Recommendations For Management Of Diabetes Research Articles

Integrated image-based deep learning and language models for primary diabetes care

Primary diabetes care and diabetic retinopathy (DR) screening persist as major public health challenges due to a shortage of trained primary care physicians (PCPs), particularly in low-resource settings. Here, to bridge the gaps, we developed an integrated image–language system (DeepDR-LLM), combining a large language model (LLM module) and image-based deep learning (DeepDR-Transformer), to provide individualized diabetes management recommendations to PCPs. In a retrospective evaluation, the LLM module demonstrated comparable performance to PCPs and endocrinology residents when tested in English and outperformed PCPs and had comparable performance to endocrinology residents in Chinese. For identifying referable DR, the average PCP’s accuracy was 81.0% unassisted and 92.3% assisted by DeepDR-Transformer. Furthermore, we performed a single-center real-world prospective study, deploying DeepDR-LLM. We compared diabetes management adherence of patients under the unassisted PCP arm (n = 397) with those under the PCP+DeepDR-LLM arm (n = 372). Patients with newly diagnosed diabetes in the PCP+DeepDR-LLM arm showed better self-management behaviors throughout follow-up (P < 0.05). For patients with referral DR, those in the PCP+DeepDR-LLM arm were more likely to adhere to DR referrals (P < 0.01). Additionally, DeepDR-LLM deployment improved the quality and empathy level of management recommendations. Given its multifaceted performance, DeepDR-LLM holds promise as a digital solution for enhancing primary diabetes care and DR screening.

Expert Opinion on Current Trends in the Use of Insulin in the Management of People with Type 2 Diabetes from the South-Eastern European Region and Israel.

Despite the availability of various antihyperglycaemic therapies and comprehensive guidelines, glycaemic control in diabetes management has not improved significantly during the last decade in the real-world clinical setting. Treatment inertia arising from a complex interplay among patient-, clinician- and healthcare-system-related factors is the prime reason for this suboptimal glycaemic control. Also, the key factor leading to inadequate glycaemic levels remains limited communication between healthcare professionals (HCPs) and people with type 2 diabetes (PwT2D). Early insulin administration has several advantages including reduced glucotoxicity, high efficacy and preserved β-cell mass/function, leading to lowering the risk of diabetes complications. The current publication is based on consensus of experts from the South-Eastern European region and Israel who reviewed the existing evidence and guidelines for the treatment of PwT2D. Herein, the experts emphasised the timely use of insulin, preferably second-generation basal insulin (BI) analogues and intensification using basal-plus therapy, as the most-potent glucose-lowering treatment choice in the real-world clinical setting. Despite an increase in the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), the experts urged timely insulin initiation for inadequate glycaemic control in PwT2D. Furthermore, the combination of BI and GLP-1 RA addressing both fasting plasma glucose and post-prandial excursions as a free- or fixed-ratio combination was identified to reduce treatment complexity and burden. To minimise discontinuation and improve adherence, the experts reiterated quality, regular interactions and discussions between HCPs and PwT2D/carers for their involvement in the diabetes management decision-making process. Clinicians and HCPs should consider the opinions of the experts in accordance with the most recent recommendations for diabetes management.

Multidisciplinary Panel Consensus for the Management of Patients with Type 2 Diabetes: A Delphi Study

To reach a multidisciplinary consensus on managing patients with type 2 diabetes among specialists in family medicine, cardiology, endocrinology, internal medicine, and nephrology. A two-round Delphi study was conducted using a questionnaire with 68 positive/negative statements distributed in four thematic blocks on diabetes management: early diagnosis and prediabetes, referral criteria, treatment and comorbidities, and clinical management. The expert panel was composed of 105 physicians from different specialties (family medicine, cardiology, endocrinology, internal medicine, and nephrology) with experience in managing patients with diabetes and who were members of a diabetes-related society. Response rates for the first and second rounds were 86.7 and 75.2%, respectively. After both rounds, a consensus was reached on 52 (76.5%) items. The recommendations with the highest degree of consensus (median=10, IQR=0.00) were related to anti-smoking education, cardiovascular risk factor target control, and diabetic kidney disease. There were significant differences between family physicians and other specialties for some items. This study provides a set of recommendations for diabetes management agreed upon by specialists from different healthcare settings.

Evidence-based European recommendations for the dietary management of diabetes.

Diabetes management relies on effective evidence-based advice that informs and empowers individuals to manage their health. Alongside other cornerstones of diabetes management, dietary advice has the potential to improve glycaemic levels, reduce risk of diabetes complications and improve health-related quality of life. We have updated the 2004 recommendations for the nutritional management of diabetes to provide health professionals with evidence-based guidelines to inform discussions with patients on diabetes management, including type 2 diabetes prevention and remission. To provide this update we commissioned new systematic reviews and meta-analyses on key topics, and drew on the broader evidence available. We have strengthened and expanded on the previous recommendations to include advice relating to dietary patterns, environmental sustainability, food processing, patient support and remission of type 2 diabetes. We have used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to determine the certainty of evidence for each recommendation based on findings from the commissioned and identified systematic reviews. Our findings indicate that a range of foods and dietary patterns are suitable for diabetes management, with key recommendations for people with diabetes being largely similar for those for the general population. Important messages are to consume minimally processed plant foods, such as whole grains, vegetables, whole fruit, legumes, nuts, seeds and non-hydrogenated non-tropical vegetable oils, while minimising the consumption of red and processed meats, sodium, sugar-sweetened beverages and refined grains. The updated recommendations reflect the current evidence base and, if adhered to, will improve patient outcomes.

PSUN325 Provider Time Required for Effective Remote Glucose Monitoring Among Patients with Type 1 Diabetes

Abstract Background Recent advances in digital health technology have accelerated interest in remote patient monitoring (RPM) for chronic disease management. Diabetes management – which has a long history of utilizing patient-generated health data (PGHD) – is well-suited to RPM innovation. However, building RPM programs requires designing new workflows for providers, who are accustomed to accessing PGHD only at scheduled visits. We conducted a pilot study of RPM in a pediatric population with type 1 diabetes (T1D) to estimate the frequency and duration of contact between patients and providers that would be needed in such a program. Methods Patients who met these criteria were approached for participation: 1) age 1-20 years, 2) diagnosis of T1D with a duration of ≥12 months, 3) use of a glooko-compatible continuous glucose monitoring (CGM) device for ≥3 months. After providing informed consent, participants’ CGM data were linked to a research team account on the glooko platform and followed for a one-month baseline period to ensure the data relay was consistently functioning, with technical assistance provided by research staff as needed. CGM data were then analyzed using the glooko population analytics platform once per month during a six-month intervention period. Participants meeting high-risk criteria, defined as &amp;gt;15% of glucose values &amp;gt;250 mg/dl or &amp;gt;5% of glucose values &amp;lt;70 mg/dl, in the prior 30 days were contacted by a pediatric endocrinologist with individualized recommendations for diabetes management. Time spent communicating recommendations to the participant by phone or electronic messaging was recorded by the provider on each date of contact. Results Of 39 participants who were enrolled and linked to the research team via glooko, 35 (90%) were successful in establishing consistent data-sharing during the baseline period and moved on to the intervention period. To date, 20 participants have completed at least 3 months of the intervention. In preliminary analyses, an average of 47% have met high-risk criteria monthly (range 40 to 55%). Contact from the pediatric endocrinologist has required a median of 10 minutes (range 5 to 25 minutes) per participant contacted each month. Of the 20 participants who have completed 3 months of intervention, 14 have repeat hemoglobin A1c (HbA1c) data available thus far, which demonstrate a median HbA1c change of -0.55% from baseline (range -1.5 to +0.5%). Complete data analysis will be available in April 2022. Discussion This pilot study indicates that RPM is feasible and potentially beneficial in a population of pediatric patients with T1D. Our data also provide preliminary estimates for provider time required to deliver effective remote assistance to patients with concerning glycemic profiles. This study and others of its type are essential so that endocrinologists can design RPM programs which efficiently provide individualized care to high-risk patients without over-burdening a limited supply of providers. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Perioperative management of diabetes in patients undergoing bariatric and metabolic surgery: a narrative review and the Cleveland Clinic practical recommendations.

Bariatric and metabolic surgery is an effective treatment for patients with severe obesity and obesity-related diseases. In patients with type 2 diabetes, it provides marked improvement in glycemic control and even remission of diabetes. In patients with type 1 diabetes, bariatric surgery may offer improvement in insulin sensitivity and other cardiometabolic risk factors, as well as amelioration of the mechanical complications of obesity. Because of these positive outcomes, there are increasing numbers of patients with diabetes who undergo bariatric surgical procedures each year. Prior to surgery, efforts should be made to optimize glycemic control. However, there is no need to delay or withhold bariatric surgery until a specific glycosylated hemoglobin target is reached. Instead, treatment should focus on avoidance of early postoperative hyperglycemia. In general, oral glucose-lowering medications and noninsulin injectables are not favored to control hyperglycemia in the inpatient setting. Hyperglycemia in the hospital is managed with insulin, aiming for perioperative blood glucose concentrations between 80 and 180 mg/dL. Following surgery, substantial changes of the antidiabetic medication regimens are common. Patients should have a clear understanding of the modifications made to their treatment and should be followed closely thereafter. In this review article, we describe practical recommendations for the perioperative management of diabetes in patients with type 2 or type 1 diabetes undergoing bariatric surgery. Specific recommendations are delineated based on the different treatments that are currently available for glycemic control, including oral glucose-lowering medications, noninsulin injectables, and a variety of insulin regimens.

Low diet quality is associated with adverse levels of metabolic health markers and clustering of risk factors in adults with type 2 diabetes.

Nutritional recommendations for diabetes management emphasise an overall, healthful diet consistent with the guidelines for the general population. The present study assessed the relationship of diet quality, as measured by Healthy Eating Index-2015 (HEI-2015), with metabolic health markers and risk factor clustering in type 2 diabetes patients using National Health and Nutrition Examination Survey 2011-2016 data. HEI-2015 diet quality scores were calculated using 24-h dietary recalls. Adults with type 2 diabetes (n = 2220) were assessed for: (1) hyperglycaemia; (2) overweight/obesity; (3) dyslipidaemia; and (4) hypertension. Logistic regression examined associations of diet quality quartiles with odds of hyperglycaemia, overweight/obesity, dyslipidaemia and hypertension, as well as odds of clustering of these risk factors. Odds of overweight/obesity and hyperglycaemia were significantly greater for participants in the lowest HEI-2015 quartile compared to those in the highest quartile. Furthermore, individuals in the bottom two HEI-2015 quartiles had increased odds of dyslipidaemia. Those in the lowest quartile also had significantly higher odds of having ≥ 2, ≥ 3 and 4 risk factors (vs. having ≤ 1 risk factor). Low diet quality was related to increased odds of hyperglycaemia, dyslipidaemia, overweight/obesity and risk factor clustering. Findings imply poorer prognosis of diabetes in individuals with low diet quality.

Peak performance: Putting type 1 diabetes management recommendations for athletes to the test

BackgroundAthletes with type 1 diabetes (T1D) face unique challenges to maintain optimal glucose levels and therefore require tailored guidance from their healthcare providers. Herein, we aim to summarize and compare recommendations targeted at T1D management in athletes in commonly used clinical practice guidelines and topical position statements. The objective is to assess if the available recommendations are comprehensive enough for athletes to apply to high-performance sport. MethodsFrom seven clinical practice guidelines and positions statements, we identified recommendations relevant to athletes with T1D, based on a specific hierarchy. For included recommendations, we extracted relevant information including the year of publication, author(s), chapter name or number, text for the recommendation, and level of evidence. Based, on the clinical topic covered, we grouped included recommendations to five themes. ResultsWe screened a total of 126 recommendations, of which 60 recommendations were included. The National Athletic Trainers’ Association provided the highest number of recommendations relevant to athletes with T1D (n = 27). Insulin modifications was the most covered clinical theme (n = 18). The 2018 Diabetes Canada and 2021 American Diabetic Association guidelines linked recommendations directly with levels and grades of evidence. None of the recommendations had level 1 or grade A evidence. Three recommendations from Diabetes Canada reported level 2, grade B evidence. American Diabetic Association reported 1 recommendation with grade B evidence, and 2 recommendations with grade C evidence. ConclusionsThere is an opportunity for expansion of clinical practice guidelines to increase the depth and breadth of recommendations for high performance athletes with T1D.

Using Social Media for More Engaged Users and Enhanced Health Communication in Diabetes Care

Background: Recent literature identified social media message features predictive of user engagement. Desired information from a patient perspective and use of social media information from a provider perspective in diabetes care is less clear. Purpose: Our study analyzed diabetes patients’ desired information from social media and how such information could be used in conjunction with doctor–patient communication to enhance compliance with recommended care. Methods: A survey examined diabetic patients’ interests in searching for various diabetes information on social media and assessed the potential impact of social media sourced information on doctor–patient communication. This survey was followed by a content analysis of major US diabetes organizations’ Facebook pages, which were considered for effectiveness in their communication with diabetes patients. Results: Survey participants were most interested in diabetes management recommendations. Diabetes knowledge positively correlated with interests in diabetes management recommendations but negatively correlated with prior use of social media for diabetes information. 70.9% of patients had discussed information from social media with their doctor. The content analysis showed narrative evidence and updates on diabetes-related research findings, and medical policies generated a higher level of user engagement. Conclusion: While survey participants showed greatest interests in health recommendations and tips, only 11.7% of the analyzed social media posts included such information. Posts that included diabetes-related information led to higher engagement than posts that emphasized social values. Patients in general have asked doctors about information received on social media which suggests that social media can be a useful platform for communicating diabetes care information.

Printed educational materials directed at Ontario family physicians do not improve adherence to guideline recommendations for diabetes management: a pragmatic, factorial, cluster randomized controlled trial [ISRCTN72772651

BackgroundPrinted educational materials (PEMs) have long been used to inform clinicians on evidence-based practices. However, the evidence for their effects on patient care and outcomes is unclear. In Ontario, despite widely available clinical practice guidelines recommending antihypertensives and cholesterol-lowering agents for patients with diabetes, prescriptions remain low. We aimed to determine whether PEMs can influence physicians to intensify prescribing of these medications.MethodsA pragmatic, 2 × 2 factorial, cluster randomized controlled trial was designed to ascertain the effect of two PEM formats on physician prescribing: a postcard-sized message (“outsert”) or a longer narrative article (“insert”). Ontario family physician practices (clusters) were randomly allocated to receive the insert, outsert, both or neither. Physicians were eligible if they were in active practice and their patients were included if they were over 65 years with a diabetes diagnosis; both were unaware of the trial. Administrative databases at ICES (formerly the Institute for Clinical Evaluative Sciences) were used to link patients to their physician and to analyse prescribing patterns at baseline and 1 year following PEM mailout. The primary outcome was intensification defined as the addition of a new antihypertensive or cholesterol-lowering agent, or dose increase of a current drug, measured at the patient level. Analyses were by intention-to-treat and accounted for the clustering of patients to physicians.ResultsWe randomly assigned 4231 practices (39% of Ontario family physicians) with a total population of 185,526 patients (20% of patients with diabetes in Ontario primary care) to receive the insert, outsert, both, and neither; among these, 4118 practices were analysed (n = 1025, n = 1037, n = 1031, n = 1025, respectively). No significant treatment effect was found for the outsert (odds ratio (OR) 1.01, 95% confidence interval (CI) 0.98 to 1.04) or the insert (OR 0.99, 95% CI 0.96 to 1.02). Percent of intensification in the four arms was similar (approximately 46%). Adjustment for physician characteristics (e.g., age, sex, practice location) had no impact on these findings.ConclusionsPEMs have no effect on physician’s adherence to recommendations for the management of diabetes-related complications in Ontario. Further research should investigate the effect of other strategies to narrow this evidence-to-practice gap.Trial registrationISRCTN72772651. Retrospectively registered 21 July 2005.

Assessing the physical healthcare gap among patients with severe mental illness: large real-world investigation from Italy

Background One critical barrier to the uptake of mental health programmes is the so-called physical healthcare gap, a concern raised by the unattended physical comorbidity and early mortality of persons with severe mental illness. Aims To evaluate the extension of physical healthcare gap among persons with severe mental illness under chronic drug therapies. Method A population-based cohort study was carried out, using Lombardy healthcare utilisation databases. Prevalent patients treated with blood pressure-, lipid- or glucose-lowering agents were identified in January 2017. Among these, those who were receiving care for depression, schizophrenia, bipolar disorder or personality disorder formed the study cohort. A reference cohort was randomly selected from prevalent patients treated with chronic therapies without signs of severe mental disorders, to be matched with study cohort members for gender, age and number of previous contacts with the National Health System. One-year adherence to healthcare was measured through the proportion of days covered (drug adherence), and exposure to selected recommendations (clinical control adherence). Results The 55 162 patients with severe mental illness were less likely to have high adherence to blood pressure-lowering, lipid-lowering or antidiabetic agents than the reference cohort by −24% (95% CI −26 to −22%), −10% (95% CI −14 to −6%) and −25% (95% CI −29 to −21%), respectively. The 9250 patients with diabetes and severe mental illness had −18% (95% CI −22% to −13%) reduced likelihood to meet recommendations for the clinical management of diabetes, compared with the reference cohort. Conclusions Adherence to chronic drug therapies was sensibly worse among patients living with mental illness than those without signs of mental disorders.

Diabetes and Frail Older Patients: Glycemic Control and Prescription Profile in Real Life.

(1) Background: The latest recommendations for diabetes management adapt the objectives of glycemic control to the frailty profile in older patients. The purpose of this study was to evaluate the proportion of older patients with diabetes whose treatment deviates from the recommendations. (2) Methods: This cross-sectional observational study was conducted in older adults with known diabetes who underwent an outpatient frailty assessment in 2016. Glycated hemoglobin (HbA1c) target is between 6% and 7% for nonfrail patients and between 7% and 8% for frail patients. Frailty was evaluated using the Fried criteria. Prescriptions of glucose-lowering drugs were analyzed based on explicit and implicit criteria. (3) Results: Of 110 people with diabetes with an average age of 81.7 years, 67.3% were frail. They had a mean HbA1c of 7.11%. Of these patients, 60.9% had at least one drug therapy problem in their diabetes management and 40.9% were potentially overtreated. The HbA1c distribution in relation to the targets varied depending on frailty status (p < 0.002), with overly strict control in frail patients (p < 0.001). (4) Conclusions: Glycemic control does not seem to be routinely adjusted to the health of frail patients. Several factors can lead to overtreatment of these patients.

Bangladesh Endocrine Society (BES) Position Statement for Management of Diabetes and Other Endocrine Diseases in Patients with COVID-19.

BackgroundThe year 2020 witnessed a largely unprecedented pandemic of coronavirus disease (COVID-19), caused by SARS COV-2. Many people with COVID-19 have comorbidities, including diabetes, hypertension and cardiovascular diseases, which are significantly associated with worse outcomes. Moreover, COVID-19 itself is allied with deteriorating hyperglycemia. Therefore, Bangladesh Endocrine Society has formulated some practical recommendations for management of diabetes and other endocrine diseases in patients with COVID-19 for use in both primary and specialist care settings.ObjectiveThe objective of the article is to develop a guideline to protect the vulnerable group with utmost preference – the elderly and those with comorbid conditions. Therefore, to ensure the adequate protective measures and timely treatment for COVID-19 patients with diabetes, other endocrine diseases or any other comorbidities.Considering and Monitoring IssuesThe risk of a fatal outcome from COVID-19 may be up to 50% higher in patients with diabetes than in non-diabetics.Patients with diabetes and COVID had CFR 7.3–9.2%, compared with 0.9–1.4% in patients without comorbidities.Diabetic ketoacidosis may be one of the causes of mortality in COVID-19.There is wide fluctuation of blood glucose in these patients, probably due to irregular diet, reduced exercise, increased glucocorticoids secretion, and use of glucocorticoids. HbA1c should be <7.0% for the majority of the patients, this target may be relaxed in appropriate clinical settings.More emphasis should be given on day-to-day blood glucose levels. Hypoglycemia (<3.9 mmol/l) must be avoided.Frequent monitoring of blood glucose is needed in critically ill patients.ConclusionThe fight against COVID-19 has been proven to be a challenging one. Therefore, all healthcare personnel should make the best use of updated knowledge and skills to ensure adequate protective measures and timely treatment for COVID-19 patients with diabetes, other endocrine diseases or any other comorbidities.

Effects of Recommendations for Diabetes Management at Hospital Discharge on Long-Term Diabetes Control

ObjectiveTo determine the impact of diabetes-specific recommendations at 1 year after hospital discharge on glycemic control and diabetes care in an outpatient setting. MethodsA total of 139 patients with type 2 diabetes on a basal-bolus insulin regimen during hospitalization were included in the statistical analysis. We gathered data on treatment regimens after 12 to 16, 26 to 30, and 52 to 56 weeks following discharge as well as glycosylated hemoglobin (HbA1c) levels for all patients. Prescriptions for diabetes therapy were retrieved. All changes in insulin or oral/noninsulin injectable drug regimens were recorded. ResultsHalf of the patients (n = 69) were discharged on their preadmission regimen (no change), and a change in the home treatment was recommended in the other half (n = 70). In the group of patients whose preadmission therapy was adjusted, HbA1c decreased from 9.6% (80 mmol/mol) to 8.5% (69 mmol/mol) (P = .0004) 1 year after discharge. In the group of patients discharged on their preadmission regimen, no significant changes in HbA1c levels during the study were observed.At follow-ups occurring 12 to 16 weeks after discharge, 52% (95% CI: 37.4%-66.3%) of patients in the change group had their treatment modified, compared with 18.6% (95% CI: 9.7%-30.9%) in the no-change group. In the group of patients discharged on their preadmission regimen, no significant change was observed. At the beginning of the study, patients in the change treatment group had higher HbA1c levels than patients in the no-change group (9.6 ± 2.0 vs 8.6 ± 1.7, P < .001). At the end of the study, no significant changes in terms of HbA1c levels were found between the groups (8.8 ± 1.9 vs 8.5 ± 1.9, P = .2). ConclusionsSignificant improvement in diabetes control occurred 1 year after hospital discharge in patients who underwent modifications in their treatment. This supports the relevance of providing and implementing proper care recommendations at transition.

Cultural Influences on Dietary Self-Management of Type 2 Diabetes in East Asian Americans: A Mixed-Methods Systematic Review.

Purpose: Many East Asian Americans (EAAs) (populations originating from China, Korea, Japan, and Taiwan) with type 2 diabetes mellitus (T2DM) experience unique challenges in managing their disease, including language barriers and traditional cultural beliefs, particularly among first-generation immigrants.. The purpose of this mixed-methods systematic review was to examine cultural perspectives of EAAs that influence dietary self-management of T2DM and identify education interventions and their approaches to enhance EAAs' dietary self-management of diabetes.Methods: A mixed-methods systematic review was conducted to examine EAAs' perspectives from qualitative studies and to identify education interventions and their approaches from quantitative studies. A literature search was conducted using PubMed/MEDLINE, SCOPUS, CINAHL, and Web of Science from 1995 to 2018. Sixteen studies (10 qualitative and 6 quantitative) met criteria for analysis. Thematic synthesis of qualitative data was conducted using a line-by-line coding strategy. Extracted quantitative data were assessed for cultural approaches used in the interventions and diabetes-related outcomes.Results: In the qualitative studies, beliefs about food impacted EAAs' abilities to adopt appropriate dietary recommendations for diabetes management. Requiring a specialized diet disrupted social harmony and made EAAs feel burdensome to others. Having bilingual and bicultural resources eased the stress of making dietary modifications. The most commonly incorporated approaches in diabetes education interventions were bilingual education and culturally specific dietary recommendations. Social roles and harmony were not discussed. Significant reductions in hemoglobin A1c and increases in diabetes knowledge were reported post-intervention.Conclusions: Beliefs about food, beliefs about social roles, and access to culturally competent care play an important role in dietary self-management of T2DM among EAAs. Understanding the cultural influences on dietary self-management of T2DM and tailoring interventions to meet the needs of EAAs are essential in effort to address the growing epidemic and improve patient outcomes.

Personalized diabetes management recommendations at hospital discharge based on a computerized, pre-hospitalization clinical profile analysis: A prospective, electronic health records-based study.

While glycemic control of hospitalized diabetic patients is straightforward, personalization of management at discharge is challenging. Treatment guidelines base recommendations on the clinical profile of patients. We checked the feasibility of implementing discharge recommendations, based on the clinical profile in the patients' electronic health records (EHR). A decision-making algorithm was devised according to current guidelines. It was incorporated into the EHR. A prospective follow-up of eligible diabetes patients was done. During 15 months, 835 patients (HbA1c was 6.9% [6.2%-7.8%]) met our inclusion criteria. The rate of HbA1c acquisition increased from 55% during Q1 to 85%, 86%, 88%, and 87% thereafter. Also, the rate of incorporating personalized management recommendations to discharge letters increased: from 14.9% during Q1 to 42.9%, 43.0%, 47.2%, and 53.4% thereafter. Fifty-eight (17.3%) of patients who got personalized recommendations upon discharge were found to have HbA1c values that were over 1% deviating from suggested target HbA1c. They got the most stringent recommendations. Twenty-nine (50%) of them had available follow-up HbA1c values showing a significant drop in HbA1c: from 9.1% (8.4%-10.2%) to 8.5% (7.4%-9.5%), P = .03. Personalized, EHR algorithm-based, management recommendations for diabetes upon discharge from hospitalization are feasible and beneficial.

A Diabetes Education Model in Primary Care: Provider and Staff Perspectives.

The purpose of this qualitative study was to explore the effectiveness of Glucose to Goal (G2G), a diabetes self-management education and support (DSMES) model for primary care (PC). PC providers and staff were recruited from 5 PC practices participating in the 18-month intervention to participate in focus groups and interviews, which were used to gain insights about their perspectives on DSMES and how G2G was implemented across the intervention. Data were collected by qualitative researchers at baseline, midpoint, and study completion. At baseline, PC participants held a favorable view of DSMES and welcomed having a diabetes educator (DE) in their practice. Most participants suggested DEs would be helpful in meeting patients' nutrition needs but should give therapeutic advice only with a doctor's oversight. Participants anticipated that having a DE onsite would mitigate transportation, scheduling, communication, and cost barriers. Participant viewpoints about G2G remained unchanged from midpoint to study end, while barriers regarding location and transportation were perceived as being reduced by having a DE in the practice. Despite referral rates remaining low in some practices, many concerns stated at earlier timepoints appeared to have been attenuated by G2G components (eg, bringing the DE onsite, preidentifying patients, and DE ability to communicate and make diabetes management recommendations). This study demonstrates that G2G, providing DSMES in PC, appeared to be a welcome service where acceptance of and enthusiasm for the model grew over the course of the intervention.

Patient Perspectives on Managing Type 1 Diabetes During High-Performance Exercise: What Resources Do They Want?

Objective.Athletes with type 1 diabetes face unique challenges that make it difficult for health care providers to offer concise recommendations for diabetes management. Moreover, little is known about patient preferences for diabetes management during high-level and competitive exercise. We undertook a qualitative study to understand patient perspectives on managing type 1 diabetes during exercise.Methods.A qualitative design using focus groups was selected. Samples of 5–10 participants per group were recruited to participate in one of three 1.5-hour sessions focusing on experiences in managing diabetes, supports, and desired resources. Sessions were audiotaped and transcribed verbatim. Data were analyzed iteratively among team members.Results.The study included 21 participants (10 male and 11 female) with a mean age of 41 years. Most participants used trial and error to manage their blood glucose around exercise. Frequent monitoring of blood glucose was a common strategy and a challenge during exercise. Hypoglycemia after exercise and adrenaline-fueled hyperglycemia during exercise were the most prevalent concerns. Most participants relied on themselves, an endocrinologist, or the Internet for support but said they would prefer to rely more on peers with type 1 diabetes and mobile apps. Peer support or mentorship was strongly supported with recommendations for moving forward.Conclusion.This study highlights the individualized nature of balancing glycemic control in athletes and athletes’ heavy self-reliance to develop strategies. Expanding the availability of resources such as peer mentoring and mobile apps could potentially support athletes with type 1 diabetes.

Recommendations for management of diabetes and its complications during Hajj (Muslim pilgrimage)

Hajj is one of the five pillars of Islam and is a must-do for all adult Muslims once in their life provided they are able to do it. Considering the...

Management of Diabetes During Air Travel: A Systematic Literature Review of Current Recommendations and their Supporting Evidence

Individuals with diabetes are increasingly seeking pretravel advice, but updated professional recommendations remain scant. We performed a systematic review on diabetes management during air travel to summarize current recommendations, assess supporting evidence, and identify areas of future research. A systematic review of the English literature on diabetes management during air travel was undertaken utilizing PubMed and MEDLINE. Publications regarding general travel advice; adjustment of insulin and noninsulin therapies; and the use of insulin pumps, glucometers and subcutaneous glucose sensors at altitude were included. Gathered information was used to create an updated summary of glucose-lowering medication adjustment during air travel. Sixty-one publications were identified, most providing expert opinion and few offering primary data (47 expert opinion, 2 observational studies, 2 case reports, 10 device studies). General travel advice was uniform, with increasing attention to preflight security. Indications for oral antihyperglycemic therapy adjustments varied. There were few recommendations on contemporary agents and on nonhypoglycemic adverse events. There was little consensus on insulin adjustment protocols, many antedating current insulin formulations. Most publications advocated adjusting insulin pump time settings after arrival; however, there was disagreement on timing and rate adjustments. Glucometers and subcutaneous glucose sensors were reported to be less accurate at altitude, but not to an extent that would preclude their clinical use. Recommendations for diabetes management during air travel vary significantly and are mostly based on expert opinion. Data from systematic investigation on glucose-lowering medication adjustment protocols may support the development of a future consensus statement. CSII = continuous subcutaneous insulin infusion (device) DPP-4 = dipeptidyl peptidase 4 EGA = error grid analysis GDH = glucose dehydrogenase GOX = glucose oxidase GLP1 = glucagon-like peptide-1 NPH = neutral protamine Hagedorn SGLT2 = sodium-glucose cotransporter-2.