Research design and baseline participant characteristics of the Resilient, Empowered, Active Living with Diabetes - Telehealth (REAL-T) Study: A randomized controlled trial for young adults with type 1 diabetes.

BACKGROUND: Type 1 diabetes (T1D) is a chronic condition affecting nearly 1.9 million people in the United States. Young adults (YAs) with T1D face unique challenges in managing their condition, experiencing poorer health and well-being than other age groups. The current study is evaluating the Resilient, Empowered, Active Living (REAL) intervention, previously shown to improve glucose levels and quality of life among YAs with diabetes, using telehealth delivery (REAL-T) to expand reach and accessibility. This paper reports on the methodology and baseline participant characteristics of the REAL-T study. METHODS: REAL-T is a two-arm randomized controlled trial that recruited 18-30 year olds with T1D via clinics and social media advertising. Data collection, which was adapted to be fully remote due to COVID-19, occurs every three months for one year. Participants receive either usual care or a 6-month telehealth occupational therapy intervention. The primary outcome is glycated hemoglobin (A1c); secondary outcomes include diabetes distress, quality of life, and continuous glucose monitor-derived measures. RESULTS: The study enrolled a diverse sample of 209 YAs with T1D. Analysis of baseline data indicates equivalence between the intervention and control groups. Study participants have notably higher diabetes distress and poorer mental well-being than similar populations. CONCLUSION: The REAL-T study successfully adapted to remote implementation during the COVID-19 pandemic. By examining long-term outcomes, mediating pathways, and cost-effectiveness, the study will contribute knowledge of the impact of tailored interventions for YAs with T1D, designed to reduce disparities and improve health and well-being in this population.

Microstructural brain tissue changes contribute to cognitive and mood deficits in adults with type 2 diabetes mellitus.

Type 2 diabetes mellitus (T2DM) patients show brain tissue changes in mood and cognitive regulatory sites, but the nature and extent of tissue injury and their associations with symptoms are unclear. Our aim was to examine brain tissue damage in T2DM over controls using mean diffusivity (MD) computed from diffusion tensor imaging (DTI), and assess correlations with mood and cognitive symptoms in T2DM. We collected DTI series (MRI), mood, and cognitive data, from 169 subjects (68 T2DM and 101 controls). Whole-brain MD-maps were calculated, normalized, smoothed, and compared between groups, as well as correlated with mood and cognition scores in T2DM subjects. Type 2 diabetes patients showed altered cognitive and mood functions over control subjects. Multiple brain sites in T2DM patients showed elevated MD values, indicating chronic tissue changes, including the cerebellum, insula, and frontal and prefrontal cortices, cingulate, and lingual gyrus. Associations between MD values and mood and cognition scores appeared in brain sites mediating these functions. Type 2 diabetes patients show predominantly chronic brain tissue changes in areas mediating mood and cognition functions, and tissue changes from those regions correlate with mood and cognitive symptoms suggesting that the microstructural brain changes may account for the observed functional deficits.

Utilizing point-of-care A1c to impact outcomes - can we make it happen in primary care?

PURPOSE OF REVIEW: Hemoglobin A1c testing provides a marker of glycemic control and is the standard for diabetes risk assessment. According to the Centers for Disease Control (CDC), only 67.3-71.4% of diabetic patients between 2011 and 2016 had at least two A1c levels tested per year. Moreover, 27.8% had uncontrolled diabetes with an A1c of ≥8.0%, increasing the risk of microvascular complications. Lack of monitoring presents a significant barrier, and improving ease of testing could improve glycemic control. RECENT FINDINGS: Point-of-care (POC) A1c testing, obtained via capillary blood with results provided in 5-6 min, is available and used frequently in endocrine clinics. However, POC A1c testing is not standard in primary care, where 90% of type 2 diabetes patients are treated. Barriers include access and costs of POC A1c machines and standardization of testing in the primary care setting. Review of literature, however, suggests that POC A1c testing in primary care may lead to A1c reduction whereas being potentially cost-effective and strengths the patient-physician relationship. SUMMARY: POC A1c testing in primary care, if widely available and integrated into workflow, has the potential to positively impact diabetes care. Real-time feedback may change patient and physician behaviors, allowing earlier therapeutic intensification.

Poor Sleep Quality Linked to Decreased Brain Gray Matter Density in Adults with Type 2 Diabetes.

BACKGROUND: Poor sleep is common in adults with Type 2 Diabetes Mellitus (T2DM), which may contribute to brain tissue changes. However, the impact of sleep quality on brain tissue in T2DM individuals is unclear. We aimed to evaluate differential sleep quality with brain changes, and brain tissue integrity in T2DM patients. METHODS: Data were collected from 34 patients with T2DM and included sleep quality (assessed by the Pittsburgh Sleep Quality Index [PSQI], and high-resolution T1-weighted brain images using a 3.0-Tesla MRI scanner. Gray matter density (GMD) maps were compared between subjects with good vs poor sleep quality as assessed by PSQI (covariates: age, sex, BMI). RESULTS: Of 34 T2DM patients, 17 showed poor sleep quality. Multiple brain sites, including the hippocampus, cerebellum, prefrontal, amygdala, thalamus, hypothalamus, insula, cingulate, and temporal areas, showed reduced gray matter in T2DM patients with poor sleep quality over patients with good sleep quality. Negative associations emerged between PSQI scores and gray matter density in multiple areas. CONCLUSIONS: T2DM patients with poor sleep quality show brain tissue changes in sites involved in sleep regulation. Findings indicate that improving sleep may help mitigate brain tissue damage, and thus, improve brain function in T2DM patients.

Regional Brain Gray Matter Changes in Patients with Type 2 Diabetes Mellitus.

Patients with Type 2 diabetes mellitus (T2DM) show cognitive and mood impairment, indicating potential for brain injury in regions that control these functions. However, brain tissue integrity in cognition, anxiety, and depression regulatory sites, and their associations with these functional deficits in T2DM subjects remain unclear. We examined gray matter (GM) changes in 34 T2DM and 88 control subjects using high-resolution T1-weighted images, collected from a 3.0-Tesla magnetic resonance imaging scanner, and assessed anxiety [Beck Anxiety Inventory], depressive symptoms [Beck Depression Inventory-II], and cognition [Montreal Cognitive Assessment]. We also investigated relationships between GM status of cognitive and mood control sites and these scores in T2DM. Significantly increased anxiety (p = 0.003) and depression (p = 0.001), and reduced cognition (p = 0.002) appeared in T2DM over controls. Decreased GM volumes appeared in several regions in T2DM patients, including the prefrontal, hippocampus, amygdala, insular, cingulate, cerebellum, caudate, basal-forebrain, and thalamus areas (p < 0.01). GM volumes were significantly associated with anxiety (r = -0.456,p = 0.009), depression (r = -0.465,p = 0.01), and cognition (r = 0.455,p = 0.009) scores in regions associated with those regulations (prefrontal cortices, hippocampus, para hippocampus, amygdala, insula, cingulate, caudate, thalamus, and cerebellum) in T2DM patients. Patients with T2DM show brain damage in regions that are involved in cognition, anxiety, and depression control, and these tissue alterations are associated with functional deficits. The findings indicate that mood and cognitive deficits in T2DM patients has brain structural basis in the condition.

Efficacy of video-based education program in improving metabolic surgery perception among patients with obesity and diabetes.

BACKGROUND: Metabolic surgery remains underutilized despite its efficacy and safety. Poor perception of surgery has been cited as one of the major reasons. OBJECTIVES: Evaluate current patient perceptions about metabolic surgery and measure the impact a video-based education program has on changing the perceptions of patients diagnosed with obesity and type 2 diabetes. SETTING: A university hospital in the United States. METHODS: A prospective interventional study was performed at an endocrinology clinic. Patients were asked to complete surveys evaluating their perception of metabolic surgery before and after watching a short educational video. RESULTS: A total of 51 patients were recruited; almost all patients (98%) attempted weight loss in the past, and approximately 90.1% voiced dissatisfaction with their current weight. The video-based education program was effective in improving the patient's perception of the efficacy and safety with regard to surgery. In addition, the proportion of patients with overall positive impression toward metabolic surgery increased from 22.5% to 53.1% (P < .01) and those willing to undergo surgical consultation increased from 41.7% to 51.0% (P < .01). Among those that remained unwilling, fear of surgery in general was the most commonly voiced reason (31.4%), with safety (27.5%) and cost of metabolic surgery (27.5%) being equally concerning. CONCLUSIONS: Most patients with obesity and type 2 diabetes held negative impressions of metabolic surgery due to its perceived risk profile. A video-based educational intervention may improve patients' perception and increase their willingness for surgical referral. Future trials with a broader sample and longer follow-up could provide answers to its efficacy in increasing metabolic surgery accessibility.

Cross-sectional and Test-Retest Characterization of PET with [(18)F]FP-(+)-DTBZ for ß Cell Mass Estimates in Diabetes.

PURPOSE: The vesicular monoamine transporter, type 2 (VMAT2) is expressed by insulin producing ß cells and was evaluated as a biomarker of ß cell mass (BCM) by positron emission tomography (PET) with [(18)F]fluoropropyl-dihydrotetrabenazine ([(18)F]FP-(+)-DTBZ). PROCEDURES: We evaluated the feasibility of longitudinal pancreatic PET VMAT2 quantification in the pancreas in two studies of healthy controls and patients with type 1 or 2 diabetes. VMAT2 binding potential (BPND) was estimated voxelwise using a reference tissue method in a cross-sectional study, followed by assessment of reproducibility using a test-retest paradigm. Metabolic function was evaluated by stimulated c-peptide measurements. RESULTS: Pancreatic BPND was significantly decreased in patients with type 1 diabetes relative to controls and the test-retest variability was 9.4%. CONCLUSIONS: Pancreatic VMAT2 content is significantly reduced in long-term diabetes patients relative to controls and repeat scans are sufficiently reproducible to suggest the feasibility clinically VMAT2 measurements in longitudinal studies of new onset diabetes.

The utility of [(11)C] dihydrotetrabenazine positron emission tomography scanning in assessing beta-cell performance after sleeve gastrectomy and duodenal-jejunal bypass.

BACKGROUND: The aim of this study was to evaluate the effect of sleeve gastrectomy (SG) and duodenal-jejunal bypass (DJB) on glucose homeostasis and to evaluate the utility of positron emission tomography (PET) scanning for assessing beta-cell mass. METHODS: Goto-Kakizaki rats were divided into 4 groups: control, sham, SG, or DJB. Oral glucose tolerance, insulin, and glucagon-like peptide-1 (GLP-1) were measured before and after surgery. Before and 90 days after treatment, [(11)C] DTBZ micro PET scanning was performed. RESULTS: The control and sham animals gained more weight compared with SG and DJB animals (P < or = .05). Compared with control animals, the glucose area under the curve was lower in DJB animals 30 and 45 days after operations (P < or = .05). At killing, GLP-1 levels were greater in the DJB group compared with sham and SG (P < or = .05), whereas insulin levels were greater in both DJB and SG compared with sham (P < or = .05). With PET scanning, the 90-day posttreatment mean vesicular monoamine transporter type 2 binding index was greatest in the DJB animals (2.45) compared with SG (1.17), both of which were greater than baseline control animals (0.81). CONCLUSION: In type 2 diabetic rodents, DJB leads to improved glucose homeostasis and an increase in VMAT2 density as measured by PET scanning.

Clinical characteristics and medication use among premenopausal women with osteoporosis and low BMD: the experience of an osteoporosis referral center.

AIMS: Osteoporosis is uncommon in premenopausal women, and most cases have a secondary cause. Women with osteoporosis and no known secondary cause are said to have idiopathic osteoporosis (IOP). We aimed to estimate the proportion of premenopausal women seen in our referral center with IOP as opposed to secondary osteoporosis, to describe their clinical characteristics, to compare women with a low-trauma fracture history with those with low bone mineral density (BMD) alone, and to estimate the frequency of bisphosphonate use. METHODS: We reviewed medical records from all premenopausal women evaluated for osteoporosis or low BMD in our center during 2005. We included premenopausal women diagnosed on the basis of low-trauma fracture, low BMD or both (Z score < or= -2.0 or T score < or = -2.5), or both. RESULTS: Among these patients (n = 61; mean age 37 +/- 8), 57 (93%) were Caucasian, 34 (57%) had a family history of osteoporosis, and 26 (43%) had used bisphosphonates. The most common secondary causes were amenorrhea (34%, n = 21), anorexia nervosa (16%, n = 10), and glucocorticoid exposure (13%, n = 8). After exclusion of secondary causes, 39% (24 of 61) of the entire group and 48% (14 of 29) of the fracture group were thought to have IOP. Women with a known secondary cause had lower BMD Z scores at the spine and hip than those with IOP. Women with low BMD and no fractures had shorter stature and weighed less than those with fractures, but overall differences between the groups were not statistically significant. Bisphosphonates had been prescribed for 38% (11 of 29) of women with a fracture history and 47% (15 of 32) of women with low BMD and no fractures. CONCLUSIONS: Our findings suggest that IOP is common among premenopausal women with osteoporosis or low BMD evaluated at a referral center. The smaller stature of women diagnosed only on the basis of BMD criteria raises the question of whether their areal BMD measurements are spuriously low because of smaller bone size. The high proportion of premenopausal women who had been prescribed oral bisphosphonates for low BMD measurements is of concern, as such women are likely to be at low short-term risk of fracture, and a more conservative approach to therapy is preferable in this group.