Lower A1C Values Research Articles

Evaluation of a Pharmacist-Managed Diabetes Transitions of Care Medication Management Clinic.

The purpose of this study was to determine the impact of a pharmacist-managed transitions of care (TOC) clinic on outcomes in a posthospitalization population with diabetes. A retrospective single center cohort study utilized electronic health records to identify discharged patients followed by the inpatient endocrinology team. The primary outcome was 30-day readmission rates in the target population. Secondary outcomes include 90-day readmission rates, time to first follow-up, emergency department/urgent care encounters, change in A1C, retention with endocrinology, referrals for diabetes education, and types of interventions. The control group included patients prior to the initiation of the TOC clinic compared to patients seen in the TOC clinic, evenly matched by A1C. Readmission rates and other clinical data were queried up to 4 months after discharge. Patients in the TOC cohort had similar 30-day readmission rates compared to the non-TOC cohort and were found to have lower A1C values within 120 days of discharge. Overall, patients in the TOC cohort were more likely to have a follow-up appointment and had closer follow-up after discharge. This study highlights that although there was no difference in readmission rates, a pharmacist-managed diabetes TOC clinic may decrease time to follow-up and improve long-term diabetes outcomes.

Dried Blood Spot Test for Glycated Hemoglobin Measurement in Pediatric Diabetes Care

BackgroundThe dried blood spot (DBS) card is a novel collection method for measuring glycated hemoglobin (A1C) in individuals with diabetes mellitus. The potential benefits of DBS specimens compared with traditional phlebotomy include a reduction in required total blood volume, reduced procedural pain, and an ability for self-initiated collection. DBS cards for A1C measurement have been validated in the adult population, but there is a paucity of pediatric data. MethodsThe aim of this study was to validate the use of A1C measurement by DBS cards in comparison to venous A1C and to identify potential barriers to implementing this novel approach. Venous and DBS card A1C samples were collected simultaneously from 62 patients at their local laboratory and transported to the central provincial lab for analysis. Correlation analyses compared venous and DBS A1C with data rescaling performed to account for the DBS–venous interassay difference. ResultsMean venous A1C was 7.49% and DBS A1C was 7.26%, with an interassay difference of 0.23%. Data showed a strong, positive correlation between A1C collection methods (r=0.86, p<0.001); this was further strengthened at lower A1C values (A1C <7.5%, r=0.87, p<0.0001). A stronger relationship emerged when the data were rescaled to account for the DBS–venous interassay difference (r=0.8935, p<0.0001). ConclusionsGiven the potential feasibility, practicality, accessibility, cost-effectiveness, and performance characteristics of the DBS A1C, especially at lower A1C values hovering around the diagnostic threshold for diabetes, this study provides supporting evidence for consideration of the use of DBS A1C testing in pediatric diabetes care.

Telehealth Use, Care Continuity, and Quality: Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic.

Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship. We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth. This was a cohort study. Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020. Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020. MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (β=-2.90, P<0.001) and diastolic blood pressure (β=-1.44, P<0.001) in 2020, and lower A1c values (2019: β=-0.57, P=0.007; 2020: β=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing. Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.

The Official Journal of ATTD Advanced Technologies &amp; Treatments for Diabetes Conference 22‐25 February 2023 I Berlin &amp; Online

The Official Journal of ATTD Advanced Technologies &amp; Treatments for Diabetes Conference 22‐25 February 2023 I Berlin &amp; Online

Expected or unexpected clinical findings in liver glycogen storage disease type IX: distinct clinical and molecular variability.

To reveal the different clinical presentations of liver glycogen storage disease type IX (GSD IX), which is a clinically and genetically heterogeneous type of glycogenosis. The data from the electronic hospital records of 25 patients diagnosed with liver GSD IX was reviewed. Symptoms, clinical findings, and laboratory and molecular analysis were assessed. Of the patients, 10 had complaints of short stature in the initial presentation additionally other clinical findings. Elevated serum transaminases were found in 20 patients, and hepatomegaly was found in 22 patients. Interestingly, three patients were referred due to neurodevelopmental delay and hypotonia, while one was referred for only autism. One patient who presented with neurodevelopmental delay developed hepatomegaly and elevated transaminases during the disease later on. Three of the patients had low hemoglobin A1C and fructosamine values that were near the lowest reference range. Two patients had left ventricular hypertrophy. Three patients developed osteopenia during follow-up, and one patient had osteoporosis after puberty. The most common gene variant, PHKA2, was observed in 16 patients, 10 variants were novel and six variants were defined before. Six patients had variants in PHKG2, two variants were not defined before and four variants were defined before. PHKB variants were found in three patients. One patient had twonovel splice site mutations in trans position. It was revealed that one novel homozygous variant and one defined homozygous variant were found in PHKB. This study revealed that GSD IX may present with only hypotonia and neurodevelopmental delay without liver involvement in the early infantile period. It should be emphasized that although liver GSDIX is thought of as a benign disease, it might present with multisystemic involvement and patients should be screened with echocardiography, bone mineral densitometry, and psychometric evaluation.

Reduced erythrocyte lifespan measured by chromium-51 in patients with type 2 diabetes undergoing long-term hemodialysis.

A reduced erythrocyte lifespan potentially explains the low hemoglobin A1c values found in hemodialysis patients. However, data supporting this notion in patients with type 2 diabetes is unclear. We evaluated the erythrocyte lifespan in patients with type 2 diabetes undergoing long-term hemodialysis and investigated potential predictors of erythrocyte lifespan. Long-term hemodialysis patients with type 2 diabetes and type 2 diabetes patients without nephropathy (estimated glomerular filtration rate > 60 mL/min/1.73 m2 ) were included. The erythrocyte lifespan was measured using chromium-51 (51 Cr)-labeled erythrocytes. Blood radiotracer activity was measured six to nine times over a period of 3-5 weeks to determine the erythrocyte lifespan of each patient. Biochemical markers were obtained five times over 16 weeks and associated with the erythrocyte lifespan. Type 2 diabetes patients undergoing hemodialysis (N = 13) had a significantly shorter median erythrocyte lifespan of 49.7 (interquartile range [IQR] = 44.1-58.6) days compared with 64.2 (IQR = 62.6-83.5) days in the control group (N = 10) (P ˂ 0.001) with a difference between medians of 14.5 (95% confidence interval = 8.1-38.8) days. In the hemodialysis group, no association could be detected between the erythrocyte lifespan and markers of hemolysis, level of inflammation, or urea. A reduced erythrocyte lifespan was detected in type 2 diabetes patients undergoing long-term hemodialysis. This may contribute to the reduced hemoglobin A1c values observed in the type 2 diabetic hemodialysis population. An association could not be detected between the erythrocyte lifespan and biochemical markers of hemolysis or inflammation.

388-P: Real-World Associations between Glucose Management Indicator and CGM-Derived Metrics of Hypoglycemia

Early randomized controlled trials (RCTs) showed a strong inverse relationship between A1C and severe hypoglycemia (SH) risk, which could potentially limit therapy intensification and resulted in some guidelines suggesting increased A1C goals in at-risk patients. Subsequently, RCTs demonstrated that real-time continuous glucose monitoring (CGM) alters this relationship and attenuates SH risk associated with low A1C values ≥6.5%. The glucose management indicator (GMI) reflects average CGM glucose and correlates with A1C. This analysis uses real-world evidence to explore the relationship between GMI and hypoglycemia exposure. Data were from an anonymized convenience sample of 151,315 U.S.-based Dexcom G6 CGM app users with good device adherence evidenced by having uploaded ≥80% of possible CGM values in 3Q 2019. Hypoglycemia exposure was reported as the percentage of glucose values &amp;lt;70 or &amp;lt;54 mg/dL (level 1 or level 2 hypoglycemia, respectively). The Figure shows hypoglycemia and the number of users in six GMI categories. Although there are small, incremental increases in hypoglycemia until GMI is &amp;lt;6.5%, time spent in level 1 and level 2 hypoglycemia remains below the consensus goals of &amp;lt;4% and &amp;lt;1% for users with GMI values ≥6.5%. On average, CGM users with GMI values ≥6.5% have acceptably low rates of hypoglycemia, obviating the need to relax GMI goals as a strategy to reduce the risk of SH. Disclosure T.C. Walker: Employee; Self; Dexcom, Inc. J. Welsh: Employee; Self; CSL Behring. G.J. Norman: Employee; Self; Dexcom, Inc. A. Parker: Employee; Self; Dexcom, Inc. Stock/Shareholder; Self; Dexcom, Inc. D.A. Price: Employee; Self; Dexcom, Inc.

134. Identification of Type 2 Diabetes (T2D) at Lower A1c Values Leads to Improved A1c Outcomes

134. Identification of Type 2 Diabetes (T2D) at Lower A1c Values Leads to Improved A1c Outcomes

202-OR: Comparing Glycemic Control of Youth with T1D in NICH to Referred Youth: Quality Control (Group)

Objective: Youth with T1D who experience avoidable complications often have dangerously high and relatively stable A1c values. Although Novel Interventions in Children’s Healthcare (NICH) has demonstrated success improving A1c in these youth, this is the first study to compare the A1c values of those served by NICH to those of a control group. Methods: Youth with T1D and avoidable complications were referred to NICH (n=110). A subset had available lab values and chronically high A1c (≥10%; n=67); 36 received NICH, and 31 were denied NICH by insurance (i.e., unserved). No significant demographic differences existed between NICH and unserved youth (M age= 14.1 years; 54% female; 78% non-Hispanic white). Medical record review included 1 year prior to, during, and two years following NICH. Results: NICH youth had lower A1c values during (11.1%), 1 year post (11.2%), and 2 years post (11.2%) NICH, when compared to pre-treatment A1c (12.0%; p&amp;lt;.05). Unserved youth did not show meaningful changes when comparing pre-A1c (11.5%) to similar time periods (i.e., 10.9%, 12.0%, 12.2%). Compared to unserved youth, NICH youth demonstrated larger A1c reduction one (p&amp;lt;.01) and two years (p&amp;lt;.05) post treatment. Conclusions: This study was the first to compare the A1c of NICH youth to a comparable control group. NICH youth demonstrated and maintained improved A1c after treatment, while those denied access did not demonstrate similar changes. Disclosure D.V. Wagner: None. J. Mahon: None. C. Jenisch: None. S.A. Barry: None. H. Luzod: None. K. Kraus: None. M.A. Harris: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Difference in Glycemic Profile With the Pump vs Multiple Daily Injections in Treating Type 1 Diabetes in Pregnancy [32F

INTRODUCTION: Previous literature suggests that patients with type 1 diabetes (T1DM) utilizing continuous subcutaneous insulin infusion (CSII) have lower hemoglobin A1c values compared to multiple daily injections (MDI). Despite improved glycemic control, rates of large for gestational age (LGA) infants are not different between these groups. This study investigates differences in glycemic profiles between CSII and MDI glucose logs. METHODS: Retrospective cohort study of all singleton pregnancies complicated by T1DM from 2012-2016. Patients were separated into groups by insulin delivery method. Glucose logs were reviewed for each trimester and a median glucose, interquartile range (IQR), and glycemic variability (IQR/median glucose) were calculated. Continuous data was compared using the Wilcoxon rank sum test. Spearman correlation coefficients were calculated comparing trimester specific median glucose and glycemic variability with neonatal birth weight percentile. RESULTS: 117 patients met inclusion criteria with 37,262 fasting and post-prandial values recorded. The rate of LGA was not different between groups (CSII: 57%, MDI: 49%; p=.370) despite CSII users having both a lower early A1c (&lt;20 weeks [6.8% vs. 8.6%; &lt;.001]) and late A1c (&gt;26 weeks [6.5% vs. 6.9%; p=.008]) when compared to MDI users. Median reported glucose values were similar between groups, but glycemic variability was substantially increased in CSII users. However, glycemic variability did not correlate with birthweight percentile in any trimester independent of insulin delivery method. CONCLUSION: Patients using CSII have lower A1c values, but significantly more glycemic variability when compared to MDI users. However, degree of glycemic variability does not correlate with neonatal birthweight percentiles.

Family physician perceptions of the role and value of the clinical pharmacist in the management of patients with type 2 diabetes

AbstractPurposeClinical pharmacists can help primary care physicians (PCPs) manage medications for patients with poorly controlled type 2 diabetes. Studies have shown that clinical pharmacist involvement in care can improve outcomes such as glycosylated hemoglobin (A1C), blood pressure and lipid control, and decrease episodes of hypoglycemia. Despite these findings, some PCPs may be slow or disinclined to refer to clinical pharmacists when available. This study addressed PCP perceptions regarding referral to clinical pharmacists and endocrinologists for patients with poorly controlled type 2 diabetes.MethodsPhysicians from five family medicine sites were surveyed. Physicians were queried regarding their patterns for patient referral to endocrinologists and/or clinical pharmacists. Clinical contributions and importance of factors to consider when referring were compared between clinical pharmacists and endocrinologists using paired t tests.ResultsFifty physicians responded to the survey, resulting in a response rate of 73.5%. The majority of PCPs indicated that they have referred to endocrinologists (89.5%) and clinical pharmacists (93.5%) for specialty care. PCPs tended to refer to clinical pharmacists sooner and at lower A1C values than to endocrinologists. PCPs also considered multiple medical comorbidities, history of noncompliance with medical recommendations, low reading ability or math skills, complex psychosocial situations, fear of needles, or difficulty affording medications or supplies to be more important when referring patients to clinical pharmacists than endocrinologists.ConclusionWe hypothesized that referrals to a clinical pharmacist or endocrinologist are made with careful consideration of the patients' needs. PCPs reported increased utilization of clinical pharmacists for patients with nonmedical needs, indicating that extra time, education, and psychosocial support provided by the clinical pharmacist is highly valued.

The Relationship between A1C and Hypoglycemia in the HypoDE Study

There is an inverse relationship between A1C and hypoglycemia which may be impacted by use of continuous glucose monitoring (CGM). Using data from the HypoDE clinical trial, we compared usual care to real-time CGM in subjects with type 1 diabetes using MDI and impaired hypoglycemia awareness or recent severe hypoglycemia. Data from 149 subjects (75 CGM/intervention and 74 SMBG/control) were analyzed. The percentages of sensor glucose (SG) values ≤70 mg/dL (≤3.9 mmol/L) (“%≤70”) and of those indicating clinically significant hypoglycemia (≤54 mg/dL [≤3.0 mmol/L]) (“%≤54”) during the blinded 4-week run-in and the final 4 weeks of the 26-week study were calculated for each subject and compared to corresponding baseline and 26-week A1C values. At baseline, the percent ≤70 and the percent ≤54 were similar for the two groups and there was a trend toward more hypoglycemia for subjects with lower A1C values (Figure A). At 26 weeks (Figure B), there were significant (p&amp;lt;0.01) between-group differences in favor of CGM at both thresholds, and the association between decreasing A1C and increasing exposure to SG values ≤54 mg/dL was attenuated. These data suggest patients at highest risk of hypoglycemia with access to CGM alerts and alarms take appropriate and timely measures to nearly eliminate exposure to clinically meaningful hypoglycemia. CGM allows safe intensification of MDI therapy and achievement of near-normal A1C levels in hypoglycemia-prone individuals. Disclosure N. Oliver: Advisory Panel; Self; Dexcom, Inc., Roche Diabetes Care Health and Digital Solutions, Medtronic. Research Support; Self; Dexcom, Inc., Roche Diabetes Care Health and Digital Solutions. Other Relationship; Self; Novo Nordisk A/S, Takeda Development Centre Europe Ltd. G. Freckmann: Speaker's Bureau; Self; Ascensia Diabetes Care. Research Support; Self; Ascensia Diabetes Care. Speaker's Bureau; Self; Roche Diabetes Care Health and Digital Solutions. Advisory Panel; Self; Roche Diabetes Care Health and Digital Solutions. Research Support; Self; Roche Diabetes Care Health and Digital Solutions. Advisory Panel; Self; Abbott, Novo Nordisk Inc.. Consultant; Self; Sensile Medical AG. Speaker's Bureau; Self; Ypsomed AG. M. Gimenez: None. M. Reddy: Advisory Panel; Self; Roche Diabetes Care Health and Digital Solutions. Other Relationship; Self; Dexcom, Inc. N. Hermanns: Speaker's Bureau; Self; Berlin-Chemie AG. Advisory Panel; Self; Abbott. Research Support; Self; Abbott. Speaker's Bureau; Self; Abbott. Research Support; Self; Berlin-Chemie AG. Advisory Panel; Self; Eli Lilly and Company. Speaker's Bureau; Self; Eli Lilly and Company. Advisory Panel; Self; Roche Diabetes Care Health and Digital Solutions. Research Support; Self; Ypsomed AG, Dexcom, Inc.. Speaker's Bureau; Self; Novo Nordisk Inc. L. Heinemann: Stock/Shareholder; Self; Profil Institute for Metabolic Research, ProSciento. Consultant; Self; Roche Diabetes Care Health and Digital Solutions.

Associations between A1C and Continuous Glucose Monitoring–Derived Glycemic Parameters

The percentage of continuous glucose monitoring (CGM)-derived sensor glucose (SG) values in the 70-180 mg/dL range (time in range [TIR]) is an important outcome for patients and their clinicians; however, consensus TIR goals are lacking. This study aimed to characterize associations between CGM-derived glycemic metrics and A1C in 4 clinical trials: DIAMOND Phase 1 (N=104), DIAMOND Phase 2 (N=69), REPLACE-BG (N=216), and HypoDE (N=141). Each study lasted ≥24 weeks, used current-generation CGM systems (Dexcom, Inc.), and included comparisons of central-lab end-of-study A1C to CGM data during the preceding 3 mo. Data from 530 adults with diabetes (455 type 1) were analyzed. The Figure shows mean SG (MSG), TIR, time &amp;lt;70, &amp;lt;54, and &amp;gt;250 mg/dL for individuals in 6 A1C bins. Higher A1C bins were associated with higher MSG and lower TIR; lower A1C bins were associated with lower MSG and higher TIR. For subjects with A1C &amp;lt;7.0%, median TIR was 72%, with 90% of subjects having TIR &amp;gt;57%. Median time with SG &amp;lt;54 mg/dL was &amp;lt;20 min/day for all A1C bins, but median time with SG &amp;gt;250 mg/dL increased from 0.6 h/day to 6.7 h/day across bins. For subjects with A1C ≥8.0%, median TIR was 44%, with 90% of the subjects having TIR &amp;lt;59%. In CGM users, low A1C values can be achieved with minimal additional exposure to very low SG values. The observed associations between TIR and A1C may help clinicians and patients establish appropriate TIR goals. Disclosure P. Calhoun: Employee; Self; Dexcom, Inc.. Stock/Shareholder; Self; Dexcom, Inc.T. Johnson: Employee; Self; Dexcom, Inc.J. Welsh: Employee; Self; Dexcom, Inc.. Stock/Shareholder; Self; Dexcom, Inc., Medtronic. T.C. Walker: Employee; Self; Dexcom, Inc.D.A. Price: Employee; Self; Dexcom, Inc..

Canagliflozin in Type 1 Diabetes: A Case Series of Patient Outcomes in a Diabetes Clinic.

Canagliflozin is a member of the sodium–glucose cotransporter 2 (SGLT2) inhibitor class and is approved by the U.S. Food and Drug Administration (FDA) for use in patients with type 2 diabetes as an adjunct to diet and exercise to improve glycemic control. Canagliflozin works by inhibiting SGLT2 in the proximal renal tubules, causing a reduction of filtered glucose reabsorption, lowering of the renal threshold for glucose, and increasing urinary glucose excretion (1). The American Diabetes Association (ADA) Standards of Medical Care in Diabetes—2017 (2) and the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) (3) recommend SGLT2 inhibitors as add-on to metformin for patients with type 2 diabetes uncontrolled after 3 months of metformin use. The ADA lists the SGLT2 inhibitors as investigational agents for patients with type 1 diabetes because of the risk of diabetic ketoacidosis (DKA). Despite concerns for DKA in patients with type 2 diabetes treated with an SGLT2 inhibitor, a clinical review by an expert panel found that DKA occurred infrequently and recommended no change to their labeling (4). Although SGLT2 inhibitors are not FDA-approved for use in patients with type 1 diabetes, providers have prescribed these agents for off-label use in this patient population. Glycemic variability may be problematic in patients with type 1 diabetes; therefore, adding an SGLT2 inhibitor can assist in not only improving glycemic control but also reducing glycemic fluctuations. Although adding an SGLT2 inhibitor to insulin may increase the risk of hypoglycemia, the potential to reduce the need for increasing insulin doses may moderate this effect. Patients with type 1 diabetes uncontrolled with insulin therapy who are overweight/obese and have hypertension may benefit from the addition of an SGLT2 inhibitor because these medications help to lower A1C values and can reduce both weight and blood pressure. Several studies have …

Oral health in predialysis patients with emphasis on periodontal disease.

Oral and periodontal infection load need to be treated in the predialysis stage among chronic kidney disease (CKD) patients in order to avoid later complications in dialysis or transplantation. Periodontal health was studied by specifically comparing diabetic nephropathy patients with those with other kidney disease. This descriptive retrospective study comprised 144 predialysis patients (47 women), aged 23 to 83 years, examined at the Helsinki University Hospital, Finland. Of them, 52 (36%) had diabetic nephropathy. Oral and general health data, Periodontal Inflammatory Burden Index (PIBI), and Total Dental Index (TDI) were recorded from hospital records. Results were analyzed with cross tabulation, Pearson chi-square test, and binary logistic regression with Wald test. Of the diabetic nephropathy patients 39%, and of those with high A1C values 36%, respectively, had two or more sites with probing depths ≥ 6 mm compared with 19% in the other CKD group, and 18% of those with lower A1C values. TDI scores were high among 55% of the diabetic nephropathy patients. A1C values ≥ 6.5% associated with moderate periodontitis in 67%, and elevated PIBI in 62%. High A1C values associated with high oral infection burden indices. Diabetic nephropathy patients had more often high TDI scores and deep periodontal pockets compared with the other CKD patients.

Care Utilization in a Pediatric Diabetes Clinic: Cancellations, Parental Attendance, and Mental Health Appointments

To examine care utilization, family attendance, and hemoglobin A1c levels in a multidisciplinary pediatric diabetes clinic. This retrospective electronic record review of deidentified data included patients (99% with type 1 diabetes) with established diabetes care, aged <30 years (mean age, 15 ± 5.2 years), and duration of diabetes >1 year (mean 8.5 ± 5.1 years) at first visit during a 2-year period. Outcomes included care utilization, family attendance, and glycemic control, as indicated by hemoglobin A1c level. Analyses included t tests, ANOVA, χ2 tests, ORs and 95% CIs, and multivariate analyses. The study cohort comprised 1771 patients, with a mean of 5.8 ± 2.8 visits per patient. Roughly 15% of the scheduled appointments resulted in a cancellation or no-show; 61% of patients missed ≥1 visit. Patients with ≥2 missed appointments had higher A1c values and were older than those with <2 missed visits. Almost one-half of visits were attended by mothers alone; fathers attended 22% of visits. Patients whose fathers attended ≥1 visit had lower A1c values than patients whose fathers never attended. Eighteen percent of patients had onsite mental health visits. Patients with ≥1 mental health visit had higher mean A1c values, shorter duration of diabetes, and were younger compared with those with no mental health visits. Our observations suggest the need to encourage attendance at diabetes visits and to include fathers to improve A1c values. The high rate of missed visits, especially in patients with poor glycemic control, identifies wasted provider effort when late cancellations/no-shows result in vacant clinic time. It is important to explore reasons for missed visits and to identify approaches to maximizing attendance, such as extended evening/weekend clinic hours and virtual visits.

Monitoring HIV-infected Patients with Diabetes: Hemoglobin A1c, Fructosamine, or Glucose?

BACKGROUNDPublished studies report inappropriately low hemoglobin A1C (HbA1c) values that underestimate glycemia in HIV patients.METHODSWe reviewed the charts of all HIV patients with diabetes mellitus (DM) at our clinic. Fifty-nine patients had HbA1c data, of whom 26 patients also had fructosamine data. We compared the most recent HbA1c to finger-stick (FS) glucose averaged over three months, and fructosamine to FS averaged over six weeks. Predicted average glucose (pAG) was calculated as reported by Nathan et al: pAG (mg/dL) = 28.7 × A1C% − 46.7. Data were analyzed using the Statistical Analysis System (SAS) and Kruskal–Wallis test.RESULTSHbA1c values underestimated (UE) actual average glucose (aAG) in 19% of these patients and overestimated (OE) aAG in 27%. HbA1c estimated aAG within the established range in only 54% of the patients. There were no statistical differences in the types of HIV medication used in patients with UE, OE, or accurately estimated (AE) glycemia. A Spearman correlation coefficient between HbA1c and aAG was r = 0.53 (P < 0.0001). Correlation between fructosamine and aAG was r = 0.47 (P = 0.016).CONCLUSIONSThe correlations between HbA1c and aAG and between fructosamine and aAG were weaker than expected, and fructosamine was not more accurate than HbA1c.

Combination effect of ribavirin and erythropoietin treatment on hemoglobin A1c in a diabetic patient with chronic hepatitis C

Any condition that shortens erythrocyte lifespan or decreases mean erythrocyte age may falsely lower hemoglobin A1c (A1C) test results. Ribavirin (RBV) used for chronic hepatitis C virus (HCV) infection can cause reversible hemolytic anemia; erythropoietin (EPO) used for treatment-related anemia can stimulate the production of red blood cells. We reported a 55-year-old woman with diabetes who received peginterferon alfa plus RBV for HCV infection. Four weeks following HCV therapy, her Hb level declined from 13.3 g/dL to 11.3 g/dL with elevated lactate dehydrogenase and reduced haptoglobin, which confirmed hemolysis. As her Hb fell to a nadir of 8.5 g/dL at the eighth week, darbepoetin alfa was administered to treat anemia consecutively for 10 weeks. Two months later, the patient's A1C declined from 7.5% to an extremely low value of 4.0%, accompanied by a fasting glucose level of 116 mg/dL. During the preceding 3 months, there was no self-reported hypoglycemia or documented low blood glucose. About 3 months after HCV therapy was terminated, the A1C returned to 6.1% without medication adjustment. The concurrent use of RBV and EPO treatments can synergistically cause falsely low A1C values and may lead to inappropriate relaxation of glycemic control. During HCV treatment with RBV, A1C should not be used alone to guide diabetes therapy.

Abdominal adiposity and daily step counts as determinants of glycemic control in a cohort of patients with type 2 diabetes mellitus

Objective:Favorable effects of walking levels on glycemic control have been hypothesized to be mediated through reductions in abdominal adiposity, but this has not been well studied. We addressed this issue in patients treated for type 2 diabetes.Design:Cross-sectional analysis.Subjects:A total of 201 subjects with type 2 diabetes underwent assessments of pedometer-measured daily step counts, blood pressure, A1C and anthropometric measures (2006–2010). Associations of anthropometric indicators of abdominal adiposity (that is, waist circumference; waist-to-hip ratio (WHR)) with A1C were evaluated through linear regression models adjusting for age, ethnicity, sex and the use of insulin and oral hypoglycemic agents. Models including waist circumference were additionally adjusted for body mass index (BMI). A similar approach was used to examine A1C and daily step associations.Results:Among the 190 subjects (mean age 60 years; mean BMI 30.4 kg m−2), mean values (s.d.) for waist circumference and WHR were respectively, 99.1 cm (13.3) and 0.88 (0.07) in women, and 104.5 cm (13.1) and 0.97 (0.06) in men. Mean A1C and daily step count were respectively, 7.6% (1.4) and 5 338 steps per day (2609), and were similar for both sexes.There was a 0.51% (95% confidence interval (CI): 0.10, 0.93) A1C increment per s.d. increase in waist circumference and a 0.32% (95% CI: 0.08, 0.56) A1C increment per s.d. increase in WHR in fully adjusted models. Each s.d. increase in daily step count was associated with clinically significant reductions in waist circumference and BMI. Each s.d. increase in daily steps was associated with a 0.21% (95% CI: 0.02, 0.41) A1C decrement that declined to 0.16% (95% CI: −0.35, 0.04) with further adjustment for anthropometric indicators of abdominal adiposity.Conclusion:Higher daily steps may be associated with lower A1C values both directly and via changes in abdominal adiposity.

Caregiver reports of provider recommended frequency of blood glucose monitoring and actual testing frequency for youth with type 1 diabetes

Aims To identify demographic, family and clinical characteristics associated with provider recommended frequency of blood glucose monitoring (BGM), actual frequency of BGM, and concordance between these categories in youth with type 1 diabetes (T1D) as reported by child‘s caregiver. Methods Caregivers of 390 children 10-17 years were interviewed about their children's providers’ recommendations for frequency of BGM and their child's frequency of performance of BGM. Results The majority (92%) of caregivers reported being told that their child should BGM ≥4 times per day and 78% reported their child checked that frequently. Caregivers of children who were younger, non-Hispanic White, from two-parent households, higher income households, and on insulin pumps were more likely to report being told by their provider to perform BGM ≥6 times per day and more likely to report that their child performed BGM ≥6 times per day. Younger children and those with private health insurance were more likely to adhere to reported recommendations. Children whose caregivers reported that their child met/exceeded their provider recommendations had lower A1c values than those who did not. Conclusions These findings may help clinicians identify subgroups of youth at-risk for poor diabetes management and provide further education in order to improve outcomes.