Hypoglycemia preceding fatal car collisions

A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications

BACKGROUND

Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice.

OBJECTIVE

To understand physicians' decision-making around deintensifying diabetes treatment.

DESIGN

National physician survey.

PARTICIPANTS

US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care.

MAIN MEASURES

Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models.

KEY RESULTS

There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003).

CONCLUSIONS

While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.

Assessment and prevention of hypoglycaemia in primary care among U.S. Veterans: a mixed methods study

Background

Hypoglycaemia from diabetes treatment causes morbidity and lower quality of life, and prevention should be routinely addressed in clinical visits.

Methods

This mixed methods study evaluated how primary care providers (PCPs) assess for and prevent hypoglycaemia by analyzing audio-recorded visits from five Veterans Affairs medical centres in the US. Two investigators independently coded visit dialogue to classify discussions of hypoglycaemia history, anticipatory guidance, and adjustments to hypoglycaemia-causing medications according to diabetes guidelines.

Findings

There were 242 patients (one PCP visit per patient) and 49 PCPs. Two thirds of patients were treated with insulin and 40% with sulfonylureas. Hypoglycaemia history was discussed in 78/242 visits (32%). PCPs provided hypoglycaemia anticipatory guidance in 50 visits (21%) that focused on holding diabetes medications while fasting and carrying glucose tabs; avoiding driving and glucagon were not discussed. Hypoglycaemia-causing medications were de-intensified or adjusted more often (p < 0.001) when the patient reported a history of hypoglycaemia (15/51 visits, 29%) than when the patient reported no hypoglycaemia or it was not discussed (6/191 visits, 3%). Haemoglobin A1c (HbA1c) was not associated with diabetes medication adjustment, and only 5/12 patients (42%) who reported hypoglycaemia with HbA1c <7.0% had medications de-intensified or adjusted.

Interpretation

PCPs discussed hypoglycaemia in one-third of visits for at-risk patients and provided limited hypoglycaemia anticipatory guidance. De-intensifying or adjusting hypoglycaemia-causing medications did not occur routinely after reported hypoglycaemia with HbA1c <7.0%. Routine hypoglycaemia assessment and provision of diabetes self-management education are needed to achieve guideline-concordant hypoglycaemia prevention.

Funding

U.S. Department of Veterans Affairs and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Evaluation of motor vehicle crashes between scooter riders and car drivers after diagnosis of type 2 diabetes in Taiwan

BACKGROUND

Despite the plausibility that diabetes may increase the risk of motor vehicle crashes (MVCs) due to various diabetes related complications and co-morbidity, findings from epidemiological studies on the relationship between diabetes and MVCs remained inclusive mainly due to heterogeneity in the study design and failure to complete consideration of potential confounders. This study re-visited this putative association with an improved study design.

METHOD

This study employed a controlled before-after study design and included 1,264,280 people aged 18-75 years with T2D newly diagnosed from 2009-2014 and an equal number of age-, sex-, and time-matched controls. The rate ratios (RRs) of vehicle type-specific incidence rates of MVCs in the 1 and 2 years before and after diabetes diagnosis (or the matched dates) were compared between the individuals with type 2 diabetes (T2D) and their matched controls.

RESULTS

The rate of MVCs increased slightly among people with T2D over 1 and 2 years following diabetes diagnosis, with RRs of 1.04 (95% confidence interval [CI]=1.02-1.07) and 1.11 (95% CI=1.09-1.13), respectively. These RRs were comparable to those obtained for controls (1.06 and 1.12, respectively). By contrast, the RRs of scooter crashes were significantly higher in the T2D group than in the control group during the 1 year (1.28 vs. 1.08, p < 0.001) and 2 years (1.32 vs. 1.08, p < 0.001) following diabetes diagnosis.

CONCLUSION

T2D diagnosis was associated with a moderate but significant increase in the risk of MVCs among scooter drivers, but not among car drivers.

Determinants of driving among oldest-old Australian women

This study examined predictors of driving among oldest-old Australian women in their late 80s in accordance with the World Health Organization's healthy aging framework. The study used data from the 1921-26 cohort of the Australian Longitudinal Study on Women's Health, wave-6 (n = 4025). The result of the multivariable logistic regression showed providing care, living alone, volunteering, living in rural/outer regional Australia, having higher educational attainment, and social interactions were associated with driving. The findings indicate driving should not be dismissed based on age alone. Policymakers need to also consider social roles, driving environment and context with the goals of healthy aging.

Beyond A1C-Standardization of Continuous Glucose Monitoring Reporting: Why It Is Needed and How It Continues to Evolve

Continuous glucose monitoring (CGM) systems are becoming part of standard care for type 1 diabetes, and their use is increasing for type 2 diabetes. Consensus has been reached on standardized metrics for reporting CGM data, with time in range of 70-180 mg/dL and time below 54 mg/dL recognized as the key metrics of focus for diabetes management. The ambulatory glucose profile report has emerged as the standard for visualization of CGM data and will continue to evolve to incorporate other elements such as insulin, food, and exercise data to support glycemic management.

Nasogastric tube feeding in line with new dietetic guidelines for the treatment of anorexia nervosa in a specialist children and adolescent inpatient unit: a case series

BACKGROUND

The present study reports a case series where three adolescent patients with anorexia nervosa (AN) (two cases with typical AN and one case atypical AN) received nasogastric tube feeding under restraint in line with new dietetic clinical guidelines.

METHODS

Three cases were chosen out of 61 admitted patients over the period of 1 year who were fed via a nasogastric tube under restraint in a specialist eating disorders unit for children and adolescents. These cases were chosen to highlight a range of clinical scenarios that clinicians may encounter. They also represent clinical scenarios where decisions to feed patients under restraint were rendered more complex by additional concerns.

RESULTS

Despite the complexity of the cases, all patients tolerated the feeds well and were discharged home eating solid food.

CONCLUSIONS

The decision to feed a patient against their will is never an easy one. Sadly, there have been some recent high-profile deaths of adult patients on medical wards where treatment opinion was not considered, and the patient received no or minimal nutrition when awaiting specialist treatment. Dietetic guidelines have been published to help inform clinicians for whom feeding under restraint may be out of the scope of their daily practice. This case series highlights clinical scenarios that illustrate the utility of the guidelines, which we hope will support clinicians when making, potentially lifesaving decisions in children and young people.

The Association of Biochemical Hypoglycemia with the Subsequent Risk of a Severe Hypoglycemic Event: Analysis of the DCCT Data Set

OBJECTIVE

To evaluate the association of biochemical hypoglycemia with subsequent severe hypoglycemia (SH) events using the Diabetes Control and Complications Trial (DCCT) data set.

RESEARCH DESIGN AND METHODS

The frequency of biochemical hypoglycemia (percentage of values <70 and <54 mg/dL [3.9 and 3.0 mmol/L) was assessed using DCCT blood glucose concentrations measured at a central laboratory from seven finger-stick samples (7-point testing: pre- and 90-min postmeals and at bedtime) collected during 1 day every 3 months. SH events required a change in mental status necessitating the involvement of another individual to provide treatment. A Poisson model accounting for repeated measures from each participant was used to assess the association of biochemical hypoglycemia frequency, computed from the 7-point finger-stick data, with the development of SH events.

RESULTS

The risk of SH during a 3-month period was substantially higher (P < 0.001) when there was at least one hypoglycemic blood glucose value in the preceding 7-point profile, with similar results seen for both the 70 mg/dL (rate ratio = 3.0 [95% confidence interval: 2.6-3.3]) and 54 mg/dL (rate ratio = 2.7 [95% confidence interval: 2.4-3.1]) thresholds.

CONCLUSIONS

The occurrence of biochemical hypoglycemia <70 or <54 mg/dL is associated with an increased risk of SH. For this reason as well as the deleterious effects of hypoglycemia on glucose counter-regulation and hypoglycemia awareness, cognition, quality of life, and arrhythmias, it is important in diabetes management to avoid hypoglycemic glucose levels as much as possible.

Self-reported health conditions and related driving reduction in older drivers

We surveyed self-reported lifetime health conditions (using National Health and Aging Trends Study questions) and related driving reduction in a large multi-site older driver cohort (n = 2990) from the AAA Longitudinal Research on Aging Drivers (LongROAD) Study's baseline assessment. Those reporting reduced driving (n = 337) largely attributed reduction to musculoskeletal (29%), neurologic (13%), and ophthalmologic (10%) conditions. Women reported health condition-related driving reduction more often than men (14% versus 8%, p<.001). Mobility affects well-being; health professionals should consider that health conditions may cause older adults to reduce driving. Gender differences deserve attention in future research and education efforts.

Safe driving practices and factors associated with motor-vehicle collisions among people with insulin-treated diabetes mellitus: Results from the Diabetes and Driving (DAD) study

INTRODUCTION

The aim of this study was to assess the prevalence of people with insulin-treated diabetes mellitus (ITDM) who have discussed issues related to diabetes and driving with their health care providers (HCPs). We also sought to determine the safe driving practices that are currently employed by this group. Finally, we investigated the factors that might increase the risk of motor-vehicle collisions (MVCs) among this group in Saudi Arabia.

METHOD

This cross-sectional study surveyed a representative sample of 429 current male drivers with ITDM using a structured questionnaire in Saudi Arabia.

RESULTS

Most of the participants (76.5%) never discussed topics regarding diabetes and driving with their HCPs. The majority of the participants (61.8%) reported at least never doing one of the following: (a) carrying a blood glucose testing kit while driving, (b) testing their blood glucose level before driving or during a journey, or (c) having thought of a specific threshold of blood glucose level that would preclude driving. Three factors were associated with a higher risk of MVCs among participants with ITDM: (a) being on a basal/boluses regimen, (b) never having a discussion regarding diabetes and driving with their HCPs, and (c) having experienced hypoglycemia during driving.

CONCLUSIONS

The majority of people with ITDM had not had a discussion regarding diabetes and driving with their HCPs, which was reflected by a lack of safe driving practices. People with ITDM should be encouraged to take precautions while driving in order to prevent future MVCs.

PRACTICAL APPLICATIONS

This research highlights the importance of investing more effort in educating drivers who have diabetes about safe driving practices by their health care providers. Also, it will attracts the attention of policymakers for an urgent need to establish clear policies and procedures for dealing with drivers who have diabetes.

Assessment of patients' medical fitness to drive by primary care physicians: A cross-sectional study

OBJECTIVES

Motor vehicle collisions (MVCs) are a significant health burden in Saudi Arabia. The literature has consistently indicated that chronic medical conditions, such as diabetes, heart disease, stroke, obstructive sleep apnea, and neurodevelopmental disorders, increase the risk of MVCs. Therefore, assessment of driver fitness by primary care physicians (PCPs) remains a major health intervention that might reduce MVCs. We studied the practices of PCPs in assessing medical fitness to drive in at-risk patients.

METHODS

We conducted a cross-sectional study of all 88 government-funded primary care centers in the city of Riyadh, Saudi Arabia. We administered a self-reported questionnaire to PCPs that inquired about their driving risk assessment for specific medical conditions.

RESULTS

Among all PCPs and centers, 189 PCPs (63%) from 74 centers (84%) participated in our survey. The mean age of the PCPs was 40 ± 10 years, and 108 (57%) were men. The average clinical experience of the group was 13 ± 9 years. Fewer than half of PCPs considered diabetes mellitus (45%) and obstructive sleep apnea (46%) as potential risks for MVCs. Approximately 45% of PCPs did not notify any authority or relatives of potential driving issues that they noticed in their patients. Only 15% of the participants believed that PCPs were responsible for alerting authorities about their fitness to drive.

CONCLUSIONS

PCPs did not adequately assess their patients' driving history and eligibility. Efforts are needed to improve awareness among PCPs regarding the effects of chronic medical conditions on driving.

Risk Factors and Adverse Outcomes of Severe Hypoglycemia in Type 2 Diabetes Mellitus

Hypoglycemia has been considered as a major barrier to achieving the proper glycemic target in type 2 diabetes mellitus patients. In particular, severe hypoglycemia (SH), which is defined as a hypoglycemic episode requiring the assistance of another person to raise the patient's glucose level, is a serious complication of diabetes because of its possible fatal outcomes. Recently, the recommendations for diabetes care have emphasized a patient-centered approach, considering the individualized patient factors including hypoglycemia. Many studies have been performed which analyzed the risk factors and clinical outcomes for SH. From the studies, researchers recommend that targeting a less stringent glycosylated hemoglobin level and selecting a safer class of drugs for hypoglycemia are appropriate for patients with a high risk of SH. Also, careful clinical attention to prevent hypoglycemia, including intensive education, is necessary to minimize the risk of SH and SH-related fatal outcomes.

Traumatic injuries in patients with diabetes mellitus

Diabetes mellitus (DM) is associated with increased in-hospital morbidity and mortality in patients sustained traumatic injuries. Identification of risk factors of traumatic injuries that lead to hospital admissions and death in DM patients is crucial to set effective preventive strategies. We aimed to conduct a traditional narrative literature review to describe the role of hypoglycemia as a risk factor of driving and fall-related traumatic injuries. DM poses significant burden as a risk factor and predictor of worse outcomes in traumatic injuries. Although there is no consensus on the impact and clear hazards of hyperglycemia in comparison to the hypoglycemia, both extremes of DM need to be carefully addressed and taken into consideration for proper management. Moreover, physicians, patients, and concerned authorities should be aware of all these potential hazards to share and establish the right management plans.

Association between hypoglycaemia and impaired hypoglycaemia awareness and mortality in people with Type 1 diabetes mellitus

AIMS

To examine whether severe hypoglycaemia and impaired hypoglycaemic awareness, a principal predictor of severe hypoglycaemia, are associated with all-cause mortality or cardiovascular mortality in Type 1 diabetes mellitus.

METHODS

Mortality was recorded in two cohorts, one in Denmark (n = 269, follow-up 12 years) and one in the Netherlands (n = 482, follow-up 6.5 years). In both cohorts, awareness class was characterized and numbers of episodes of severe hypoglycaemia either during lifetime (Danish cohort) or during the preceding year (Dutch cohort) were recorded. In addition, episodes of severe hypoglycaemia were prospectively recorded every month for 1 year in the Danish cohort. Follow-up data regarding mortality were obtained through medical reports and registries (Danish cohort).

RESULTS

All-cause mortality was 14% (n = 39) in the Danish and 4% (n = 20) in the Dutch cohort. In either cohort, neither presence of episodes with severe hypoglycaemia nor impaired hypoglycaemia awareness were associated with increased mortality in age-truncated Cox proportional hazard regression models. Variables associated with increased risk of all-cause mortality in both cohorts were evidence of macrovascular disease and reduced kidney function.

CONCLUSIONS

Severe hypoglycaemia and hypoglycaemia unawareness are not associated with increased risk of all-cause or cardiovascular mortality in people with Type 1 diabetes mellitus.

Driving and diabetes: problems, licensing restrictions and recommendations for safe driving

Driving is a complex process that places considerable demands on cognitive and physical functions. Many complications of diabetes can potentially impair driving performance, including those affecting vision, cognition and peripheral neural function. Hypoglycemia is a common side-effect of insulin and sulfonylurea therapy, impairing many cognitive domains necessary for safe driving performance. Driving simulator studies have demonstrated how driving performance deteriorates during hypoglycemia. Driving behavior that may predispose to hypoglycemia while driving is examined. Studies examining the risk of road traffic accidents in people with insulin-treated diabetes have produced conflicting results, but the potential risk of hypoglycemia-related road traffic accidents has led to many countries imposing restrictions on the type and duration of driving licenses that can be issued to drivers with diabetes. Guidance that promotes safe driving practice has been provided for drivers with insulin-treated diabetes, which is the group principally addressed in this review.

Mechanisms of hypoglycemia unawareness and implications in diabetic patients

Hypoglycemia unawareness (HU) is defined at the onset of neuroglycopenia before the appearance of autonomic warning symptoms. It is a major limitation to achieving tight diabetes and reduced quality of life. HU occurs in approximately 40% of people with type 1 diabetes mellitus (T1DM) and with less frequency in T2DM. Though the aetiology of HU is multifactorial, possible mechanisms include chronic exposure to low blood glucose, antecedent hypoglycaemia, recurrent severe hypoglycaemia and the failure of counter-regulatory hormones. Clinically it manifests as the inability to recognise impeding hypoglycaemia by symptoms, but the mechanisms and mediators remain largely unknown. Prevention and management of HU is complex, and can only be achieved by a multifactorial intervention of clinical care and structured patient education by the diabetes team. Less know regarding the impact of medications on the development or recognition of this condition in patients with diabetes. Several medications are thought to worsen or promote HU, whereas others may have an attenuating effect on the problem. This article reviews recent advances in how the brain senses and responds to hypoglycaemia, novel mechanisms by which people with insulin-treated diabetes develop HU and impaired counter-regulatory responses. The consequences that HU has on the person with diabetes and their family are also described. Finally, it examines the evidence for prevention and treatment of HU, and summarizes the effects of medications that may influence it.

Haemoglobin A1c in the diagnosis and monitoring of diabetes mellitus

Haemoglobin A(1c) (HbA(1c)) is due to celebrate its 40th birthday. Many people would argue that the clinical studies relating the test to diabetes complications while in its late 20s are likely to be its finest ever achievement. However, this article looks at how HbA(1c) has matured since then and discusses in detail how its many strengths and idiosyncrasies as a marker of glycaemic risk have, as a 30-something, become more clearly understood. As HbA(1c) approaches middle age, this paper also describes how the test appears to be developing a mid-life crisis, as debate over how its results should be expressed seems likely to divide opinion among clinicians for some time to come.

Hypoglycemia in patients with type 1 diabetes: epidemiology, pathogenesis, and prevention

Hypoglycemia is uncommon in the general, nondiabetic population but occurs frequently in persons with diabetes treated with insulin or insulin secretagogues. Thus, iatrogenic hypoglycemia explains the majority of cases among persons with type 1 diabetes (T1DM). Since T1DM is characterized by absolute insulin dependence, the current imperfections in insulin replacement therapies often lead to a mismatch between caloric supply and circulating insulin levels, thus increasing the risk for glycemic fluctuations. Hypoglycemia is the limiting factor to excellent glycemic control in insulin-treated subjects. Intensification of glycemic control was associated with a 300 % increase in the rate of hypoglycemia in the Diabetes Control and Complications Trial. Recent measurements using continuous glucose monitoring reveal an alarming rate of daytime and nocturnal episodes of hypoglycemia in patients with T1DM. Etiological factors underlying hypoglycemia in T1DM include predictable triggers (skipped meals, exercise, insulin over dosage) as well as defective counterregulation, a component of hypoglycemia-associated autonomic failure.

Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society

OBJECTIVE

To review the evidence about the impact of hypoglycemia on patients with diabetes that has become available since the past reviews of this subject by the American Diabetes Association and The Endocrine Society and to provide guidance about how this new information should be incorporated into clinical practice.

PARTICIPANTS

Five members of the American Diabetes Association and five members of The Endocrine Society with expertise in different aspects of hypoglycemia were invited by the Chair, who is a member of both, to participate in a planning conference call and a 2-day meeting that was also attended by staff from both organizations. Subsequent communications took place via e-mail and phone calls. The writing group consisted of those invitees who participated in the writing of the manuscript. The workgroup meeting was supported by educational grants to the American Diabetes Association from Lilly USA, LLC and Novo Nordisk and sponsorship to the American Diabetes Association from Sanofi. The sponsors had no input into the development of or content of the report.

EVIDENCE

The writing group considered data from recent clinical trials and other studies to update the prior workgroup report. Unpublished data were not used. Expert opinion was used to develop some conclusions.

CONSENSUS PROCESS

Consensus was achieved by group discussion during conference calls and face-to-face meetings, as well as by iterative revisions of the written document. The document was reviewed and approved by the American Diabetes Association's Professional Practice Committee in October 2012 and approved by the Executive Committee of the Board of Directors in November 2012 and was reviewed and approved by The Endocrine Society's Clinical Affairs Core Committee in October 2012 and by Council in November 2012.

CONCLUSIONS

The workgroup reconfirmed the previous definitions of hypoglycemia in diabetes, reviewed the implications of hypoglycemia on both short- and long-term outcomes, considered the implications of hypoglycemia on treatment outcomes, presented strategies to prevent hypoglycemia, and identified knowledge gaps that should be addressed by future research. In addition, tools for patients to report hypoglycemia at each visit and for clinicians to document counseling are provided.

Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society

OBJECTIVE

To review the evidence about the impact of hypoglycemia on patients with diabetes that has become available since the past reviews of this subject by the American Diabetes Association and The Endocrine Society and to provide guidance about how this new information should be incorporated into clinical practice.

PARTICIPANTS

Five members of the American Diabetes Association and five members of The Endocrine Society with expertise in different aspects of hypoglycemia were invited by the Chair, who is a member of both, to participate in a planning conference call and a 2-day meeting that was also attended by staff from both organizations. Subsequent communications took place via e-mail and phone calls. The writing group consisted of those invitees who participated in the writing of the manuscript. The workgroup meeting was supported by educational grants to the American Diabetes Association from Lilly USA, LLC and Novo Nordisk and sponsorship to the American Diabetes Association from Sanofi. The sponsors had no input into the development of or content of the report.

EVIDENCE

The writing group considered data from recent clinical trials and other studies to update the prior workgroup report. Unpublished data were not used. Expert opinion was used to develop some conclusions.

CONSENSUS PROCESS

Consensus was achieved by group discussion during conference calls and face-to-face meetings, as well as by iterative revisions of the written document. The document was reviewed and approved by the American Diabetes Association's Professional Practice Committee in October 2012 and approved by the Executive Committee of the Board of Directors in November 2012 and was reviewed and approved by The Endocrine Society's Clinical Affairs Core Committee in October 2012 and by Council in November 2012.

CONCLUSIONS

The workgroup reconfirmed the previous definitions of hypoglycemia in diabetes, reviewed the implications of hypoglycemia on both short- and long-term outcomes, considered the implications of hypoglycemia on treatment outcomes, presented strategies to prevent hypoglycemia, and identified knowledge gaps that should be addressed by future research. In addition, tools for patients to report hypoglycemia at each visit and for clinicians to document counseling are provided.

Older farmers and machinery exposure-cause for concern?

BACKGROUND

The average age of farmers in North America is increasing each year. We had the unique opportunity to examine work patterns and how they change across the lifespan in a large cohort of farm operations.

METHODS

Saskatchewan farms were surveyed via questionnaire during the winter of 2007 to examine the determinants of injury. A sub-sample of 2,751 male farmers aged 25 and older was used in this project. The primary dependent variable was the proportion of work time devoted to specific farm tasks which was related to advancing age.

RESULTS

The weekly hours of work declined approximately 34% as farmers aged over the lifespan. Older farmers disproportionately retained tasks involving tractors and combines as they aged, so that the proportion of time spent operating machinery such as tractors and combines increased by about 40% in the older age groups.

CONCLUSION

Exposure to potentially dangerous farm equipment does not decrease as much as would be expected based on an equal linear reduction in all work tasks as overall work quantity decreases with age. Older farmers remain relatively active in the workplace, and, therefore, prevention efforts should focus on safe machinery operation.

Harvesting experiential expertise to support safe driving for people with diabetes mellitus: a qualitative study evaluated by peers in a survey

BACKGROUND

Hypoglycemia is a frequent phenomenon in people being treated for diabetes mellitus, which can acutely disrupt driving performance. For the benefit of personal and public traffic safety, we decided to identify successful diabetes-related (SDR) behaviors to support safe driving for people with diabetes, from the perspective of experiential experts with diabetes mellitus. Experiential experts are people who can manage their own illness and conditions by developing expertise relevant to maintaining health and countering illness, and who are able to use this expertise to the benefit of peers.

OBJECTIVE

The aim of our study was to objectify and systematize experiential expertise in terms of SDR behaviors, based on reports by experiential experts, to support safe driving for people with type 1 and type 2 diabetes mellitus. The emphasis was on preventing hypoglycemia as a short-term complication during driving.

METHODS

We performed a mixed-methods study involving (i) semi-structured in-depth interviews with 33 experiential experts with diabetes mellitus from the Dutch Diabetes Association (DVN; Diabetesvereniging Nederland), in order to identify SDR behaviors regarding safe driving, and (ii) a validation study by means of a survey among a panel of 98 experiential experts (peers) from the DVN, to determine the extent to which they agreed with the communicability, importance, and feasibility of these behaviors for drivers with diabetes mellitus.

RESULTS

We identified a comprehensive set of 11 SDR behaviors, differentiated into seven general and four specific behaviors, to support safe driving. The general behaviors concern the following topics: (i) acquiring knowledge and information; (ii) acquiring and using self-measuring of blood glucose (SMBG) equipment; (iii) knowing one's physical response pattern; (iv) obtaining knowledge about the medication used; (v) preventing long-term eye complications; (vi) influencing factors that can affect blood glucose; and (vii) renewal procedure for driving license. The four specific behaviors refer to the following topics: (i) measures to be taken before driving; (ii) responding effectively to hypoglycemia while driving; (iii) informing and instructing passengers; and (iv) preventing hypoglycemia in drivers with type 2 diabetes mellitus not using SMBG equipment. Key factors for safe driving proved to be the ability of drivers to anticipate and respond effectively to hypoglycemia while driving and to inform and instruct fellow passengers. Participants of the validation survey agreed to a considerable degree with the communicability, importance, and feasibility of these behaviors to support safe driving for people with diabetes mellitus.

CONCLUSIONS

This study resulted in the identification and description of SDR behaviors to support safe driving. It proved possible to operationalize experiential expertise in terms of such behaviors. The next step is to have these behaviors validated by professional care providers in the field of diabetes, followed by translation into recommendations in self-management programs.

Type 1 diabetic drivers with and without a history of recurrent hypoglycemia-related driving mishaps: physiological and performance differences during euglycemia and the induction of hypoglycemia

OBJECTIVE

Collisions are more common among drivers with type 1 diabetes than among their nondiabetic spouses. This increased risk appears to be attributable to a subgroup of drivers with type 1 diabetes. The hypothesis tested is that this vulnerable subgroup is more at risk for hypoglycemia and its disruptive effects on driving.

RESEARCH DESIGN AND METHODS

Thirty-eight drivers with type 1 diabetes, 16 with (+history) and 22 without (-history) a recent history of recurrent hypoglycemia-related driving mishaps, drove a virtual reality driving simulator and watched a videotape of someone driving a simulator for 30-min periods. Driving and video testing occurred in a double-blind, randomized, crossover manner during euglycemia (5.5 mmol/l) and progressive hypoglycemia (3.9-2.5 mmol/l). Examiners were blind to which subjects were +/-history, whereas subjects were blind to their blood glucose levels and targets.

RESULTS

During euglycemia, +history participants reported more autonomic and neuroglycopenic symptoms (P≤0.01) and tended to require more dextrose infusion to maintain euglycemia with the same insulin infusion (P<0.09). During progressive hypoglycemia, these subjects demonstrated less epinephrine release (P=0.02) and greater driving impairments (P=0.03).

CONCLUSIONS

Findings support the speculation that there is a subgroup of type 1 diabetic drivers more vulnerable to experiencing hypoglycemia-related driving mishaps. This increased vulnerability may be due to more symptom "noise" (more symptoms during euglycemia), making it harder to detect hypoglycemia while driving; possibly greater carbohydrate utilization, rendering them more vulnerable to experiencing hypoglycemia; less hormonal counterregulation, leading to more profound hypoglycemia; and more neuroglycopenia, rendering them more vulnerable to impaired driving.

Neurocognitive Differences Between Drivers with Type 1 Diabetes with and without a Recent History of Recurrent Driving Mishaps

OBJECTIVE: A subset of drivers with type 1 diabetes mellitus (T1DM) may be at significant risk of hypoglycemia-related driving collisions and moving vehicle violations due to acute and chronic neurocognitive impairment. The present study compared drivers with T1DM with and without a recent history of multiple driving mishaps on a neurocognitive battery during euglycemia, progressive mild hypoglycemia, and recovery from hypoglycemia, to determine whether neurocognitive measures differentiate the two risk groups. We hypothesized that drivers with a history of multiple recent hypoglycemia-related driving mishaps would demonstrate greater psychomotor slowing, both during hypoglycemia and euglycemia. STUDY DESIGN: Partcipants were 42 adults with T1DM and were assigned to one of two groups: those reporting no driving mishaps in the last year (-History) and those reporting two or more (+History).Neurocognitive testing was conducted before and repeated during a hyper-insulinemic clamping procedure. RESULTS: Not surprisingly, all drivers demonstrated a decrease in functioning across all neurocognitive tasks during hypoglycemia. However, in contrast to the common belief that neurocognitive functions return slowly and gradually following hypoglycemia, baseline neurocognitive functioning immediately recovered upon return of BG to euglycemia for all subjects. Between-group analyses revealed that subjects with a recent history of driving mishaps consistently demonstrated poorer performance on tasks measuring working memory. CONCLUSION: Working memory is a potential neurocognitive indicator that may help differentiate adults with T1DM with and without a history of driving mishaps, predict future risk for driving mishaps, and provide targeted intervention programs to address this critical public health issue.

The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study

OBJECTIVE

To determine whether there is a link between hypoglycaemia and mortality among participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

DESIGN

Retrospective epidemiological analysis of data from the ACCORD trial. Setting Diabetes clinics, research clinics, and primary care clinics.

PARTICIPANTS

Patients were eligible for the ACCORD study if they had type 2 diabetes, a glycated haemoglobin (haemoglobin A(1C)) concentration of 7.5% or more during screening, and were aged 40-79 years with established cardiovascular disease or 55-79 years with evidence of subclinical disease or two additional cardiovascular risk factors. Intervention Intensive (haemoglobin A(1C) <6.0%) or standard (haemoglobin A(1C) 7.0-7.9%) glucose control.

OUTCOME MEASURES

Symptomatic, severe hypoglycaemia, manifest as either blood glucose concentration of less than 2.8 mmol/l (<50 mg/dl) or symptoms that resolved with treatment and that required either the assistance of another person or medical assistance, and all cause and cause specific mortality, including a specific assessment for involvement of hypoglycaemia.

RESULTS

10 194 of the 10 251 participants enrolled in the ACCORD study who had at least one assessment for hypoglycaemia during regular follow-up for vital status were included in this analysis. Unadjusted annual mortality among patients in the intensive glucose control arm was 2.8% in those who had one or more episodes of hypoglycaemia requiring any assistance compared with 1.2% for those with no episodes (53 deaths per 1924 person years and 201 deaths per 16 315 person years, respectively; adjusted hazard ratio (HR) 1.41, 95% CI 1.03 to 1.93). A similar pattern was seen among participants in the standard glucose control arm (3.7% (21 deaths per 564 person years) v 1.0% (176 deaths per 17 297 person years); adjusted HR 2.30, 95% CI 1.46 to 3.65). On the other hand, among participants with at least one hypoglycaemic episode requiring any assistance, a non-significantly lower risk of death was seen in those in the intensive arm compared with those in the standard arm (adjusted HR 0.74, 95% 0.46 to 1.23). A significantly lower risk was observed in the intensive arm compared with the standard arm in participants who had experienced at least one hypoglycaemic episode requiring medical assistance (adjusted HR 0.55, 95% CI 0.31 to 0.99). Of the 451 deaths that occurred in ACCORD up to the time when the intensive treatment arm was closed, one death was adjudicated as definitely related to hypoglycaemia.

CONCLUSION

Symptomatic, severe hypoglycaemia was associated with an increased risk of death within each study arm. However, among participants who experienced at least one episode of hypoglycaemia, the risk of death was lower in such participants in the intensive arm than in the standard arm. Symptomatic, severe hypoglycaemia does not appear to account for the difference in mortality between the two study arms up to the time when the ACCORD intensive glycaemia arm was discontinued.

TRIAL REGISTRATION

NCT00000620.

Driving mishaps among individuals with type 1 diabetes: a prospective study

OBJECTIVE

Hypoglycemia-related neuroglycopenia disrupts cognitive-motor functioning, which can impact driving safety. Retrospective studies suggest that drivers with type 1 diabetes experience more collisions and citations than their nondiabetic spouses. We present the first prospective data documenting the occurrence of apparent neuroglycopenia-related driving performance impairments.

RESEARCH DESIGN AND METHODS

We completed the initial screening of 452 drivers from three geographically diverse centers who then reported monthly occurrences of driving "mishaps," including collisions, citations, losing control, automatic driving, someone else taking over driving, and moderate or severe hypoglycemia while driving.

RESULTS

Over 12 months, 52% of the drivers reported at least one hypoglycemia-related driving mishap and 5% reported six or more. These mishaps were related to mileage driven, history of severe hypoglycemia, and use of insulin pump therapy.

CONCLUSIONS

Many individuals with type 1 diabetes report hypoglycemia-related driving events. Clinicians should explore the recent experiences with hypoglycemia while driving and the risk of future events.