Developing a Diabetes Discharge Order Set for Patients With Diabetes on Insulin.

BACKGROUND: Insulin, a high-risk medication, is prone to prescribing errors. Patients with diabetes experience higher hospitalization rates and extended hospital stays. Prescription errors, such as missing orders, inappropriate insulin type, missing instructions, and lack of appropriate intensification of insulin regimens are common issues. This project explored the use of system-based interventions and educational tools to minimize errors and improve the quality of insulin discharge regimens. METHODS: A needs assessment and baseline chart review were conducted before adapting a diabetes order set obtained from the University of California, San Diego. Subsequent beta testing and broader implementation were followed by repeat chart reviews to assess the impact. RESULTS: Providers strongly desired an insulin discharge order set, with 98% of those surveyed expressing this preference. Those who were high utilizers of the order set showed increased rates of ordering all supplies (55%), compared with pre-intervention rates (27%). However, no change was observed in the practice of intensifying insulin regimens in patients with uncontrolled diabetes upon discharge. DISCUSSION: Insulin prescribing is prone to error. A diabetes discharge order set may improve the percentage of patients who receive necessary insulin supplies at discharge and provide educational resources to encourage appropriate insulin regimens at hospital discharge.

Associations between COVID-19 therapies and inpatient gastrointestinal bleeding: A multisite retrospective study.

Little data is available regarding the incidence of gastrointestinal bleeding in adults hospitalized with COVID-19 infection and the influence of patient comorbidities and demographics, COVID-19 therapies, and typical medications used. In this retrospective study, we utilized the National COVID Cohort Collaborative to investigate the primary outcome of the development of gastrointestinal bleeding in 512 467 hospitalized US adults (age >18 years) within 14 days of a COVID-19 infection and the influence of demographics, comorbidities, and selected medications. Gastrointestinal bleeding developed in 0.44% of patients hospitalized with COVID-19. Comorbidities associated with gastrointestinal bleeding include peptic ulcer disease (adjusted odds ratio [aOR] 10.2), obesity (aOR 1.27), chronic kidney disease (aOR 1.20), and tobacco use disorder (aOR 1.28). Lower risk of gastrointestinal bleeding was seen among women (aOR 0.76), Latinx (aOR 0.85), and vaccinated patients (aOR 0.74). Dexamethasone alone or with remdesivir was associated with lower risk of gastrointestinal bleeding (aOR 0.69 and aOR 0.83, respectively). Remdesivir monotherapy was associated with upper gastrointestinal bleeding (aOR 1.25). Proton pump inhibitors were more often prescribed in patients with gastrointestinal bleeding, likely representing treatment for gastrointestinal bleeding rather than a risk factor for its development. In adult patients hospitalized with COVID-19, the use of dexamethasone alone or in combination with remdesivir is negatively associated with gastrointestinal bleeding. Remdesivir monotherapy is associated with increased risk of upper gastrointestinal bleeding.

Physician Assistant Student Attitudes and Empathy Following Virtual Immersion.

BACKGROUND: Addressing provider attitudes associated with diabetes and social determinants of health (SDH) can help improve a patient's overall health and wellbeing. Empathy can improve patient care and outcomes. Cinematic virtual reality (Cine-VR) has been shown to positively affect student empathy. The purpose of this study was to measure and compare empathy and diabetes attitudes among physician assistant students following immersion in 12 virtual-reality video modules. METHODS: Students (n=57) completed the Diabetes Attitude Scale-version 3 (DAS-3) and Jefferson Empathy Scale (JES) before and after completion of the modules. Data were analyzed using paired t-tests to determine differences in scales from baseline to post. RESULTS: After viewing the 12 modules, four DAS-3 subscales significantly increased and the JES showed increases from baseline to post, although not significant. DISCUSSION: Utilization of a common virtual patient can help engage students in improving attitudes toward patients with diabetes experiencing SDH and enhancing empathy.

Creating Patient Context: Empathy and Attitudes Toward Diabetes Following Virtual Immersion.

BACKGROUND: Pandemic circumstances created challenges for doctor of physical therapy (DPT) students to understand social determinants of health (SDH) in clinical rotations. Instead of canceling clinical rotations, a virtual reality cinema (cine-VR) education series was implemented. The purpose of this project is to describe the effect of this simulated immersion on student empathy and attitudes toward diabetes. METHOD: The DPT students (n=59) participated in 12 cine-VR education modules, completing surveys at three time points as part of coursework. The students completed baseline measures of the Diabetes Attitude Scale-Version 3 (DAS-3) and Jefferson Empathy Scale (JES), and then were immersed in 12 cine-VR modules. One week after module completion, students participated in a class discussion about the modules. The students repeated the JES and DAS-3 scales at postclass and six weeks later. Three subscales from the Presence Questionnaire (PQ) were used to measure the virtual experience. RESULTS: Student scores on three DAS-3 subscales significantly improved on posttest: Attitude toward patient autonomy, Mean: 0.75, SD: 0.45; t(58) = 12.742, P < .001; Psychosocial impact of diabetes, Mean: -0.21, SD: 0.41; t(58) = -3.854, P < .001; and Seriousness of type 2 diabetes, Mean: -039, SD: 0.44; t(58) = -6.780, P < .001, with lower scores six weeks later. Student scores increased on the JES and remained high (P < .001). High subscale scores on the PQ demonstrated immersion and involvement in the virtual experience. DISCUSSION: These modules can allow for a shared student experience that improves diabetes attitudes, increases empathy, and fosters meaningful classroom discussion. The cine-VR experience is flexible, and modules allow students to engage in aspects of a patient's life that were not available otherwise.

Are We Missing an Opportunity? Prediabetes in the U.S. Military.

INTRODUCTION: The prevalence of prediabetes is estimated to be one-third of Americans with approximately 80% of these individuals unaware of the diagnosis. In the active duty military population, the prevalence of prediabetes is largely unexplored. The purpose of this study was to investigate the prevalence of prediabetes in military service members by quantifying those meeting prediabetes screening criteria, those actually being screened, and those being appropriately diagnosed. MATERIALS AND METHODS: Data were analyzed from calendar years 2014 to 2018 for active duty service members 18 years of age or older. Vitals records were collected to obtain body mass index values. Composite Health Care System laboratory data were queried for hemoglobin A1c (HbA1c) results as well as fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) results. The percentage of active duty service members meeting criteria for prediabetes screening was determined by totaling members age 45 and older with members age 18- to 44-year old with a body mass index ≥25.0 kg/m2, then dividing by the total number of members for each respective military branch. The percentage of active duty service members actually screened for prediabetes was determined based on members meeting prediabetes screening criteria who in fact had FPG, OGTT, or HbA1c labs. The total number of labs meeting prediabetes criteria was determined based on those aforementioned labs with results in the prediabetes range (FPG between 100 and 125 mg/dL, OGTT between 140 and 199 mg/dL, or HbA1c range of 5.7%-6.4%). The total number of service members with appropriate prediabetes International Classification of Disease (ICD) code was determined by identifying members with ICD-9 and ICD-10 codes 790.21, 790.22, and R73.01-R73.03 in their medical record. RESULTS: From 2014 to 2018, 53.9% of 332,502, 56% of 543,081, and 47.3% of 531,313 active duty service members in the Air Force, Army and Navy, respectively, met criteria for prediabetes screening. The rates of actually screening for prediabetes were similar across the Air Force (4.8%), Army (6.7%), and Navy (5.5%). The percentage with labs meeting prediabetes criteria ranged from 17.9% to 28.4% in the Air Force, 24.2% to 30.3% in the Army, and 24.2% to 30.9% in the Navy. The rate of ICD coding for prediabetes increased from 2014 to 2018 across all branches (29.8%-65.3% for the Air Force, 24.6%-46.8% for the Army, and 40.0%-45.5% for the Navy). CONCLUSION: Screening for prediabetes in the active duty military population is grossly inadequate, and even of those screened, diagnosing those meeting prediabetes criteria is similarly inadequate. Although this scenario is not unique to the Military Health System, but reflective of a larger national problem, efforts should be made within the Military Health System to increase the screening for this common disorder. Identifying service members with prediabetes enables opportunities for targeted interventions to delay or prevent the progression to diabetes mellitus.

A Retrospective, Epidemiological Review of Type 2 Diabetes Mellitus in a Military Population.

OBJECTIVE: Examine incidence rates of Type 2 Diabetes Mellitus (T2DM) in a military population over a tenyear period and whether demographic characteristics differ within the same population. METHODS: Diagnostic data and demographic variables from 23,821 active duty service members between 2006 and 2015 were analyzed from the Defense Medical Epidemiological Database. RESULTS: The incidence rates of new onset cases ranged from .22 (per 1,000 service members) in 2015 to a high of 1.46 (per 1,000 service members) in 2006 for T2DM without complications and .00 (per 1,000 service members) in 2007 to a high of .29 (per 1,000 service members) in 2015 for T2DM with complications. The one-sample chi-square test showed the observed, and expected frequencies differed significantly for all demographic variables tested. CONCLUSIONS: Although there was a significant increase in the diagnosis of T2DM with complications in 2015, the overall downtrend is similar to that of the general US population. Older age and higher rank were more likely to be associated with the diagnosis of T2DM with and without complications, again suggestive of similar trends with the general US population. Continued efforts towards early diagnosis and treatment of these service members are needed to address this problem regarding military readiness.

Adult-Onset Type 1 Diabetes: Current Understanding and Challenges.

Recent epidemiological data have shown that more than half of all new cases of type 1 diabetes occur in adults. Key genetic, immune, and metabolic differences exist between adult- and childhood-onset type 1 diabetes, many of which are not well understood. A substantial risk of misclassification of diabetes type can result. Notably, some adults with type 1 diabetes may not require insulin at diagnosis, their clinical disease can masquerade as type 2 diabetes, and the consequent misclassification may result in inappropriate treatment. In response to this important issue, JDRF convened a workshop of international experts in November 2019. Here, we summarize the current understanding and unanswered questions in the field based on those discussions, highlighting epidemiology and immunogenetic and metabolic characteristics of adult-onset type 1 diabetes as well as disease-associated comorbidities and psychosocial challenges. In adult-onset, as compared with childhood-onset, type 1 diabetes, HLA-associated risk is lower, with more protective genotypes and lower genetic risk scores; multiple diabetes-associated autoantibodies are decreased, though GADA remains dominant. Before diagnosis, those with autoantibodies progress more slowly, and at diagnosis, serum C-peptide is higher in adults than children, with ketoacidosis being less frequent. Tools to distinguish types of diabetes are discussed, including body phenotype, clinical course, family history, autoantibodies, comorbidities, and C-peptide. By providing this perspective, we aim to improve the management of adults presenting with type 1 diabetes.

Glycemic benefits with adherence to testosterone therapy in men with hypogonadism and type 2 diabetes mellitus.

BACKGROUND: While previous studies have demonstrated testosterone's beneficial effects on glycemic control in men with hypogonadism and Type 2 Diabetes, the extent to which these improvements are observed based on the degree of treatment adherence has been unclear. OBJECTIVES: To evaluate the effects of long-term testosterone therapy in A1C levels in men with Type 2 Diabetes Mellitus and hypogonadism, controlling for BMI, pre-treatment A1C, and age among different testosterone therapy adherence groups. MATERIALS AND METHODS: We performed a retrospective analysis of 1737 men with diabetes and hypogonadism on testosterone therapy for 5 years of data from 2008-2018, isolating A1C, lipid panels, and BMI results for analysis. Subjects were categorized into adherence groups based on quartiles of the proportion of days covered (> 75% of days, 51-75% of days, 26-50% of days and 0-25% of days), with >75% of days covered considered adherent to therapy. RESULTS: Pre-treatment median A1C was 6.8%. Post-treatment median A1C was 7.1%. The adherent group, >75%, was the only group notable for a decrease in A1C, with a median decrease of -0.2 (p = 0.0022). BMI improvement was associated with improved post-treatment A1C (p = 0.007). When controlling for BMI, age, and pre-treatment A1C, the >75% adherence group was associated with improved post-treatment A1C (p < 0.001). DISCUSSION: When controlling for all studied variables, testosterone adherence was associated with improved post-treatment A1C. The higher the initial A1C at the initiation of therapy, the higher the potential for lowering the patient's A1C with >75% adherence. Further, all groups showed some reduction in BMI, which may indicate that testosterone therapy may affect A1C independent of weight loss. CONCLUSION: Even when controlling for improved BMI, pre-treatment A1C, and age, testosterone positively impacted glycemic control in diabetes patients with hypogonadism, with the most benefit noted in those most adherent to therapy (>75%).

IMPACT OF STRUCTURED INSULIN ORDER SETS ON INPATIENT HYPOGLYCEMIA AND GLYCEMIC CONTROL.

Objective: In hospitalized patients, glycemic excursions outside recommended glycemic targets have been associated with increased morbidity and mortality. Despite recommendations to avoid use of correctional insulin alone for managing hyperglycemia, this approach remains common. We performed a quality improvement project aimed at both reducing hypoglycemic events and promoting increased use of basal insulin by updating our insulin order sets to reflect clinical practice guideline recommendations. Methods: Brooke Army Medical Center correctional insulin order sets were modified to reflect higher treatment thresholds and targets, and a basal insulin order was added with a recommended weight-based starting dose. Pre- and postintervention analyses were performed. Patients were included if they were prescribed subcutaneous insulin during their hospital stay. The following outcomes were measured: (1) glucose levels, and (2) prescriptions for basal insulin. Results: A significant reduction in hypoglycemia events was noted following the intervention (glucose <70 mg/dL: 9.2% pre-intervention vs. 8.8% postintervention; glucose <55 mg/dL: 4.2% pre-intervention vs. 2.2% postintervention). When excluding patients that were ordered correctional insulin alone but did not receive a dose, an increase in basal insulin use was seen (50% pre-intervention vs. 61% postintervention). Rates and severity of hyperglycemia (glucose >180 mg/dL) remained unchanged. Conclusion: The alteration in insulin order set parameters resulted in a significant reduction in hypoglycemia without significant increases in hyperglycemia. Although basal insulin use increased, optimal dosing recommendations were not often utilized. Further interventions are necessary to reduce hyperglycemia. Abbreviations: CPOE = computerized provider order entry; EMR = electronic medical record; HbA1c = hemoglobin A1c; LOS = length of stay; QI = quality improvement; SSI = sliding scale insulin.

Preconception Counseling for Women With Diabetes.

"Quality Improvement Success Stories" are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the efforts of a U.S. Airforce diabetes specialty clinic to improve the delivery of preconception counseling to women with diabetes who are of childbearing potential.

Leadership Training in Graduate Medical Education: Time for a Requirement?

INTRODUCTION: The need for all physicians to function as leaders in their various roles is becoming more widely recognized. There are increasing opportunities for physicians at all levels including Graduate Medical Education (GME) to gain leadership skills, but most of these opportunities are only for those interested. Although not an Accreditation Council for Graduate Medical Education (ACGME) requirement, some US graduate medical education programs have incorporated leadership training into their curricula. Interestingly, the Royal College of Physicians and Surgeons of Canada adopted the Leader role in its 2015 CanMEDS physician training model and requires leadership training. We sought to understand the value of a leadership training program in residency in our institution. MATERIALS AND METHODS: Our 2017 pilot leadership training program for senior military internal medicine residents consisted of four one-hour sessions of mini-lectures, self-assessments, case discussions, and small group activities. The themes were: Introduction to Leadership, Emotional Intelligence, Teambuilding, and Conflict Management. Participants were given an 18-question survey (14 Likert scale multiple-choice questions and 4 open-ended response questions) to provide feedback about the course. The Brooke Army Medical Center Institutional Review Board approved this project as a Quality Improvement effort. RESULTS: The survey response rate was 48.1% (26 of 54). The majority of respondents (84.6%) agreed the leadership training sessions were helpful and relevant. Following the sessions, 80.8% saw a greater role for physicians to function as leaders. Most (88.4%) agreed that these sessions helped them understand the importance of their roles as leaders, with 80.8% feeling more empowered to be leaders in their areas, 76.9% gaining a better understanding of their own strengths and weaknesses as leaders, and 80.8% feeling better prepared to meet challenges in the future. After exposure to leadership training, 73.1% indicated a plan to pursue additional leadership development opportunities. All respondents agreed that internists should be able to lead and manage a clinical team, and every respondent agreed that leadership principles should be taught in residency. CONCLUSIONS: This pilot project supports the premise that leadership training should be integrated into GME. Initial results suggest training can improve leadership skills and inspire trainees to seek additional leadership education. Moreover, much like the published literature, residents believe they should learn about leadership during residency. While more effort is needed to determine the best approach to deliver and evaluate this content, it appears even small interventions can make a difference. Next steps for this program include developing assessment tools for observation of leadership behaviors during routine GME activities, which would allow for reinforcement of the principles being taught. Additionally, our experience has led our institution to make leadership training a requirement in all of our GME programs, and we look forward to reporting future progress. Finally, an ACGME requirement to incorporate leadership training into GME programs nationwide would prove useful, as doing so would reinforce its importance, accelerate implementation, and expand knowledge of best approaches on a national level.

The Choice Should Be Yours: Diabetes-Related Distress by Insulin Delivery Method for People with Type 1 Diabetes.

Background: American Diabetes Association (ADA) recommends psychosocial assessment for people with diabetes, including diabetes-related distress. Elevated diabetes-related distress is associated with poor self-management, lower medication adherence, and poorer quality of life. Insulin delivery methods are multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Because people with type 1 diabetes mellitus (T1DM) require comprehensive insulin therapy to manage blood glucose, we explored the association of insulin delivery methods and diabetes distress in this group. Methods: The U.S. Air Force Diabetes Center of Excellence (DCOE), a specialty clinic for adults who are Military Health System beneficiaries, administers the validated 17-item Diabetes-related Distress Scale (DDS-17) as part of standard care. Patient data were analyzed from June 2015 to August 2016 using SPSS version 22. Patients were free to choose the method of insulin delivery with minimal or no additional cost. Results: There were 203 patients with T1DM who completed the DDS-17 as part of standard care during the time period. Patients were categorized as CSII (57.6%) or MDI (42.4%). Women were significantly more likely to choose MDI over CSII than men (P = 0.003). DDS-17 scores were low in both groups, and there were no significant differences in DDS-17 by insulin delivery method. Furthermore, no significant differences were found in hemoglobin A1c (HbA1c) between CSII (7.9% or 63 mmol/mol) and MDI (8.1% or 65 mmol/mol) users (P = 0.22) and no significant differences in body mass index (BMI) between patients using CSII (M = 28.33 kg/m2) and MDI (28.49 kg/m2) users (P = 0.15). Conclusions: Our study demonstrated that if patients are relatively free to choose the insulin delivery method (minimal or no financial constraints), there were no differences in diabetes distress scores, HbA1c, or BMI between CSII and MDI. Therefore, people with T1DM may benefit from choosing the method of insulin delivery that will enable them to achieve individual goals and manage diabetes-related distress.

Diabetes by Air, Land, and Sea: Effect of Deployments on HbA1c and BMI.

INTRODUCTION: Service members (SMs) in the United States (U.S.) Armed Forces have diabetes mellitus at a rate of 2-3%. Despite having a chronic medical condition, they have deployed to environments with limited medical support. Given the scarcity of data describing how they fare in these settings, we conducted a retrospective study analyzing the changes in glycated hemoglobin (HbA1c) and body mass index (BMI) before and after deployment. MATERIALS AND METHODS: SMs from the U.S. Army, Air Force, Navy, and Marine Corps with diabetes who deployed overseas were identified through the Military Health System (MHS) Management Analysis and Reporting Tool and the Defense Manpower Data Center. Laboratory and pharmaceutical data were obtained from the MHS Composite Health Care System and the Pharmacy Data Transaction Service, respectively. Paired t-tests were conducted to calculate changes in HbA1c and BMI before and after deployment. RESULTS: SMs with diabetes completed 11,325 deployments of greater than 90 days from 2005 to 2017. Of these, 474 (4.2%) SMs had both HbA1c and BMI measurements within 90 days prior to departure and within 90 days of return. Most (84.2%) required diabetes medications: metformin in 67.3%, sulfonylureas in 19.0%, dipeptidyl peptidase-4 inhibitors in 13.9%, and insulin in 5.5%. Most SMs deployed with an HbA1c < 7.0% (67.1%), with a mean predeployment HbA1c of 6.8%. Twenty percent deployed with an HbA1c between 7.0 and 7.9%, 7.2% deployed with an HbA1c between 8.0 and 8.9%, and 5.7% deployed with an HbA1c of 9.0% or higher. In the overall population and within each military service, there was no significant change in HbA1c before and after deployment. However, those with predeployment HbA1c < 7.0% experienced a rise in HbA1c from 6.2 to 6.5% (P < 0.001), whereas those with predeployment HbA1c values ≥7.0% experienced a decline from 8.0 to 7.5% (P < 0.001). Those who deployed between 91 and 135 days had a decline in HbA1c from 7.1 to 6.7% (P = 0.010), but no significant changes were demonstrated in those with longer deployment durations. BMI declined from 29.6 to 29.3 kg/m2 (P < 0.001), with other significant changes seen among those in the Army, Navy, and deployment durations up to 315 days. CONCLUSIONS: Most SMs had an HbA1c < 7.0%, suggesting that military providers appropriately selected well-managed SMs for deployment. HbA1c did not seem to deteriorate during deployment, but they also did not improve despite a reduction in BMI. Concerning trends included the deployment of some SMs with much higher HbA1c, utilization of medications with adverse safety profiles, and the lack of HbA1c and BMI evaluation proximal to deployment departures and returns. However, for SMs meeting adequate glycemic targets, we demonstrated that HbA1c remained stable, supporting the notion that some SMs may safely deploy with diabetes. Improvement in BMI may compensate for factors promoting hyperglycemia in a deployed setting, such as changes in diet and medication availability. Future research should analyze in a prospective fashion, where a more complete array of diabetes and readiness-related measures to comprehensively evaluate the safety of deploying SMs with diabetes.

THE IMPACT OF GLP-1 RECEPTOR AGONISTS ON PATIENTS WITH DIABETES ON INSULIN THERAPY.

Objective: The clinical benefit of adding a glucagon-like peptide-1 receptor agonist (GLP-1RA) to basal-bolus or very high dose insulin regimens is unclear. This study investigated the impact of adding a GLP-1RA to a spectrum of insulin regimens (basal, basal-bolus, and U-500) to determine the impact on hemoglobin A1c (HbA1c), weight loss, and total daily insulin dose (TDD) over the course of 12 months. Methods: A retrospective chart review was conducted on 113 participants with type 2 diabetes mellitus using insulin therapy. Each participant's HbA1c, body weight, and TDD were recorded prior to initiation of GLP-1RA therapy and at the 3, 6, and 12-month time points while on combination therapy. Results: Across all participants, the HbA1c values decreased significantly from a baseline of 8.9 (74 mmol/mol) ± 0.14% to 8.2 (66 mmol/mol) ± 0.14% (P<.01) in the first 3 months, 8.0 (64 mmol/mol) ± 0.12% (P<.01) at 6 months, to 8.3 (67 mmol/mol) ± 0.14% (P<.01) at 12 months. There was no significant decrease in weight or TDD with the addition of a GLP-1RA overall or in different insulin groups. However, there was a clinically significant decrease in weight over the study duration. Conclusion: The results of this study suggest that adding a GLP-1RA to various insulin regimens may help to achieve glycemic goals while avoiding the less desirable side effects of weight gain and increasing insulin regimens. However, the expected weight loss and decrease in TDD may not be as sizable in the clinical setting. Abbreviations: DCOE = Diabetes Center of Excellence; DM = diabetes mellitus; GLP-1RA = glucagon-like peptide-1 receptor agonist; HbA1c = hemoglobin A1c; RCT = randomized controlled trial; TDD = total daily dose.

Is It Distress, Depression, or Both? Exploring Differences in the Diabetes Distress Scale and the Patient Health Questionnaire in a Diabetes Specialty Clinic.

IN BRIEF Patients (n = 314) completed the Patient Health Questionnaire and the Diabetes Distress Scale as part of standard care. Although most patients (70.4%) had no symptoms of depression or diabetes-related distress, 23.9% scored high on the distress questionnaire in at least one of its four domains. Regular screening for distress related to the demands of living with diabetes is crucial in identifying and preventing poor health outcomes associated with diabetes-related distress.

Effect of Military Deployment on Diabetes Mellitus in Air Force Personnel.

Introduction: Military deployments relocate service members to austere locations with limited medical capabilities, raising uncertainties whether members with diabetes can participate safely. Military regulations require a medical clearance for service members with diabetes prior to deployment, but there is a dearth of data that can guide the provider in this decision. To alleviate the lack of evidence in this area, we analyzed the change in glycated hemoglobin (HbA1c) and body mass index (BMI) before and after a deployment among active duty U.S. Air Force personnel who deployed with diabetes. Materials and Methods: A retrospective analysis was conducted using HbA1c and BMI values obtained within 3 mo before and within 3 mo after repatriation from a deployment of at least 90 d between January 1, 2004 through December 31, 2014. The study population consisted of 103 and 195 subjects who had an available pre- and post-deployment HbA1c and BMI values, respectively. Paired t-tests were conducted to determine significant differences in HbA1C and BMI values. Results: The majority (73.8%) of members had a HbA1c <7.0% (53 mmol/mol) prior to deployment. For the overall population, HbA1c before and after deployment decreased from 6.7% (50 mmol/mol) to 6.5% (40 mmol/mol) (p = 0.03). Subgroup analysis demonstrated a significant decline in HbA1c among males, those aged 31-40 yr, and those with a pre-deployment HbA1c of >7%. BMI declined for the overall population (28.3 kg/m2 vs. 27.7 kg/m2, p < 0.0001) and for most of the subgroups. Conclusion: Air Force service members who deployed with diabetes, including those with a HbA1c > 7%, experienced a statistically significant improvement in HbA1c and BMI upon repatriation. A prospective study design in the future can better reconcile the effect of a military deployment on a more comprehensive array of diabetes parameters.

Who's distressed? A comparison of diabetes-related distress by type of diabetes and medication.

OBJECTIVE: We hypothesized that diabetes-related distress would vary by type of diabetes and medication regimen [Type 1 diabetes (T1DM), Type 2 diabetes with insulin use (T2DM-i), Type 2 diabetes without insulin use (T2DM)]. Thus, the aim of this study was to identify groups with elevated diabetes-related distress. METHODS: We administered the 17-item Diabetes-related Distress Scale (DDS-17) to 585 patients. We collected demographics, medications, and lab results from patient records. RESULTS: Patients were categorized by type of diabetes and medication: T1DM (n = 149); T2DM-i (n = 333); and T2DM (n = 103). ANOVA revealed significant differences in sample characteristics. ANCOVA were conducted on all four DDS-17 domains [Emotional Burden (EB); Physician-related Distress (PD); Regimen-related Distress (RD); and Interpersonal Distress (ID)]; covariates included in the models were sex, age, duration of diabetes, BMI, and HbA1c. EB was significantly lower in T1DM than T2DM-i, p < 0.05. In addition, RD was significantly lower in T1DM than either T2DM-i, p < 0.05 and T2DM, p < 0.05. CONCLUSIONS: EB and RD are higher for those with type 2 diabetes. Thus, interventions to reduce EB and RD need to be considered for patients with type 2 diabetes. IMPLICATIONS: DDS-17 is useful in identifying diabetes-related distress in patients with diabetes. Efforts need to be made to reduce EB and RD.