bluuebunny/crossref_metadata_2025_split huggingface dataset:
450-P: Increasing Trends in Major Amputations among Patients with Diabetes in Kentucky, 2008-2018
Authors: SOHN MIN-WOONG , KIM WOOK-JOONG , LACY MARY ELIZABETH 
Published: June 2021

Objective: CDC’s recent data (Harding et al. 2020) showed that rates of major lower-extremity amputations (ankle or above) rapidly decreased in 2000 - 2010 and then stabilized at slightly lower than 0.1% of Medicare beneficiaries with diabetes since then. We examined the commonwealth of Kentucky (KY) inpatient data to track trends in diabetic major amputations in 2008 - 2018.
Methods: We used KY HCUP inpatient data to identify all patients with diabetes using ICD9/10 codes and those who have underwent major amputations using CPT codes.
Results: The number of hospitalizations by patients with diabetes in KY decreased by 8% in 2008 - 2018 but the number of major amputations increased from 560 to 795 limbs, representing a 42% increase in the same period. Medicare paid for 44% of these surgeries in 2008 and 61% in 2018, while Medicaid covered 38% in 2008 but only 31% in 2018 despite the expansion in Medicaid coverage since 2014. KY inpatient users with diabetes had 46% higher odds of having a major amputation in 2018 compared to those in 2008, adjusting for age, sex, and race/ethnicity. Compared to pre-2014 era, the odds of having a major amputation was 27% higher after the Medicaid expansion in 2014.
Conclusion: It is concerning that, while the rest of the country showed decreasing or stationary trends in major amputation rates, KY experienced continuously increasing number of major amputations in the last two decades. Although Medicaid expansion era had a significantly higher odds of major amputations compared to the pre-expansion era, it is not clear whether this reflects the effect of policy or is part of a secular trend since 2010. More careful analysis is needed to better understand the underlying causes of this trend and what needs to done to reverse it.

Disclosure
M. Sohn: None. W. Kim: None. M. Lacy: None.
452-P: Effect of Virtual Education on Glycemic Control in Patients with Type 1 Diabetes during Fasting Ramadan
Authors: KHOGEER GHOFRAN S. , ALAMOUDI REEM , ALOTIBI MARYAM N. 
Published: June 2021

Managing patients with T1DM who fast Ramadan is challenging. The COVID-19 related strict imposed curfew in Saudi Arabia affected access to healthcare and made virtual education (VD) a necessity.
Objective: To assess the impact of VD on glycemic control and self-management in T1DM during Ramadan fasting.
Methods: Pre-post Ramadan survey at endocrine clinics of National Guards Hospital, Jeddah, Saudi Arabia. Patients were contacted by phone due to COVID 19 restrictions. The VD methods (video + booklet) were sent to patients via WhatsApp. HbA1c was measured before and after Ramadan.
Results: 89 patients enrolled: 51.2% males, DM duration 13.8 ±7.7 years, age 24.4 ±8.1 years. &gt; 90% stated that VD used was well done/acceptable, and 57% confirmed using it as reference. During Ramadan 88% complied with frequent SMBG, 72.6% reported breaking the fast at the recommended threshold of &lt;70mg/dl, but only 22.6% broke fasting if &gt;300 mg/dL. 61% followed the recommended insulin adjustments to basal and sahoor doses, and to adjustment of meal timings (delay of sahoor), and fluid intake. 43% complied with eating proteins at sahoor. Baseline HbA1c 8.46 ±1.85 and decreased to 8.32 ±1.47 after the intervention process (P=0.004).
Conclusion: Diabetes virtual education was well received and improved glycemic control and self-care among patients with T1DM during Ramadan fasting.

Disclosure
G. S. Khogeer: None. R. Alamoudi: None. M. N. Alotibi: None.
457-P: Effectiveness of an Empowerment-Based Self-Management Intervention on Glycemic Control, Self-Management Behaviors, and Psychological Distress in Middle-Aged Patients with Poorly Controlled Type 2 Diabetes
Authors: CHENG LI , SIT JANET WH , XIE QINQIN 
Published: June 2021

Objectives: This study aimed to evaluate the effectiveness of an empowerment-based, self-management intervention among middle-aged patients with poorly controlled type 2 diabetes.
Methods: This is a secondary data analysis of an assessor-masked, multi-center, randomized controlled trial. A total of 166 middle-aged patients with poorly controlled type 2 diabetes were randomized to either intervention or control group. Participants in the intervention group received a patient-centered self-management intervention program guided by the Empowerment Process Model with emphasis on personally-meaningful goal-setting and action-reflection dynamics. Generalized estimating equation (GEE) was used to compare the changes in glycemic control, self-management behaviors, and psychological distress over the study periods.
Results: Participants in the intervention (n= 80) and control (n= 86) groups were homogeneous at the baseline. The intervention group demonstrated a significant and clinical meaningful reduction in HbA1c value mean (SD) from baseline (10.11% [1.76]) to 3-month (9.19% [2.06]) post-intervention (p&lt; 0.001). Participants in the intervention groups showed significant between-group differences in diet management (p= 0.001), frequency of blood glucose self-monitoring (p= 0.005), and distress level (p&lt; 0.001) at three-month after the completion of the intervention. However, GEE showed non-significant differences on outcome parameters.
Discussion: Middle-aged patients with poor diabetes control did not benefit from the empowerment-based self-management intervention. Considering the deteriorated consequence of poor glycemic control and expected long-term trajectory of disease management, special attention should be paid to optimize the biochemical and patient-centered outcomes of middle-aged patients with poor diabetes control.

Disclosure
L. Cheng: None. J. Sit: None. Q. Xie: None.
467-P: Immediate and Sustained Trends in Glycemic Control during Remote Patient Monitoring in People with Type 2 Diabetes
Authors: SHENG TONG , BABIKIAN SARINE , SINGH VIKRAM , CLEMENTS MARK A. 
Published: June 2021

Technologies that let patients share diabetes data with care teams can help care teams identify patients with deteriorating glycemic control and facilitate timely and remote-based interventions outside of routine clinic visits. In the current study, we investigated whether people with type 2 diabetes (PWT2D) demonstrate improved glycemia after enrolling in remote patient monitoring (RPM) pilot programs that incorporated remote data syncing and coaching. All program participants were instructed to sync their blood glucose meters with either a mobile app or a computer-based software regularly during program participation. Synced blood glucose data were available to the RPM teams via a web-based dashboard, and remote coaching was administered either regularly and/or as needed. Data from 384 PWT2D (42% female; median age: 50 years) were included in cross-sectional comparisons at baseline and at 3, 6, and 12 months of RPM program participation. Overall trends of immediate (i.e., at 3 months) and sustained (at 6 and 12 months) improvements were observed for mean blood glucose levels (baseline: 178 mg/dL to ~155 mg/dL at 3, 6, 12 months; all Ps &lt;.05), and mean proportion of in-range (70-180 mg/dL; baseline: 60% to ~74% at 3, 6, 12 months; all Ps &lt;.05) and high SMBG readings (&gt;250 mg/dL; baseline: 14% to ~8% at 3, 6, 12 months; all Ps &lt;.05), with no differences in the proportion of low (&lt;70 mg/dL) readings.
In summary, glycemic improvements are seen within 3 months of program participation and are sustained with continued engagement. These findings indicate that RPM programs that incorporate remote data sharing and coaching can make a substantial impact on glycemic control for people with type 2 diabetes.

Disclosure
T. Sheng: Employee; Self; Glooko, Inc. S. Babikian: Employee; Self; Glooko, Inc. V. Singh: Employee; Self; Glooko, Inc. M. A. Clements: Employee; Self; Glooko, Inc., Other Relationship; Self; Glooko, Inc.
469-P: Health Care Providers’ Experiences with a Virtual Reality Program Focused on Diabetes, Social Determinants of Health, and Appalachian Culture
Authors: BEVERLY ELIZABETH A. , LOVE CARRIE , LOVE MATTHEW 
Published: June 2021

The prevalence of diabetes in southeastern Appalachian Ohio is 19.9%, nearly double the national average of 10.5%. Here, people are more likely to be diagnosed late, have limited access to healthcare, and lower health literacy. Moreover, people in southeastern Ohio are more likely to be unemployed, food insecure, have lower educational achievement, and limited access to transportation. These social determinants of health (SDoH) contribute to the diabetes disparities observed in the region. One approach to address these disparities is to develop tailored continuing education for healthcare providers. We developed a 3-hour cinematic virtual reality (cine-VR) program to educate providers about diabetes, SDoH, and Appalachian culture. We conducted 20 in-depth interviews with providers (age=43.8±11.8 years; 90.0% female; 95.0% white, 20.0% nurses) to explore their experiences with the cine-VR program. Three researchers independently coded the interviews, resolved discrepancies, and agreed on themes. Qualitative analysis revealed three themes: 1) Feeling Like You Are in the Room: Providers commented on the realism of cine-VR. They had access to the whole environment via a 360-degree headset and felt fully immersed in the simulations as if they were in the room with the patient. 2) Empathizing with People’s Stories: Providers identified with the content in the cine-VR, specifically the clothing, cars, houses, and the notion of “taking care of everyone else but yourself.” They understood the patient’s frustrations, disappointments, and competing priorities. 3) Highlighting the Strengths of Appalachia: Providers noted the program’s emphasis on family, caregiving, loyalty, and generosity, and how these cultural values can be utilized in diabetes care. These qualitative findings demonstrate the value of culturally tailored digital storytelling as engaging content for providers to learn about diabetes, SDoH, and Appalachian culture.

Disclosure
E. A. Beverly: None. C. Love: None. M. Love: None.
472-P: Online Patient Education on GLP-1 Receptor Agonists in Patients with T2D and CVD Prompts Real-Life Changes
Authors: LARKIN AMY , LE ANNE 
Published: June 2021

We sought to measure the impact of online education for patients on knowledge, confidence, and prompting change in daily life. Two educational activities were available online, comprised of text and integrated visuals as well as either a patient or clinician video. Demographic questions were asked prior to starting the education. A knowledge question was asked both before and after the activity to assess learning gains, as well as intent to change and confidence questions at the end. Absolute improvements were calculated for pre/post questions. The activities launched in August, 2020, and preliminary data collected through November, 2020. Activity 1: To date, 28,983 learners have participated in the patient/caregiver activity, “How is Diabetes Related to Heart Disease?” Of which, 4,912 completed all questions (included in outcomes analysis): 51% male; 51% white, non-Hispanic; 66% over the age of 54; 71% have diabetes, 18% were interested in learning more about diabetes and heart disease. Intent-to-act: 85% plan to talk to their HCP about their risk for heart disease. Confidence changes: 87% reported increased confidence talking to my doctor or healthcare provider about how to lower their risk for heart disease. Activity 2: To date, 40,812 learners have participated in the patient/caregiver activity, “How Can I Make my Heart Healthier and Control my Sugar Better at the Same Time?” Of these, 10,233 completed all questions (included in outcomes analysis): 52% female; 53% white, non-Hispanic; 66% over the age of 54; 69% have diabetes, 22% were interested in learning more about ways to treat diabetes and heart disease. Knowledge changes: 54% improvement in recognizing GLP-1 RAs can treat T2D and lower the risk for heart disease (12% pre to 66% post). The metrics and outcomes gathered in this assessment are a strong indicator that these patient-focused online educational activities improved knowledge, confidence, and prompted intent to act by patients related to T2D and CVD risk reduction.

Disclosure
A. Larkin: None. A. Le: None.

Funding
Novo Nordisk
48-OR: Changes in Global Cerebral Blood Flow in Response to Hypoglycemia in Type 1 Diabetes Do Not Influence Awareness Status
Authors: JACOB PETER , ODALY OWEN , AMIEL STEPHANIE A. , CHOUDHARY PRATIK 
Published: June 2021

Changes in global cerebral blood flow (gCBF) have been suggested as a mechanism for mitigating the functional impact of hypoglycemia on the brain. The impact of type 1 diabetes (T1D) or hypoglycemia awareness status is not clear. We measured gCBF during progressive lowering of plasma glucose in people with and without T1D, and with retained or impaired awareness of hypoglycemia.
Methods: Fifty-one participants (15 with no diabetes (ND), 15 with T1D and normal awareness of hypoglycemia (NAH) and 21 with T1D and impaired awareness of hypoglycemia (IAH)) underwent a two-step hyperinsulinemic hypoglycemic clamp. gCBF was estimated using pseudocontinuous arterial spin labelling magnetic resonance imaging at 6 timepoints: 2 euglycemic, two in the descent phase and two hypoglycemic. gCBF was extracted using a global grey matter mask in SPM12. Statistical analysis and thresholded linear models were performed in R.
Results: The mean (+ SD) glucose values at the six timepoints were 95.8 (8.0), 95.5 (9.2), 55.0 (8.3), 50.8 (5.3), 45.7 (4.3) and 45.8 (4.0) mg/dL. Symptom responses to hypoglycemia were absent in IAH. There was a significant increase in CBF in response to hypoglycemia (3-way ANOVA p = 0.04). This was driven by responses in NAH (+7.3%, p &lt; 0.05) and IAH (+10.6% p &lt; 0.01) with no response in ND (+3.5% p = 0.16). The response was not linear, with glucose thresholds of 55.8 mg/dL in NAH and 54.0 mg/dL in IAH (pNAH vs IAH = 0.9) with no threshold in ND.
Conclusion: In people with T1D, there is a non-linear relationship between falling glucose and rising gCBF which is not related to awareness status and is not seen in health. The threshold glucose between 54 and 56 mg/dL corresponds closely with level 2 hypoglycemia cut-offs used in current clinical practice. We propose that there is a failure of cerebral vascular autoregulation in response to hypoglycemia in T1D. gCBF responses to hypoglycemia in T1D are independent of symptomatic responses and not responsible for lack of hypoglycemia awareness.

Disclosure
P. Jacob: None. O. Odaly: None. S. A. Amiel: Advisory Panel; Self; Diabetes UK, Medtronic, Other Relationship; Self; Sanofi, Research Support; Self; Diabetes UK, European Union, JDRF. P. Choudhary: Advisory Panel; Self; Abbott Diabetes, Insulet Corporation, Lilly Diabetes, Medtronic, Sanofi-Aventis, Speaker’s Bureau; Self; Dexcom, Inc., Novo Nordisk.

Funding
JDRF (3-SRA-2017-484-S-B)
494-P: Canagliflozin Prevents Hyperglycemia-Associated Muscle Extracellular Matrix Accumulation and Restores the Adaptive Response to Aerobic Exercise
Authors: MACDONALD TARA , PATTAMAPRAPANONT PATTARAWAN , LESSARD SARAH J. 
Published: June 2021

In rodent models and humans, hyperglycemia is associated with an impaired adaptive response to aerobic exercise, which includes blunted improvements in aerobic capacity and impaired aerobic remodeling of skeletal muscle. To test whether glucose lowering therapy can restore the response to exercise, aerobic training studies were performed on hyperglycemic mice treated with or without the SGLT2 inhibitor, Canagliflozin (CANA) for 16-wks. Hyperglycemia was induced using two injections of streptozotocin (STZ; 40 mg/kg). A cohort of STZ-treated mice were administered CANA in their food (30 mg/kg/day), which normalized blood glucose to the level of untreated normoglycemic controls. The adaptive response to aerobic exercise training was blunted in STZ compared to control, but was restored by CANA treatment. Following training, CANA had improved aerobic exercise capacity (VO2peak), higher capillary density in cardiac and skeletal muscle, and a more oxidative fiber-type in skeletal muscle, compared to STZ. Recent work implicates glucose-induced accumulation of the skeletal muscle extracellular matrix (ECM), leading to hyper-activation of JNK/SMAD2 mechanical signaling after acute exercise as potential mechanisms underlying low exercise response. Consistent with this, STZ had significant accumulation of muscle ECM compared to control which was prevented by treatment with CANA, as assessed by histological staining. In addition, hyper-activation of JNK/SMAD2 mechanical signaling after a bout of acute exercise was 2-fold higher in STZ compared to control, but was normalized by CANA. These data demonstrate that hyperglycemia-associated impairments in exercise adaptation can be ameliorated by Canagliflozin treatment. Moreover, we identify skeletal muscle ECM accumulation and JNK/SMAD2 hyper-activation as potential mechanisms for impaired aerobic adaptation with hyperglycemia.

Disclosure
T. Macdonald: None. P. Pattamaprapanont: None. S. J. Lessard: None.

Funding
National Institutes of Health (R01DK124258)
508-P: Correlations between Burden and Quality of Life for Caregivers of Children Living with Type 1 Diabetes
Authors: JEWELL VANESSA D. , LEE GILLIANE , HARMON KASEY , GALLEGOS ERICA 
Published: June 2021

Providing continuous care to a child living with type 1 diabetes impacts not only the child’s well-being, but also a caregiver’s quality of life and overall feelings of burden from this omnipresent disease. The hypervigilance required for diabetes management can cause declines in a caregiver’s physical, emotional, and social health. Therefore, it is imperative that practitioners understand the impact of diabetes management on caregivers to develop and implement appropriate family-centered interventions. The purpose of this descriptive, cross-sectional survey was to examine the relationships between caregiver burden and quality of life of caregivers of children living with type 1 diabetes. Caregivers (n=212) who had provided care to a child with type 1 diabetes for a minimum of six months completed an electronic survey that included demographic information, the Zarit Burden Interview Scale, and the WHOQoL-BREF. Most of the respondents were female (98%), aged 36-45 years (56%), married (82%), and had completed at least some college (82%). Caregiver burden was reported by all respondents, with the majority reporting moderate to severe burden (68%). One-way ANOVA analysis indicated a significant weak, negative correlation between caregiver burden and quality of life domains, including physical health (r = 0.360, p&lt;0.001), psychological health (r = 0.460, p&lt;0.001), social relationships (r = 0.394, p&lt;0.001), and environment (r = 0.462, p&lt;0.001). It is not surprising that respondents who reported increased caregiver burden also reported lower quality of life, indicating that managing a chronic condition may lead to increased stress and declined overall health and well-being. As it is known that improved quality of life is related to improved blood glucose control and overall health, interprofessional endocrinology healthcare teams are encouraged to provide family-centered approaches to care to address both the child and caregiver concerns related to diabetes management.

Disclosure
V. D. Jewell: Research Support; Self; Dexcom, Inc. G. Lee: None. K. Harmon: None. E. Gallegos: None.
522-P: Perception Regarding Marriage in Unmarried Diabetics in Central India
Authors: SABOO BHARAT , SHRIVASTAVA ABHISHEK , SABOO BANSHI D. 
Published: June 2021

Background: Marriage is an integral part of Indian society. In spite of the large number of people with diabetes mellitus (DM) in India, India is not a diabetes-friendly society. This survey highlights perceptions of diabetes patient population with regards to marriage, associated diabetes distress, and suggests potential solutions. If Diabetic patients consider them unfit to marry and think that people don’t accept diabetics as a bride or groom and they can’t have a family, it’s a serious issue. There is no survey till date on this topic with surveyed population.
Methods: 68 randomly selected unmarried diabetes patient, males and females, from rural and urban areas of central India were asked to fill a survey questionnaire online. The inclusion criteria were age 18-35, having T1DM or T2DM and no history of mental disorder.
Results: Responses were analyzed and plotted. Most of the respondents (85 %) were not willing to accept a diabetic groom or bride, the acceptability was more in males, in urban dwellers, with higher academic qualification, and parents without diabetes. Most were worried about the complication of the disease. Majority of responders (76 %) think diabetes affect future progeny. (87 %) think they will become burden for their life partner, (T1DM &gt; T2DM).
Conclusion: Misconception regarding social, occupational, marital abilities, fertility, genetics, quality of life in young people living with DM raises major barriers to marriage, People with DM are wrongly assumed to be sick, disabled, dependent persons, unsuitable for marriages, and likely to have complicated pregnancies with the possibility of having children with diabetes. Diabetes distress and psychological issues are major problems related to marriage in young people with DM. Counseling of patients, family, relatives, prospective spouse, and increasing social awareness regarding diabetes through mass communication will serve as the keys to their resolution.

Disclosure
B. Saboo: None. A. Shrivastava: None. B. D. Saboo: None.
524-P: Diabetes Device Use Linked with Lower Family Conflict in Teens with Type 1 Diabetes
Authors: MOORE HAILEY R. , JASER SARAH S. , STREISAND RANDI , INVERSO HAILEY , MORROW TROY 
Published: June 2021

Introduction: Use of hybrid closed-loop insulin delivery systems have been associated with better glycemic control and lower hemoglobin A1c (HbA1c) values, and better glycemic control is linked with less diabetes-specific family conflict among adolescents with type 1 diabetes (T1D). Little is known, however, about how the use of closed-loop systems relates to diabetes family conflict.
Methods: Participants included 60 teens ages 13-17 who had been diagnosed with T1D for ≥1 year and who reported at least moderate diabetes distress (M age= 16.15±1.4, 68% white, non-Hispanic 68% female), and their parents (78% white, non-Hispanic, 78% Married, 83% female). As part of baseline data collection of an ongoing two-site trial of a behavioral intervention, parents and teens each reported on diabetes device use and diabetes-related family conflict. HbA1c values were obtained from teens’ medical records or mail-in kits. Nonparametric (Mann-Whitney) tests were conducted to examine differences between parent and teen-reported diabetes family conflict and HbA1c in relation to use of closed-loops systems.
Results: Of the participants, 12 teens (20%) were using a closed-loop system. The use of closed-loop systems was associated with lower levels of parent-reported diabetes-related family conflict (z= -2.372, p=0.018). Use of closed-loop systems was also associated with lower HbA1c values (z= -2.865, p=.004). However, teens’ own report of family conflict was not significantly related to use of the closed-loop systems (z= -1.331, .183).
Conclusion: Results suggest that the use of closed-loop systems is associated with both lower HbA1c and lower parent perceptions of diabetes-related family conflict. While future studies are needed to replicate these findings in larger samples and over time, our findings further support that closed-loop systems may reduce the burden of diabetes - particularly for parents - and improve both psychosocial and glycemic outcomes in families of youth with T1D.

Disclosure
H. R. Moore: None. S. S. Jaser: None. R. Streisand: None. H. Inverso: None. T. Morrow: None.

Funding
National Institute of Diabetes and Digestive and Kidney Diseases (R01DK121316)