IntroductionDiabetes-related distress is present in a high proportion of people with type 2 diabetes mellitus. We hypothesized that complexity of the antidiabetic medication regimen is a factor that is associated with diabetes-related distress.Research design and methodsThis was a retrospective study including a group of 74 patients managed at a tertiary care center. Patients with type 1 diabetes mellitus, steroid-induced diabetes, post-transplant diabetes, and other types of diabetes were excluded. Patients were screened using the Diabetes Distress Scale-2 (DDS-2). A Diabetes Medication Complexity Scoring (DMCS) system was developed to objectively assess the diabetes medication complexity. Based on DMCS, participants were categorized into three groups: low (n=26), moderate (n=22), and high (n=26) medication complexity.ResultsComplexity groups were similar in sociodemographic characteristics, diabetes duration, body mass index, and blood pressure as well as the prevalence of hypertension, hyperlipidemia and hypoglycemic episodes. However, there were significant differences for HbA1c with higher HbA1c in the high and moderate complexity groups than in the low group (p=0.006). The microvascular complications were also more common in higher complexity groups (p=0.003). The prevalence of diabetes-related distress (DDS-2 ≥6) was 34.6% in the low, 36.4% in the moderate and 69.2% in the high complexity groups (p=0.021). There were significant differences in DDS-2 score among complexity groups (p=0.009), with higher DDS-2 score in the high complexity group compared with the moderate (p=0.008) and low complexity groups (p=0.009). The difference in DDS-2 score remained significant after adjusting for HbA1c (p=0.024) but did not reach statistical significance after controlling for both HbA1c and microvascular complications (p=0.163).ConclusionsA complex antidiabetic medication regimen may be associated with high levels of diabetes-related distress.

Case 1 was a 72-year-old female with type 2 diabetes who presented to our clinic to optimize glycemic control. The patient had a history of end-stage renal disease (ESRD) related to prolonged hypertension, and she had received a kidney transplant about 5 years before presentation. Case 2 was a 71-year-old male with type 2 diabetes who presented to our clinic to optimize glycemic control. The patient had multiple comorbidities including hypertension, heart failure secondary to ischemic cardiomyopathy, Paget’s disease of the bone, and severe osteoarthritis.

Background: Osteitis fibrosa cystica is an uncommon complication of untreated secondary hyperparathyroidism in patients with end-stage renal disease. The characteristic bony lesions that are seen in this condition very rarely can regress after medical treatment or parathyroidectomy. Clinical Case: A 65-year-old male with PMH of Systemic Lupus Erythematous (SLE) resulting in End-Stage Renal Disease (ESRD) on peritoneal dialysis (PD) and HTN, presented to his primary care physician for evaluation of a painful, enlarging lesion in his left forearm. The patient reported no history of trauma and denied having systemic symptoms. An X-Ray of his left forearm showed a lytic lesion within the proximal neck of the ulna, with erosion of the adjacent cortex. CT of the forearm showed a very vascular soft tissue mass causing significant erosive changes of the anterior cortex in the proximal ulna. Due to the characteristics of the lesion, an underlying malignancy was suspected as a possible diagnosis. The patient had a whole-body PET CT which showed multiple scattered hypermetabolic lytic osseous lesions throughout the axial and appendicular skeleton, including a large left proximal ulnar lesion. The patient had a bone biopsy from the lesion in his left ulna which showed a giant cell proliferation in a background of fibrosis and hemosiderin, suggestive of Osteitis Fibrosa Cystica (brown tumor of hyperparathyroidism). His laboratory workup around the time of the symptoms showed a normal serum calcium (9 mg/dl), associated with a high serum phosphorus (6.2 mg/dl), low vitamin D (20 ng/ml), and an elevated PTH (900 pg/ml). The patient was started on Cinacalcet, an increased dose of phosphate binders, as well as Calcitriol and the lesions and pain disappeared. Follow up lab work showed a normal Vitamin D (34 mg/dl), normal Phosphorus (4 mg/dl), and a PTH of 199 mg/dl, with a normal serum Calcium. A surveillance PET was performed 6 months after the initial one when the lesions clinically had disappeared and it showed again the presence of the bony lesions described prior, including the one in the left ulna, but with decreased FDG uptake, as well as new lesions in the spine. To date, the patient is asymptomatic and has not noted any new painful lesions. Conclusions: Osteitis fibrosa cystica remains a rare manifestation of secondary hyperparathyroidism, which may lead to an initial impression of malignancy. This patient exhibited clinical resolution of the painful symptoms associated with osteitis fibrosa cystica following medical management, though the lytic lesions involving the axial and appendicular skeleton persisted on surveillance imaging. This case serves as a reminder of the severe manifestations of a skeletal disease that has become rare given advances in early detection of and appropriate medical management of hyperparathyroidism.

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Objective: Diabetes-related distress is present in a high proportion of people with type 2 diabetes mellitus (T2DM). We hypothesized that complexity of the antidiabetic medication regimen is a factor that increases diabetes-related distress. Research Design and Methods: We studied 74 consecutive patients with T2DM managed at a tertiary care center. Patients were screened for diabetes-related distress using the Diabetes Distress Scale-2 (DDS-2). A Diabetes Medication Complexity Scoring (DMCS) system was developed to objectively assess the diabetes medication complexity. Based on DMCS, participants were categorized into one of three groups: low (n = 26), moderate (n = 22) and high (n = 26) medication complexity. Results: The prevalence of diabetes-related distress (DDS-2 ≥6) was 34.6% in the low, 36.4% in the moderate, and 69.2% in the high complexity groups (χ2(2) = 7.75, p= 0.021). Complexity groups were similar on sociodemographic characteristics, diabetes duration, BMI and blood pressure as well as the prevalence of hypertension, hyperlipidemia and hypoglycemic episodes over the last year (ps>0.05). The prevalence of microvascular complications varied as a function of low (28%), moderate (45%), and high (76%) regimen complexity (χ2(2) = 11.8, p = 0.003). One-way ANOVA showed significant complexity group differences for HbA1c (F(2,70) = 5.47, p = 0.006) with higher HbA1c in the high and moderate complexity groups than in the low group. Analysis of covariance adjusting for HbA1c showed that DDS-2 significantly differed as a function of complexity group (F (2,69) = 3.93, p = .024). The model explained 16.2% of the variance in DDS-2 (R2 = 0.162). Post hoc analyses revealed that diabetes-related distress was significantly greater for the high (DDS-2 = 6.6) complexity group compared to the moderate complexity group (DDS-2 = 4.5) (p = .031). Conclusions: A complex antidiabetic medication regimen is associated with high levels of diabetes distress. Disclosure M. Luzuriaga: None. R. Leite: None. H. Ahmed: None. P. G. Saab: None. R. Garg: None.