bluuebunny/crossref_metadata_2025_split huggingface dataset:
848-P: Understanding Diabetes-Related Stigma in African-American Churches: The Blame and Shame Game
Authors: PIATT GRETCHEN 
Published: June 2019

Stigma impacts the way that communities, families, and partners interact with people living with diabetes, and undermines efforts to curtail the disease. We explored stigma and its associated attributes in 21 African American churches in 4 metropolitan areas. All churches are actively taking part in a 33-month, cluster randomized controlled trial focused on self-management support efforts to improve diabetes outcomes. Baseline data for participants (n=309) [(mean age: 65.3±11.1 years, 100% African American, 25.6% male, 50.8% obese (BMI&gt;=30 kg/m2), mean diabetes distress scale score: 2.0±0.98] were examined to determine levels of stigma using the Type 2 Diabetes Stigma Assessment Scale (DSAS-2). DSAS-2 is a validated, 19-item scale with 3 subscales (Treated Differently, Blame and Judgement, and Self-Stigma). Average overall stigma scores were not significantly different by gender; however, there was a strong correlation between younger age and overall stigma (r=-0.19, p=0.001), feelings of being treated differently (r=-0.1, p=0.09), blame and judgement (r=-0.18, p=0.001), and self-stigma (r=-0.21, p&lt;0.0001). The same pattern was apparent for participants who were obese. Obese participants were significantly more likely to feel overall stigmatization (p=0.03), blame and judgement (p=0.003) and self-stigma about their diabetes (p=0.04) compared to non-obese participants. After controlling for age, gender, obesity, and diabetes distress, younger male participants who experienced more diabetes distress were 1.4x more likely to feel stigmatized about their diabetes compared to their counterparts. The addition of distress to the models attenuated the association between stigma and obesity, suggesting that participants with higher distress levels often feel stigmatized about their diabetes. Future efforts aimed at ways to decrease distress levels, particularly in younger African American men, who oftentimes do not understand “why this happened to them" are paramount.

Disclosure
G. Piatt: None.

Funding
National Institutes of Health
852-P: Reduction in Emotional Burden in Type 2 Diabetes Is Associated with Improved Medication Adherence: Results from COMRADE
Authors: CUMMINGS DOYLE M. , BROWN MACKENZIE , LUTES LESLEY , HAMBIDGE BERTHA , CARRAWAY MARISSA A. , PATIL SHIVAJIRAO P. , ADAMS ALYSSA , LITTLEWOOD KERRY , EDWARDS SHEILA B. , GATLIN PEGGY 
Published: June 2019

The presence of distress symptoms in patients with uncontrolled type 2 diabetes (T2D) negatively influences diabetes management behaviors (DMB) and increases the risk of co-morbid complications. Cognitive behavioral interventions (CBI) are successful at reducing these symptoms, but the role of reducing Emotional Burden (EB) on diabetes behaviors is poorly understood. A prospective randomized trial involving 139 patients (mean age = 52.6 +/- 9.5 years; 27% black; 78% female; BMI = 37.0 +/- 9.0) with uncontrolled T2D (mean A1c = 9.6 +/-2) compared the effectiveness of a 16-week severity-tailored CBI plus lifestyle coaching (n=67; IG=intervention group) to usual care (n=72; CG=control group) on reducing EB and its impact on DMB such as self-care behaviors and medication adherence. Trained staff at a rural primary care clinic measured EB (subscore of Diabetes Distress Scale-17), self-care behaviors (Summary of Diabetes Self-Care Activities, SDSCA), and medication adherence (ModMAS) at baseline and 12-months follow-up using validated instruments. There were no differences between groups at baseline in mean age, race, or gender. The average reduction in EB, average improvement in ModMAS, and average improvement in self-care (SDSCA) were all significantly greater in the IG (-1.00 +/- 1.17; +1.0 ± 2.0; +1.1 ± 1.3) than in the CG (-.06 +/- 1.38; + 0.17 ± 1.9; +0.58 ± 1.4) (p=0.0001; p = 0.02; p = 0.027, respectively). Mean improvement in ModMAS was significantly and progressively related to improvements in EB in the IG (worse/same EB = -0.25 ±0.96; moderately improved EB = +0.79 ± 1.9; markedly improved EB = +1.6 ± 2.2; p = 0.045). A linear regression model showed that EB remained significantly associated with ModMAS even when controlling for age, race, and treatment group (β = -0.55; 95% CI: -0.8 to -0.3; p = 0.0001). A severity-tailored CBI plus lifestyle coaching significantly improves EB in T2D patients which is associated with significantly improved medication adherence.

Disclosure
D.M. Cummings: None. M. Brown: None. L. Lutes: None. B. Hambidge: None. M.A. Carraway: None. S.P. Patil: Research Support; Self; Novo Nordisk Inc. A. Adams: None. K. Littlewood: None. S.B. Edwards: None. P. Gatlin: None.

Funding
Bristol-Myers Squibb Foundation
869-P: A Path Model of Quality of Life in Insulin-Treated Patients: A Nine-Month Prospective Study
Authors: WANG RUEY H. , LEE TAO-CHUN , HSU HUI-CHUN , CHEN SIH-YU 
Published: June 2019

Background: Insulin therapy is recognized as a key component of effective diabetes management over the course of the diabetes. Nevertheless, insulin-treated patients report worse quality of life (QoL) than patients who receive oral drug therapy. Understanding the path model of QoL might help improve QoL in insulin-treated patients.
Purpose: To test a path model of QoL based on baseline diabetes distress and self-efficacy for insulin injection as well as 9-month resilience and decisional balance of insulin injection (DBIJ) (relative weight on the difference between perceived benefit and barriers for insulin injection) in insulin-treated patients.
Methods: A 9-month prospective design was employed. Questionnaires were used to collect data from 185 insulin-treated patients. At baseline, diabetes distress and self-efficacy for insulin injection were collected. QoL, resilience, and DBIJ were further collected 9 months later. Structural equation modeling was used to test a hypothesized model.
Results: Structural equation modeling supported the finding that baseline diabetes distress directly affected 9-month resilience (β=-0.31, p&lt;0.001) and 9-month QoL (β=-0.51, p&lt;0.001). Baseline self-efficacy for insulin injection directly affected 9-month DBIJ (β=0.29, p&lt;0.01). The 9-month DBIJ directly affected 9-month QoL (β=0.29, p&lt;0.01). Baseline diabetes distress indirectly affected 9-month QoL through 9-month resilience and 9-month DBIJ (βindirect=-0.29, p&lt;0.01). The 9-month resilience directly affected 9-month DBIJ (β=0.67, p&lt;0.001) and indirectly affected 9-month QoL through 9-month DBIJ (βindirect=-0.19, p&lt;0.01).
Conclusions: Diabetes distress plays a crucial role in affecting QoL 9 months later. Healthcare providers should regularly assess diabetes distress and provide more timely intervention to improve QoL. Improving resilience and self-efficacy for insulin injection could be promising strategies to enhance DBIJ, and finally, improve QoL of insulin-treated patients.

Disclosure
R.H. Wang: None. T. Lee: None. H. Hsu: None. S. Chen: None.

Funding
Ministry of Science and Technology of the People´s Republic of China (2013ZX09401301)
87-LB: Reduced Risk of Metabolic Syndrome and T2DM after One Year in an Automated No-Coaches Online Behavior Change Program
Authors: BLOCK GLADYS , BLOCK TORIN , BLOCK CLIFFORD H. 
Published: June 2019

Adults (n=339) at risk of diabetes, 68.1% with Metabolic Syndrome (MetSyn), were randomized to immediate intervention or to 6-month delayed control. Other than quarterly clinic visits for blood and weight measurement, there was no contact with study staff. The intervention, Alive-PD, was algorithm-driven, low-cost, and had no human coaching. Published 6-month results showed significant (p&lt;0.001) treatment vs. control effects on HbA1c, glucose (FG), and weight.
Baseline means (SD) were: age 55 (8.9)y, BMI 31.2 (4.4), FG 109.9 (8.4) mg/dL, HbA1c 5.6 (0.3)%. Most were male (68.7%), college-educated (82%), and white (68%).
We calculated change from baseline to 12 months, and MetSyn severity Z-score (MetSynZ), a continuous variable associated with long-term risk for CVD, T2DM and MetSyn. We present data for those who provided 12-month biometric data (n=240), and also an intention-to-treat analysis for all 339 using Last Observation Carried Forward (LOCF).
In the 240 with 12-month data, pre-post improvements at 1 year were significant at p&lt;0.001 for HbA1c, weight, waist, HDL, TG/HDL ratio and MetSynZ. The pre-post effect sizes ((12-month - baseline)/SD) were -0.50 for waist (half a SD), -0.43 for HbA1c and -0.36 for MetSynZ. These represent medium to low-medium effects. Changes, effect sizes and significance were similar in the LOCF n=339 analysis. Effect sizes of other analytes were significant but small. Only change in FG failed to maintain significance at 1 year.
Prevalence of metabolic syndrome was 68% at baseline, similar to that of the DPP sample (70%). It fell to 42% at 1 year, similar to that of DPP (45%). The MetSyn severity Z-score declined from 0.60 to 0.32, p&lt;0.001. Insulin resistance by TG/HDL fell from 41% to 27% at 12 months.
These data indicate that at least for well-educated participants receiving quarterly clinic visits, this automated online coach-free program can help users achieve and maintain significant and non-trivial one-year reductions in risk of MetSyn and T2DM at relatively low cost.

Disclosure
G. Block: Other Relationship; Self; Turnaround Health (NutritionQuest). T. Block: Other Relationship; Self; Turnaround Health. C.H. Block: None.

Funding
National Institutes of Health
878-P: Beyond Tracking: The Benefits of Contextual Annotation in a Diabetes Digital Therapeutic
Authors: DUGAS MICHELLE , CROWLEY KENYON , WANG WEIGUANG , IYER ANAND K. , PEEPLES MALINDA M. , SHOMALI MANSUR , GAO GUODONG 
Published: June 2019

Objective: Digital therapeutics manage chronic diseases by leveraging structured data like blood glucose/pressure, diet, etc. Addition of free-text notes associated with this data may help patients/providers make sense of trends by tracking unique concerns, providing the benefits of deeper cognitive processing. We explored the impact of contextual annotation in a digital therapeutic on A1C.
Method and Results: Free-text note usage from 3,142 users of BlueStar® digital therapeutic was summarized using NLP techniques. 941 users (29.9%) recorded 31,443 notes. A lexicon of note content was generated from the most common words (Table 1). We tested if note usage was associated with A1C reduction in a subgroup (N = 378) with two lab A1C values. A repeated measures ANCOVA, controlling for demographics and usage, showed the highest note takers exhibiting significantly larger declines in A1C (-2.13%) compared with those who took no notes (-0.86%) or very few notes (-0.79%), F(3,357) = 3.55, p =.02.
Conclusions: A substantial subgroup used free-text notes in BlueStar reflecting a diverse range of self-management themes from nondiabetes physical/mental health issues to core diabetes concerns like BG, medication, diet, and activity. Contextual annotation was associated with greater A1C improvement, suggesting that note-taking may offer unique benefit to digital therapeutic users; future studies should address causality.

Disclosure
M. Dugas: None. K. Crowley: None. W. Wang: None. A.K. Iyer: Employee; Self; WellDoc, Inc. M.M. Peeples: Employee; Self; WellDoc, Inc. M. Shomali: Consultant; Self; WellDoc, Inc. G. Gao: None.
883-P: Diabetes Distress: Provider Perspectives
Authors: JOHN ANN-MARIE 
Published: June 2019

Purpose: Though many studies focus on patient perspectives of diabetes distress (DD), provider perceptions of DD require further investigation. Defined as diabetes-specific distress related to the emotional and behavioral burden of living with type 2 diabetes (T2DM), DD is a major psychological challenge to diabetes (DM) self-management. The purpose of this qualitative study was to explore how interdisciplinary interprofessional primary care team members identify factors that contribute to a DD future intervention.
Methods: A total of 18 providers from three rural nurse-managed clinics located in Northern Virginia participated in the study. Using purposive sampling, providers were interviewed for their perspectives on DD. 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 theory 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 populations. When asked about DD, most participants discussed biomedical aspects of DM 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.
897-P: Continuous Glucose Monitoring (CGM) in Management of Patients with Severe Traumatic Brain Injury
Authors: DASKALOVA IVONA , TOTOMIROVA TZVETELINA , PETROV NIKOLAY , ARNAUDOVA MILA 
Published: June 2019

Hyperglycemia after severe traumatic brain injury patients is frequent finding that has impact on clinical outcome and increases mortality. Management of increased blood glucose but also prevention of hypoglycemic episodes are crucial in those patients. The aim of our observation is to analyze the effect of CGM in management of diabetic patients with severe traumatic brain injury (TBI) Our study included 37 patients (20 men, 17 women, mean age 34.6±9.7 years) hospitalized in Intensive Care Unit. All patients have diabetes with duration 7.3±5.8 years, with severe TBI and Glasgow coma scale of 8 or less. For monitoring of glucose level patients real-time CGM - Paradigm Medtronic Minimed was placed for 5 days period. Simultaneous glucose measurements were performed four times daily. Patients received continuous venous infusion of fast acting insulin for maintaining glucose level below 10mmol/l. Number of CGM measurements was significantly higher compared to conventional monitoring of blood glucose (288 measurements vs. 4 measurements daily, p&lt;0.05). None of the patients showed any problems with CGM-device like technical problems and irritation or allergy at the site of sensor insertion. More than one hypoglycemic episodes (blood glucose below 3.9mmol/) were detected in 37.8% (n=14) based on CGM data and only in 18.9% (n=7) from four-point profiles. CGM defined that patients spent about 54.9±12.2% of observed period in hyperglycemic state (blood glucose above 10mmol/l) while with conventional monitoring this time was 28.7±9.8% (p&lt;0.05). Data from CGM allow more precise adjustment of insulin infusion for maintaining glucose in targets and preventing complications of insulin treatment. Results from real-time CGM has impact on the glycemic control in diabetic patients with severe TBI and should be recommended in protocols for management and used whenever it is possible.

Disclosure
I. Daskalova: None. T. Totomirova: None. N. Petrov: None. M. Arnaudova: None.
9-LB: Hypoglycemia in Patients with Diabetes: Therapeutic Strategies and Associated Risk Factors
Authors: MARKLEY WEBSTER SARA C. , KURGANSKY KATHERINE E. , PHILLIPS LAWRENCE S. , GAGNON DAVID R. , WILSON PETER W. , RHEE MARY K. 
Published: June 2019

Use of insulin or sulfonylureas (SU) carries a risk of hypoglycemia, but the risk with different diabetes therapies, such as premixed insulin, is not well known. We conducted a case-control analysis of 297,263 patients with DIAB and 487,226 NONDIAB in the national VA database who had ≥4 primary care visits, ≥1 A1c, and ≥3 outpatient random plasma glucoses (RPG) in 2002-2003, and examined hypoglycemia by diabetic medication use and other risk factors, through 2012. Hypoglycemia was defined as severe (Emergency Department visit with hypoglycemia [EDHypo]) and by outpatient lab (RPGHypo = RPG &lt;70 mg/dl); both were associated with increased mortality (2.1- and 1.5-fold, respectively, p&lt;0.001). At baseline, DIAB had mean age 66 year, BMI 31 kg/m2, and A1c 7.5%; and were 98% male, 80% white, and 18% with retinopathy; NONDIAB were similar but had lower BMI. Among DIAB, 49% were on SU, 29% insulin (5% basal, 5% basal+SU, 1% bolus, 8% basal+bolus, 10% premixed), 11% otherRx (non-insulin/non-SU), 11% no meds. RPGHypo and EDHypo occurred in 6.8% and 0.3% of DIAB, respectively, vs. 2.1% and &lt;0.1% of NONDIAB, p&lt;0.001. During mean follow-up 7.5 year, 35% of DIAB (n=102,063; 229,612 events) had ≥1 RPGHypo, an incidence rate of 0.10 events/pt-year, and 4% had EDHypo. In adjusted models compared to otherRx, the risk of any hypo and EDHypo, respectively, was highest with basal+bolus (OR 1.4 and 17.8) and premixed insulin (OR 1.4 and 13.8), and lower with basal Insulin (OR 1.4 and 10.5), and SU (OR 1.2 and 5.1), all p&lt;0.001. Black race and retinopathy also conferred higher risk of both any hypoglycemia and EDHypo (black race, OR 1.9 and 2.1; retinopathy OR 1.3 and 1.6, respectively; all p&lt;0.001), much higher than the risk with A1c &lt;6.0% (OR 1.0 and 1.3).
Conclusions: Clinically significant hypoglycemia, including both outpatient RPG &lt;70 mg/dl and ED visits, is common in DIAB patients, particularly in those using basal+bolus or premixed insulin, and with black race or retinopathy, and should prompt consideration of altered management.

Disclosure
S.C. Markley Webster: Stock/Shareholder; Self; Dexcom, Inc. K.E. Kurgansky: None. L.S. Phillips: Advisory Panel; Self; Janssen Pharmaceuticals, Inc. Research Support; Self; AbbVie Inc., GlaxoSmithKline plc., Kowa Pharmaceutical Europe Co. Ltd., Novartis Pharmaceuticals Corporation, Novo Nordisk Inc., Pfizer Inc. Stock/Shareholder; Self; Diasyst Inc. Other Relationship; Self; Diasyst Inc., Janssen Pharmaceuticals, Inc. D.R. Gagnon: None. P.W. Wilson: None. M.K. Rhee: None.

Funding
Million Veteran Program
936-P: Annual Cost to Achieve Cost Effectiveness of Continuous Glucose Monitoring in Hypoglycemia-Unaware Type 1 Diabetes Patients Using Intensive Insulin in the United Kingdom
Authors: PINAR BILIR S. , CAMPBELL CARESSE , HELLMUND RICHARD , MUNAKATA JULIE 
Published: June 2019

Background: Type 1 diabetes (T1D) patients with impaired awareness of hypoglycemia (IAH) face higher risk of severe hypoglycemic events. Continuous glucose monitoring (CGM) has been found to prevent severe hypoglycemic events in this population (van Beers 2016) compared to self-monitoring of blood glucose (SMBG). This study aimed to evaluate the annual cost of a hypothetical CGM intervention that would be cost-effective vs. SMBG in the United Kingdom (UK) according to a willingness-to-pay threshold of £30,000/QALY.
Methods: The IQVIA Core Diabetes Model was used to run analyses over multiple time horizons (50-, 5-, and 1-year to test impact of assuming continued intervention effects over time) with an IAH population reflecting the IN CONTROL study (van Beers 2016). This study evaluated impact of CGM on hypoglycemia in an IAH population. CGM intervention effects included: odds ratio 0.45 for severe hypoglycemic events (requiring third party intervention); 0.03 utility benefit associated with reduced finger prick requirements of CGM (Matza 2016). HbA1c was assumed equivalent between CGM and SMBG. All other inputs reflected published literature and/or public tariffs, with costs in 2018 GBP. Threshold analyses were performed to identify the annual cost of intervention associated with incremental cost-effectiveness ratio (ICER) threshold £30,000/QALY over each time horizon. Sensitivity analyses were also performed on key input variables.
Results: Over 50 years, up to £1,354 could be spent annually on CGM to achieve a £30,000/QALY ICER threshold. With shorter time horizons, the annual intervention cost to achieve cost-effectiveness was slightly lower, ranging from £1,344 over 5 years to £1,301 for a 1-year horizon.
Conclusions: Based on recent evidence that CGM reduces severe hypoglycemia in IAH T1D patients, CGM can be considered cost-effective in the UK at costs per year of up to approximately £1,350.

Disclosure
S. Bilir: Employee; Self; IQVIA. C. Campbell: Consultant; Self; Abbott. R. Hellmund: Employee; Self; Abbott Laboratories. Stock/Shareholder; Self; Abbott Laboratories. J. Munakata: Employee; Self; IQVIA.
95-OR: Interleukin-17 Receptor C Is a Regulator of Autoimmune Diabetes in Humans
Authors: CHAMBERLAIN CHESTER , WANG JUEHU , GITELMAN STEPHEN E. , GERMAN MICHAEL , ANDERSON MARK S. 
Published: June 2019

Rare cases of monogenic type 1 diabetes (T1D) represent defects in critical pathways of immune tolerance and autoimmune disease. We therefore identified and recruited patients with likely monogenic causes of T1D and performed next-generation sequencing to discover new candidate genes and mechanisms of disease. We discovered a large kindred with an autosomal dominant inheritance pattern of T1D, with all affected members positive for autoantibodies and the index patient also having inflammatory bowel disease. Whole exome sequencing analysis of six family members across three generations revealed a novel mutation in the interleukin-17 receptor C gene (IL17RC) that cosegregated with T1D and was predicted to be both damaging and rare. No other mutations were identified. IL17RC is broadly expressed and encodes a single-pass transmembrane receptor that mediates the inflammatory activities of Th17 cells. We found that cells expressing the mutant IL17RC did not ectopically activate IL-17 signaling but instead had a hyperactive response to the Th17 cytokine IL17A and other inflammatory signals. Our data identifies inflammatory signaling via IL17RC as an important and novel regulator of autoimmune diabetes in humans.

Disclosure
C. Chamberlain: None. J. Wang: None. S.E. Gitelman: Advisory Panel; Self; Avortes, Intermountain Therapeutics, Lilly Diabetes, Tolerion, Inc. Research Support; Self; Caladrius Biosciences, Inc., Janssen Research & Development. Other Relationship; Self; Novo Nordisk Inc. M. German: Advisory Panel; Self; Encellin. Stock/Shareholder; Self; Encellin, Viacyte, Inc. M.S. Anderson: None.

Funding
The Leona M. and Harry B. Helmsley Charitable Trust; Larry L. Hillblom Foundation; Nora Eccles Treadwell Foundation; National Institutes of Health