Abstract

People with diabetes treated with insulin have often faced blanket bans from safety-critical occupations, largely because of fear of incapacitation due to hypoglycaemia. Recent advances in insulin therapies, modes of administration, monitoring, and noninvasive monitoring techniques have allowed stereotypical views to be challenged. The aviation sector has led the way, in allowing pilots to fly while on insulin. Recently, countries that have traditionally been opposed to this have changed their minds, largely due to the increasing evidence of safety. The purpose of this review was to gather all available information to update clinicans. The physiology and pathophysiology underpinning glucose regulation and the management of diabetes in the air allowing certain insulin-treated pilots to fly are discussed.


Authors

Russell-Jones, David L.;  Hutchison, Ewan J.;  Roberts, Graham A.

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  • 4 reviewers
  • pre-publication peer review (FINAL ROUND)
    Decision Letter
    2021/03/04

    04-Mar-2021

    Dear Prof. Russell-Jones

    Thank you very much for submitting this revised manuscript.

    Following further peer review, I am pleased to tell you that it is now acceptable for publication in Diabetes, Obesity and Metabolism. For your interest I attach any further / final comments from referees following the latest round of peer review: you can find these below.

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    Referee: 1

    Comments to the Author
    (There are no comments.)

    Referee: 2

    Comments to the Author
    The authors properly responded to the comments.

    Decision letter by
    Cite this decision letter
    Reviewer report
    2021/03/04

    The authors properly responded to the comments.

    Reviewed by
    Cite this review
    Author Response
    2021/03/03

    We have answered all comments by reviewers and enclose a detailed response.



    Cite this author response
  • pre-publication peer review (ROUND 1)
    Decision Letter
    2021/02/06

    06-Feb-2021

    Dear Prof. Russell-Jones

    Thank you for your patience, this manuscript has now been evaluated by one of the editors and two or more expert referees. The comments from reviewers are available at the bottom of this letter, alternately, you can log onto the manuscriptcentral website to view their feedback.

    The reviewers have also given the editor a separate assessment of the quality, originality and likely impact of your submission. These comments and scores, together with the editor’s judgment, are used to prioritise manuscripts for publication. The process is highly competitive, DOM has an impact factor of 5.9 and is currently ranked 18th out of 143 journals in the Endocrine Category.

    You will see that the reviewers have raised a number of points which require clarification and amendment, and suggested ways in which the manuscript might be improved. These comments are intended to be constructive and helpful.

    In addition, the handling editor has made the following comments to summarise the peer review: Nice review, thanks. Various revisions. I disagree with referee #4. The title should be clearer that this article refers to pilots.

    The reviewers and editor would appreciate the opportunity to re-evaluate a revised manuscript which addresses the points raised. The revision should be accompanied by a separate document providing a point by point response to the reviewers’ comments and identifying where significant changes have been incorporated in the text.

    The revised manuscript will be re-assessed by the original reviewers and the handling editor. Only those manuscripts which are full competitive will be accepted for publication, therefore at this stage I cannot guarantee ultimate acceptance.

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    Referee: 1

    Comments to the Author
    This is a narrative review article regarding the insulin treated airclaft pilots with diabetes.

    The topic is timely and important to clear the “stigma” of diabetes.

    There are some comments.

    1. The title does not clearly describe the contents of this review. The term “pilot” should be included in the title.

    2. The purpose of the review was not clearly described. This should be clearly stated in the abstract and the main text.

    3. The methods of the review were also not clearly described. The inclusion criteria of literatures should be clearly described.

    4. The subtitles are only the noun phrases and do not effectively explain the contents. Please use more meaningful subtitles to guide the readers.

    5. Page 6, lines 18-20. The reference is needed for this sentence.

    6. The authors described only CGM as new technologies. Advances in insulin and insulin devices should be also discussed.

    7. Conclusion was not clear. Conclusion section should be added.

    Referee: 2

    Comments to the Author
    Thank you very much for asking me to review this very useful review article on Flying with insulin treated Diabetes.

    Paper is written well and easy to follow and understand.

    It is likely to be a really useful paper for clinicians all around the world.

    I found no significant issues with the paper.

    I have two minor suggestions only

    Under new technology section please comment on the use of closed-loop systems. This is likely to be increasingly important.

    Systems like Dexcom G6 has an non-adjunct licence – Are pilots allowed to use these instead of finger-stick? In plans to review this in future?

    On the PDF review document it appears that last column is not shown due to formatting – the last column I can see is complications surveillance

    Thank you very much

    Referee: 3

    Comments to the Author
    Russell-jones et al have compiled an excellent and very useful review on the issue of flying with diabetes.

    I have only a few minor comments.

    Minor:

    Page 3, Line 12: typographical error 'Tthere' to be corrected.

    Page 3, Para 2, Certification: Please add the relevant references for the section on Certification.

    Page 13 Line 39-40. Typo "protttocol"

    Referee: 4

    Comments to the Author
    Dear Editor-in Chief and authors,

    Thank you for this invitation to review the manuscript by Russell-Jones D et al. entitled: “Flying with insulin treated Diabetes" submitted to the Diabetes, Obesity and Metabolism.

    This is a review discussing the physiology and pathophysiology of glucose regulation and management of diabetes in the air allowing certain insulin treated pilots to fly

    Major concerns
    1.1. Among keywords, “Systematic review” is stated. This is not a systematic review.

    1.2. Table 1 cannot be seen in full length. It may be the pdf file that somehow has cut the table into half.

    1.3. According to the journal website, “the scope of the journal includes human pharmacokinetics and pharmacodynamics, cost-effectiveness studies, preclinical pharmacology, and phase I-IV clinical trials. High-quality meta-analyses and systematic reviews that provide original information on treatment effects and safety are also considered as original research papers”.

    I do not find the manuscript to fit into the aim or scope of the journal. This is more or less a narrative review and may better be suited in another journal, e.g. Diabetic Medicine, Diabetes Metabolism Research and Review, or in a non-diabetes journal focusing on aviation.

    Minor Concerns:
    2.1 Page 3 line 21: A typo “regulation”

    2.2 Page 4 line 12 A typo “There”

    2.3. Could the authors provide information of altitude induced effects on CGM accuracy? It is well-known that pressure on the CGM can alter the CGM signal, the so-called PISA.

    2.4. Are there any studies investigating whether high altitude affect hypoglycemia awareness?

    Decision letter by
    Cite this decision letter
    Reviewer report
    2021/02/04

    Dear Editor-in Chief and authors,

    Thank you for this invitation to review the manuscript by Russell-Jones D et al. entitled: “Flying with insulin treated Diabetes" submitted to the Diabetes, Obesity and Metabolism.

    This is a review discussing the physiology and pathophysiology of glucose regulation and management of diabetes in the air allowing certain insulin treated pilots to fly

    Major concerns
    1.1. Among keywords, “Systematic review” is stated. This is not a systematic review.

    1.2. Table 1 cannot be seen in full length. It may be the pdf file that somehow has cut the table into half.

    1.3. According to the journal website, “the scope of the journal includes human pharmacokinetics and pharmacodynamics, cost-effectiveness studies, preclinical pharmacology, and phase I-IV clinical trials. High-quality meta-analyses and systematic reviews that provide original information on treatment effects and safety are also considered as original research papers”.

    I do not find the manuscript to fit into the aim or scope of the journal. This is more or less a narrative review and may better be suited in another journal, e.g. Diabetic Medicine, Diabetes Metabolism Research and Review, or in a non-diabetes journal focusing on aviation.

    Minor Concerns:
    2.1 Page 3 line 21: A typo “regulation”

    2.2 Page 4 line 12 A typo “There”

    2.3. Could the authors provide information of altitude induced effects on CGM accuracy? It is well-known that pressure on the CGM can alter the CGM signal, the so-called PISA.

    2.4. Are there any studies investigating whether high altitude affect hypoglycemia awareness?

    Reviewed by
    Cite this review
    Reviewer report
    2021/01/31

    Russell-jones et al have compiled an excellent and very useful review on the issue of flying with diabetes.

    I have only a few minor comments.

    Minor:

    Page 3, Line 12: typographical error 'Tthere' to be corrected.

    Page 3, Para 2, Certification: Please add the relevant references for the section on Certification.

    Page 13 Line 39-40. Typo "protttocol"

    Reviewed by
    Cite this review
    Reviewer report
    2021/01/30

    Thank you very much for asking me to review this very useful review article on Flying with insulin treated Diabetes.

    Paper is written well and easy to follow and understand.

    It is likely to be a really useful paper for clinicians all around the world.

    I found no significant issues with the paper.

    I have two minor suggestions only

    Under new technology section please comment on the use of closed-loop systems. This is likely to be increasingly important.

    Systems like Dexcom G6 has an non-adjunct licence – Are pilots allowed to use these instead of finger-stick? In plans to review this in future?

    On the PDF review document it appears that last column is not shown due to formatting – the last column I can see is complications surveillance

    Thank you very much

    Reviewed by
    Cite this review
    Reviewer report
    2021/01/21

    This is a narrative review article regarding the insulin treated airclaft pilots with diabetes.

    The topic is timely and important to clear the “stigma” of diabetes.

    There are some comments.

    1. The title does not clearly describe the contents of this review. The term “pilot” should be included in the title.

    2. The purpose of the review was not clearly described. This should be clearly stated in the abstract and the main text.

    3. The methods of the review were also not clearly described. The inclusion criteria of literatures should be clearly described.

    4. The subtitles are only the noun phrases and do not effectively explain the contents. Please use more meaningful subtitles to guide the readers.

    5. Page 6, lines 18-20. The reference is needed for this sentence.

    6. The authors described only CGM as new technologies. Advances in insulin and insulin devices should be also discussed.

    7. Conclusion was not clear. Conclusion section should be added.

    Reviewed by
    Cite this review
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