Experience with the Internet release of AIDA v4.0--http://www.diabetic.org.uk.aida.htm--an interactive educational diabetes simulator

Leeno: Type 1 diabetes management training environment using smart algorithms

A growing number of Type-1 Diabetes (T1D) patients globally use insulin pump technologies to monitor and manage their glucose levels. Although recent advances in closed-loop systems promise automated pump control in the near future, most patients worldwide still use open-loop continuous subcutaneous insulin infusion (CSII) devices which require close monitoring and continuous regulation. Apart from specialized diabetes units, hospital physicians and nurses generally lack necessary training to support the growing number of patients on insulin pumps. Most hospital staff and providers worldwide have never seen or operated an insulin pump device. T1D patients at nurseries, schools, in hospital emergency rooms, surgery theatres, and in-patient units all require close monitoring and active management. The lack of knowledge and necessary training to support T1D patients on pumps puts them at life-threatening risks. In this work, we develop a training simulation software for hospitals to educate and train their physicians and nurses on how to effectively operate a T1D pump and reduce hypoglycemia events. The software includes clinically validated T1D virtual patients that users can monitor and adjust their pump settings to improve glycemic outcomes. We develop a Fuzzy-Logic learning algorithm that helps guide users learn how to improve pump parameters for these patients. We recruited and trained 13 nurses on the software and report their improvement in pump administration, basal rates adjustments, and ICR modulation.

Development platform for artificial pancreas algorithms

BACKGROUND AND AIMS

Assessing algorithms of artificial pancreas systems is critical in developing automated and fault-tolerant solutions that work outside clinical settings. The development and evaluation of algorithms can be facilitated with a platform that conducts virtual clinical trials. We present in this paper a clinically validated cloud-based distributed platform that supports the development and comprehensive testing of single and dual-hormone algorithms for type 1 diabetes mellitus (T1DM).

METHODS

The platform is built on principles of object-oriented design and runs user algorithms in real-time virtual clinical trials utilizing a multi-threaded environment enabled by concurrent execution over a cloud infrastructure. The platform architecture isolates user algorithms located on personal machines from proprietary patient data running on the cloud. Users import a plugin into their algorithms (Matlab, Python, or Java) to connect to the platform. Once connected, users interact with a graphical interface to design experimental protocols for their trials. Protocols include trial duration in days, mealtimes and amounts, variability in mealtimes and amounts, carbohydrate counting errors, snacks, and onboard insulin levels.

RESULTS

The platform facilitates development by solving the ODE model in the cloud on large CPU-optimized machines, providing a 62% improvement in memory, speed and CPU utilization. Users can easily debug & modify code, test multiple strategies, and generate detailed clinical performance reports. We validated and integrated into the platform a glucoregulatory system of ordinary differential equations (ODEs) parameterized with clinical data to mimic the inter and intra-day variability of glucose responses of 15 T1DM patients.

CONCLUSION

The platform utilizes the validated patient model to conduct virtual clinical trials for the rapid development and testing of closed-loop algorithms for T1DM.

Development of AIDA v4.3b Diabetes Simulator: Technical Upgrade to Support Incorporation of Lispro, Aspart, and Glargine Insulin Analogues

Introduction. AIDA is an interactive educational diabetes simulator available on the Internet without charge since 1996 (accessible at: http://www.2aida.org/). Since the program’s original release, users have developed new requirements, with new operating systems coming into use and more complex insulin management regimens being adopted. The current work has aimed to design a comprehensive diabetes simulation system from both a clinical and information technology perspective.Methods. A collaborative development is taking place with a new generic model of subcutaneous insulin absorption, permitting the simulation of rapidly-acting and very long-acting insulin analogues, as well as insulin injections larger than 40 units. This novel, physiological insulin absorption model has been incorporated into AIDA v4. Technical work has also been undertaken to install and operate the AIDA software within a DOSBox emulator, to ensure compatibility with Windows XP, Vista and 7 operating systems as well as Apple Macintosh computers running Parallels PC emulation software.Results. Plasma insulin simulations are demonstrated following subcutaneous injections of a rapidly-acting insulin analogue, a short-acting insulin preparation, intermediate-acting insulin, and a very long-acting insulin analogue for injected insulin doses up to 60 units of insulin.Discussion.The current work extends the useful life of the existing AIDA v4 program.

Teaching diabetes to Middle-School students with the www.2aida.net AIDA online diabetes software simulator

INTRODUCTION

The lifetime risk of developing diabetes for students born in the new millennium in the United States is estimated to be 27% to 52%. Many students need to learn about diabetes for their personal care, or desire to learn about diabetes to develop a career in healthcare. Most teenagers are adept at learning through Web-based computer tools.

METHODS

Twenty-one students entering 8(th) and 9(th) grades (aged 12 to 14 years old) enrolled in a Biotechnology Summer Camp focused on diabetes. Lectures on pathophysiology and clinical aspects of diabetes were followed by simulated cases using the AIDA online diabetes software simulator accessed via the internet at www.2aida.net. Two cases demonstrated glycemic effects and pharmacokinetics of insulin administration, diet, and exercise in insulin-dependent (Type 1) diabetes and non-insulin-dependent (Type 2) diabetes. Students filled out standardized evaluations at the end of the session to assess receptiveness to this type of learning; opinions on the utility, information, and ease of use; and perceived risks of using the online simulator to understand diabetes.

RESULTS

All students were receptive to this educational tool. The majority found AIDA online useful (17/21 [81%]), educational (21/21 [100%]), worthy of wider distribution (20/21 [95%]), and would recommend the program to others with diabetes or wanting to learn about diabetes (18/21 [86%]). A minority (2/21 [9.5%]) found the program risky regarding the information given to the students. Positive comments included the ability to visualize concepts being taught in earlier lectures, and recognized the rigors required to manage diabetes. Fewer negative comments reflected frustration with the web-based user interface, the course materials, or difficulty in achieving good simulated glycemic control.

DISCUSSION

Teaching pathophysiology of diabetes and pharmacology of insulin to middle school students is enhanced with the AIDA online diabetes simulator. Future versions of this program, and development of similar programs, could be useful in teaching adolescents who have diabetes, and might help stimulate interested students to learn more about the care of people with diabetes.

Retrospective pilot feedback survey of 200 users of the AIDA Version 4 Educational Diabetes Program. 1--Quantitative Survey Data

This column reports a detailed, questionnaire-based, post-release feedback survey of 200 users of the AIDA version 4 educational diabetes simulator. AIDA is a freeware computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, self-learning, and research purposes. Since its Internet launch in 1996 over 700,000 visits have been logged to the AIDA Websites-including www.2aida.org-and over 200,000 program copies have been downloaded free-of-charge. The main goals of the current study were: (1) to establish what people have thought about the AIDA program, (2) to assess the utility of the software, and (3) to ascertain how much people have actually used it. An analysis was therefore undertaken of the first 200 feedback forms that were returned by AIDA users. The questionnaire-based survey methodology was found to be robust and reliable. Feedback forms were received from participants in 21 countries. One hundred six of 209 responses (50.7%) were received from people with diabetes, and 36 of 209 (17.2%) from relatives of patients, with lesser numbers from doctors, students, diabetes educators, nurses, pharmacists, and other end users. Please note some respondents fulfilled more than one end-user category, hence the denominator <200; for example, someone with diabetes who was also a doctor. This study has established the feasibility of using a simple feedback form to survey a substantial number of diabetes software users. In addition, it has yielded interesting data in terms of who are the main users of the AIDA program, and has also provided technical (computer) information that has aided the release of a freeware upgrade to the software. In general, users reported finding the program to be of educational value. The majority also felt it would be of interest to diabetes educators and people with diabetes. Most were clear about its limitations as a simulator-based learning tool. The implications of these findings will be discussed.

Interactive educational diabetes/insulin tutorial at www.2aida.info

The World Wide Web now hosts a multitude of diabetes educational materials in various formats. Of particular interest is the diabetes/insulin tutorial available at the AIDA Website (accessible directly at: www.2aida.info). The tutorial combines textual or "static" information with an interactive diabetes simulator-AIDA online-to provide an engaging and effective educational tool. AIDA online (accessible directly at: www.2aida.net) enables the simulation of plasma insulin and blood glucose levels from user-defined insulin injection and carbohydrate intake data. A haemoglobin A1c value is also computed, giving an indication of overall blood glucose control in the virtual patient with diabetes. The diabetes/insulin tutorial is currently composed of four sections: the first two cover in considerable depth insulin injection regimens and insulin dosage adjustment; the third section introduces the principles of carbohydrate counting and, specifically, matching insulin doses to carbohydrate intake; and the fourth section illustrates the relationship between blood glucose levels and renal excretion of glucose. The simulator runs alongside the tutorial, and allows various concepts described in the text to be explored freely by the user and simulated interactively. This introduces a novel way of learning how injected insulin and dietary carbohydrate interact in various insulin injection regimens. A fifth section- for which any offers of assistance would be gratefully received-is planned. This will consider the use of insulin pumps and rapidly acting and very long-acting insulin analogues. Further improvements that may strengthen the existing tutorial and/or use of the online simulator are discussed in this column.

Diabetes website review: www.2aida.org

Previous Diabetes Information Technology & WebWatch columns have addressed the use of diabetes simulators, and, in particular, aspects of the AIDA software. AIDA is a freeware computer program, which simulates the interaction of carbohydrates and insulin administered in people with insulin-dependent (type 1) diabetes mellitus. The program is intended to be used as an educational support tool, and is available via the Internet without charge from www.2aida.org. In this article, the AIDA Website is described and reviewed in terms of both content and functionality. This popular non-commercial Internet site provides free access to a downloadable PC version of AIDA, as well as access to a Web-based version of the simulator that can be run online (accessible directly at: www.2aida.net). User feedback suggests that the Website and the AIDA software have been of significant interest and value to many patients, their relatives and carers, students, and a variety of health-care professionals and researchers. The interactive and dynamic nature of the simulations adds a real-life dimension to the Web-based educational material, and the software is complemented by a substantial amount of supporting information at the Website. The on-going collection of subjective feedback continues to provide anecdotal evidence of the utility of the software, and this will hopefully be corroborated by results from more formal and objective evaluations. The future potential of diabetes simulators, in both education and research, is becoming increasingly apparent, and the AIDA Website is evolving accordingly.

Informal diabetes education: impact on self-management and blood glucose control

PURPOSE

The purpose of this study was to determine if participation in screening clinics to detect and treat diabetes-related eye disease also led to informal patient learning that had an impact on self-management behavior and blood glucose control.

METHODS

To evaluate the evidence for patient learning over time, the data of patients who returned as advised for 2 subsequent annual diabetes disease screenings were analyzed. Evaluation measures included medication use, self-management behavior, and hemoglobin A1c (A1C).

RESULTS

During the 2-year study period, the use of insulin increased by 37% at the first exam, 43% at the second exam, and 42% at the third exam (P = .02). No significant changes were found in the use of oral medication. Glucose self-monitoring also increased by 61% at the first exam, 71% at the second exam, and 76% at the third exam (P < .01). Mean A1C values for returning participants declined by 9.2% at the first exam, 8.9% at the second exam, and 8.6% at the third exam (P = .03).

CONCLUSIONS

The screening clinics had an educational impact associated with behavior change (improved self-management and glucose control) even though the clinics were not intended to produce such change. Therefore, caregivers should consider that patient learning can and should be part of every diabetes care encounter.

British Diabetic Association review of the AIDA v4 diabetes software simulator program

AIDA is a diabetes-computing program freely available from www.2aida.org on the Web. The software is intended to serve as an educational support tool, and can be used by anyone who has an interest in diabetes, whether they be patients, relatives, health-care professionals, or students. In 1996, during the beta-testing phase of the AIDA v4 project, the British Diabetic Association (BDA)-now called Diabetes UK-was approached and offered the AIDA software by the author, without charge, as a noncommercial contribution to continuing diabetes education. The BDA undertook their own independent assessment of the program, which involved distributing AIDA to a panel of potential end-users (health-care professionals and patients). Comments were solicited regarding the utility, clarity, and perceived safety of the software from users outside the BDA, as well as from various internal assessors. As a result of the feedback, a decision was taken by the BDA to offer AIDA to health-care professionals through the BDA's health-care professional brochure. One thousand copies of the software were produced on diskette, and 1,000 copies of the BDA's version of the program's user guide-printed as a small book-were made available for distribution by post. In this Diabetes Information Technology & WebWatch column an overview is given of the anonymous feedback provided to the BDA by some of the external evaluators. Looking back, nearly 8 years after the launch of AIDA, it is interesting to review some of the comments received and compare these with what has actually happened with the software. To date over 400,000 visits have been logged at the AIDA Web pages, and over 80,000 copies of the program have been downloaded free-of-charge. It is highlighted that this widespread downloading of, and interest in, the AIDA software seems to largely have been fuelled by the program's free availability on the Internet. The use of the World Wide Web to enhance the distribution of other medical (diabetes) programs is highlighted.

Why people download the freeware AIDA v4.3a diabetes software program: a proof-of-concept semi-automated analysis

AIDA is a diabetes-computing program freely available at www.2aida.org on the Web. The software is intended to serve as an educational support tool and can be used by anyone who has an interest in diabetes, whether they be patients, relatives, health-care professionals, or students. In previous "Diabetes Information Technology & WebWatch" columns various indicators of usage of the AIDA program have been reviewed, and various comments from users of the software have been documented. The purpose of this column is to overview a proof-of-concept semi-automated analysis about why people are downloading the latest version of the AIDA educational diabetes program. AIDA permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, self-learning, and research purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 300,000 visits have been logged at the main AIDA Website-www.2aida.org-and over 60,000 copies of the AIDA program have been downloaded free-of-charge. This column documents the results of a semi-automated analysis of comments left by Website visitors while they were downloading the AIDA software, before they had a chance to use the program. The Internet-based survey methodology and semi-automated analysis were both found to be robust and reliable. Over a 5-month period (from October 3, 2001 to February 28, 2002) 400 responses were received. During the corresponding period 1,770 actual visits were made to the Website survey page-giving a response rate to this proof-of-concept study of 22.6%. Responses were received from participants in over 54 countries-with nearly half of these (n = 194; 48.5%) originating from the United States, United Kingdom, and Canada; 208 responses (52.0%) were received from patients with diabetes, 50 (12.5%) from doctors, 49 (12.3%) from relatives of patients, with fewer responses from students, diabetes educators, nurses, pharmacists, and other end users. The semi-automated analysis adopted for this study has re-affirmed the feasibility of using the Internet to obtain free-text comments, at no real cost, from a substantial number of medical software downloaders/users. The survey has also offered some insight into why members of the public continue to turn to the Internet for medical information. Furthermore it has provided useful information about why people are actually downloading the AIDA v4.3a interactive educational "virtual diabetes patient" simulator.

Who is downloading the free AIDA v4.3a interactive educational diabetes computer software? A 1-year survey of 3864 downloads

AIDA is a free diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, self-learning, and research purposes. To date over 70000 copies of the software have been downloaded from the AIDA Website, www.2aida.org. This column documents a survey of downloaders of the latest release of the program (AIDA v4.3a). The Internet-based survey methodology was confirmed to be robust and reliable. Over a 1-year period (from March 2001 to February 2002) in total 3864 responses were received. During the corresponding period some 8578 actual downloads of the software were independently logged via the same route at the AIDA Website, giving a response rate for this survey of 45%. Responses were received from participants in 66 countries - over half of these (n = 2,137; 55.3%) were from the United States and the United Kingdom. There were 2318 responses (60.0%) received from patients with diabetes and 443 (11.5%) from relatives of patients, with fewer responses from doctors, students, diabetes educators, nurses, pharmacists, and other end users. This study highlights considerable interest amongst patients and their relatives to learn more about balancing insulin and diet in diabetes, as well as possibly to get more involved in self-management of insulin dosages. More computer applications that can cater for this interest in diabetes patient self-care need to be developed and made available. The Internet provides an ideal medium for the distribution of such educational tools.

Research use of the AIDA www.2aida.org diabetes software simulation program: a review-part 1. decision support testing and neural network training

The purpose of this two-part review is to overview research use of the AIDA diabetes software simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 300,000 visits have been logged at the main AIDA Website-www.2aida.org-and over 60,000 copies of the AIDA program have been downloaded free-of-charge. This review describes research projects and ventures, undertaken for the most part by other research workers in the diabetes computing field, that have made use of the freeware AIDA software. Relevant research work was identified in three main ways: (i) by personal (e-mail/written) communications from researchers, (ii) via the ISI Web of Science citation database to identify published articles that referred to AIDA-related papers, and (iii) via searches on the Internet. In a number of cases research students who had sought advice about AIDA, and diabetes computing in general, provided copies of their research dissertations/theses upon the completion of their projects. The two reviews highlight some of the many and varied research projects that have made use of the AIDA diabetes simulation software to date. A wide variety of diabetes computing topics have been addressed. In Part 1 of the review, these range from testing decision support prototypes to training artificial neural networks. In Part 2 of the review, issues surrounding dietary assessments, developing new diabetes models, and performance monitoring of closed-loop insulin delivery devices are considered. Overall, research projects making use of AIDA have been identified in Australia, Italy, South Korea, the United Kingdom, and the United States. These reviews confirm an unexpected but useful benefit of distributing medical software, like AIDA, for free via the Internet-demonstrating how it is possible to have a synergistic benefit with other researchers-facilitating their own research projects in related medical fields. The reviews highlight a variety of these projects that have benefited from the free availability of the AIDA diabetes software simulator. In a number of cases these other research projects simply would not have been possible without unrestricted access to the AIDA software and/or technical descriptions of its workings. In addition, some specific common themes begin to emerge from the research ventures that have been reviewed. These include the use of simulated blood glucose data from the AIDA program for preliminary computerlab-based testing of other decision support prototypes. Issues surrounding such use of simulated data for separate prototype testing are discussed further in Part 2 of the review.

Usage of the www.2aida.org AIDA diabetes software Website: a pilot study

AIDA is a diabetes-computing program freely available from www.2aida.org on the Web. The software is intended to serve as an educational support tool, and can be used by anyone who has an interest in diabetes, whether they be patients, relatives, health-care professionals, or students. In previous "Diabetes Information Technology & WebWatch" columns various indicators of usage of the AIDA program have been reviewed, and various comments from users of the software have been documented. One aspect of AIDA, though, that has been of considerable interest has been to investigate its Web-based distribution as a wider paradigm for more general medically related usage of the Internet. In this respect we have been keen to understand in general terms: (1) why people are turning to the Web for health-care/diabetes information; (2) more specifically, what sort of people are making use of the AIDA software; and (3) what benefits they feel might accrue from using the program. To answer these types of questions we have been conducting a series of audits/surveys via the AIDA Website, and via the software program itself, to learn as much as possible about who the AIDA end users really are. The rationale for this work is that, in this way, it should be possible to improve the program as well as tailor future versions of the software to the interests and needs of its users. However, a recurring observation is that data collection is easiest if it is as unobtrusive and innocuous as possible. One aspect of learning as much as possible about diabetes Website visitors and users may be to apply techniques that do not necessitate any visitor or user interaction. There are various programs that can monitor what pages visitors are viewing at a site. As these programs do not require visitors to do anything special, over time some interesting insights into Website usage may be obtained. For the current study we have reviewed anonymous logstats data, which are automatically collected at many Websites, to try and establish a baseline level of usage for the AIDA site. For the initial pilot study the analysis was performed from October 1, 2000 to November 1, 2001. The study has yielded an interesting insight into how the AIDA Website is being used. The results also confirm those of previous audits based on different self-reported methodologies, confirming, amongst other things, what countries people are visiting from and what operating systems/computers they are using. These analyses have been informative and useful. Given this, it is proposed to repeat the current pilot survey approach on a routine basis, in the future, as a way of monitoring on-going usage of the AIDA Website.

Evaluation of accessibility and use of new communication technologies in patients with type 1 diabetes mellitus

BACKGROUND

The role of patients in the management and control of type 1 diabetes mellitus, a chronic disease, is well established. The advent of new communication technologies is expected to improve patients' access to health information. However, little is known about the extent to which patients with type 1 diabetes mellitus use the Internet to retrieve medical information and about the impact, if any, this retrieval has on their health status.

OBJECTIVE

To evaluate the accessibility and use of new communication technologies in a population of patients with type 1 diabetes mellitus.

METHODS

Patients with type 1 diabetes mellitus attending the Diabetes Clinic of the Hospital de Sabadell, Sabadell, Spain, in a 6-month period were asked to answer a structured questionnaire about education level, Internet accessibility, use of health-related Web sites, and mobile-phone ownership and use.

RESULTS

Of 302 patients with type 1 diabetes mellitus attending the Diabetes Clinic on a regular basis, 244 (115 men, 129 women) were interviewed (response rate 80.8%). Personal computers were owned by 58.2% of patients. Fifty-nine percent had access to the Internet, 39.3% had access to the Internet at home; however, only 36.5% were regular Internet users. Internet users were younger, more frequently men, and of higher education level. Among Internet users only 49.4% had ever accessed a health-related Web site. Internet users who had ever accessed a health-related Web site had a higher level of education, presented severe hypoglycemia more frequently, and were more likely to have access to the Internet at home. No differences were found in metabolic control between Internet users and nonusers or between Internet users who had ever accessed a health-related Web site and Internet users who had never accessed a health-related Web site. Of the 76.6% of the patients that owned a mobile phone, 96% used it more than once a week.

CONCLUSIONS

The impact of new communication technologies might be jeopardized by the low rate of access and utilization of the Internet for health-related purposes. Because of their high rate of ownership and use, mobile phones show promise as a tool in health care communication technologies.

Why are people downloading the freeware AIDA diabetes computing software program: a pilot study

The purpose of this paper is to report a pilot survey about why people are downloading the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 well over 200,000 visits have been logged at the main AIDA Website--www.2aida.org--and over 40,000 copies of the AIDA program have been downloaded free-of-charge. This article documents a pilot survey of comments left by Website visitors while they were downloading the AIDA software, before they had a chance to actually use the program. The overall paradigm adopted for this study has endeavored to establish why people are resorting to the Internet to obtain diabetes information. Specific intended goals of the study were: (1) to demonstrate ongoing use of the World Wide Web for surveying diabetes software users by obtaining their free-text comments; (2) to identify what sort of things people were planning to do with the AIDA software simulator; and (3) to more generally gain some insight into why people are turning to the Web for healthcare-related information. The Internet-based survey methodology was found to be robust and reliable. Over an 8-month period (from February 2, 2001 to October 1, 2001) 642 responses were received. During the corresponding period 2,248 actual visits were made to the Website survey page--giving a response rate to this pilot study of 28.6%. Responses were received from participants in over 56 countries--although over half of these (n = 343; 53.4%) originated from the United States and United Kingdom. Two hundred forty-four responses (38.0%) were received from patients with diabetes, and 73 (11.4%) from relatives of patients, with fewer responses from doctors, students, diabetes educators, nurses, pharmacists, and other end users. This pilot survey has confirmed the feasibility of using the Internet to obtain free-text comments, at no real cost, from a large number of medical software downloaders/users. The survey has also offered a valuable insight into why members of the public are turning to the Internet for medical information. Furthermore it has provided useful information about why people are actually downloading the AIDA interactive educational "virtual diabetes patient" simulator.

Using the AIDA--www.2aida.org--diabetes simulator. Part 1: recommended guidelines for health-carers planning to teach with the software

AIDA is a novel diabetes-computing program freely available from www.2aida.org on the Web. The software is intended to serve as an educational support tool and can be used by anyone-patient with diabetes, relative of patient, health-care professional, or student-who has a minimal knowledge of the pathophysiology of diabetes. However, to obtain maximum benefit from the program, a teacher or demonstrator may be helpful. How much (or little) experience should the potential teacher have prior to giving formal lessons with the program? There is no hard or fast "rigid" answer to this. However, one of the aims of this article is to try and encourage people to consider these issues. In this respect it is important to make clear that health-carers cannot just download the program and start teaching with it the next day (or week) if they want their patients to get the most out of lessons with the program. As with many teaching interventions, the rewards of education-"what one gets out of it"-are in part dependent on the effort that one is willing to put in. Therefore teachers have to invest some time and effort into finding out how they can best work with the program to teach their patients in their particular local hospital/clinic setting. A further purpose of this article, and the one that follows in a future issue, is to generate some guidelines and provide some minimum recommendations for small group teaching sessions using AIDA. Previous experience of the authors has revealed a number of ways to improve the outcome of lessons that make use of the software. Among the most important points seem to be the preparation of the teacher, consideration of how to impart preliminary information to help patients understand the pathophysiology of diabetes, the optimum selection of topics to be covered, the arrangement of the lessons, how to involve each of the participants, and how to deal with questions. Other important topics include how to spot and deal with some of the difficulties that may be encountered by participants who apparently seem disinterested, obtaining feedback from the lessons, and practical ideas on how to lead a class.

Using the AIDA--www.2aida.org--diabetes simulator. Part 2: recommended training requirements for health-carers planning to teach with the software

The purpose of this article is to document some recommended training requirements for health-carers planning to teach using the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 200,000 visits have been logged at the AIDA Website--www.2aida.org--and over 40,000 copies of the AIDA program have been downloaded free-of-charge. This report describes various training requirements that are recommended for health-care professionals who are interested in teaching with the software. Intended goals of this article are to answer possible questions from teachers using the program, highlight some minimum recommended training requirements for the software, suggest some "hints and tips" for teaching ideas, explain the importance of performing more studies/trials with the program, overview randomised controlled trial usage of the software, and highlight the importance of obtaining feedback from lesson participants. The recommendations seem to be straightforward and should help in formalising training with the program, as well as in the development of a network of teachers "accredited" to give lessons using the software. This report, together with the previous article (Part 1, Diabetes Technol Ther 2002;4:401-414), highlights the utility of providing guidelines and suggesting recommended training requirements for health-carers planning to make use of educational medical/diabetes software.

Who is downloading the freeware AIDA v43 interactive educational diabetes simulator? An audit of 2437 downloads

The purpose of this paper is to report an audit of 2437 downloads of the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 200000 visits have been logged at the AIDA Website - www.2aida.org - and over 37000 copies of the AIDA program have been downloaded free-of-charge. This report documents an audit of downloaders of the software, with the intended goals of the study being to demonstrate the use of the Internet for auditing and surveying diabetes software users and to confirm the proportion of patients with diabetes and their relatives who are actually making use of the AIDA v4.3 program. The Internet-based survey methodology was confirmed to be robust and reliable. Over a 7(1/2)-month period (from mid-July 2000 to early March 2001) 2437 responses were received. During the corresponding period 4100 actual downloads of the software were independently logged via the same route at the AIDA Website - giving a response rate to this audit of 59.4%. Responses were received from participants in 61 countries - although over half of these (n = 1533; 62.9%) originated from the United States and United Kingdom. Of these responses 1,361 (55.8%) were received from patients with diabetes and 303 (12.4%) from relatives of patients, with fewer responses from doctors, diabetes educators, students, nurses, pharmacists, and other end users. This study has confirmed the feasibility of using the Internet to survey, at no real cost, a large number of medical software downloaders/users. In addition, it has yielded up-to-date and interesting data about who are the main downloaders of the AIDA program.

Further user comments regarding usage of an interactive educational diabetes simulator (AIDA)

This "Diabetes Information Technology & WebWatch" column continues the diabetes simulation theme from previous issues and overviews various user experience with the AIDA v4 interactive educational freeware diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose (BG) profiles for educational, demonstration, and self-learning purposes. It has been made freely available, without charge, via the Web as a noncommercial contribution to continuing diabetes education. Since its Internet launch in 1996, over 145,000 visits have been logged at the AIDA Website--www.2aida.org--and over 29,000 copies of the program have been downloaded, free of charge. While these statistics may appear impressive, they do not tell the personal story of how people have been making use of the software, and what they actually think about the program. In this respect, this column documents some of the independent user comments about AIDA sent in spontaneously via electronic mail (email) by patients with diabetes and their relatives, as well as by health-care professionals. Comments posted to diabetes newsgroups and diabetes email lists, as well as a selection of those which have been found at other, linked, diabetes Websites are also highlighted.

Utility of the AIDA diabetes simulator as an interactive educational teaching tool for general practitioners (primary care physicians)

In previous "Diabetes Information Technology & WebWatch" columns, various user experience with an interactive educational "virtual diabetes patient" simulator called AIDA have been documented. The simulator is available free of charge from http://www.2aida.org on the Web, and user comments that have been received to date about the program have highlighted some of the many and varied ways in which a range of people have been applying the diabetes simulations in their own particular situations and practices. Inevitably, up to now, a great deal of attention has focused on use by individuals with diabetes and their relatives, as well as by health-care professionals such as diabetologists/endocrinologists and diabetes educators. However, an important group of health-carers involved in the provision of day-to-day care for many people with diabetes are primary care physicians (general practitioners). The current "Diabetes Information Technology & WebWatch" column addresses this area, overviewing a workshop which was held in September 2000 in Italy to gain experience with application of the AIDA diabetes simulation approach as a teaching tool for general practitioners (GPs). Feedback obtained from participants attending the workshop was very positive, with GPs reporting the simulation approach to be both of interest and use. Further workshops involving other healthcare professionals--in particular, nurses--are planned.

Use of the AIDA diabetes simulation software--www.2aida.org--as an interactive educational tool for teaching student nurses

In previous "Diabetes Information Technology & WebWatch" columns, various user experiences with an interactive educational virtual diabetes patient simulator, called AIDA, have been documented. The simulator is available free of charge from www.2aida.org on the Web. In the 5+ years since the program was first made available on the Internet, over 125,000 people have visited the AIDA Website and over 27,000 copies of the program have been downloaded, gratis. User comments that have been received about the program have highlighted some of the many and varied ways in which a range of people have been applying the diabetes simulations in their own particular situations and practices. Inevitably, up to now, a great deal of attention has focused on use of the program by individuals with diabetes and their relatives, as well as by health-care professionals such as diabetologists/endocrinologists, diabetes educators, and primary care physicians (general practitioners [GPs]). However, an important group of health-carers involved in the provision of day-to-day care for many people with diabetes are nurses. The current "Diabetes Information Technology & WebWatch" column overviews a workshop held in June 2001 in Italy to gain experience with application of the AIDA diabetes simulation approach as a teaching tool for student nurses. Feedback obtained from participants attending the workshop was generally very positive, with the student nurses reporting the simulation approach to be both of interest and of use. Further workshops involving other health-care students and professionals-in particular, medical students and qualified nurses-are planned.

Simulating glycosylated hemoglobin (HbA1c) levels in diabetes using an interactive educational virtual diabetes patient simulator

In 1996, an interactive educational diabetes simulator called AIDA was released without charge on the Internet as a noncommercial contribution to continuing diabetes education. Over the past 5 years, over 100,000 people have visited the AIDA Web pages at http://www.2aida.org and over 25,000 copies of the program have been downloaded free-of-charge. Previous Diabetes Information Technology & WebWatch columns have described various user feedback comments about the AIDA software. This current column overviews the method applied for modelling glycosylated hemoglobin (HbA1c) levels within an updated version of the AIDA program (v4.3). The result seems to be a useful and novel addition to the diabetes simulations, providing a parameter with which most users will be familiar, and able to relate. It is expected that the HbA1c indicator may prove useful in enhancing the educational value of the diabetes simulations.

Spontaneous comments from users of the AIDA interactive educational diabetes simulator

The user experience with the AIDA simulator demonstrates one of the advantages of making such diabetes software readily available for free via the Internet. The comments collectively provide a picture of some of the many and varied ways in which the simulator has been applied by different users. These comments also demonstrate the potential for empowerment that some people feel can result from the use of the software. The experience with this approach is sufficiently encouraging to warrant formal evaluation studies to quantify the clinical utility of such an interactive educational diabetes simulation program. For this reason, a formal survey of 200 AIDA users (patients, relatives, and healthcare professionals) from at least 15 different countries is currently ongoing, and further formal evaluation studies in the clinic setting are planned.

The promise of technology in the management of the patient with diabetes

The advent of technology has brought many improvements in the management of individual aspects of the care of the patient with diabetes. However, the best management requires communication between systems to enable the clinician to coordinate these various aspects. This article reviews examples of the application of technology to the individual aspects of care. It also discusses the problems and promise of technology to improve overall care management.