and individuals with type 2 diabetes mellitus (DM) and peripheral arterial disease (PAD).

Methods: Twenty subjects were examined in three groups using a 3T MRI scanner: 5 participants without DM and PAD (WDM), 11 with DM only, and 4 with PAD only. We used a custom-made MRI compatible ergometer that allows a constant exercise load. Diffusion tensor imaging (DTI) indices including fractional anisotropy (FA), mean diffusivity (MD), and percentage fiber length changes were calculated for medial, lateral gastrocnemius (MG, LG), and soleus (SOL) muscles.

Results: Among all muscles, MD increased during exercise in both patient groups with significant difference in the DM (P<0.05). Significant differences in FA and MD between WDM and PAD during exercise were observed in LG and SOL muscles (P<0.05). The DM group showed slightly greater fiber length reduction compared to other groups (P<0.05).

Conclusion: While FA and MD showed similar values in DM and PAD groups, fiber length changes appeared more in DM than that in PAD. It suggests that the severity of microstructure dysfunction may be equal to or greater in DM compared to PAD.

Disclosure

M. Edalati: None. C.J. Sorensen: None. M. Hastings: None. M.A. Zayed: None. M.J. Mueller: None. J. Zheng: None.
Reducing Basal Insulin 90 Minutes before Exercise Protects Against Hypoglycemia Better than Insulin Suspension at Exercise Onset in T1D—The OmniTIME Results
Authors: ZAHARIEVA DESSI , MCGAUGH SARAH M. , POONI RUBIN , VIENNEAU TODD , LY TRANG T. , RIDDELL MICHAEL
Published: June 2018

Guidelines for T1D suggest reducing basal insulin delivery 60 to 90 min before aerobic exercise. In this study, participants with T1D on CSII (Omnipod®, Insulet) (n=13) were randomized in a crossover design to three basal rate reduction strategies pre-exercise. All participants completed three 60 min aerobic exercise sessions (walking, ∼50% VO2max). Basal insulin delivery was reduced by; a) -80%, 90 min pre-exercise; b) -50%, 90 min pre-exercise or; c) -100% at exercise onset. Basal rates were resumed post exercise and participants then took 75% of usual bolus with a standardized meal. Pre-exercise blood glucose (BG) was similar in all conditions (9.5 ± 2.8 mmol/L). The mean BG drop during exercise was greater (p<0.05) in the -100% (-4.2 ± 3.3 mmol/L) compared to the -50% and -80% conditions (-3.3 ± 2.4 vs. -2.0 ± 2.1 mmol/L), respectively. In the -100% condition, seven (54%) participants had hypoglycemia (hypo), whereas in the other two conditions only one hypo event occurred (8%, p<0.001). Meal related BG responses after exercise were similar among all conditions.

In summary, reducing basal insulin delivery by 50-80% 90 min before aerobic exercise better mitigates hypo risk vs. basal suspension or disconnection at exercise onset. Basal rate reductions well in advance of exercise do not cause pre-exercise hyperglycemia or meal related rebound hyperglycemia.

Disclosure

D. Zaharieva: Speaker's Bureau; Self; Medtronic, Ascensia Diabetes Care. S.M. McGaugh: None. R. Pooni: None. T. Vienneau: Employee; Self; Insulet Corporation. Stock/Shareholder; Self; Insulet Corporation, GlaxoSmithKline plc. T.T. Ly: Employee; Self; Insulet Corporation. M. Riddell: Speaker's Bureau; Self; Medtronic. Consultant; Self; Eli Lilly and Company, JAEB Center For Health Research, Xeris Pharmaceuticals, Inc.. Research Support; Self; Insulet Corporation. Speaker's Bureau; Self; Insulet Corporation. Advisory Panel; Self; Sanofi. Speaker's Bureau; Self; Ascensia Diabetes Care. Stock/Shareholder; Self; Zucara Theraputics. Other Relationship; Self; JDRF.
Parents with Type 1 Diabetes—Children's Role in Self-Management
Authors: KRALL JODI , HELGESON VICKI , VAN VLEET MEREDITH , LEE EUNJIN , SIMMS MARYJANE , KORYTKOWSKI MARY T. , BERG CYNTHIA
Published: June 2018

Family members are a potential resource to support DM self-management, but how children are involved in their parents’ T1DM has not been well explored. The purpose of this study was to examine parents’ perceptions of the role children play in their DM care. Young, middle-age, and older adults with T1DM (n=85) and their romantic partners (n=55) participated in interviews during which they described their children’s knowledge and involvement in DM care. Interviews were transcribed and responses coded. All parents reported that children knew of their DM, which they learned about progressively from a young age, first being aware of blood glucose (BG) checks and devices. Some parents felt that children, particularly younger ones, detracted from DM management on occasion (e.g., nursing infant, caring for busy toddler), but this was usually expected and considered transient. Conversely, parents reported children to be accepting and understanding of the ways that DM affected their family experiences (e.g., pause to check and/or treat low BG), while also taking on a level of responsibility or concern (e.g., carrying a snack for treatment, worry about driving). Regardless of child age, many parents did not want DM to burden children and limited their involvement in DM care. When asked about DM-related behaviors, parents rated “making parent feel better about DM” as the most frequently occurring behavior. Only 3% of parents who used continuous glucose monitors and/or insulin pumps (n=60) said that children received notifications. Almost 40% of parents (n=33) expressed concern that children would develop DM. Parents, and more so partners, requested resources to enhance child awareness and preparedness to support parents with DM as well as ways to learn how to better communicate as a family and share perspectives on how DM affects individual family members. Diabetes educators should consider developmentally and relationally appropriate ways to engage children of parents with T1DM in education and self-management.

Disclosure

J. Krall: None. V. Helgeson: None. M. Van Vleet: None. E. Lee: None. M. Simms: None. M.T. Korytkowski: Advisory Panel; Self; Novo Nordisk Inc.. Other Relationship; Self; JAEB Center For Health Research. C. Berg: None.
Digging Deep into Diabetes—Barriers to Achieving Glycemic Control in Diabetic Patients in a Resident-Run Clinic
Authors: HAWATMEH SARA , MEIER MAGGIE , QAIYUM OSMAN , FARHAN ASGHAR MUHAMMAD , TALEBIAN AMIR , KAUR HARINDERJEET , HAQUE RAMZA , SHAILLY RAJAT , KAWSAR HAMEEM
Published: June 2018

Introduction: Diabetes mellitus (DM) affects over 29 million Americans with an estimated annual cost of $245 billion. Diabetes in patients with multiple comorbidities, financial, and/or social hardships pose challenges to achieve target hemoglobin A1c (HbA1c). We investigated the barriers to achieve the HbA1c goal in patients in a federally funded resident-run clinic.

Methods: Among diabetic patients in our clinic, 29% had a HbA1c >9.0 in 2016. We reviewed these patients’ medical records, and interviewed them to identify the barriers in achieving HbA1c ≤9.0. Interviews were used to assess their knowledge about diabetes, perceived self-efficacy of disease management, confidence level regarding treatment plan, and the patient’s declaration of barriers of diabetic management. Then, we conducted an intervention to include regular telephone follow-up and clinic visits to ensure adequate supplies, medication refills, and diet and medication compliance. We have also engaged social service workers to address issues with transportation, medication costs and insurance coverage.

Results: A total of 87 patients with HbA1C >9.0 qualified for the study, 94% were African American with female predominance (55%). Average age was 52.2 years and average BMI was 33.32 kg/m2. Average HbA1c was 11.5%. We were able to reach 59 patients to interview. Of those reached, 98% knew they had DM, 83% knew about HbA1c, but only 32% knew their last HbA1c. Major obstacles to achieve HbA1C goal are noncompliance with diabetic diet (29%), inability to afford medications (22%), inadequate medication refills (25%) and forgetting to take medication (20%). After 3 months of intervention, average hemoglobin A1c dropped to 9.7% from 11.5%, and 34 (58%) patients had an absolute decrease in their HbA1c from pre-intervention period. HbA1C dropped below 9% in 12 patients (20%). The intervention is currently ongoing.

Disclosure

S. Hawatmeh: None. M. Meier: None. O. Qaiyum: None. M. Asghar: None. A. Talebian: None. H. Kaur: None. R. Haque: None. R. Shailly: None. H. Kawsar: None.
Diabetes Distress—Provider Perspectives
Authors: JOHN ANN-MARIE
Published: June 2018

Purpose: Though many studies focus on patient perspectives of diabetes distress (DD), provider perceptions of DD require further investigation. Defined as the diabetes-specific distress related to the emotional and behavioral burden of living with type 2 diabetes (T2DM), DD is a major psychological challenge to self-management. The purpose of this qualitative study was to explore how primary care team members identify factors that contribute to DD future intervention.

Methods: Eighteen care providers from three rural nurse-managed interprofessional clinics located in Northern Virginia participated in the study. Using purposive sampling, providers were interviewed to obtain perspectives on DD in the management of T2DM. Face-to-face interviews were conducted, digitally recorded, and transcribed. Two researchers coded the transcripts into themes. Data collection and analysis occurred sequentially using a constructivist grounded approach.

Results: Provider narratives identified a lack of awareness of DD in their experiences with T2DM-related psychological and emotional challenges in a low-income, immigrant, underserved patient population. When asked about DD, most participants discussed the biomedical aspects of diabetes management, such as diet, exercise, medications, and blood glucose management. The key facilitator identified by the few participants who recognized DD was the interdisciplinary team practice model. Perceived barriers included: 1.) limited knowledge of DD by the healthcare team, 2.) under recognition of DD in reported practice, 3.) time constraints, and 4.) limited clinical experience with treating or referring patients with DD to appropriate mental health services.

Conclusions: The American Diabetes Association (ADA) Standards of Medical Care in Diabetes recommends ongoing assessment and monitoring of DD to prevent and delay its progression. Therefore, the challenge is to enhance provider understanding of DD and promote strategies and activities that help reduce DD and improve diabetes outcomes.

Disclosure

A. John: None.
Weight Loss Achieved by Participants with Hypertension/Elevated Blood Pressure in a Diabetes Prevention Program
Authors: BROKAW SARAH M. , CARPENEDO DOROTA , TYSK SONJA , FERNANDES JESSIE , HELGERSON STEVEN D. , HARWELL TODD S. ,   MONTANA DIABETES PREVENTION PROGRAM STUDY GROUP
Published: June 2018

In light of new national guidelines by the AHA/ACC that recommend lifestyle intervention as the primary mode of treatment for adults with hypertension (HTN), we assessed weight loss achieved by adults that had a HTN diagnosis and/or a measured blood pressure (BP) ≥140/90 mm Hg in an intensive lifestyle change intervention provided by lifestyle coaches using the National Diabetes Prevention Program (DPP) curriculum. From 2008-2016, 6,418 participants enrolled in the Montana DPP, and 55.8% (n=3,582) had HTN/BP on enrollment. Participants with HTN/BP were significantly older, weighed more at baseline, had greater fasting glucose, and attended more sessions than did other participants (Table). After the 16-week core sessions four months), participants in both groups achieved significant weight loss. Results from the logistic regression model indicated that the factors independently associated with achieving 7% weight loss were being female [AOR 0.57, 95% 0.44-0.74], having low prediabetes risk score of 3-8 [AOR 0.60, 95% 0.40-0.89], meeting the physical activity goal [AOR 1.46, 95% 1.17-1.82], and self-monitoring fat for 7-13 weeks [AOR 5.66, 95% 4.10-7.81] and 14-16 weeks [AOR 12.81, 95% 8.87-18.49]. These data suggest, the DPP is likely an effective method to support adults with HTN/BP in making recommended lifestyle changes and decreasing an important blood pressure risk.Table. Participant baseline characteristics and outcomes during the 16-week core (four months), by hypertension/BP status, Montana DPP, 2008-2016.Hypertension/BP ≥140/90 (N = 3,582)No Hypertension/BP <140/90 (N = 2,828)Mean (SD)Mean (SD)Age (Years)55.8 (11.6)51.2 (12.5)*Baseline BMI (kg/m2)37.1 (7.3)35.2 (7.0)*Baseline fasting blood glucose (mg/dL)101.4 (13.7)98.5 (13.3)Sessions attended15.0 (6.1)14.7 (6.0)*Weight change (kg)-5.1 (5.3)-4.8 (5.3)*% (n)% (n)Sex (Female)79.1 (2,836)85.2 (2,406)*Prediabetes risk score (low 3-8)7.9 (108)12.7 (109)Met ≥150 min/week physical activity goal58.3 (1,867)57.7 (1,449)Self-monitored fat intake 14-16 weeks30.8 (1,015)26.0 (659)*Achieved ≥5% weight loss47.4 (1,701)46.0 (1,300)Achieved ≥7% weight loss goal31.7 (1,138)30.0 (848)*P≤0.05

Disclosure

S.M. Brokaw: None. D. Carpenedo: None. S. Tysk: None. J. Fernandes: None. S.D. Helgerson: None. T.S. Harwell: None.
HCP and Patient Perspectives on Basal Insulin Titration
Authors: UZOIGWE-SMITH CHIOMA , LEVIN MARGARITA , PFAFF DOUGLAS B. , MOCARSKI MICHELLE , HAMERSKY CAROL M. , POLONSKY WILLIAM
Published: June 2018

Little is known about the discussion regarding titration at the time basal insulin is initiated for people with type 2 diabetes (T2DM) and about how titration occurs in the real world. This qualitative study investigated attitudes and practices of health care professionals (HCPs) and patients associated with basal insulin titration. Twelve virtual focus groups, comprising 23 HCPs (8 endocrinologists, 15 primary care physicians) and 22 adult patients with T2DM whose length of time since starting basal insulin was ≤ 4 years, were recruited from panels from across the U.S. from June to August 2017. Fifteen of 23 HCPs (65%) reported that they typically discussed titration at the time basal insulin was first prescribed. Twelve of 23 (52%) discussed target blood glucose (BG) ranges in initial conversations. Thirteen of 23 (57%) said most of their patients did not completely understand elements of the titration discussion. Of 16 HCPs who discussed what they do when their patients appear overwhelmed by or do not comprehend treatment instructions, 9 would start most of their patients on HCP-guided titration, 5 would delay titration and 2 would encourage self-titration without delay. HCPs on average reported 43% of their adult T2DM patients reached their A1c target within 6 months; they also reported 40% of their self-titrating patients ever reached their A1c target. Seventeen of 22 patients (77%) began titration when basal insulin was prescribed, and recalled injection and dose adjustment instruction from initial conversations. Twelve of 22 (55%) felt they were provided insufficient context on expectations around increasing insulin and/or how long titration could take. Four patients said they linked dose increases to personal failure. Eleven of 22 patients identified as self-titraters. Of 16 patients aware of their A1c or BG targets, 5 (31%) achieved them and 3 of 5 patients took ≥ 12 months to do so. HCPs and patients revealed patients often do not understand the basal insulin titration process and often do not achieve treatment goals.

Disclosure

C. Uzoigwe-Smith: Employee; Self; Novo Nordisk Inc.. M. Levin: None. D.B. Pfaff: None. M. Mocarski: Employee; Self; Novo Nordisk Inc.. Stock/Shareholder; Self; Novo Nordisk A/S. C.M. Hamersky: Employee; Self; Novo Nordisk Inc. W. Polonsky: Consultant; Self; Abbott, AstraZeneca, Dexcom, Inc., Sanofi, Novo Nordisk Inc., Eli Lilly and Company, Intarcia Therapeutics, Inc., Servier, Ascensia Diabetes Care, Merck & Co., Inc., MannKind Corporation, Glooko, Inc., Roche Diabetes Care Health and Digital Solutions.
Virtual Simulation Improves Clinical Decision-Making in Managing Type 2 Diabetes
Authors: LARKIN AMY , HANLEY KELLY L. , WARTERS MARTIN , LITTMAN GWEN S.
Published: June 2018

This study was conducted to determine if online, virtual patient simulation (VPS)-based continuing medical education (CME) intervention that engages clinicians in a practical learning experience could improve performance of diabetologists/endocrinologists (D/Es) and primary care physicians (PCPs) in the management of T2D and sleep problems. The CME VPS intervention comprised one patient presenting at 2 different points. The VPS platform allows learners to order lab tests, make diagnoses, and prescribe treatments in a manner matching the scope and depth of actual practice. Learners’ choices were analyzed using a sophisticated decision engine. Tailored clinical guidance (CG), based on current evidence and expert recommendation, was provided following each decision. Learners were given the opportunity to modify their decisions after receiving CG. Decisions were collected post-CG and compared with each user’s baseline (pre-CG) decisions using a 2-tailed paired t-test to determine P values. Through November 2017, significant improvements were documented among participating learners after clinical guidance (D/Es n=19; PCPs n=391): Diagnosis of uncontrolled T2D: 40% absolute improvement among PCPs (3% pre-CG vs. 43% post-CG; P<.001) and 26% improvement among D/Es (0% pre-CG vs. 26% post-CG; P=.004)Diagnosis of insomnia: 31% absolute improvement among PCPs (28% pre-CG vs. 58% post-CG; P<.001) and 537 improvement among D/Es (11% pre-CG vs. 47% post-CG; P=.003)Insomnia treatment: 56% absolute improvement among PCPs (10% pre-CG vs. 66% post-CG; P<.001) and 42% improvement among D/Es (11% pre-CG vs. 53% post-CG; P<.001)Intensification of T2D treatment: 36% absolute improvement among PCPs (28% pre-CG vs. 64% post-CG; P<.001) and 35% improvement among D/Es (29% pre-CG vs. 65% post-CG; P=.013)

This study demonstrates that VPS that immerses and engages the clinical learners in an authentic and practical learning experience can improve evidence-based clinical decisions related to the management of T2D.

Disclosure

A. Larkin: None. K.L. Hanley: None. M. Warters: None. G.S. Littman: None.
User Experience with a New Smartphone Application for Blood Glucose Monitoring (BGM) in an Information-Motivation-Behavioral Skills (IMB) Model Study
Authors: FISHER WILLIAM , STUHR ANDREAS , WALLACE JANE , ZHUPLATOV SERGEY , BAILEY TIMOTHY S. , PARDO SCOTT
Published: June 2018

The CONTOUR®NEXT ONE BGM system (BGMS) includes a wireless-enabled BG meter that links to the CONTOUR®Diabetes app installed on a mobile device. The system, based on the IMB model, detects and reports patterns of BG readings and provides guidance for self-management. The IMB model emphasizes the need for actionable information, motivation to act, and behavioral skills for acting effectively, to strengthen self-management of diabetes. This 6-week study with 46 insulin-using individuals with diabetes assessed the BGMS with the CONTOUR®Diabetes app Version 2 Prototype. Participant appraisal of the BGM/app system was positive on multiple dimensions (Table 1). Participants strongly agreed/agreed that using this BGM/app system provided them with a better understanding of their disease (98%), helped them feel more engaged with their diabetes management program (91%), they felt more motivated to adhere to their health care provider's therapy and testing recommendations (76%), that the “My Patterns” pattern recognition feature was helpful in managing their diabetes (73%), and that they found themselves testing more frequently throughout the day (56%).

Disclosure

W. Fisher: Consultant; Self; Bayer AG, Ascensia Diabetes Care, Roche Diabetes Care Health and Digital Solutions. A. Stuhr: Employee; Self; Ascensia Diabetes Care. J. Wallace: Employee; Self; Ascensia Diabetes Care. S. Zhuplatov: Employee; Self; Ascensia Diabetes Care. T.S. Bailey: Research Support; Self; Abbott. Consultant; Self; Abbott. Speaker's Bureau; Self; Abbott. Research Support; Self; Ambra BioScience, Ascensia Diabetes Care, Becton, Dickinson and Company. Consultant; Self; Becton, Dickinson and Company. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Calibra Medical. Consultant; Self; Calibra Medical. Research Support; Self; Companion Medical, Dexcom, Inc., Glooko, Inc., GlySens Incorporated, Lexicon Pharmaceuticals, Inc., Eli Lilly and Company. Consultant; Self; Eli Lilly and Company. Speaker's Bureau; Self; Eli Lilly and Company. Research Support; Self; Medtronic MiniMed, Inc.. Consultant; Self; Medtronic MiniMed, Inc.. Speaker's Bureau; Self; Medtronic MiniMed, Inc.. Research Support; Self; Novo Nordisk Inc.. Consultant; Self; Novo Nordisk Inc.. Speaker's Bureau; Self; Novo Nordisk Inc.. Research Support; Self; Sanofi. Consultant; Self; Sanofi. Speaker's Bureau; Self; Sanofi. Research Support; Self; Senseonics. Consultant; Self; Intarcia Therapeutics, Inc.. Research Support; Self; Versartis, Inc., Xeris Pharmaceuticals, Inc., MannKind Corporation. S. Pardo: Employee; Self; Ascensia Diabetes Care.
Impact of Certified Diabetes Educators following Preapproved Protocols on Diabetes Self-Care Behaviors—Results of the REMEDIES 4D Trial
Authors: JOHNSON KRYS M. , MALMI MARKKU , KUO SHIHCHEN , ZGIBOR JANICE C.
Published: June 2018

Diabetes self-care behaviors (DSCBs) play a significant role in controlling risk factors for diabetes-related complications when practiced consistently. Our objective was to evaluate changes in DSCBs in people with type 2 diabetes from primary care practices participating in the REMEDIES 4D study. REMEDIES 4D was a clustered, randomized trial in which certified diabetes educators (CDEs) implemented standardized treatment protocols to intensify treatment for glucose, lipid or blood pressure control. Fifteen practices and their patients were randomized to the intervention (n=175) or usual care (n=65). Eligible participants had uncontrolled HbA1c, blood pressure, or LDLc. The intervention group received diabetes self-management education in addition to treatment intensification, while the usual care group participated in monthly support groups for one year. DSCBs were measured via the Summary of Diabetes Self-Care Activities scale (SDSCA). Two-sample t-tests were conducted to examine differences in adherence to recommended daily diabetes self-care behaviors between the intervention and usual care groups. The population was 49% male with a mean age of 61 years. The main results of the trial demonstrated a significant 1% decline in HbA1c in the intervention group and no significant change in the usual care group. At baseline, intervention participants tested blood glucose (BG) an average of 4.3 days compared with usual care 3.0 days (P=0.232). At follow-up, intervention participants tested BG an average of was 4.9 days, 1.3 days more frequently than the control group (P=0.004). There was no significant difference between groups for adherence to the self-care behaviors of general diet, specific diet, exercise, or foot care. These findings suggest that CDEs following standardized treatment protocols will improve adherence to recommendations for daily blood glucose testing which may enable patients to maintain better glycemic control.

Disclosure

K.M. Johnson: None. M. Malmi: None. S. Kuo: None. J.C. Zgibor: None.
National Snapshot of State Health Department Outcomes and Lessons Learned from Implementing Diabetes Self-Management Education and Support Programs and National Diabetes Prevention Programs
Authors: RUTLEDGE GIA E. , ANAND MEENU , MENSA-WILMOT YVONNE
Published: June 2018

In 2013, CDC developed the State Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke, a five-year cooperative agreement which combined the efforts of four divisions to fund 50 state health departments (SHDs) to implement strategies to work through health systems and communities to prevent chronic disease and reduce complications from multiple chronic diseases. The Division of Diabetes Translation recommended several strategies to support type 2 diabetes prevention and diabetes management. The strategies focused on 1) increasing referrals to CDC-recognized lifestyle change programs operating under the National Diabetes Prevention Program (National DPP); 2) securing the program as a covered benefit for state or public employees and Medicaid beneficiaries; and 3) increasing referrals to, coverage for, and availability of diabetes self-management education and support (DSMES) programs. Quantitative analysis of SHD performance measures data shows that from baseline to year 4, there was an increase in access to and participation in DSMES and the National DPP. Qualitative analysis of SHD workplans identified program accreditation, technical assistance, partnerships, reimbursement for DSMES, and flexible scheduling for patients as key facilitators for increased DSMES program utilization. SHD grantees reported reimbursement availability, practice/provider referral policies, and having standard curricula as facilitators to implementing the National DPP lifestyle change program.

Disclosure

G.E. Rutledge: None. M. Anand: None. Y. Mensa-Wilmot: None.
Cardiovascular Disease (CVD) Decision Aid for Youth with Type 1 Diabetes (T1DM)—Perspectives of Health Care Providers (HCPs) with Pediatric-Onset T1DM
Authors: KRALL JODI , LIBMAN INGRID , AFREEN SAMINA , SIMINERIO LINDA M.
Published: June 2018

CVD is the leading cause of premature death in people with T1DM, yet many individuals are unaware. Strategies to engage youth in CVD prevention and lifelong disease management are needed. The purpose of this study was to gain insight from HCPs about a shared decision making (SDM) aid centered on CVD modifiable risk factors (A1c, blood pressure (BP), and cholesterol), and designed to present facts, risks/benefits, and actionable steps relevant to teenagers. Five HCPs with pediatric onset T1DM, age 27-30y, working in a pediatric DM center, participated in multiple focus groups, to iteratively guide development of the SDM aid. Based on their experience in having T1DM and providing DM care to youth, HCPs offered perspectives on the aid in terms of value, content, delivery, and support mechanisms. Feedback was transcribed and summarized. HCPs agreed that introducing the topic of CVD to teenagers was important. Reflecting on their own experiences, HCPs regretted that the topic was not discussed during their pre-adult care conversations, which they said contributed to their unawareness of CVD prevention at the time. In terms of content, HCPs found the aid to be well suited for the intended audience, easy to understand, and not overwhelming. They thought illustrations were helpful to convey key facts and prevention messages, and voiced that even if it would be unlikely that their patients would have abnormal BP or lipids presently, educating about target values and testing intervals would be beneficial in preparation for adulthood. HCPs did not anticipate that the aid would cause distress, noting it was well balanced, informative, but not intimidating and refrained from scare tactics. HCPs unanimously agreed they would use the aid with patients (and parents), and recommended applying it when reviewing lab results.

In summary, HCPS endorsed using the SDM aid to guide CVD discussions with youth. Studies are ongoing to assess its impact on youth with T1DM.

Disclosure

J. Krall: None. I. Libman: Consultant; Self; Novo Nordisk A/S. S. Afreen: None. L.M. Siminerio: None.
Training Nursing Staff to Improve Diabetes Care for Long-Term Care Facility (LTCF) Residents
Authors: HUBBERD ABEGAIL L. , HERNANDEZ CHRISTINA M.
Published: June 2018

One out of four people age 65 and older residing in a long term care facility (LTCF) has type 2 diabetes (T2DM). Care and management of this population is a challenge for nurses and other providers. American Diabetes Association Guidelines (2017) recommend application of individualized HbA1c targets for LTCF residents, especially for those with compromises in clinical and functional status.

A needs assessment in a local LTCF identified deficiencies in the provision of evidence-based T2DM care for this LTCF population. This quality improvement (QI) project strove to 1) educate nurses about these residents’ needs and 2) incorporate the use of best practice diabetes standards in the nurse practitioner’s practice by providing in-service education. Specifically, emphasis was placed on HbA1c and finger stick monitoring, eye exams, and foot care.

Results indicated that educational in-services were an effective approach to improving knowledge concerning care of complex TD2M patients. The Advanced Practice Registered Nurse (APRN) (60% to 100%), the 3 registered nurses (63% to 87%) and 9 licensed vocational nurses (63% to 71%) increased in knowledge from baseline to the final 10 question post-test.

However, ophthalmology and podiatry referrals were not ordered routinely because of APRN, staff, and organizational resistance. Per an audit of 22 patient charts, utilization of standardized orders improved routine T2DM care. There were 13 HbA1c due and 12 were ordered (92%); the one renal panel that was due was ordered, and all 5 urine to albumin creatinine ratio were ordered. In addition, the APRN has awareness to evaluate discrepancies between HbA1c results and finger stick values.

QI projects in LTCFs may be difficult to implement and sustain related to staff turnover, understaffing, high patient acuity, and organizational and provider opposition. APRNs must advocate for continual utilization of evidence-based practice guidelines for all LTCF residents.

Disclosure

A.L. Hubberd: None. C.M. Hernandez: None.
Diabetes Inside—Following the Long-Term Impact of a Diabetes Quality Improvement (QI) Initiative in Primary Care
Authors: GUNASEKARAN UMA , FURMAN ROY E. , RODRIGUEZ KELLIE M. , ELIZABETH OBIALO E. , KASSA SENTAYEHU , SANTINI NOEL O. , FURMAN ELISE , MENEGHINI LUIGI
Published: June 2018

In collaboration with the ADA, we implemented a QI project to improve glycemia in patients with type 2 diabetes (T2D) and poor glycemic control (A1C > 9%) receiving care in a large urban safety net health system. The 18-month initiative focused on developing shared medical appointments for insulin initiation and management, supported by a primary care QI committee, educational interventions and development of EMR tools to facilitate diabetes management and documentation. We report 2-year data following implementation of the QI intervention.

Of 23,611 individuals (mean age 58 years) with 73,849 A1C data points over a period of 3 years 60% were female; 57% Hispanic white, 27% non-Hispanic Black, 9% non-Hispanic white; 62% received charity care, 30% Medicare/Medicaid, 5% commercial insurance. Control charts first demonstrated statistically significant increases in insulin use in poorly controlled patients followed by statistically significant improvement in population glycemic control (A1C average) and proportion of patients with A1c>9% (see figure).

A primary care-based QI initiative targeting patients with T2D and A1C > 9% led to appropriate increases in insulin prescriptions, which was followed by a system-wide improvement in diabetes control.

Disclosure

U. Gunasekaran: None. R.E. Furman: Consultant; Self; Novo Nordisk Inc.. K.M. Rodriguez: None. E. Obialo: None. S. Kassa: None. N.O. Santini: None. E. Furman: None. L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Sanofi US, Novo Nordisk Inc.. Advisory Panel; Self; Intarcia Therapeutics, Inc.. Other Relationship; Self; American Diabetes Association.
An Interdisciplinary Team Approach to Managing Diabetes in a Patient-Centered Medical Home
Authors: LAMIE STEVEN M. , BAILLOD JANET C. , ROCKAFELLOW STUART D. , GIBBS MARILYN B. , SCHEPPERLY DEBRA
Published: June 2018

Background: Our private practice Patient-Centered Medical Home (PCMH) clinic proposed a pilot team-based program where patients would be seen between physician visits by an interdisciplinary team comprised of our CDE, Clinical Pharmacist, and Care Manager with the goal of helping to improve glycemic goals.

Methods: Patients age 18 or older with an A1c greater than 8.0 were identified through registry review and invited to participate. Team providers were under the supervision of the project lead physician. Number of visits was individualized for each patient. Visits centered on diabetes education, goal setting, and motivational interviewing. The project was pre-defined to have been successful if 15% of patients achieved improved control.

Results: A recruitment goal of 100 was targeted and 107 patients were identified and enrolled. One hundred and six patients completed the pilot program. Average A1c at the beginning of the study was 9.1%. A1c decreased to 8.2% at the end of pilot, a 0.9% decrease. A1c ranged from 8.0 to 14.5% at pilot initiation. At the end of the pilot A1c ranged from 5.1 to 10.8%. This represents a change of -7.4 to +1.8%. Seventy patients (65%) achieved improved A1c. Forty four (41%) patients achieved an A1c less than 8.0%. An additional 26 (24%) patients had improvement in A1c. Patients had an additional 7 visits on average. Average blood pressures declined by 2.7 mmHg systolic and 0.11 mmHg diastolic. Microalbumin to creatinine ratio testing increased to 95% compliance, an increase of 20%. Appropriate statin use was unchanged at 79% of patients.

Conclusions: The majority of pilot enrollees improved their diabetic control over the course of the pilot program. The pre-specified level for success was exceeded. This project demonstrates the ability of a private practice with limited resources to seek creative solutions and partnerships to improve patient care of challenging and complex patients.

Disclosure

S.M. Lamie: Speaker's Bureau; Self; Sanofi-Aventis. J.C. Baillod: None. S.D. Rockafellow: None. M.B. Gibbs: None. D. Schepperly: None.
Projecting Long-Term Diabetes Complications through a BRAVO-Based Mock Simulation for Promoting Diabetes Prevention Program (DPP)
Authors: SHAO HUI , YANG SHUANG , FONSECA VIVIAN , JI XU , SHI LIZHENG
Published: June 2018

Correctly understanding consequences of diabetes is essential for motivating prediabetic patients to join the diabetes prevention program (DPP). The overall population estimates on diabetes complications may be lower than individual’s risk estimates which are subjective to their life expectancy. This study using a newly developed diabetes model aimed to project major diabetes complications, conditioning on a range of survival lengths. 2011-2016 National Health and Nutrition Examination Survey data were used to generate a nationally representative sample of newly diagnosed diabetes patients. The Building, Relating, Validating, Acting and Validating Outcomes (BRAVO) diabetes simulation model was used to project the long-term risks of diabetes complications for the NHANES sample. The cohort of simulated patients were followed up for 20/40 years, conditioning on zero mortality (i.e., mock simulation experiment) and cumulative incidence during the follow-up periods for each complication were recorded. The average age of newly diagnosed diabetes was 51.66 y. For diabetes patients who have survived for 20 years after diabetes onset, the probabilities for diabetes complications were: MI (20.4%), stroke (7.8%), congestive heart failure (CHF, 10.6%), angina (13.4%), revascularization surgery (RS, 54.4%), end-stage renal disease (ESRD, 11.7%), severe pressure sensation loss (SPSL, 56.6%), and blindness (27%). For diabetes patients who have survived for 40 years after diabetes onset, the probabilities of diabetes complications were: MI (55.8%), stroke (24.3%), CHF (46.1%), angina (34.4%), RS (85.8%), ESRD (31.7%), SPSL (86.9%), blindness (64.9%). The presentation of diabetes complications for a long survival time could help prediabetes patients better assess diabetes impact on health. The BRAVO-base decision support simulation could serve as a tool to educate prediabetes population on benefits of diabetes prevention program.

Disclosure

H. Shao: None. S. Yang: None. V. Fonseca: Consultant; Self; Abbott. Board Member; Self; American Association of Clinical Endocrinologists. Consultant; Self; Eli Lilly and Company. Stock/Shareholder; Self; Amgen Inc.. Consultant; Self; Asahi Kasei Corporation, AstraZeneca, Novo Nordisk Inc., ADOCIA, Intarcia Therapeutics, Inc., Sanofi-Aventis. X. Ji: None. L. Shi: None.