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BackgroundAdult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management.ObjectiveTo review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia.MethodsA multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.ResultsThe panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition–associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes.ConclusionThe recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.

In an effort to enhance the trustworthiness of its clinical practice guidelines, the Endocrine Society has recently adopted new policies and more rigorous methodologies for its guideline program. In this Clinical Practice Guideline Communication, we describe these recent enhancements—many of which reflect greater adherence to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to guideline development—in addition to the rationale for such changes. Improvements to the Society’s guideline development practices include, but are not limited to, enhanced inclusion of nonendocrinologist experts, including patient representatives, on guideline development panels; implementation of a more rigorous conflict/duality of interest policy; a requirement that all formal recommendations must be demonstrably underpinned by systematic evidence review; the explicit use of GRADE Evidence-to-Decision frameworks; greater use and explanation of standardized guideline language; and a more intentional approach to guideline updating. Lastly, we describe some of the experiential differences our guideline readers are most likely to notice.

While affect is linked to a number of diabetes outcomes, the specific role of positive affect (PA) in HbA1c remains unclear. The present study examined whether PA prospectively predicted lower HbA1c among adults with type 2 diabetes and whether this relation was moderated by stress. Participants were 123 adults (44.7% female; 60.2% White, 39.8% Black) recently diagnosed with type 2 diabetes. Perceived stress, diabetes-specific distress, and PA were assessed at baseline; HbA1c was assessed at baseline (T1), six months (T2), and five years (T3). PA was cross-sectionally associated with lower HbA1c at T1 and prospectively predicted lower HbA1c at T3. PA interacted with both measures of T1 stress to predict T1 HbA1c, and PA interacted with T3 perceived stress to predict T3 HbA1c. Interactions were consistent with stress buffering. Sensitivity analyses attentuated findings, but robust evidence remained for PA as a protective factor for blood glucose five years later and for a stress-buffering effect of PA on diabetes-specific distress. Findings suggest PA may be a clinically useful indicator among adults with type 2 diabetes and may be particularly important for those experiencing the greatest stress from their disease.

The majority of observed couple communication research has focused on physically healthy couples and those who are White, educated, and affluent. In the present study, we observed persons with Type 2 diabetes and their romantic partners discuss how to improve diabetes management; afterward, we measured positive affect, negative affect, and discussion evaluations. We also measured mood and self-care behavior over the next 2 weeks. Couples (n = 207) were recruited from the community and varied in education, income, and race. Half of patients were White (53%), and half were Black (47%). Results showed that observed patient warmth was related to a more positive evaluation of the discussion, more postdiscussion positive affect, less postdiscussion negative affect, and better 2-week daily happy mood; observed patient negativity was related to less postdiscussion progress, a more negative evaluation of the discussion, less postdiscussion positive affect, and poorer 2-week dietary adherence; and observed patient distress was related to a more negative discussion evaluation, more postdiscussion negative affect, and worse mood over the next 2 weeks. Two of the findings were moderated by race, in the direction of links being stronger for Black than White patients. Partner warmth was rarely related to outcomes, but partner negativity was related to patients' poorer discussion evaluation, patient's lower happy mood and higher angry mood over the next 2 weeks, and patient's poorer 2-week dietary adherence. Future research on couple interactions should attend to important contextual variables such as race, ethnicity, income, and social status. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

OBJECTIVE Approximately 34 million people in the U.S. have diabetes. With this illness come substantial changes to psychological and physical health. However, type 2 diabetes disproportionately affects non-Hispanic Black compared with non-Hispanic White populations. The purpose of this study was to examine racial differences in psychological, behavioral, and physical health over time among individuals recently diagnosed with type 2 diabetes. RESEARCH DESIGN AND METHODS Data were collected from a community sample of 193 adults recently diagnosed with type 2 diabetes (44% female; 45% Black). Measures of distress, self-care behaviors, and HbA1c were taken at an initial interview (time 1) and 6 months later (time 2). Individuals wore an Actical accelerometer to assess physical activity and participated in three 24-h dietary recall interviews to assess dietary intake within 2 weeks of the initial interview. RESULTS From time 1 to time 2, Black women showed the highest increase in depressive symptoms. There was a greater increase in regimen and physician distress among White compared with Black participants. White men and Black women reported a decline in medication adherence over time. There were no racial differences in changes in physical activity across 6 months. However, Black individuals had higher overall calorie consumption with greater protein, saturated fat, and cholesterol intake than White individuals. There were no race or sex differences in changes in glycemic stability. CONCLUSIONS Initial adjustment to a diagnosis of type 2 diabetes differentially influences Black and White men and women in terms of depressive symptoms, diabetes distress, and self-care.

The real-world weight loss effectiveness of GLP-1RAs have not been well described. We conducted a cohort study using EHR data from an integrated healthcare system based in PA. Non-pregnant adults first dispensed a GLP-1RA between 20 and 2018 were eligible. We excluded those without: 1) at least 72 weeks of continuous enrollment after the first dispense date,2) at least 1 year of baseline enrollment data, and3) at least one valid weight measurement within the 8 wks before the dispense date and at least one weight measure during follow-up. We used descriptive statistics to report percent change in body weight from baseline in each 8 wk follow-up interval ending in +72 wks. We used linear mixed models with a person-level random intercept controlling for variables associated with missing weight data to estimate percent body weight change during follow-up. Our cohort included 2,398 patients (mean[SD] age 48.4[10.3], 53% female) , with a BMI[SD] of 37[7.5] and a mean baseline weight of 238[54] lbs. In the final 8 wk interval of follow-up (64-72 wks) , the modeled mean percent weight change was -2.5% (95% CI: -2.8 to -2.1) . An estimated 29.9% (95% CI: 27.2 to 32.6) of patients lost at least 5% body weight at this time. In this real-world study using data from ∼2,400 patients with overweight or obese and type 2 diabetes, starting a GLP-1RA was associated with a modest amount of weight loss through 72 weeks. Disclosure J.Luo: None. I.Shu: None. M.T.Korytkowski: None. D.A.Rometo: Advisory Panel; Nestlé Health Science. J.Arnold: None. G.E.White: None. Funding NIDDK (K23ADK120956)

Background: Although DKA has been traditionally managed in intensive care units (ICU) , some studies suggest that DKA can be safely treated in non-critical care areas. Objective: To compare safety & efficacy of a DKA IV insulin protocol in ICU with stepdown unit (SDU) . Methods: A retrospective chart review of all DKA patients (Age >yrs) admitted to ICU (N=45) & SDU (N=23) from January 20to August 2020. The admission to SDU was based on our hospital protocol (pH>7.2 without organ failure) . We analyzed the compliance to the DKA protocol (Table) and adverse outcomes. Mann-Whitney U & Chi-square/Fishers exact tests were used to compare continuous & categorical variables respectively. Results: ICU & SDU groups were demographically similar: mean age (36.2 ± 15.2 vs. 37.6 ± 18.9 yrs) , sex (F 67% vs. 70%) & BMI (21.2 vs. 21.8 kg/m2) . As expected, ICU group had severe DKA as compared to SDU group with higher mean BG & lower mean serum Bicarb (p0.05) . Conclusions: Our study suggested that a DKA IV insulin can be safely managed in SDU in selected patients, which can help avoid ICU overcrowding. The observed trend toward less strict compliance with the DKA protocol can be overcome with nurse education and optimal nurse to patient ratio. Disclosure T.Ahmad: None. N.Mehrotra: None. W.Ali: None. D.Ren: None. J.Arnold: None. M.T.Korytkowski: None. S.Mon: None.

Objective This study was designed to determine whether intensive lifestyle intervention (ILI) aimed at weight loss lowers cancer incidence and mortality. Methods Data from the Look AHEAD trial were examined to investigate whether participants randomized to ILI designed for weight loss would have reduced overall cancer incidence, obesity-related cancer incidence, and cancer mortality, as compared with the diabetes support and education (DSE) comparison group. This analysis included 4,859 participants without a cancer diagnosis at baseline except for nonmelanoma skin cancer. Results After a median follow-up of 11 years, 684 participants (332 in ILI and 352 in DSE) were diagnosed with cancer. The incidence rates of obesity-related cancers were 6.1 and 7.3 per 1,000 person-years in ILI and DSE, respectively, with a hazard ratio (HR) of 0.84 (95% CI: 0.68-1.04). There was no significant difference between the two groups in total cancer incidence (HR, 0.93; 95% CI: 0.80-1.08), incidence of nonobesity-related cancers (HR, 1.02; 95% CI: 0.83-1.27), or total cancer mortality (HR, 0.92; 95% CI: 0.68-1.25). Conclusions An ILI aimed at weight loss lowered incidence of obesity-related cancers by 16% in adults with overweight or obesity and type 2 diabetes. The study sample size likely lacked power to determine effect sizes of this magnitude and smaller.

ContextIndividuals with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. Management of hyperglycemia in these patients is challenging.ObjectiveTo support development of the Endocrine Society Clinical Practice Guideline for management of hyperglycemia in adults hospitalized for noncritical illness or undergoing elective surgical procedures.MethodsWe searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence.ResultsWe included 94 studies reporting on 135 553 patients. Compared with capillary blood glucose, continuous glucose monitoring increased the number of patients identified with hypoglycemia and decreased mean daily blood glucose (BG) (very low certainty). Data on continuation of insulin pump therapy in hospitalized adults were sparse. In hospitalized patients receiving glucocorticoids, combination neutral protamine hagedorn (NPH) and basal-bolus insulin was associated with lower mean BG compared to basal-bolus insulin alone (very low certainty). Data on NPH insulin vs basal-bolus insulin in hospitalized adults receiving enteral nutrition were inconclusive. Inpatient diabetes education was associated with lower HbA1c at 3 and 6 months after discharge (moderate certainty) and reduced hospital readmissions (very low certainty). Preoperative HbA1c level ConclusionThe certainty of evidence supporting many hyperglycemia management decisions is low, emphasizing importance of shared decision-making and consideration of other decisional factors.

IntroductionThe purpose of this prospective observational cohort study was to examine sex differences in glycemic measures, diabetes-related complications, and rates of postdischarge emergency room (ER) visits and hospital readmissions in non-critically ill, hospitalized patients with diabetes.Research design and methodsDemographic data including age, body mass index, race, blood pressure, reason for admission, diabetes medications at admission and discharge, diabetes-related complications, laboratory data (hematocrit, creatinine, hemoglobin A1c, point-of-care blood glucose measures), length of stay (LOS), and discharge disposition were collected. Patients were followed for 90 days following hospital discharge to obtain information regarding ER visits and readmissions.Results120 men and 100 women consented to participate in this study. There were no sex differences in patient demographics, diabetes duration or complications, or LOS. No differences were observed in the percentage of men and women with an ER visit or hospital readmission within 30 (39% vs 33%, p=0.40) or 90 (60% vs 49%, p=0.12) days of hospital discharge. More men than women experienced hypoglycemia prior to discharge (18% vs 8%, p=0.026). More women were discharged to skilled nursing facilities (p=0.007).ConclusionsThis study demonstrates that men and women hospitalized with an underlying diagnosis of diabetes have similar preadmission glycemic measures, diabetes duration, and prevalence of diabetes complications. More men experienced hypoglycemia prior to discharge. Women were less likely to be discharged to home. Approximately 50% of men and women had ER visits or readmissions within 90 days of hospital discharge.Trial registration numberNCT03279627.

Introduction: Hypoglycemia is a rare paraneoplastic manifestation of several non-islet cell tumors (NICT) that is rarely reported in individuals with diabetes. We report the first case of a patient with type 1 diabetes (T1D) and a recurrent gastrointestinal stromal tumor (GIST) who required discontinuation of all insulin therapy with continuous parenteral glucose infusions to avoid hypoglycemia. Case: The patient is an underweight (BMI 14.9 kg/m2) 59-year-old female with a 24-year history of T1D treated with insulin pump therapy who was diagnosed with GIST in 2003. Following surgical resection with postoperative adjuvant therapy, she remained tumor free until 2012 when she had disease recurrence unresponsive to several tyrosine kinase inhibitors. In 2014, she reported frequent episodes of documented hypoglycemia despite continued reductions in basal insulin infusion rates. Laboratory testing following several hours of insulin discontinuation revealed undetectable insulin and C-peptide levels, low IGF-1, normal IGF-2, and an IGF-2: IGF-1 ratio of 7.86. Thyroid, kidney and adrenal tests were normal. Initiation of prednisone alone then in combination with octreotide did not abate the hypoglycemia. During a hospitalization for hypoglycemia, exogenous insulin therapy was discontinued and 10% dextrose infusions started. Attempts at weaning the dextrose infusions resulted in hypoglycemia, prompting insertion of a PICC line prior to discharge home with continuous 25% dextrose infusions at 40-60 mg per hour. Discussion: NICT hypoglycemia (NICTH) is characterized by excessive tumor production of IGF-2 or pro-IGF-2. The structure of IGF-2 is similar to insulin, allowing cross reactivity at the insulin receptor. IGF binding proteins (IGFBPs) are responsible for transporting IGF-2 in plasma. Abnormal processing of the gene for IGF-2 results in increased production of the more biologically active pro-IGF-2 that does not form a complex with IGFBP3 and is available to interact with insulin receptors. In patients with normal IGF-2 (chronic kidney disease, poor nutritional status), an IGF-2: IGF-1 ratio >3 can be used to confirm NICTH. IGFBP-3 was not measured in this patient but it is likely this was low due to her poor nutritional status. The most definitive treatment for NICTH is resection of the tumor. Pharmacological management can be considered in patients who are not surgical candidates, but is not always successful as was observed in this patient. Conclusion:This is an unusual case of malignancy associated hypoglycemia in a woman with type 1 diabetes who required discontinuation of all insulin therapy as well as continuous dextrose infusions to achieve euglycemia and briefly maintain an acceptable quality of life over a period of several months.

Background: Patient portals empower patients by providing access to their health information and facilitating communication with care providers. This study aimed to examine the usage patte...

Objective: To determine the efficacy and safety of a diabetic ketoacidosis (DKA)-Power Plan (PP) for guiding intravenous (IV) insulin infusions prior to anion gap (AG) closure and administering subcutaneous (SC) insulin ≥1 hour before discontinuing IV insulin. Methods: Retrospective chart review of patients with DKA before (pre-PP) (n = 60) and following (post-PP) (n = 60) implementation of a DKA-PP. Groups were compared for percentage of patients for whom IV insulin therapy was continued until AG closure, the percentage of patients receiving SC insulin ≥1 hour before discontinuation of IV insulin, and percentage of patients with rebound DKA during the index hospitalization. Results: Admission plasma glucose (514 mg/dL vs. 500 mg/dL; P = .36) and venous pH (7.2 vs. 7.2; P = .57) were similar in pre- and post-PP groups. Inappropriate discontinuation of IV insulin occurred less frequently in post-PP patients (28% vs. 7%; P = .007), with a lower frequency of rebound DKA (40% vs. 8%; P = .001) following acute management. More post-PP patients received SC insulin ≥1 hour before discontinuation of IV insulin (65% vs. 78%; P = .05). Conclusion: Implementation of a DKA-PP was associated with appropriate discontinuation of IV insulin in more patients, more frequent administration of SC insulin ≥1 hour prior to discontinuation of IV insulin, and fewer episodes of rebound DKA. Abbreviations: ADA = American Diabetes Association; AG = anion gap; BG = blood glucose; DKA = diabetic ketoacidosis; DKA-PP = DKA-Power Plan; ICU = intensive care unit; IQR = interquartile range; IV = intravenous; IVF = IV fluid; LOS = length of stay; SC = subcutaneous

Background: The incidence and predictors of primary nonadherence (when a medication is prescribed but not dispensed) for newer glucose lowering medications including SGLT2i and GLP-1a is not known. Methods: Using a database that links electronic health records with commercial claims from an integrated health system in PA (UPMC), we identified patients with T2D newly prescribed an SGLT2i or GLP-1a from 2011-2019. We measured the incidence of 30-day primary nonadherence to both overall and by individual drug. We used multivariable logistic regression to examine patient and provider factors associated with primary nonadherence. Results: Our cohort included 5,505 commercially insured adults (mean age 50[SD11]) with T2D newly prescribed an SGLT2i (n=2,844) or GLP-1a (n=2,661). Overall, 1,867(34%) patients did not fill their first prescription. Among the most commonly prescribed drugs, the incidence of primary nonadherence was lowest for dulaglutide(30%) and highest for canagliflozin(44%). In a multivariable model, age>65 (OR 1.3, 95%CI:1.06-1.61), hypertension (OR 1.18, 95%CI:1.02-1.35), and number of hospitalizations (OR 1.39, 95%CI:1.16-1.65) was associated with an increased odds of primary nonadherence. Female sex (OR 0.88, 95%CI:0.77-0.99), PAD (OR 0.73, 95%CI:0.57-0.93), having a HbA1c value (OR 0.76, 95%CI:0.64-0.89), having a creatinine value (OR 0.82, 95%CI:0.71-0.94), and having an endocrinologist vs. PCP prescribe the index drug (OR 0.77, 95% CI:0.65-0.91) were associated with decreased odds of primary nonadherence. Conclusions: In this integrated health system, 1 out of 3 patients prescribed a SGLT2i and GLP-1 agonist did not fill their prescription within 30 days. Older age and increasing morbidity predicted higher odds while more active engagement with providers, including diabetes specialists, was associated with reduced odds of primary nonadherence. Disclosure J. Luo: Consultant; Self; Alosa Health, Research Support; Self; Health Action International. R. Feldman: None. S. D. Rothenberger: None. M. Fischer: None. M. T. Korytkowski: None. W. F. Gellad: None. Funding National Center for Advancing Translational Sciences (KL2TR001856)

Insomnia is frequently co-morbid with obstructive sleep apnea (OSA); the effect of insomnia or co-morbid insomnia and OSA (OSA + I) on associated metabolic outcomes in adults with type 2 diabetes (T2D) remains unclear. This study in adults with T2D compared metabolic outcomes among persons with OSA, insomnia, or OSA + I. This study analyzed baseline data from the Diabetes Sleep Treatment Trial of persons recruited for symptoms of OSA or poor sleep quality. Home sleep studies determined OSA presence and severity. Insomnia was evaluated using the Insomnia Severity Index. Height and weight to calculate body mass index (BMI) and blood for laboratory values were obtained. Multivariate general linear models were used to examine the impact of the type of sleep disorder and sociodemographic, lifestyle, and sleep risk factors on metabolic outcomes. Participants (N = 253) were middle-aged (56.3 ± 10.5 years), white (60.5%), obese (mean BMI of 35.3 ± 7.1 kg/m2), and male (51.4%) with poor glucose control (mean HbA1c of 8.0 ± 1.8%). Most participants had OSA + I (42.7%) or insomnia only (41.0%). HbA1c and BMI differed among the sleep disorder groups. In addition, in the adjusted models, having insomnia only, compared to OSA only, was associated on average with higher HbA1c levels (b = 1.08 ± 0.40, p

Objective The primary objective of this study was to examine the patient comprehension of diabetes self-management instructions provided at hospital discharge as an associated risk of readmission. Methods Noncritically ill patients with diabetes completed patient comprehension questionnaires (PCQ) within 48 hours of discharge. PCQ scores were compared among patients with and without readmission or emergency department (ED) visits at 30 and 90 days. Glycemic measures 48 hours preceding discharge were investigated. Diabetes Early Readmission Risk Indicators (DERRIs) were calculated for each patient. Results Of 128 patients who completed the PCQ, scores were similar among those with 30-day (n = 31) and 90-day (n = 54) readmission compared with no readmission (n = 72) (79.9 ± 14.4 vs 80.4 ± 15.6 vs 82.3 ± 16.4, respectively) or ED visits. Clarification of discharge information was provided for 47 patients. PCQ scores of 100% were achieved in 14% of those with and 86% without readmission at 30 days (P = .108). Of predischarge glycemic measures, glycemic variability was negatively associated with PCQ scores (P = .035). DERRIs were significantly higher among patients readmitted at 90 days but not 30 days. Conclusion These results demonstrate similar PCQ scores between patients with and those without readmission or ED visits despite the need for corrective information in many patients. Measures of glycemic variability were associated with PCQ scores but not readmission risk. This study validates DERRI as a predictor for readmission at 90 days.

Objective The transition of diabetes care from home to hospital, within the hospital, and upon discharge is fraught with gaps that can adversely affect patient safety and length of stay. We aimed to highlight the variability in care during these transitions and point out areas where research is needed. Methods A PubMed search was performed with a combination of search terms that pertained to diabetes, hyperglycemia, hospitalization, locations in the hospital, discharge to home or a nursing facility, and diabetes medications. Studies with at least 50 patients that were written in the English language were included. Results With the exception of transitioning from intravenous insulin infusion to subcutaneous insulin and perhaps admission to the regular floors, few studies pointedly focused on transitions of care, leading us to extrapolate recommendations based on data from disparate areas of care in the hospital. There is evidence at every stage of care, starting from the entry into the hospital and ending with discharge home or to a facility, that patients benefit from having protocols in place guiding overall care. Conclusion Pockets of care exist in hospitals where methods of effective diabetes management have been studied and implemented. However, there is no sustained continuum of care. Protocols and care teams that follow patients from one physical location to the other may result in improved clinical outcomes during and following a hospital stay.

Purpose The purpose of this study was to examine parents’ perceptions of the role children play in their type 1 diabetes (T1DM) care. Family members are a resource to support T1DM self-management, but how children are involved in their parents’ diabetes has not been well explored. Methods Parents with T1DM (n = 85) and a subset of their romantic partners (n = 55) participated in interviews during which they described their children’s knowledge of and involvement in diabetes care. Interviews were transcribed, responses coded/tallied, and themes identified. Results All parents reported that children knew of their diabetes, which they learned about progressively from a young age. Most parents reported children to be accepting and understanding of the ways that diabetes affected their family experiences (eg, pause to treat low blood glucose). When asked about specific support, parents rated “making parent feel better about diabetes” as the most frequently occurring behavior. Some parents felt that children, particularly younger ones, occasionally detracted from T1DM management, but this was usually expected and considered transient. Regardless of child age, many parents did not want diabetes to burden children and limited their involvement. Both parents with T1DM and partners requested resources to enhance child awareness and preparedness to support diabetes. Respondents, particularly partners, were also interested in learning how to communicate better as a family and share perspectives on how diabetes affects individual family members. Conclusions Diabetes care and education specialists should consider developmentally and relationally appropriate ways to engage children of parents with T1DM in education and self-management.

The pandemic of COVID-19 has presented new challenges to hospital personnel providing care for infected patients with diabetes who represent more than 20% of critically ill patients in intensive care units. Appropriate glycemic management contributes to a reduction in adverse clinical outcomes in acute illness but also requires intensive patient interactions for bedside glucose monitoring, intravenous and subcutaneous insulin administration, as well as rapid intervention for hypoglycemia events. These tasks are required at a time when minimizing patient interactions is recommended as a way of avoiding prolonged exposure to COVID-19 by health care personnel who often practice in settings with limited supplies of personal protective equipment. The purpose of this manuscript is to provide guidance for clinicians for reconciling recommended standards of care for infected hospitalized patients with diabetes while also addressing the daily realities of an overwhelmed health care system in many areas of the country. The use of modified protocols for insulin administration, bedside glucose monitoring, and medications such as glucocorticoids and hydroxychloroquine that may affect glycemic control are discussed. Continuous glucose monitoring systems have been proposed as an option for reducing time spent with patients, but there are important issues that need to be addressed if these are used in hospitalized patients. On-site and remote glucose management teams have potential to provide guidance in areas where there are shortages of personnel who have expertise in inpatient glycemic management.

Several risk factors for hospital readmission in patients with diabetes (DM) have been identified. The Diabetes Early Readmission Risk Indicator (DERRITM) is a tool that identifies patients at high risk for readmission within 30 days of hospital discharge, but does not incorporate several DM specific factors such as type of DM and pre-discharge glycemic measures. The purpose of this investigation was to prospectively examine DM specific factors and DERRI scores as predictors of readmission risk at 90 days in participants in the Readmission and Comprehension of Discharge Education in Diabetes (RECODED) study. Among the 126 patients, (age mean (STD) 61(12) yrs, BMI 32.9 (9.6) kg/m2, A1c 8.0 (2.2%), 45% women, 22% Black, 85% type 2 DM), readmission occurred in 54 (42.9%) of patients within 90 days of discharge. Factors identified as predicting risk for hospital readmission included the presence of known macrovascular (CAD, p = 0.039; CHF, p = 0.029; CVA, p = 0.054) but not microvascular complications. DERRI scores were higher in those with a readmission compared to those without (27 ± 12% vs. 20 ± 11%, p = 0.006).No differences were observed for age, BMI, type of diabetes, eGFR, history of DM self-management education, inpatient DM service consultation, education level, employment history, A1c, pre-discharge hypoglycemia, hyperglycemia or glycemic variability, or hospital length of stay among those with and without a readmission. In summary, these results reinforce the complexity of identifying risk factors for hospital readmission in DM patients. Certain macrovascular complications, which are collectively components of the DERRI, individually demonstrate an association with readmission risk at 90 days, as does DERRI. This is the first demonstration of DM related macrovascular complications and DERRI score as a predictor of readmission beyond 30 days of hospital discharge. Disclosure D. Pinkhasova: None. J. Swami: None. N. Patel: None. A. Donihi: None. L.M. Siminerio: Research Support; Self; Becton, Dickinson and Company. K. Delisi: None. D.S. Hlasnik: None. D.J. Rubin: None. M.T. Korytkowski: None. Funding National Institutes of Health (UL1TR001857)

Hospitalized patients with DM represent a group at high risk for readmission. Variability in how instructions for home DM management are provided at discharge can contribute to this risk. At our institution, recommendations made by the endocrine consult service were not always accurately translated into patient discharge orders by the primary service. Therefore, the EFR embedded within the EMR was developed. We investigated its effectiveness by reviewing the EMR of 48 patients discharged with insulin prior to (group 1) and following implementation (group 2) for fidelity of recommendations carried out by the primary service. Accuracy of the diabetes-related discharge regimen was defined as correct type and dose of insulin, correct administration supplies (syringes vs. pen needles), and provision of appropriate glucose monitoring supplies by the primary team. About 50% of patients had a change in their DM regimen at discharge. Insulin was added as a new medication in 29% vs. 44% of patients in groups 1 and 2 respectively. There was significant improvement in the accuracy of the diabetes-related discharge regimen (68% vs. 96%, p = 0.001). These results demonstrate that deficiencies in the discharge process can be ameliorated by EMR tools which facilitate a safer transition of care from inpatient to outpatient settings for patients with DM. Disclosure D. Pinkhasova: None. A. Donihi: None. K. Feterik: None. M.T. Korytkowski: None. E. Karslioglu French: None.

Introduction: Inpatient hypoglycemia is commonly associated with high mortality and morbidity. Several factors contribute to hypoglycemia in patients with diabetes, and not all causes are inevitable. However, it is important to recognize the causes of hypoglycemia to prevent further episodes. We investigate the potential causes of hypoglycemic episodes in our community hospital as part of a quality improvement project. Our aim is to reduce risks of hypoglycemia by identifying potential preventable etiologies and educate providers and the nursing team. Methods: A retrospective chart review of patients was performed for all non-critically ill diabetic patients who experienced point of care blood glucose Results: The mean age was 62.3 years+/-17.1, 63.5% males, BMI (mean 33.31+/-20.8kg/m2), 79.4% type 2 diabetes with mean A1C 8.2+/-1.6%. Median length of hospital stay was 6 days. 16(25.4%) patients had >2 episodes of hypoglycemia and 15 patients (23.9%) had severe hypoglycemia (defined as blood glucose < or = to 45 mg/dl). 8 patients (12%) were readmitted within 7 days and 20 patients (31%) had readmission within 30 days. The most common cause of hypoglycemia was due to basal insulin excess (n=17 patients, 27%), overuse of sliding scale (n=16 patients, 25.4%), reduce food intake (n=11 patients , 25.4%), inpatient use of premixed insulin (n=6 patients, 9.5%) and use of sulfonylurea (n=2 patients, 3.2%). Two other hypoglycemic events appeared to occur when steroids dose was tapered without insulin dose adjustments. Conclusion: The results demonstrate that several major causes of hypoglycemia are preventable and reinforce the need for determination of the cause of these events as a way of modifying therapy to prevent further episodes. Disclosure N. Mehrotra: None. H. Atalay: None. M.T. Korytkowski: None. S. Mon: None.

Purpose The purpose of this study is to examine the association of current smoking as one of several potential predictors of elevated A1C in adults with type 2 diabetes (T2D). Methods Using a cross-sectional design, baseline data (N = 282) were analyzed from a randomized clinical trial examining treatment of obstructive sleep apnea in persons with T2D. Sociodemographic, clinical, and behavioral data were collected using questionnaires and physical examinations. Physical activity (mean daily steps walked) was measured with the BodyMedia Armband. Participants were asked if they never smoked, had previously smoked, or currently smoke. The sample distributions of demographic and clinical characteristics were examined using descriptive statistics. Continuous variables were described using means and standard deviations; categorical variables were described as numbers and percentages. Multiple linear regression analysis with backward selection was conducted to develop a parsimonious predictive model for the dependent variable A1C. Results Participants were generally middle-aged and, on average, obese with suboptimal blood glucose control; almost 1 of every 5 participants currently smoked. After controlling for age, race, education, financial difficulty, diabetes education, physical activity, and diabetes knowledge, 4 variables were found in the final model to be independently associated with higher A1C: (1) current smoking status, (2) younger age, (3) longer diabetes duration, and (4) higher diabetes-related distress. Conclusions The study found that not only is smoking prevalent among persons with T2D with self-reported sleep problems but smoking is also an independent predictor of elevated A1C. The results highlight the vital role diabetes educators have in promoting risk reduction through education and support for smoking cessation.

Introduction Optimal insulin injection technique is crucial for therapeutic success in patients with diabetes who require insulin therapy for glycemic control. One of the causes for failure to reach glycemic goals can be attributed to improper injection technique. Problems related to poor injection technique may arise at a later stage and hence, may lead to a major barrier to intended glycemic control. We present a patient with worsening glycemic control and significant insulin requirement due to ineffective injection technique. Our case highlights the importance of direct observation of the patient injecting insulin, even for those who have been on insulin therapy for years. Case Presentation A 55-year-old woman with T2DM and Class III obesity was referred for endocrine consultation with HbA1c >12% for 9 months despite adhering to 4.7 unit/kg/day basal bolus daily Insulin, Metformin 1000 mg twice daily and liraglutide 1.8 mg daily. Secondary causes of insulin resistance were ruled out. Initial review of injection technique on an insulin-injection pad failed to identify the error. However, a leakage was observed when patient was asked to demonstrate injection technique on herself, using the BD AutoShield Duo needle, which she was using at that time. Patient was advised to switch to BD nano needles and given proper training. Following this adjustment, her HbA1c improved to 6.9% within 3 months with a decrease in daily insulin requirement to 1 unit/kg/day. Discussion In optimizing glycemic control, proper insulin injection technique is as essential as the appropriate type and dose of insulin; however, this is often overlooked. Studies assessing proper insulin injection technique by direct observation are limited. Problems experienced by patients are rarely brought up and often neglected during the follow-up visits. Supervision of injection technique periodically can help identify injection errors. The BD AutoShield Duo offers the distinct advantages of concealing the needle which benefits those who have an aversion to needles and reduces the risks of accidental needlesticks. The force required to deliver a successful injection of insulin using this needle is greater in comparison to traditional needles. Such force and lack of direct visualization may potentially lead to failure of insulin delivery. Such challenges may be more obvious in patients with obesity. Our case highlights the importance of periodic review of insulin injection technique, particularly when glycemic control is suboptimal, and emphasizes the correct choice of insulin pen needle. References 1.King, Laila. “Subcutaneous insulin injection technique.” Nursing Standard, vol. 17, no. 34, 2003, p. 45+. Academic OneFile, https://link.galegroup.com/apps/doc/A130629162/AONE?u=googlescholar&sid=AONE&xid=5f28fd49. Accessed 18 Nov. 2018.

Aim This study examined glycemia level over a 2-year period between portal users and non-users. Methods This retrospective cohort study used data from electronic health records (EHRs) of a large academic medical center and its ancillary patient portal. A total of 15,528 patients with uncontrolled type 2 diabetes mellitus (T2DM) were included. Using propensity score matching (PSM), portal users and non-users were balanced on demographic and clinical characteristics. Mixed-effects polynomial regression modeling was employed to evaluate the HbA1c change over time between groups. Results The patient sample was 85.9% (13,333) white and 52.5% (7375) male. On average, patients were 62.8 (SD, 11.7) years old and with obesity (mean BMI: 34.2 ± 7.2 kg/m2) with uncontrolled T2DM (initial HbA1c: 8.5 ± 1.5%). After PSM, portal users (n = 4924) and non-users (n = 4924) were matched on all variables except for the insurance. The mixed-effects modeling showed a nonlinear decrease of HbA1c in both groups over time. A significant interaction was observed with a greater decline, followed by a smaller rise of HbA1c in portal users than non-users. Conclusions The use of the patient portal was significantly associated with a lower HbA1c. This finding supports patient portals as a promising tool for improving clinical outcomes in patients with uncontrolled T2DM.

Communal coping is a form of interpersonal coping that involves a shared illness appraisal and collaborating to address illness-related issues. We hypothesized that communal coping among couples in which one person is recently diagnosed with Type 2 diabetes would be related to better diabetes problem-solving, better mood, greater relationship quality, and less psychological distress for both partners. Communal coping was coded from videotaped interactions in which 119 heterosexual couples discussed difficulties in managing diabetes. Actor-partner interdependence models were performed to isolate associations of actor communal coping and partner communal coping with outcomes, and examined whether the couple-member had diabetes and sex as moderator variables. We expected that communal coping would be more beneficial for women than men, and that partner communal coping would be more strongly linked to outcomes than actor communal coping. Results were largely consistent with hypotheses, suggesting that communal coping is beneficial to couples coping with diabetes. (PsycINFO Database Record

In May 2017, the Diabetes Technology Society convened a panel of US experts on inpatient diabetes management to discuss the current and potential role of continuous subcutaneous insulin infusion (CSII) therapy in the hospital. The panel (1) discussed evidence for current use of CSII in the hospital, (2) recommended contraindications for use in the hospital, and (3) recommended guidelines to maximize chances for safe use of CSII in the hospital. Panel members agreed that larger, prospective, randomized studies are needed to evaluate safety and efficacy of CSII use in the hospital. As CSII technology becomes more complex and its use increases, it is imperative that institutional protocols be in place to ensure safe use of this technology and safe transitions across care areas. Providers need to be cognizant that not all patients currently using CSII as an outpatient are appropriate candidates for continued use in the hospital. This consensus statement provides guidelines for practitioners who may encounter patients using this technology in the inpatient setting.

Communal coping, which involves a shared illness appraisal and engaging in collaboration when illness-related problems arise, is likely beneficial for individuals with type 2 diabetes. The purpose of this work was to examine the process by which communal coping may lead to such benefits. First, we hypothesized that illness-related interactions characterized by more communal coping would involve greater spouse support provision and greater patient receptivity to support. Second, we hypothesized that such interactions would lead to greater perceived problem resolution and more positive perceptions of the interaction. Third, we expected communal coping to predict changes in long-term diabetes outcomes—increased self-efficacy, improved self-care, and reduced diabetes distress—6 months later. Finally, we predicted that these long-term links would be partially explained by the immediate interaction outcomes. We tested these hypotheses in a sample of 123 persons with recently diagnosed type 2 diabetes and their spouses. Patient and spouse communal coping was observed in the laboratory during a diabetes stressor discussion, and patients reported outcomes immediately after the discussion and 6 months later. Results were largely consistent with hypotheses, but spouse communal coping was more consistently linked to support outcomes, and only patient communal coping was linked to changes in long-term outcomes. This work contributes to the literature indicating communal coping is beneficial for individuals with chronic illness and provides insight into the process by which communal coping exerts these effects.

Background: MODY 5 is an infrequently reported form of monogenic diabetes attributed to deletions of chromosome 17q12 with impaired expression of HNF1β (Hepatocyte Nuclear Factor 1 Beta). We report a patient who presented with hyperglycemia and hypomagnesemia with an eventual diagnosis of MODY5 that responded to treatment with the SGLT2 inhibitor (SGLT2i), canagliflozin. Clinical case: A 64-year-old male diagnosed with diabetes at age 60 and treated with glimepiride and metformin (HbA1c 6.1–6.2% without hypoglycemia) presented to establish care. He had a prior history of hypermagnesuric hypomagnesemia (serum Magnesium (Mg) 1.4 ± 0.3 mg/dl with Fractional Excretion of Mg (FEMg) 32 ± 3% [values >3–4% in the setting of normal renal function and hypomagnesemia indicates renal Mg loss]) that developed while taking Triamterene- HCTZ for hypertension, prompting discontinuation. Treatment with oral and intravenous (IV) Magnesium along with Amiloride failed to normalize serum Mg levels. Genetic evaluation revealed 17q12 deletion consistent with a diagnosis of MODY 5. Referral to nephrology resulted in discontinuation of glimepiride and addition of canagliflozin 100 mg titrated to 300 mg daily. Mg levels normalized (serum Mg level 1.9 ± 0.1 mg/dL) within 8 weeks of canagliflozin therapy, allowing discontinuation of IV Mg and patient reported improvement in physical stamina and quality of life. At his 1 year follow up visit, his serum Mg remains stable at 1.8mg/dl with a FEMg of 22 ± 2.5%. His current therapy includes Metformin 2 gm, Canagliflozin 300 mg, Amiloride 10 mg tid, and oral Mg. Discussion: Prior to introduction of the SGLT2i, MODY 5 patients required oral and IV Mg repletion in combination with amiloride to achieve near normal Mg levels. Several clinical trials with SGLT2i demonstrated dose and agent dependent improvement in Mg levels in patients with type 2 diabetes. Proposed explanations include reductions in eGFR, changes in intraluminal electrical potential, and activation of renin angiotensin aldosterone system. Mg replacement results not only in symptomatic improvement, but has also been demonstrated to reduce risk of stroke and all-cause mortality. In summary, SGLT2 inhibitors in patients with MODY 5 can be effective in restoring normal Mg levels, improving quality of life, and reducing all cause mortality.

Background Adjusting to the challenges of a chronic illness does not affect patients alone but also influences social network members—most notably spouses. One interpersonal framework of coping with a chronic illness is communal coping, described as when a problem is appraised as joint and the couple collaborates to manage the problem. Purpose We sought to determine whether daily communal coping was linked to daily mood and self-care behavior and examined one potential mechanism that may explain these links: perceived emotional responsiveness. Methods Patients who had been diagnosed with diabetes less than 5 years ago and their spouses (n = 123) completed a daily diary questionnaire that assessed communal coping and mood for 14 consecutive days. The patients also reported daily self-care behaviors. We used multilevel modeling to examine the links of communal coping to patient and spouse mood and patient self-care. Because both patients and spouses reported their mood, the actor-partner interdependence model (APIM) was employed to examine mood. Results Multilevel APIM showed that actor communal coping was associated with lower depressed mood, higher happy mood, and lower angry mood and partner communal coping was linked to higher happy mood. Patient communal coping was related to better dietary and medication adherence, and spouse communal coping was linked to better medication adherence. Perceived emotional responsiveness partially mediated the relations of communal coping to mood but not to self-care behaviors. Conclusions Communal coping on a daily basis may help both patients and spouses adjust psychologically to the illness as well as enhance patient self-care behaviors.

AIMS: Hospitalized patients with diabetes are have an impaired ability to detect hypoglycemia events. The purpose of this study was to compare hypoglycemia symptom scores (HSS) in hospitalized patients with diabetes after a documented blood glucose (BG)

OBJECTIVE To assess the cost-effectiveness (CE) of an intensive lifestyle intervention (ILI) compared with standard diabetes support and education (DSE) in adults with overweight/obesity and type 2 diabetes, as implemented in the Action for Health in Diabetes study. RESEARCH DESIGN AND METHODS Data were from 4,827 participants during their first 9 years of study participation from 2001 to 2012. Information on Health Utilities Index Mark 2 (HUI-2) and HUI-3, Short-Form 6D (SF-6D), and Feeling Thermometer (FT), cost of delivering the interventions, and health expenditures was collected during the study. CE was measured by incremental CE ratios (ICERs) in costs per quality-adjusted life year (QALY). Future costs and QALYs were discounted at 3% annually. Costs were in 2012 U.S. dollars. RESULTS Over the 9 years studied, the mean cumulative intervention costs and mean cumulative health care expenditures were $11,275 and $64,453 per person for ILI and $887 and $68,174 for DSE. Thus, ILI cost $6,666 more per person than DSE. Additional QALYs gained by ILI were not statistically significant measured by the HUIs and were 0.07 and 0.15, respectively, measured by SF-6D and FT. The ICERs ranged from no health benefit with a higher cost based on HUIs to $96,458/QALY and $43,169/QALY, respectively, based on SF-6D and FT. CONCLUSIONS Whether ILI was cost-effective over the 9-year period is unclear because different health utility measures led to different conclusions.

Hospitalized patients with DM are at high risk for early readmission. Improving inpatient education and discharge (DC) processes are proposed interventions for reducing this risk. We examined the contribution of blood glucose (BG) 48 hr prior to DC (nadir, peak, STD, CV) and patient comprehension (PC) of instructions for home DM management following DC to risk for 30d readmission. Insulin treated non-critically ill patients with DM (N=202) were recruited. Diabetes Early Readmission Risk Indicators (DERRI) were calculated for each participant, who were contacted within 48 hr of DC to complete a PC Questionnaire (PCQ). Of 126 participants [age mean (STD) 61(12) years, BMI 32.9 (9.6) kg/m2, A1c 8.0 (2.2%), 45% women, 22% black, 85% type 2DM] who completed the PCQ, 42 (33%) required clarification of misunderstood DC instructions. PC scores were negatively correlated with BG STD (-0.17, 95% CI:-0.32,-0.02) and CV (-0.38, -0.7, -0.05). There was no difference in median (25ile, 75ile) PC scores between patients with and without 30d readmission (79 (67, 93%) vs.83 (71,100%), p=0.19); however, there were more readmissions in those with PC scores Among all 202 participants, median DERRI scores were higher in the 25% with 30d readmission (27 (24, 30)) than those without (19 (20, 24), p = 0.002). In summary, these results demonstrate deficiencies in the hospital DC process as demonstrated by the need for clarification of information in >30% of patients following DC. It is possible that this corrected information may have served as an intervention to reduce readmission risk. PC scores were negatively associated with glycemic variability preceding DC and scores Disclosure D. Pinkhasova: None. J. Swami: None. N. Patel: None. A. Donihi: None. L.M. Siminerio: None. E. Karslioglu French: None. K. Delisi: None. D.S. Hlasnik: None. D.J. Rubin: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc. M.T. Korytkowski: None. Funding National Institutes of Health (UL1-TR-001857)

Background: Adherence to medications is vital for glycemic control in type 2 diabetes. It is unclear if insomnia is a barrier to medication adherence. The aim of this secondary analysis was to examine the association between insomnia and adherence to insulin therapy. Method: Using a cross-sectional design, baseline data from subjects (N=139) prescribed insulin from the Diabetes Sleep Treatment Trial were analyzed. Measures included demographics, A1C, BMI, the Insomnia Severity Index, and the Pittsburgh Sleep Quality Index. Self-reported adherence to insulin therapy was determined by response to the question: How many of the past 7 days did you take your recommended insulin injections and scored as 7 days for adherent (77.7%; n=107) and 0 to 6 days for non-adherent (23.0%; n=32). Data were analyzed using univariate and backward multivariate logistic regression. Results: The sample was diverse (55.4% white; 46.0% female; 41.7% married/partnered; 55.4% >2 years post high school with a mean age of 56.3±10.9 years, BMI of 35.2±6.6 kg/m2; and A1C of 8.3±1.7%). Individuals with insulin adherence had a lower A1C than those with non-adherence (8.0±1.6% vs. 9.5±1.7%, p Conclusion: These results suggest insomnia severity and race are associated with deceased insulin adherence. The mechanisms for these potential associations need to be further explored. Disclosure Y. Zheng: None. M.T. Korytkowski: None. S.M. Sereika: None. L.E. Burke: None. C.W. Atwood: None. P.J. Strollo: Consultant; Self; Emmi, Inspire Medical Systems, Philips Respironics. Research Support; Self; Jazz Pharmaceuticals, ResMed. B. Jeon: None. E.R. Chasens: Research Support; Self; National Institute of Diabetes and Digestive and Kidney Diseases, Philips Respironics, ResMed Inc. Funding National Institutes of Health (R01DK096028)

Gender differences have been described for glycemic control and prevalence of diabetes related complications in the outpatient setting but have not been examined in the hospitalized population. To address this, we investigated gender differences in demographics, glycemic control and variability (GV), macrovascular and microvascular complications, and admission diagnosis in non-critically ill hospitalized patients with a secondary diagnosis of diabetes recruited for the Readmission and Comprehension of Diabetes Education at Discharge (ReCoDED) Study. To date, 111 men and 87 women have been recruited, with the majority having type 2 DM (86 vs. 79%). Participants age (men vs. women) was 60.6 ± 11.7 vs. 57.6 ± 11.8 years, BMI 32.2 ± 8.4 vs. 32.1 ± 10.6 kg/m2, systolic (SBP) 136 ± 26 vs. 127 ± 23 mmHg, diastolic (DBP) 77 ± 13 vs. 75 ± 14 mmHg, HbA1c 8.0 ± 2.3 vs. 8.3% ± 2.5%, and DM duration 14.5 ± 10.4 vs. 14.1 ± 11.6 years. Race, education, and employment were similar. Men had more retinopathy (23 vs. 16%) and nephropathy (40 vs. 28%), but not neuropathy (60 vs. 63%). Women had a lower prevalence of CAD (49 vs. 36%), but a similar prevalence of CHF (37 vs. 37%), stroke (15 vs. 18%), and PVD (18 vs. 17%). The most frequent admission diagnoses were CVD (37 vs. 22%) and infection (10 vs. 19%). Mean blood glucose (BG) (198 ± 51 vs. 200 ± 54 mg/dl), GV (177 ± 80 vs. 182 ± 112 mg/dl), frequency of hypoglycemia (BG < 70 mg/dl) and hyperglycemia (BG >250 mg/dl) were similar in the 48 hours prior to discharge. Length of stay was 7.8 ± 6.9 vs. 8.3 ± 7.4 days. In summary, this gender-based description of glycemic control and prevalence of diabetes-related complications in an inpatient population demonstrates that hospitalized women with DM have fewer microvascular complications, a lower prevalence of CAD but a similar prevalence of CHF, stroke and PVD when compared to men, despite similar BMI and DM duration. These findings will be examined as a risk factor for hospital readmissions in this ongoing study. Disclosure N. Patel: None. D. Pinkhasova: None. A. Donihi: None. E. Karslioglu French: None. L.M. Siminerio: None. K. Delisi: None. D.S. Hlasnik: None. M.T. Korytkowski: None.

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

To test whether average long-term glucose exposure is associated with cognitive and physical function in middle-aged and younger-old adults with type 2 diabetes mellitus.Prospective cohort study.Data obtained as part of the Action for Health in Diabetes (Look AHEAD) trial (NCT00017953) and Look AHEAD Movement and Memory ancillary study (NCT01410097).Overweight and obese individuals with type 2 diabetes mellitus aged 45 to 76 at baseline (N = 879).Glycosylated hemoglobin (HbA1c) was measured at regular intervals over 7 years, and objective measures of cognitive function (Trail-Making Test, Modified Stroop Color-Word Test, Digit Symbol-Coding, Rey Auditory Verbal Learning Test, Modified Mini-Mental State Examination) and physical function (Short Physical Performance Battery, expanded Physical Performance Battery, 400-m and 20-m gait speed) and strength (grip and knee extensor strength) were assessed at the Year 8 or 9 follow-up examination.Average HbA1c exposure was 7.0 ± 1.1% (53 ± 11.6 mmol/mol), with 57% of participants classified as having HbA1c levels of less than 7% (53 mmol/mol), 27% having levels of 7% to 8% (53-64 mmol/mol), and 16% having levels of greater than 8% (64 mmol/mol). After adjustment for age, sex, race, education, smoking status, alcohol intake, knee pain, physical fitness, body mass index, diabetes mellitus medication and statin use, ancillary year visit, and study arm and site, higher HbA1c was associated with worse physical but not cognitive function. Further adjustment for prevalent diabetes mellitus-related comorbidities made all associations nonsignificant. Results did not differ when stratified according to participant baseline age (60 vs ≥ 60).Results presented here suggest that, in the absence of diabetes mellitus-related complications, longitudinal glucose exposure is not associated with future cognitive and physical function. Optimal management of diabetes mellitus-related comorbidities may prevent or reduce the burden of disability associated with type 2 diabetes mellitus.

When an individual in a close relationship is diagnosed with a chronic illness, coping can be the responsibility of the patient or couple members can cope communally. Communal coping reflects a shared appraisal of a stressor (our problem instead of my problem) and collaborative efforts to address the stressor. The current study examined whether patients’ and partners’ communal coping levels were associated with relational and health functioning among 70 couples in which one member was recently diagnosed with type 2 diabetes. We assessed explicit communal coping with self-reported “inclusion of the other in the self” in regard to diabetes management and implicit communal coping with first-person plural pronoun usage during a diabetes discussion. We also assessed patient reports of support received from partners, patient and partner psychological distress, and patient self-care behavior. Results showed that patient explicit communal coping was related to better patient relationship quality and greater support receipt from partners. Patient and partner explicit communal coping also were related to reduced partner distress but not patient distress. Instead, partner implicit communal coping was related to reduced patient distress. Most noteworthy, partner implicit communal coping was related to better patient self-care behavior. These results suggest that communal coping may be beneficial for both relationships and health but that the effects of explicit measures differ from those of implicit measures. Patients might benefit especially from partner communal coping efforts that are less obvious.

OBJECTIVEThe Insulin Resistance Intervention after Stroke (IRIS) trial recently found that pioglitazone reduced risk for stroke and myocardial infarction in patients with insulin resistance but without diabetes who had had a recent ischemic stroke or transient ischemic attack (TIA). This report provides detailed results on the metabolic effects of pioglitazone and the trial’s prespecified secondary aim of diabetes prevention.RESEARCH DESIGN AND METHODSA total of 3,876 patients with recent ischemic stroke or TIA, no history of diabetes, fasting plasma glucose (FPG) 3.0 were randomly assigned to pioglitazone or placebo. Surveillance for diabetes onset during the trial was accomplished by periodic interviews and annual FPG testing.RESULTSAt baseline, the mean FPG, HbA1c, insulin, and HOMA-IR were 98.2 mg/dL (5.46 mmol/L), 5.8% (40 mmol/mol), 22.4 μIU/mL, and 5.4, respectively. After 1 year, mean HOMA-IR and FPG decreased to 4.1 and 95.1 mg/dL (5.28 mmol/L) in the pioglitazone group and rose to 5.7 and 99.7 mg/dL (5.54 mmol/L), in the placebo group (all P < 0.0001). Over a median follow-up of 4.8 years, diabetes developed in 73 (3.8%) participants assigned to pioglitazone compared with 149 (7.7%) assigned to placebo (hazard ratio [HR] 0.48 [95% CI 0.33–0.69]; P < 0.0001). This effect was predominately driven by those with initial impaired fasting glucose (FPG >100 mg/dL [5.6 mmol/L]; HR 0.41 [95% CI 0.30–0.57]) or elevated HbA1c (>5.7% [39 mmol/mol]; HR 0.46 [0.34–0.62]).CONCLUSIONSAmong patients with insulin resistance but without diabetes who had had a recent ischemic stroke or TIA, pioglitazone decreased the risk of diabetes while also reducing the risk of subsequent ischemic events. Pioglitazone is the first medication shown to prevent both progression to diabetes and major cardiovascular events as prespecified outcomes in a single trial.

The Diabetes Sleep Treatment Trial (DSTT) is a multi-site, double-blinded, randomized, sham-controlled trial. The study objective is to test whether treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) treatment results in improved glycemic control and diabetes self-management behavior compared to participants on a sham-CPAP (sub-therapeutic) device in participants with type 2 diabetes mellitus (T2DM) and co-morbid OSA. The purpose of this paper is to describe the premise for the DSTT, the study design, and the methodology used in this on-going trial. The target enrollment is 210 randomly assigned participants recruited from two sites. The primary outcome for glucose control is HbA1C; additional outcomes for diabetes self-management include objectively measured steps walked and subjectively measured diabetes-related distress, diabetes empowerment, and diabetes knowledge. All participants receive individual diabetes education and counseling for 6 weeks over two individual sessions and three telephone calls. Participants are randomized to receive either sham or active CPAP for 12 weeks, after which, they “guess” their group assignment; this will assist in determining the success of blinding participants to treatment group assignment. Participants revealed to be on active CPAP will be encouraged to continue CPAP for an additional 12 weeks; participants who had been on sham devices will be encouraged to have a repeat CPAP titration study and to crossover to active CPAP treatment for 24 weeks. An intention-to-treat approach will be used for efficacy analyses. The trial is registered with Clinicaltrials.gov ( NCT01901055 ).

Background Health information technology tools (eg, patient portals) have the potential to promote engagement, improve patient-provider communication, and enhance clinical outcomes in the management of chronic disorders such as diabetes mellitus (DM). Objectives The aim of this study was to report the findings of a literature review of studies reporting patient portal use by individuals with type 1 or type 2 DM. We examined the association of the patient portal use with DM-related outcomes and identified opportunities for further improvement in DM management. Methods Electronic literature search was conducted through PubMed and PsycINFO databases. The keywords used were "patient portal*," "web portal," "personal health record," and "diabetes." Inclusion criteria included (1) published in the past 10 years, (2) used English language, (3) restricted to age ≥18 years, and (4) available in full text. Results This review included 6 randomized controlled trials, 16 observational, 4 qualitative, and 4 mixed-methods studies. The results of these studies revealed that 29% to 46% of patients with DM have registered for a portal account, with 27% to 76% of these patients actually using the portal at least once during the study period. Portal use was associated with the following factors: personal traits (eg, sociodemographics, clinical characteristics, health literacy), technology (eg, functionality, usability), and provider engagement. Inconsistent findings were observed regarding the association of patient portal use with DM-related clinical and psychological outcomes. Conclusions Barriers to use of the patient portal were identified among patients and providers. Future investigations into strategies that engage both physicians and patients in use of a patient portal to improve patient outcomes are needed.

Summarize safety issues related to patients using insulin pump therapy and continuous glucose monitoring systems (CGMS) in the outpatient setting when they are hospitalized and to review steps that can be taken to mitigate risk associated with use or discontinuation of these devices. Two recent consensus conferences were held on the topics of inpatient use of insulin pumps and CGMS devices. In addition to commonly known safety issues (e.g., device malfunction, infection), cybersecurity and the vulnerability of contemporary technology to hacking have emerged. CGMS capabilities offer the promise of advancing the goal for development of glucometry (centralized monitoring of real-time glucose data). Strategies to assuring safe use of insulin pumps and CGMS in the hospital include collaboration between the patient and staff, proper patient selection, and clear policies and procedures outlining safe use. Available data indicates few adverse events associated with these devices in the hospital. Current data suggests, with proper patient selection and a clear process in place for glycemic management, that adverse events are rare, and consensus favors allowing use of the technology in the hospital. The topic of insulin pump and CGMS in the hospital would greatly benefit from more institutions reporting on their experiences and prospective clinical trials.

Patients admitted to the hospital with DKA are at high-risk for readmission. We have previously demonstrated that implementation of a DKA PowerPlan (PP) that guides IV insulin dosing following acute management and transition to SC insulin reduces the frequency of recurrent DKA and rebound hyperglycemia during the index hospitalization. The purpose of this study was to determine whether the DKA PP reduces all cause and diabetes-related (recurrent DKA, hyperglycemia, hypoglycemia) hospital readmissions at 30 days and 1 year following an index hospitalization, as well to examine the contribution of high risk co-morbidities (psychiatric illness and/or history of alcohol/polysubstance abuse) associated with readmission risk in this group of patients. Retrospective chart review was performed for patients admitted with primary diagnosis of DKA prior to (pre-PP, n=60) and following DKA PP implementation (Post-PP, n=60). The groups were similar in age (Pre- vs. Post-PP: 38 ± 13.5 vs. 40 ± 16.6), BMI (26 ± 6.7 vs. 27 ± 7 kg/m2), gender (%Male: 38% vs. 48%), HbA1c (11.7 ± 2.4 vs. 11.3 ± 2.9%), admission BG (560 vs. 615 mg/dl) and anion gap (AG) (27.6 vs. 27.4), but differed in the prevalence of comorbidities which were higher in the pre-PP group (58 vs. 40%, p = 0.045). All cause readmissions were similar at 30 days (Pre vs. Post-PP: 1.4 ± 0.8 vs. 1.2 ± 0.4) but were lower at 1 year in the post-PP group (5.2 ± 4.7 vs. 3.5 ± 2.7, p = 0.07). Patients with co-morbidities in the post-PP group had lower all-cause (p = 0.023) but not diabetes related readmissions at 1 year, compared to patients with co-morbidities in the pre-PP group. In summary, these findings suggest that a DKA PP may be associated with a reduction in all cause hospital readmission in high risk patients with underlying psychiatric or substance abuse disorders. These results emphasize the need to identify and address patient specific factors that contribute to readmission in this high risk group. Disclosure N. Karajgikar: None. A. Donihi: None. R.A. Salata: None. R. Codario: None. R. Acharya: None. P. Manroa: None. M.T. Korytkowski: Advisory Panel; Self; Novo Nordisk Inc.. Other Relationship; Self; JAEB Center For Health Research.

Background: Electronic messaging via a patient portal is being used with increasing frequency for patient-provider communication, especially for the ongoing management of type 2 diabetes (T2DM). Providing patients online access to providers may reduce the need for face-to-face contact; yet little is known about the usage pattern and its association with the frequency of office visits to primary care providers (PCP). Methods: A cross-sectional analysis was conducted using the data from the ambulatory electronic health records of UPMC Physician Services. Adults with T2DM who were seen in UPMC PCP offices between Jan 2015 and Dec 2016 were included. The number of days messaging was used, and the number of PCP visits for each patient were calculated during the study period. Descriptive statistics were applied. Negative binomial regression was performed to examine the association of messaging use with the number of PCP visits, adjusting for age, gender, race, education, income, insurance type, and the number of comorbidities. Results: The sample (N=42,746) was 85.5% white and 49.9% female with a mean age of 65.2±11.9 years. About a third (36.7%, n=15,698) used the messaging feature at least once during the study period. The median number of days that patients used the messaging feature was 13.0 (range 1-395). Negative binomial regression revealed that greater use of messaging was associated with a greater number of PCP visits (Incidence Rate Ratio 1.0014, 95% CI, 1.0011-1.0018). Conclusion: In our study, over one-third of the patients used the messaging feature via the portal. More frequent use of messaging was associated with a greater number of PCP visits, suggesting that both measures represent patient engagement in health care services. However, the frequency of PCP visits may not be an accurate indicator of clinical outcomes. Future studies that include patient outcome measures, such as HbA1c, according to portal use are needed as use of this technology increases. Disclosure R. Sun: None. S.M. Sereika: None. M. Saul: None. M.T. Korytkowski: Advisory Panel; Self; Novo Nordisk Inc.. Other Relationship; Self; JAEB Center For Health Research. D. Li: None. L.E. Burke: None.

Diabetes (DM) is a major contributor to risk for hospital readmission. The Diabetes Early Readmission Risk Indicator (DERRI) is a predictor of 30-day readmission in patients with DM that may allow early identification and intervention for high-risk patients. A limitation to DERRI is the absence of DM-specific factors as contributors to this risk. To address this, we investigated HbA1c, glycemic measures and variability (GV), changes in DM therapy at discharge, and patient responses to a novel post-discharge questionnaire directed at Patient Comprehension (PC) of instructions provided for home DM management. Non-critically ill adult patients with DM were contacted by phone within 48 hours of hospital discharge to complete the PC Questionnaire. To date, 70 subjects (type 1 n=9, type 2 n=53, pancreatogenic DM n=8) (mean age 57.2 ± 12.8 years, BMI 31 ± 8.8 kg/m2, 56% men, 71% Caucasian, HbA1c 8.6 ± 2.0%, DM duration 19 ± 12 years, mean BG prior to discharge (210 ± 49 mg/dL), GV (66 ± 35 mg/dl) have been recruited. Of 41 subjects completing the PC questionnaire, those reporting that discharge instructions for home DM management were not provided had lower PC scores (70.6% vs. 81.5%, p=0.025) and more readmissions (OR 5.6, p=0.04) than those reporting that instructions were given. Among the 60 subjects with one-month post-discharge data, 22 patients (37%) reporting ≥1 readmission had higher DERRI scores than those without readmissions (26% vs. 20%, p=0.023). HbA1c, GV and changes in DM treatment regimens were not associated with readmission. In summary, these results demonstrate that PC of discharge instructions may be a novel mediator of readmission risk and may add an additional measure of risk for hospital readmission. Disclosure J. Swami: None. A. Donihi: None. E. Karslioglu French: None. K. Delisi: None. D.S. Hlasnik: None. N. Patel: None. D. Pinkhasova: None. D.J. Rubin: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc. M.T. Korytkowski: Advisory Panel; Self; Novo Nordisk Inc.. Other Relationship; Self; JAEB Center For Health Research.