Cost-effectiveness of postoperative imaging surveillance strategies for nonfunctional pituitary adenomas after resection with curative intent.

OBJECTIVE: The aim of this study was to determine an optimal follow-up imaging surveillance strategy in terms of cost-effectiveness after resection of nonfunctioning pituitary adenomas with curative intent. METHODS: An individual-level state-transition microsimulation model was used to simulate costs and outcomes associated with three postoperative imaging strategies over a lifetime time horizon: 1) annual MRI surveillance, 2) tapered MRI surveillance (annual surveillance for 5 years followed by surveillance every 2 years), and 3) personalized surveillance (annual surveillance for 5 years followed by surveillance every 2 years when MRI shows remnant disease/postoperative changes, and surveillance at 7, 10, and 15 years for disease-free MRI). Transition probabilities, utilities, and costs were estimated from recent published data and discounted by 3% annually. Model outcomes included lifetime costs (2022 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS: Under base case assumptions, annual surveillance yielded higher costs and lower health effects (QALYs) compared with the tapered and personalized surveillance strategies (dominated). Personalized surveillance demonstrated an additional 0.1 QALY at additional cost ($1298) compared with tapered surveillance (7.7 QALYs at a cost of $12,862). The ICER was $11,793/QALY. The optimal decision was most sensitive to the probability of postoperative changes on MRI after surgery and MRI cost. Accounting for parameter uncertainty, personalized surveillance had a higher probability of being a cost-effective surveillance option compared with the alternative strategies at 79%. CONCLUSIONS: Using standard cost-effectiveness thresholds in the US ($100,000/QALY), personalized surveillance that accounted for remnant disease or postoperative changes on MRI was cost-effective compared with alternative surveillance strategies.

Patient Perspectives on Virtual Care for Diabetes Management in the Era of COVID-19.

OBJECTIVE: The aim of this study was to characterize patient perspectives on the quality of diabetes care at The Ottawa Hospital Endocrinology and Metabolism multidisciplinary clinic delivered virtually during the COVID-19 pandemic. METHODS: An online survey was developed to collect quantitative and qualitative data on patients' experiences with virtual diabetes clinic visits between March 2020 and April 2021. RESULTS: A total of 333 patients were included in this study; 45% were female and had a mean age of 60 years. Seventy-nine percent were born in Canada and 87% identified as Caucasian. Thirty-six percent were treated for type 1 diabetes and 62% for type 2 diabetes. Eighty-seven percent of virtual visits occurred by phone, with 12% of these on Zoom. Overall, 83% were "very satisfied" or "satisfied" with their virtual care experience. Most respondents perceived all treatment-related factors to be equally well addressed virtually as in person, except for physical examination. Auxiliary factors like travel, cost, and time spent were rated more favourably with virtual care. Qualitative findings provided further contextualization and identified gaps in virtual care delivery. For future visits, 44% wanted in-person visits only as needed, 36% wanted a hybrid of in-person and virtual appointments, and 11% preferred in-person appointments only. CONCLUSIONS: Patients perceive that virtual care provides high-fidelity diabetes management while reducing their pandemic risks as well as minimizing travel and time associated with in-person care. Virtual care is an important medium for diabetes care delivery that should be used according to patient preference and intermixed with in-person appointments.

Approach to the Patient: Preventing Adrenal Crisis Through Patient and Clinician Education.

Adrenal crisis continues to be an important cause of death despite being a preventable condition. Significant deficits in patient education in the prevention of adrenal crisis have been identified as a contributor to adrenal crisis risk, despite the importance of patient education being highlighted in international guidelines. Deficits in clinician education have also been identified as risk factors for adrenal crisis although they have not been addressed. We use 3 clinical cases to highlight the role of both patient and clinician education in the prevention of adrenal crisis, review what is known about education related to adrenal insufficiency and provide a possible approach to addressing education deficits with the aim of reducing the risk of adrenal crisis through both patient and clinician education.

Post-operative surveillance for somatotroph, lactotroph and non-functional pituitary adenomas after curative resection: a systematic review.

CONTEXT: Pituitary tumors are the third most common brain tumor and yet there is no standardization of the surveillance schedule and assessment modalities after transsphenoidal surgery. EVIDENCE ACQUISITION: OVID, EMBASE and the Cochrane Library databases were systematically screened from database inception to March 5, 2020. Inclusion and exclusion criteria were designed to capture studies examining detection of pituitary adenoma recurrence in patients 18 years of age and older following surgical resection with curative intent. EVIDENCE SYNTHESIS: A total of 7936 abstracts were screened, with 812 articles reviewed in full text and 77 meeting inclusion criteria for data extraction. A pooled analysis demonstrated recurrence rates at 1 year, 5 years and 10 years for non-functioning pituitary adenomas (NFPA; N = 3533 participants) were 1%, 17%, and 33%, for prolactin-secreting adenomas (PSPA; N = 1295) were 6%, 21%, and 28%, and for growth-hormone pituitary adenomas (GHPA; N = 1257) were 3%, 8% and 13%, respectively. Rates of recurrence prior to 1 year were 0% for NFPA, 1-2% for PSPA and 0% for GHPA. The mean time to disease recurrence for NFPA, PSPA and GHPA were 4.25, 2.52 and 4.18 years, respectively. CONCLUSIONS: This comprehensive review of the literature quantified the recurrence rates for commonly observed pituitary adenomas after transsphenoidal surgical resection with curative intent. Our findings suggest that surveillance within 1 year may be of low yield. Further clinical trials and cohort studies investigating cost-effectiveness of surveillance schedules and impact on quality of life of patients under surveillance will provide further insight to optimize follow-up.

The Resistance Exercise in Already Active Diabetic Individuals (READI) Randomized Clinical Trial.

CONTEXT: Resistance exercise training (strength training) and aerobic exercise training are both recommended for people with type 1 diabetes, but it is unknown whether adding resistance exercise provides incremental benefits in people with this condition who already perform aerobic exercise regularly. OBJECTIVE: This work aimed to evaluate the incremental effect of resistance training on glycated hemoglobin A1c (HbA1c), fitness, body composition, and cardiometabolic risk factors in aerobically active people with type 1 diabetes. METHODS: The Resistance Exercise in Already-active Diabetic Individuals (READI) trial (NCT00410436) was a 4-center, randomized, parallel-group trial. After a 5-week run-in period with diabetes management optimization, 131 aerobically active individuals with type 1 diabetes were randomly assigned to resistance exercise (n = 71, intervention-INT) or control (n = 60, CON) for 22 additional weeks. Both groups maintained their aerobic activities and were provided dietary counseling throughout. Exercise training was 3 times per week at community-based facilities. The primary outcome was HbA1c, and secondary outcomes included fitness (peak oxygen consumption, muscle strength), body composition (anthropometrics, dual-energy x-ray absorptiometry, computed tomography), and cardiometabolic risk markers (lipids, apolipoproteins). Assessors were blinded to group allocation. RESULTS: There were no significant differences in HbA1c change between INT and CON. Declines in HbA1c (INT: 7.75 ± 0.10% [61.2 ± 1.1 mmol/mol] to 7.55 ± 0.10% [59 ± 1.1 mmol/mol]; CON: 7.70 ± 0.11% [60.7 ± 1.2 mmol/mol] to 7.57 ± 0.11% [59.6 ± 1.3 mmol/mol]; intergroup difference in change -0.07 [95% CI, -0.31 to 0.18]). Waist circumference decreased more in INT than CON after 6 months (P = .02). Muscular strength increased more in INT than in CON (P < .001). There were no intergroup differences in hypoglycemia or any other variables. CONCLUSION: Adding resistance training did not affect glycemia, but it increased strength and reduced waist circumference, in aerobically active individuals with type 1 diabetes.

Suggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes.

OBJECTIVES: The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada. METHODS: A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management. RESULTS: Glycemic management standards were developed for the following categories: Organization of Care; Preoperative Assessment; Immediate Preoperative and Intraoperative; Postanesthesia Care Unit or Recovery Room; Postoperative Period; and Transition to Outpatient Care. CONCLUSIONS: It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.

Clinical practice guideline: evidence, recommendations and algorithm for the preoperative optimization of anemia, hyperglycemia and smoking.

Preoperative optimization has not been explored comprehensively in the surgical literature, as this responsibility has often been divided among surgery, anesthesia and medicine. We developed an evidence-based clinical practice guideline to summarize existing evidence and present diagnostic and treatment algorithms for use by surgeons caring for patients scheduled to undergo major elective surgery. We focus on 3 common comorbid conditions seen across surgical specialties - anemia, hyperglycemia and smoking - as these conditions increase complication rates in patients undergoing major surgery and can be optimized successfully as soon as 6-8 weeks before surgery. With the ability to address these conditions earlier in the patient journey, surgeons can positively affect patient outcomes. The aim of this guideline is to bring optimization in the preoperative period under the existing umbrella of evidence-based surgical care.

Real-World Patient Experience of Long-Term Hybrid Closed-Loop Insulin Pump Use.

OBJECTIVES: Understanding of patient experiences and adaptations to hybrid closed-loop (HCL) pumps beyond the confines of short-term clinical trials is needed to inform best practices surrounding this emerging technology. We investigated long-term, real-world patient experiences with HCL technology. METHODS: In semistructured interviews, 21 adults with type 1 diabetes at a single Canadian tertiary diabetes centre discussed their transition to use of Medtronic MiniMed 670G auto-mode. Interviews were audio-recorded, transcribed and analyzed iteratively to identify emerging themes. RESULTS: Participants' mean age was 50±13 years, 12 of the 21 participants were female, baseline glycated hemoglobin (A1C) was 7.9±1.0% and auto-mode duration was 9.3±4.6 months. Three had discontinued auto-mode. Most participants praised auto-mode for reducing hypoglycemia, stabilizing glucose overnight and improving A1C, while also reporting frustration with frequency of alarms and user input, sensor quality and inadequate response to hyperglycemia. Participants with the highest baseline A1Cs (8.8% to 9.8%) tended to report immense satisfaction and trust in auto-mode, meeting their primary expectations of improved glycemic control. In contrast, participants with controlled diabetes (A1C <7.5%) had hoped to offload active management but experienced significant cognitive and emotional labour associated with relinquishing control during suboptimal auto-mode performance. Participants were commonly aware of workarounds to "trick" the pump, and almost all participants with A1C <7.5% tried at least 1 workaround. CONCLUSIONS: In the real-world setting, patients' goals and satisfaction with auto-mode appeared to vary considerably with their baseline diabetes control. Patients with the most suboptimal glycemic control described the greatest benefits and easiest adaptation process, challenging commonly held assumptions for patient selection for pump therapy.

Assessing the validity of an OSCE developed to assess rare, emergent or complex clinical conditions in endocrinology & metabolism.

BACKGROUND: Assessment of emergent, rare or complex medical conditions in Endocrinology and Metabolism (E&M) is an integral component of training. However, data is lacking on how this could be best achieved. The purpose of this study was to develop and administer an Objective Structured Clinical Examination (OSCE) for E&M residents, and to gather validity evidence for its use. METHODS: A needs assessment survey was distributed to all Canadian E&M Program Directors and recent graduates to determine which topics to include in the OSCE. The top 5 topics were selected using a modified Delphi technique. OSCE cases based on these topics were subsequently developed. Five E&M residents (PGY4-5) and five junior Internal Medicine (IM) residents participated in the OSCE. Performance of E&M and IM residents was compared and results were analyzed using a Generalizability study. Examiners and candidates completed a survey following the OSCE to evaluate their experiences. RESULTS: The mean score of IM and E&M residents was 41.7 and 69.3 % (p < 0.001), respectively, with a large effect size (partial η2 = 0.75). Overall reliability of the OSCE was 0.74. Standard setting using a borderline regression method resulted in a pass rate of 100 % of E&M residents and 0 % of IM residents. All residents felt the OSCE had high value for learning as a formative exam. CONCLUSIONS: The E&M OSCE is a feasible method for assessing emergent, rare and complex medical conditions and this study provides validity evidence to support its use in a competency-based curriculum.

Virtual care and the pursuit of the quadruple aim: A case example.

Many healthcare organizations have adopted the quadruple aim to create system-level improvements for delivering enhanced experience and outcomes to patients, healthier populations, reduced per-capita costs, and better provider experiences. With a maturing health technology sector, virtual care is gradually being adopted in Canada and proving to be a viable tactic for achieving the quadruple aim. Despite increased acceptance of virtual innovations and their related benefits to patients and providers, implementation of virtual care can be challenging in a Canadian healthcare system. The Ottawa Hospital developed an innovation strategy to guide the adoption and maturity of virtual care as a means of supporting the pursuit of the quadruple aim and achievement of the organization's mission and vision. A case example presenting the strategy and recommendations for health leaders and providers considering implementation of virtual care is discussed.

Variability of Clinical Practice Management of Type 1 and Type 2 Diabetes During Surgery Across Canada.

OBJECTIVE: As part of a larger project to develop quality standards in perioperative diabetes management, the goal of this project was to assess self-reported management of surgical patients with diabetes across healthcare institutions and specialties in Canada. METHODS: Current practice of perioperative management of patients with diabetes was assessed using multiple-choice questions based on commonly encountered clinical scenarios involving patients with type 1 and type 2 diabetes. The survey was sent to a broad stakeholder group of individuals involved in perioperative medicine in academic and community settings across Canada. RESULTS: Responses to clinical case scenarios demonstrated more consistent approaches for patients with type 1 diabetes undergoing cardiac surgery, possibly reflecting more robust evidence. There was more variability in the management of noninsulin antihyperglycemic agents and hyperglycemia in patients with type 2 diabetes undergoing noncardiac surgery. CONCLUSIONS: Given the variability in clinical practice, standards and clinical tools are required for perioperative and periprocedural glycemic management in Canada to inform practice, improve the experience and outcomes for people with diabetes and provide a foundation for quality improvement initiatives and benchmarking.

A Patient-Inspired Quality Improvement Initiative for Pituitary Adenoma Care.

BACKGROUND: Pituitary adenomas (PAs) are common and often require complex multidisciplinary care with multiple specialists. This may result in a healthcare system that is challenging for patients to navigate. Audits of care at our institution revealed opportunities for improvement to better align care with patients' needs. METHODS: A quality improvement initiative that incorporated a patient advisory committee of patients who had received treatment for PA at our center and their family members were used to help identify opportunities for improvement. The patient-identified gaps in care included the need to coordinate and minimize appointments and the desire for better communication and education. Based on this information, changes were implemented to the pituitary program, including increasing access to the Multidisciplinary Clinic and developing a standardized and centralized triage process. RESULTS: A pre- and post-intervention analysis consisting of retrospective chart reviews revealed that these changes had an impact on wait times for first assessment, and a significant shift in the location of this first visit - with a larger proportion of patients being seen in the Multidisciplinary Clinic after an intervention. CONCLUSIONS: We demonstrate that patient involvement, beyond individual patient-physician interactions, can lead to meaningful and observable changes, and can improve the quality of care for PA.

Type 2 diabetes does not exacerbate body heat storage in older adults during brief, extreme passive heat exposure.

Aging exacerbates hyperthermia and cardiovascular strain during passive heat exposure, but it remains unclear whether those effects worsen in older adults with type 2 diabetes (T2D). We examined these responses in unacclimatized, physically active, older individuals with (n = 13, mean ± SD age: 60 ± 8 years, HbA1c: 7.0 ± 1.0%) and without (Control, n = 30, 62 ± 6 years) well-controlled T2D during a brief, 3-h passive exposure to extreme heat (44°C, 30% relative humidity). Metabolic heat production, dry heat gain, total heat gain (metabolic heat production + dry heat gain), evaporative heat loss, body heat storage (summation of heat gain/loss), rectal and mean skin temperatures as well as heart rate were measured continuously. No between-group differences were observed for metabolic heat production (T2D vs. Control; 53 ± 5 vs. 55 ± 7 W/m2), dry heat gain (48 ± 9 vs. 47 ± 11 W/m2), total heat gain (101 ± 10 vs. 102 ± 14 W/m2) and evaporative heat loss (83 ± 10 vs. 85 ± 12 W/m2) over the 3 h (all P > 0.05). Consequently, the changes in body heat storage (380 ± 93 vs. 358 ± 172 kJ, P = 0.67) were similar between groups. Moreover, no between-group differences in rectal and mean skin temperatures or heart rate were measured. We conclude that unacclimatized, physically active, older adults with well-controlled T2D do not experience greater hyperthermia and cardiovascular strain compared to their healthy counterparts while resting in extreme heat for a brief, 3-h period.

Determinants of Poor Glycemic Control in Patients with Kidney Transplants: A Single-Center Retrospective Cohort Study in Canada.

BACKGROUND: Kidney transplant immunosuppressive medications are known to impair glucose metabolism, causing worsened glycemic control in patients with pre-transplant diabetes mellitus (PrTDM) and new onset of diabetes after transplant (NODAT). OBJECTIVES: To determine the incidence, risk factors, and outcomes of both PrTDM and NODAT patients. DESIGN: This is a single-center retrospective observational cohort study. SETTING: The Ottawa Hospital, Ontario, Canada. PARTICIPANT: A total of 132 adult (>18 years) kidney transplant patients from 2013 to 2015 were retrospectively followed 3 years post-transplant. MEASUREMENTS: Patient characteristics, transplant information, pre- and post-transplant HbA1C and random glucose, follow-up appointments, complications, and readmissions. METHODS: We looked at the prevalence of poor glycemic control (HbA1c >8.5%) in the PrTDM group before and after transplant and compared the prevalence, follow-up appointments, and rate of complications and readmission rates in both the PrTDM and NODAT groups. We determined the risk factors of developing poor glycemic control in PrTDM patients and NODAT. Student t-test was used to compare means, chi-squared test was used to compare percentages, and univariate analysis to determine risk factors was performed by logistical regression. RESULTS: A total of 42 patients (31.8%) had PrTDM and 12 patients (13.3%) developed NODAT. Poor glycemic control (HbA1c >8.5%) was more prevalent in the PrTDM (76.4%) patients compared to those with NODAT (16.7%; P < .01). PrTDM patients were more likely to receive follow-up with an endocrinologist (P < .01) and diabetes nurse (P < .01) compared to those with NODAT. There were no differences in the complication and readmission rates for PrTDM and NODAT patients. Receiving a transplant from a deceased donor was associated with having poor glycemic control, odds ratio (OR) = 3.34, confidence interval (CI = 1.08, 10.4), P = .04. Both patient age, OR = 1.07, CI (1.02, 1.3), P < .01, and peritoneal dialysis prior to transplant, OR = 4.57, CI (1.28, 16.3), P = .02, were associated with NODAT. LIMITATIONS: Our study was limited by our small sample size. We also could not account for any diabetes screening performed outside of our center or follow-up appointments with family physicians or community endocrinologists. CONCLUSION: Poor glycemic control is common in the kidney transplant population. Glycemic targets for patients with PrTDM are not being met in our center and our study highlights the gap in the literature focusing on the prevalence and outcomes of poor glycemic control in these patients. Closer follow-up and attention may be needed for those who are at risk for worse glycemic control, which include older patients, those who received a deceased donor kidney, and/or prior peritoneal dialysis.

CONTEXTE: Les médicaments immunosuppresseurs prescrits à la suite d'une transplantation rénale sont connus pour altérer le métabolisme du glucose, rendant plus difficile le contrôle de la glycémie chez les patients diabétiques avant l'intervention (DbAvT ­ diabétiques avant la transplantation) et chez les patients devenus diabétiques après l'intervention (NDbApT ­ nouveaux diabétiques après la transplantation). OBJECTIF: Déterminer l'incidence d'un contrôle de la glycémie déficient, les facteurs de risque et les résultats chez les patients DbAvT et NDbApT. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte rétrospective et observationnelle qui s'est tenue dans un seul center. CADRE: L'hôpital d'Ottawa (Ontario), au Canada. SUJETS: Les adultes receveurs d'une greffe rénale entre 2013 et 2015 (n=132) ont été suivis rétrospectivement sur une période de trois ans post-transplantation. MESURES: Les caractéristiques des patients, les informations relatives à la greffe, les taux d'HbA1C et la glycémie pré- et post-transplantation, les rendez-vous de suivi, les complications et les réadmissions. MÉTHODOLOGIE: Nous nous sommes d'abord penchés sur la prévalence d'un contrôle glycémique déficient (HbA1c >8,5 %) dans le groupe DbAvT avant et après la greffe, puis nous avons comparé la prévalence, les rendez-vous de suivi et les taux de complications et de réadmission pour les deux groupes. Nous avons déterminé les facteurs de risque d'un mauvais contrôle glycémique chez les patients DbAvT et NDbApT. Les moyennes ont été comparées à l'aide du test t de Student, et le test du chi carré a servi à comparer les pourcentages. L'analyze univariée pour déterminer les facteurs de risque a été effectuée par régression logistique. RÉSULTATS: Parmi les 132 patients étudiés, 42 (31,8 %) étaient DbAvT et 12 (13,3 %) le sont devenus après l'intervention (NDbApT). La prévalence d'un mauvais contrôle de la glycémie (HbA1c >8,5 %) était plus élevée chez les patients DbAvT que chez les patients NDbApT (76,4 % contre 16,7 %; p<0,01). Les patients DbAvT étaient plus susceptibles d'être suivis par un endocrinologue (p<0.01) et une infirmière spécialisée en diabète (p<0.01) comparativement aux patients NDbApT. Aucune différence n'a été observée entre les deux groupes pour les taux de complications et de réadmission. Un greffon provenant d'un donneur décédé a été associé à un contrôle glycémique déficient (RC=3,34; IC 95 :1,08-10,4; p=0,04). Le développement d'un NDbApT a été associé à la fois à l'âge du patient (RC=1,07 IC 95: 1,02-1,3; p<0,01) et à un traitement de dialyze péritonéale (OR=4,57; IC 95: 1,28-16,3; p=0,02) avant la greffe. LIMITES: Nos résultats sont limités par la faible taille de l'échantillon. Nous n'avons pu rendre compte des dépistages effectués hors de notre center ni des rendez-vous de suivi avec un médecin de famille ou un endocrinologue dans la communauté. CONCLUSION: Un contrôle glycémique déficient est fréquent chez les patients greffés d'un rein. Les cibles glycémiques des patients DbAvT ne sont pas rencontrées dans notre center et notre étude met en lumière les lacunes de la littérature sur la prévalence et les résultats d'un mauvais contrôle glycémique chez ces patients. Un suivi plus étroit et une plus grande attention pourraient être nécessaires pour les patients susceptibles de voir leur contrôle glycémique se détériorer, notamment les personnes âgées, les receveurs d'un rein provenant d'un donneur décédé et les patients traités par dialyze péritonéale avant l'intervention.

Management and Outcomes of Maturity-Onset Diabetes of the Young in Pregnancy.

Maturity-onset diabetes of the young (MODY) is a group of monogenic disorders that accounts for 1% to 5% of diabetes. The most common mutations are those in the hepatocyte nuclear factor-1-alpha (HNF-1-alpha) and in the glucokinase (GCK) genes. Although management of MODY is well established, no guidelines currently exist for management during pregnancy. Both maternal glycemic control and fetal mutation status are factors that may influence outcomes during pregnancy. The primary aim of this project was to describe cases of MODY during pregnancy to highlight the clinical implications of management of this disorder during pregnancy. The Ottawa Hospital is the primary referral centre for high-risk obstetrical patients, including those with diabetes in pregnancy, in Ottawa, Canada. Referrals between 2008 and 2018 were reviewed and a case series of three women and five pregnancies is described. Together with the illustrative cases, a literature review of MODY in pregnancy is used to highlight clinical considerations unique to MODY in pregnancy. We describe 5 pregnancies with MODY-2 (GCK mutation) and MODY 3 (HNF-1-alpha mutation). Important issues identified included monitoring of fetal growth and individualization of maternal glycemic control, particularly in cases where fetal mutation status is unknown. Management of MODY in pregnancy is challenging and there is little evidence to guide recommendations. Fetal growth can be used to guide management of maternal glycemic targets when fetal mutation status is unknown.

Accurate GFR in obesity-protocol for a systematic review.

BACKGROUND: Obesity is increasing globally. Chronic kidney disease (CKD) is strongly associated with obesity. Kidney function is commonly estimated with equations using creatinine (such as CKD-EPI equation) which is a product of muscle metabolism. Decisions about categorizing CKD, planning modality of renal replacement therapies, and adjusting dosages of medications excreted by the kidneys are done using these equations. However, it is not well appreciated that creatinine-based equations may not accurately estimate kidney function in obese individuals. We plan a systematic review of diagnostic studies which will compare estimating equations to actual measured kidney function. METHODS: We will systematically search electronic bibliographic databases including MEDLINE, EMBASE, and the Cochrane Library with no restrictions on language or specific dates. The search terms will be adapted for the different databases using a combination of Medical Subject Heading and relevant keywords contained in titles and abstracts. Our preliminary search strategy using Cochrane, MEDLINE, and EMBASE databases have identified 190, 1246, and 1660 citations, respectively. For all studies selected, we will extract information on general study characteristics, study participant (age, sex, ethnicity, weight, height, BMI, BSA), type and protocol of reference standard utilized, the index test studied, the methodology of measurement of index test, categories of GFR, the proportion of eGFR within 10, 20, 30, 40, and 50% of measured GFR, and bias between eGFR and measured GFR. If the quality of methods and risk of bias are adequate, we will perform a meta-analysis. We will assess the heterogeneity using the χ 2 and the I 2 statistics to examine whether the estimates from studies included could be pooled. Sensitivity and multivariate meta-regression analyses will be performed to assess the effects of clinical factors and socio-demographic characteristics reported in included studies on the meta-analytic estimates. All analysis will be performed using the Comprehensive Meta-analysis software. DISCUSSION: This systematic review might help to inform clinicians on the best equation to use in patients with obesity and CKD for staging of CKD and for medication dosing. If no equation is deemed suitable, this review will form a basis for future studies of GFR in obese individuals. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018104345.

Cardiovascular Outcomes in Autonomous Cortisol Secretion and Nonfunctioning Adrenal Adenoma: A Systematic Review.

There is growing evidence that autonomous cortisol secretion (ACS), previously known as subclinical Cushing syndrome, is associated with greater prevalence of cardiovascular (CV) risk factors. However, it is unclear whether ACS is associated with greater prevalence of CV outcomes compared with nonfunctioning adrenal adenomas (NFAAs). The objective of this study is to evaluate CV outcomes and CV risk factors in patients with adrenal adenoma with ACS compared with NFAA. A literature review was performed in Embase, Medline, Cochrane Library, and reference lists within selected articles. The study protocol was registered with PROSPERO. A literature search yielded six studies that met the inclusion criteria. Studies varied in their definitions of ACS and CV outcomes. Two retrospective longitudinal studies further demonstrated higher incidence of new CV events (ACS 16.7% vs NFAA 6.7%, P = 0.04) and higher CV mortality in patients with ACS (ACS 22.6% vs 2.5%, P = 0.02). The prevalence of CV outcomes in ACS was more than three times greater than in patients with NFAA. Three of five studies found that ACS was associated with higher prevalence of diabetes and hypertension. There was no difference in dyslipidemia or body mass index demonstrated in any study. There is heterogeneity among the few studies evaluating the association between ACS and CV outcomes. Although these studies suggest a higher risk of CV outcomes in patients with ACS, many did not adjust for known confounders. Larger, high quality, prospective studies are needed to evaluate this association and to identify modifiable risk factors.

Closing the Gap: Results of the Multicenter Canadian Randomized Controlled Trial of Structured Transition in Young Adults With Type 1 Diabetes.

OBJECTIVE: To determine if a structured transition program for young adults with type 1 diabetes improves clinic attendance, glycemic control, diabetes-related distress, quality of life, and satisfaction with care. RESEARCH DESIGN AND METHODS: In this multicenter randomized controlled trial, young adults (17-20 years) with type 1 diabetes were randomly assigned to a transition program with a transition coordinator or to standard care. The intervention lasted 18 months (6 in pediatric and 12 in adult care). The primary outcome was the proportion of participants who failed to attend at least one adult diabetes clinic visit during the 12-month follow-up after completion of the intervention. RESULTS: We randomized 205 participants, 104 to the transition program and 101 to standard care. Clinic attendance was improved in the transition program (mean [SD] number of visits 4.1 [1.1] vs. 3.6 [1.2], P = 0.002), and there was greater satisfaction with care (mean [SD] score 29.0 [2.7] vs. 27.9 [3.4], P = 0.032) and less diabetes-related distress (mean [SD] score 1.9 [0.8] vs. 2.1 [0.8], P = 0.049) reported than in standard care. There was a trend toward improvement in mean HbA1c (8.33% [68 mmol/mol] vs. 8.80% [73 mmol/mol], P = 0.057). During the 12-month follow-up, there was no difference in those failing to attend at least one clinic visit (P = 0.846), and the mean change in HbA1c did not differ between the groups (P = 0.073). At completion of follow-up, the groups did not differ with respect to satisfaction with care or diabetes-related distress and quality of life. CONCLUSIONS: Transition support during this 18-month intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but these benefits were not sustained 12 months after completion of the intervention.

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

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