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Pavan J, Noaro G, Facchinetti A, Salvagnin D, Sparacino G, Del Favero S. A strategy based on integer programming for optimal dosing and timing of preventive hypoglycemic treatments in type 1 diabetes management. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 250:108179. [PMID: 38642427 DOI: 10.1016/j.cmpb.2024.108179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/29/2024] [Accepted: 04/13/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND AND OBJECTIVES One of the major problems related to type 1 diabetes (T1D) management is hypoglycemia, a condition characterized by low blood glucose levels and responsible for reduced quality of life and increased mortality. Fast-acting carbohydrates, also known as hypoglycemic treatments (HT), can counteract this event. In the literature, dosage and timing of HT are usually based on heuristic rules. In the present work, we propose an algorithm for mitigating hypoglycemia by suggesting preventive HT consumption, with dosages and timing determined by solving an optimization problem. METHODS By leveraging integer programming and linear inequality constraints, the algorithm can bind the amount of suggested carbohydrates to standardized quantities (i.e., those available in "off-the-shelf" HT) and the minimal distance between consecutive suggestions (to reduce the nuisance for patients). RESULTS The proposed method was tested in silico and compared with competitor algorithms using the UVa/Padova T1D simulator. At the cost of a slight increase of HT consumed per day, the proposed algorithm produces the lowest median and interquartile range of the time spent in hypoglycemia, with a statistically significant improvement over most competitor algorithms. Also, the average number of hypoglycemic events per day is reduced to 0 in median. CONCLUSIONS Thanks to its positive performances and reduced computational burden, the proposed algorithm could be a candidate tool for integration in a DSS aimed at improving T1D management.
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Affiliation(s)
- J Pavan
- Department of Information Engineering, University of Padova, Via Gradenigo 6/A, Padova, 35131, Italy.
| | - G Noaro
- Department of Information Engineering, University of Padova, Via Gradenigo 6/A, Padova, 35131, Italy.
| | - A Facchinetti
- Department of Information Engineering, University of Padova, Via Gradenigo 6/A, Padova, 35131, Italy.
| | - D Salvagnin
- Department of Information Engineering, University of Padova, Via Gradenigo 6/A, Padova, 35131, Italy.
| | - G Sparacino
- Department of Information Engineering, University of Padova, Via Gradenigo 6/A, Padova, 35131, Italy.
| | - S Del Favero
- Department of Information Engineering, University of Padova, Via Gradenigo 6/A, Padova, 35131, Italy.
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2
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den Brok EJ, Svensson CH, Panagiotou M, van Greevenbroek MMJ, Mertens PR, Vazeou A, Mitrakou A, Makrilakis K, Franssen GHLM, van Kuijk S, Proennecke S, Mougiakakou S, Pedersen-Bjergaard U, de Galan BE. The effect of bolus advisors on glycaemic parameters in adults with diabetes on intensive insulin therapy: A systematic review with meta-analysis. Diabetes Obes Metab 2024; 26:1950-1961. [PMID: 38504142 DOI: 10.1111/dom.15521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/08/2024] [Accepted: 02/11/2024] [Indexed: 03/21/2024]
Abstract
AIM To conduct a systematic review with meta-analysis to provide a comprehensive synthesis of randomized controlled trials (RCTs) and prospective cohort studies investigating the effects of currently available bolus advisors on glycaemic parameters in adults with diabetes. MATERIALS AND METHODS An electronic search of PubMed, Embase, CINAHL, Cochrane Library and ClinicalTrials.gov was conducted in December 2022. The risk of bias was assessed using the revised Cochrane Risk of Bias tool. (Standardized) mean difference (MD) was selected to determine the difference in continuous outcomes between the groups. A random-effects model meta-analysis and meta-regression were performed. This systematic review was registered on PROSPERO (CRD42022374588). RESULTS A total of 18 RCTs involving 1645 adults (50% females) with a median glycated haemoglobin (HbA1c) concentration of 8.45% (7.95%-9.30%) were included. The majority of participants had type 1 diabetes (N = 1510, 92%) and were on multiple daily injections (N = 1173, 71%). Twelve of the 18 trials had low risk of bias. The meta-analysis of 10 studies with available data on HbA1c showed that the use of a bolus advisor modestly reduced HbA1c compared to standard treatment (MD -011%, 95% confidence interval -0.22 to -0.01; I2 = 0%). This effect was accompanied by small improvements in low blood glucose index and treatment satisfaction, but not with reductions in hypoglycaemic events or changes in other secondary outcomes. CONCLUSION Use of a bolus advisor is associated with slightly better glucose control and treatment satisfaction in people with diabetes on intensive insulin treatment. Future studies should investigate whether personalizing bolus advisors using artificial intelligence technology can enhance these effects.
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Affiliation(s)
- Elisabeth J den Brok
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Cecilie H Svensson
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
| | - Maria Panagiotou
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | | | - Peter R Mertens
- Department of Kidney and Hypertension Diseases, Diabetology and Endocrinology, Otto-Von-Guericke-Univeristat Magdeburg, Magdeburg, Germany
| | | | - Asimina Mitrakou
- Diabetes Center, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Gregor H L M Franssen
- University Library, Department Education, Content & Support, Maastricht University, Maastricht, The Netherlands
| | - Sander van Kuijk
- Clinical epidemiology & Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Stavroula Mougiakakou
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Lausanne, Denmark
| | - Bastiaan E de Galan
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
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3
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Jafar A, Pasqua MR. Postprandial glucose-management strategies in type 1 diabetes: Current approaches and prospects with precision medicine and artificial intelligence. Diabetes Obes Metab 2024; 26:1555-1566. [PMID: 38263540 DOI: 10.1111/dom.15463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/01/2024] [Accepted: 01/05/2024] [Indexed: 01/25/2024]
Abstract
Postprandial glucose control can be challenging for individuals with type 1 diabetes, and this can be attributed to many factors, including suboptimal therapy parameters (carbohydrate ratios, correction factors, basal doses) because of physiological changes, meal macronutrients and engagement in postprandial physical activity. This narrative review aims to examine the current postprandial glucose-management strategies tested in clinical trials, including adjusting therapy settings, bolusing for meal macronutrients, adjusting pre-exercise and postexercise meal boluses for postprandial physical activity, and other therapeutic options, for individuals on open-loop and closed-loop therapies. Then we discuss their challenges and future avenues. Despite advancements in insulin delivery devices such as closed-loop systems and decision-support systems, many individuals with type 1 diabetes still struggle to manage their glucose levels. The main challenge is the lack of personalized recommendations, causing suboptimal postprandial glucose control. We suggest that postprandial glucose control can be improved by (i) providing personalized recommendations for meal macronutrients and postprandial activity; (ii) including behavioural recommendations; (iii) using other personalized therapeutic approaches (e.g. glucagon-like peptide-1 receptor agonists, sodium-glucose co-transporter inhibitors, amylin analogues, inhaled insulin) in addition to insulin therapy; and (iv) integrating an interpretability report to explain to individuals about changes in treatment therapy and behavioural recommendations. In addition, we suggest a future avenue to implement precision recommendations for individuals with type 1 diabetes utilizing the potential of deep reinforcement learning and foundation models (such as GPT and BERT), employing different modalities of data including diabetes-related and external background factors (i.e. behavioural, environmental, biological and abnormal events).
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Affiliation(s)
- Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Melissa-Rosina Pasqua
- Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada
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4
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Jafar A, Pasqua MR, Olson B, Haidar A. Advanced decision support system for individuals with diabetes on multiple daily injections therapy using reinforcement learning and nearest-neighbors: In-silico and clinical results. Artif Intell Med 2024; 148:102749. [PMID: 38325921 DOI: 10.1016/j.artmed.2023.102749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 12/03/2023] [Accepted: 12/10/2023] [Indexed: 02/09/2024]
Abstract
Many individuals with diabetes on multiple daily insulin injections therapy use carbohydrate ratios (CRs) and correction factors (CFs) to determine mealtime and correction insulin boluses. The CRs and CFs vary over time due to physiological changes in individuals' response to insulin. Errors in insulin dosing can lead to life-threatening abnormal glucose levels, increasing the risk of retinopathy, neuropathy, and nephropathy. Here, we present a novel learning algorithm that uses Q-learning to track optimal CRs and uses nearest-neighbors based Q-learning to track optimal CFs. The learning algorithm was compared with the run-to-run algorithm A and the run-to-run algorithm B, both proposed in the literature, over an 8-week period using a validated simulator with a realistic scenario created with suboptimal CRs and CFs values, carbohydrate counting errors, and random meals sizes at random ingestion times. From Week 1 to Week 8, the learning algorithm increased the percentage of time spent in target glucose range (4.0 to 10.0 mmol/L) from 51 % to 64 % compared to 61 % and 58 % with the run-to-run algorithm A and the run-to-run algorithm B, respectively. The learning algorithm decreased the percentage of time spent below 4.0 mmol/L from 9 % to 1.9 % compared to 3.4 % and 2.3 % with the run-to-run algorithm A and the run-to-run algorithm B, respectively. The algorithm was also assessed by comparing its recommendations with (i) the endocrinologist's recommendations on two type 1 diabetes individuals over a 16-week period and (ii) real-world individuals' therapy settings changes of 23 individuals (19 type 2 and 4 type 1) over an 8-week period using the commercial Bigfoot Unity Diabetes Management System. The full agreements (i) were 89 % and 76 % for CRs and CFs for the type 1 diabetes individuals and (ii) was 62 % for mealtime doses for the individuals on the commercial Bigfoot system. Therefore, the proposed algorithm has the potential to improve glucose control in individuals with type 1 and type 2 diabetes.
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Affiliation(s)
- Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Melissa-Rosina Pasqua
- Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada; The Research Institute of McGill University Health Centre, Montreal, Quebec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Byron Olson
- Bigfoot Biomedical Inc., Milpitas, CA, United States
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada; Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada; The Research Institute of McGill University Health Centre, Montreal, Quebec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada.
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5
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 7. Diabetes Technology: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S126-S144. [PMID: 38078575 PMCID: PMC10725813 DOI: 10.2337/dc24-s007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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6
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Huang S, Liang Y, Li J, Li X. Applications of Clinical Decision Support Systems in Diabetes Care: Scoping Review. J Med Internet Res 2023; 25:e51024. [PMID: 38064249 PMCID: PMC10746969 DOI: 10.2196/51024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/10/2023] [Accepted: 11/12/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Providing comprehensive and individualized diabetes care remains a significant challenge in the face of the increasing complexity of diabetes management and a lack of specialized endocrinologists to support diabetes care. Clinical decision support systems (CDSSs) are progressively being used to improve diabetes care, while many health care providers lack awareness and knowledge about CDSSs in diabetes care. A comprehensive analysis of the applications of CDSSs in diabetes care is still lacking. OBJECTIVE This review aimed to summarize the research landscape, clinical applications, and impact on both patients and physicians of CDSSs in diabetes care. METHODS We conducted a scoping review following the Arksey and O'Malley framework. A search was conducted in 7 electronic databases to identify the clinical applications of CDSSs in diabetes care up to June 30, 2022. Additional searches were conducted for conference abstracts from the period of 2021-2022. Two researchers independently performed the screening and data charting processes. RESULTS Of 11,569 retrieved studies, 85 (0.7%) were included for analysis. Research interest is growing in this field, with 45 (53%) of the 85 studies published in the past 5 years. Among the 58 (68%) out of 85 studies disclosing the underlying decision-making mechanism, most CDSSs (44/58, 76%) were knowledge based, while the number of non-knowledge-based systems has been increasing in recent years. Among the 81 (95%) out of 85 studies disclosing application scenarios, the majority of CDSSs were used for treatment recommendation (63/81, 78%). Among the 39 (46%) out of 85 studies disclosing physician user types, primary care physicians (20/39, 51%) were the most common, followed by endocrinologists (15/39, 39%) and nonendocrinology specialists (8/39, 21%). CDSSs significantly improved patients' blood glucose, blood pressure, and lipid profiles in 71% (45/63), 67% (12/18), and 38% (8/21) of the studies, respectively, with no increase in the risk of hypoglycemia. CONCLUSIONS CDSSs are both effective and safe in improving diabetes care, implying that they could be a potentially reliable assistant in diabetes care, especially for physicians with limited experience and patients with limited access to medical resources. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.37766/inplasy2022.9.0061.
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Affiliation(s)
- Shan Huang
- Endocrinology Department, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuzhen Liang
- Department of Endocrinology, The Second Affiliated Hospital, Guangxi Medical University, Nanning, China
| | - Jiarui Li
- Department of Endocrinology, Cangzhou Central Hospital, Cangzhou, China
| | - Xuejun Li
- Department of Endocrinology and Diabetes, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Xiamen Diabetes Institute, Xiamen, China
- Fujian Provincial Key Laboratory of Translational Medicine for Diabetes, Xiamen, China
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7
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Unsworth R, Avari P, Lett AM, Oliver N, Reddy M. Adaptive bolus calculators for people with type 1 diabetes: A systematic review. Diabetes Obes Metab 2023; 25:3103-3113. [PMID: 37488945 DOI: 10.1111/dom.15204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/08/2023] [Accepted: 06/18/2023] [Indexed: 07/26/2023]
Abstract
AIM To conduct a systematic review of studies assessing adaptive insulin bolus calculators for people with type 1 diabetes (T1D). METHODS Electronic databases (Medline, Embase and Web of Science) were systematically searched from date of inception to 13 October 2022 for single-arm or randomized controlled studies assessing adaptive bolus calculators only, in children or adults with T1D on multiple daily injections or insulin pumps with glycaemic outcomes reported. The Clinicaltrials.gov registry was searched for recently completed studies evaluating decision support in T1D. The quality of extracted studies was assessed using the Standard Quality Assessment criteria and the Cochrane Risk of Bias assessment tool. RESULTS Six studies were identified. Extracted data were synthesized in a descriptive review because of heterogeneity. All the studies were small feasibility studies or were not suitably powered, and all were deemed to be at a high risk of performance and detection bias because they were unblinded. Overall, these studies did not show a significant glycaemic improvement. Two studies showed a reduction in postprandial time below range or an incremental change in blood glucose concentration; however, these were in controlled environments over a short duration. CONCLUSIONS There are limited clinical trials evaluating adaptive bolus calculators. Although results from small trials or in-silico data are promising, further studies are required to support personalized and adaptive management of T1D.
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Affiliation(s)
- Rebecca Unsworth
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Parizad Avari
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Aaron M Lett
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Monika Reddy
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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8
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Elian V, Popovici V, Ozon EA, Musuc AM, Fița AC, Rusu E, Radulian G, Lupuliasa D. Current Technologies for Managing Type 1 Diabetes Mellitus and Their Impact on Quality of Life-A Narrative Review. Life (Basel) 2023; 13:1663. [PMID: 37629520 PMCID: PMC10456000 DOI: 10.3390/life13081663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023] Open
Abstract
Type 1 diabetes mellitus is a chronic autoimmune disease that affects millions of people and generates high healthcare costs due to frequent complications when inappropriately managed. Our paper aimed to review the latest technologies used in T1DM management for better glycemic control and their impact on daily life for people with diabetes. Continuous glucose monitoring systems provide a better understanding of daily glycemic variations for children and adults and can be easily used. These systems diminish diabetes distress and improve diabetes control by decreasing hypoglycemia. Continuous subcutaneous insulin infusions have proven their benefits in selected patients. There is a tendency to use more complex systems, such as hybrid closed-loop systems that can modulate insulin infusion based on glycemic readings and artificial intelligence-based algorithms. It can help people manage the burdens associated with T1DM management, such as fear of hypoglycemia, exercising, and long-term complications. The future is promising and aims to develop more complex ways of automated control of glycemic levels to diminish the distress of individuals living with diabetes.
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Affiliation(s)
- Viviana Elian
- Department of Diabetes, Nutrition and Metabolic Diseases, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050471 Bucharest, Romania; (V.E.); (E.R.); (G.R.)
- Department of Diabetes, Nutrition and Metabolic Diseases, “Prof. Dr. N. C. Paulescu” National Institute of Diabetes, Nutrition and Metabolic Diseases, 030167 Bucharest, Romania
| | - Violeta Popovici
- Department of Microbiology and Immunology, Faculty of Dental Medicine, Ovidius University of Constanta, 7 Ilarie Voronca Street, 900684 Constanta, Romania
| | - Emma-Adriana Ozon
- Department of Pharmaceutical Technology and Biopharmacy, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania; (A.C.F.); (D.L.)
| | - Adina Magdalena Musuc
- Romanian Academy, “Ilie Murgulescu” Institute of Physical Chemistry, 202 Spl. Independentei, 060021 Bucharest, Romania;
| | - Ancuța Cătălina Fița
- Department of Pharmaceutical Technology and Biopharmacy, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania; (A.C.F.); (D.L.)
| | - Emilia Rusu
- Department of Diabetes, Nutrition and Metabolic Diseases, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050471 Bucharest, Romania; (V.E.); (E.R.); (G.R.)
- Department of Diabetes, N. Malaxa Clinical Hospital, 12 Vergului Street, 022441 Bucharest, Romania
| | - Gabriela Radulian
- Department of Diabetes, Nutrition and Metabolic Diseases, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050471 Bucharest, Romania; (V.E.); (E.R.); (G.R.)
- Department of Diabetes, Nutrition and Metabolic Diseases, “Prof. Dr. N. C. Paulescu” National Institute of Diabetes, Nutrition and Metabolic Diseases, 030167 Bucharest, Romania
| | - Dumitru Lupuliasa
- Department of Pharmaceutical Technology and Biopharmacy, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania; (A.C.F.); (D.L.)
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9
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Mosquera-Lopez C, Ramsey KL, Roquemen-Echeverri V, Jacobs PG. Modeling risk of hypoglycemia during and following physical activity in people with type 1 diabetes using explainable mixed-effects machine learning. Comput Biol Med 2023; 155:106670. [PMID: 36803791 DOI: 10.1016/j.compbiomed.2023.106670] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/19/2023] [Accepted: 02/10/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Physical activity (PA) can cause increased hypoglycemia (glucose <70 mg/dL) risk in people with type 1 diabetes (T1D). We modeled the probability of hypoglycemia during and up to 24 h following PA and identified key factors associated with hypoglycemia risk. METHODS We leveraged a free-living dataset from Tidepool comprised of glucose measurements, insulin doses, and PA data from 50 individuals with T1D (6448 sessions) for training and validating machine learning models. We also used data from the T1Dexi pilot study that contains glucose management and PA data from 20 individuals with T1D (139 session) for assessing the accuracy of the best performing model on an independent test dataset. We used mixed-effects logistic regression (MELR) and mixed-effects random forest (MERF) to model hypoglycemia risk around PA. We identified risk factors associated with hypoglycemia using odds ratio and partial dependence analysis for the MELR and MERF models, respectively. Prediction accuracy was measured using the area under the receiver operating characteristic curve (AUROC). RESULTS The analysis identified risk factors significantly associated with hypoglycemia during and following PA in both MELR and MERF models including glucose and body exposure to insulin at the start of PA, low blood glucose index 24 h prior to PA, and PA intensity and timing. Both models showed overall hypoglycemia risk peaking 1 h after PA and again 5-10 h after PA, which is consistent with the hypoglycemia risk pattern observed in the training dataset. Time following PA impacted hypoglycemia risk differently across different PA types. Accuracy of hypoglycemia prediction using the fixed effects of the MERF model was highest when predicting hypoglycemia during the first hour following the start of PA (AUROCVALIDATION = 0.83 and AUROCTESTING = 0.86) and decreased when predicting hypoglycemia in the 24 h after PA (AUROCVALIDATION = 0.66 and AUROCTESTING = 0.68). CONCLUSION Hypoglycemia risk after the start of PA can be modeled using mixed-effects machine learning to identify key risk factors that may be used within decision support and insulin delivery systems. We published the population-level MERF model online for others to use.
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Affiliation(s)
- Clara Mosquera-Lopez
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA.
| | - Katrina L Ramsey
- Biostatistics and Design Program, Oregon Health & Science University, Portland, Oregon, USA
| | - Valentina Roquemen-Echeverri
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Peter G Jacobs
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
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10
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA. 7. Diabetes Technology: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S111-S127. [PMID: 36507635 PMCID: PMC9810474 DOI: 10.2337/dc23-s007] [Citation(s) in RCA: 116] [Impact Index Per Article: 116.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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11
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Worth C, Nutter PW, Salomon-Estebanez M, Auckburally S, Dunne MJ, Banerjee I, Harper S. The behaviour change behind a successful pilot of hypoglycaemia reduction with HYPO-CHEAT. Digit Health 2023; 9:20552076231192011. [PMID: 37545627 PMCID: PMC10403985 DOI: 10.1177/20552076231192011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 07/18/2023] [Indexed: 08/08/2023] Open
Abstract
Background Children with hypoglycaemia disorders, such as congenital hyperinsulinism (CHI), are at constant risk of hypoglycaemia (low blood sugars) with the attendant risk of brain injury. Current approaches to hypoglycaemia detection and prevention vary from fingerprick glucose testing to the provision of continuous glucose monitoring (CGM) to machine learning (ML) driven glucose forecasting. Recent trends for ML have had limited success in preventing free-living hypoglycaemia, due to a focus on increasingly accurate glucose forecasts and a failure to acknowledge the human in the loop and the essential step of changing behaviour. The wealth of evidence from the fields of behaviour change and persuasive technology (PT) allows for the creation of a theory-informed and technologically considered approach. Objectives We aimed to create a PT that would overcome the identified barriers to hypoglycaemia prevention for those with CHI to focus on proactive prevention rather than commonly used reactive approaches. Methods We used the behaviour change technique taxonomy and persuasive systems design models to create HYPO-CHEAT (HYpoglycaemia-Prevention-thrOugh-Cgm-HEatmap-Assisted-Technology): a novel approach that presents aggregated CGM data in simple visualisations. The resultant ease of data interpretation is intended to facilitate behaviour change and subsequently reduce hypoglycaemia. Results HYPO-CHEAT was piloted in 10 patients with CHI over 12 weeks and successfully identified weekly patterns of hypoglycaemia. These patterns consistently correlated with identifiable behaviours and were translated into both a change in proximal fingerprick behaviour and ultimately, a significant reduction in aggregated hypoglycaemia from 7.1% to 5.4% with four out of five patients showing clinically meaningful reductions in hypoglycaemia. Conclusions We have provided pilot data of a new approach to hypoglycaemia prevention that focuses on proactive prevention and behaviour change. This approach is personalised for individual patients with CHI and is a first step in changing our approach to hypoglycaemia prevention in this group.
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Affiliation(s)
- Chris Worth
- Department of Computer Science, University of Manchester, Manchester, UK
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Paul W Nutter
- Department of Computer Science, University of Manchester, Manchester, UK
| | - Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sameera Auckburally
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Mark J Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Simon Harper
- Department of Computer Science, University of Manchester, Manchester, UK
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12
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Matter RM, Nasef MWA, ShibaAlhamd RM, Thabet RA. Cathelicidin as a marker for subclinical cardiac changes and microvascular complications in children and adolescents with type 1 diabetes. J Pediatr Endocrinol Metab 2022; 35:1509-1517. [PMID: 36196598 DOI: 10.1515/jpem-2022-0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To detect cathelicidin levels in pediatric patients with type 1 diabetes (T1D) as a potential marker for diabetic vascular complications and to assess its relation to diastolic dysfunction as an index for subclinical macrovasculopathy. METHODS Totally, 84 patients with T1D were categorized into three groups; newly diagnosed diabetes group (28 patients with a mean age of 12.38 ± 1.99) years, T1D without microvascular complications group (28 patients with a mean age of 13.04 ± 2.27), and T1D with microvascular complications group (28 patients with a mean age of 13.96 ± 2.30). Patients were evaluated using serum cathelicidin levels and echocardiography. RESULTS Total cholesterol, microalbuminuria, and cathelicidin levels were significantly higher in patients with microvascular complications when compared to the other two groups (p<0.001). Additionally, carotid intima-media thickness (CIMT) echocardiography values and diastolic functions were significantly higher in patients with complications (p<0.001). Cathelicidin was positively correlated to the duration of diabetes (r=0.542, p<0.001), total cholesterol (r=0.346, p=0.001), recurrence of hypoglycemia (r=0.351, p=0.001), recurrence of diabetes ketoacidosis (r=0.365, p=0.001), CIMT (r=0.544, p<0.001), and E/A values (r=0.405, p<0.001). CONCLUSIONS Serum cathelicidin levels can be used as an early marker for the occurrence and progression of vascular complications in patients with T1D.
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Affiliation(s)
- Randa M Matter
- Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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13
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Chow E, Chan JCN. Targeting postprandial glucose control using ultra-rapid insulins: is faster better? Sci Bull (Beijing) 2022; 67:2392-2394. [PMID: 36566058 DOI: 10.1016/j.scib.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China; Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Juliana C N Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China.
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14
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Dos Santos TJ, Chobot A, Piona C, Dovc K, Biester T, Gajewska KA, de Beaufort C, Sumnik Z, Petruzelkova L. Proceedings of 21st ISPAD science school for physicians 2022. Pediatr Diabetes 2022; 23:903-911. [PMID: 36250646 DOI: 10.1111/pedi.13412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Agata Chobot
- Department of Pediatrics, Institute of Medical Sciences, University of Opole, Opole, Poland.,Department of Pediatrics, University Clinical Hospital in Opole, Opole, Poland
| | - Claudia Piona
- Section of Pediatric Diabetes and Metabolism, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, Verona, Italy
| | - Klemen Dovc
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, Ljubljana, Slovenia
| | - Torben Biester
- AUF DER BULT, Diabetes Center for Children and Adolescents, Hannover, Germany
| | - Katarzyna Anna Gajewska
- Diabetes Ireland, Dublin, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - Carine de Beaufort
- DECCP/Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg.,Faculty of Science, Technology and Medicine, University of Luxembourg, Esch-Belval, Luxembourg.,Department of Pediatrics, UZ-VUB, Brussels, Belgium
| | - Zdenek Sumnik
- Department of Pediatrics, Motol University Hospital and 2nd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Lenka Petruzelkova
- Department of Pediatrics, Motol University Hospital and 2nd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
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15
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Worth C, Nutter PW, Dunne MJ, Salomon-Estebanez M, Banerjee I, Harper S. HYPO-CHEAT's aggregated weekly visualisations of risk reduce real world hypoglycaemia. Digit Health 2022; 8:20552076221129712. [PMID: 36276186 PMCID: PMC9580093 DOI: 10.1177/20552076221129712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 10/13/2021] [Indexed: 11/05/2022] Open
Abstract
Background Children with congenital hyperinsulinism (CHI) are at constant risk of hypoglycaemia with the attendant risk of brain injury. Current hypoglycaemia prevention methods centre on the prediction of a continuous glucose variable using machine learning (ML) processing of continuous glucose monitoring (CGM). This approach ignores repetitive and predictable behavioural factors and is dependent upon ongoing CGM. Thus, there has been very limited success in reducing real-world hypoglycaemia with a ML approach in any condition. Objectives We describe the development of HYPO-CHEAT (HYpoglycaemia-Prevention-thrOugh-CGM-HEatmap-Technology), which is designed to overcome these limitations by describing weekly hypoglycaemia risk. We tested HYPO-CHEAT in a real-world setting to evaluate change in hypoglycaemia. Methods HYPO-CHEAT aggregates individual CGM data to identify weekly hypoglycaemia patterns. These are visualised via a hypoglycaemia heatmap along with actionable interpretations and targets. The algorithm is iterative and reacts to anticipated changing patterns of hypoglycaemia. HYPO-CHEAT was compared with Dexcom Clarity's pattern identification and Facebook Prophet's forecasting algorithm using data from 10 children with CHI using CGM for 12 weeks. HYPO-CHEAT's efficacy was assessed via change in time below range (TBR). Results HYPO-CHEAT identified hypoglycaemia patterns in all patients. Dexcom Clarity identified no patterns. Predictions from Facebook Prophet were inconsistent and difficult to interpret. Importantly, the patterns identified by HYPO-CHEAT matched the lived experience of all patients, generating new and actionable understanding of the cause of hypos. This facilitated patients to significantly reduce their time in hypoglycaemia from 7.1% to 5.4% even when real-time CGM data was removed. Conclusions HYPO-CHEAT's personalised hypoglycaemia heatmaps reduced total and targeted TBR even when CGM was reblinded. HYPO-CHEAT offers a highly effective and immediately available personalised approach to prevent hypoglycaemia and empower patients to self-care.
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Affiliation(s)
- Chris Worth
- Department of Computer Science, University of Manchester, Manchester, UK,Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK,Chris Worth, Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.
| | - Paul W Nutter
- Department of Computer Science, University of Manchester, Manchester, UK
| | - Mark J Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Simon Harper
- Department of Computer Science, University of Manchester, Manchester, UK
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16
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Augstein P, Heinke P, Vogt L, Kohnert KD, Salzsieder E. Patient-Tailored Decision Support System Improves Short- and Long-Term Glycemic Control in Type 2 Diabetes. J Diabetes Sci Technol 2022; 16:1159-1166. [PMID: 34000840 PMCID: PMC9445344 DOI: 10.1177/19322968211008871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The increasing prevalence of type 2 diabetes mellitus (T2D) and specialist shortage has caused a healthcare gap that can be bridged by a decision support system (DSS). We investigated whether a diabetes DSS can improve long- and/or short-term glycemic control. METHODS This is a retrospective observational cohort study of the Diabetiva program, which offered a patient-tailored DSS using Karlsburger Diabetes-Management System (KADIS) once a year. Glycemic control was analyzed at baseline and after 12 months in 452 individuals with T2D. Time in range (TIR; glucose 3.9-10 mmol/L) and Q-Score, a composite metric developed for analysis of continuous glucose profiles, were short-term and HbA1c long-term measures of glycemic control. Glucose variability (GV) was also measured. RESULTS At baseline, one-third of patients had good short- and long-term glycemic control. Q-Score identified insufficient short-term glycemic control in 17.9% of patients with HbA1c <6.5%, mainly due to hypoglycemia. GV and hyperglycemia were responsible in patients with HbA1c >7.5% and >8%, respectively. Application of DSS at baseline improved short- and long-term glycemic control, as shown by the reduced Q-Score, GV, and HbA1c after 12 months. Multiple regression demonstrated that the total effect on GV resulted from the single effects of all influential parameters. CONCLUSIONS DSS can improve short- and long-term glycemic control in individuals with T2D without increasing hypoglycemia. The Q-Score allows identification of individuals with insufficient glycemic control. An effective strategy for therapy optimization could be the selection of individuals with T2D most at need using the Q-Score, followed by offering patient-tailored DSS.
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Affiliation(s)
- Petra Augstein
- Institute of Diabetes “Gerhardt Katsch”, Karlsburg, Germany
- Department for Diabetology, Klinikum Karlsburg, Heart and Diabetes Center Karlsburg, Germany
- Petra Augstein, MD & Dsc, Department for Diabetology, Klinikum Karlsburg, Heart and Diabetes Center Karlsburg, Greifswalder Str. 11, Germany.
| | - Peter Heinke
- Institute of Diabetes “Gerhardt Katsch”, Karlsburg, Germany
| | - Lutz Vogt
- Diabetes Service Centre DCC, Karlsburg, Germany
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17
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Nimri R, Tirosh A, Muller I, Shtrit Y, Kraljevic I, Alonso MM, Milicic T, Saboo B, Deeb A, Christoforidis A, den Brinker M, Bozzetto L, Bolla AM, Krcma M, Rabini RA, Tabba S, Gerasimidi-Vazeou A, Maltoni G, Giani E, Dotan I, Liberty IF, Toledano Y, Kordonouri O, Bratina N, Dovc K, Biester T, Atlas E, Phillip M. Comparison of Insulin Dose Adjustments Made by Artificial Intelligence-Based Decision Support Systems and by Physicians in People with Type 1 Diabetes Using Multiple Daily Injections Therapy. Diabetes Technol Ther 2022; 24:564-572. [PMID: 35325567 DOI: 10.1089/dia.2021.0566] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: Artificial intelligence-based decision support systems (DSS) need to provide decisions that are not inferior to those given by experts in the field. Recommended insulin dose adjustments on the same individual data set were compared among multinational physicians, and with recommendations made by automated Endo.Digital DSS (ED-DSS). Research Design and Methods: This was a noninterventional study surveying 20 physicians from multinational academic centers. The survey included 17 data cases of individuals with type 1 diabetes who are treated with multiple daily insulin injections. Participating physicians were asked to recommend insulin dose adjustments based on glucose and insulin data. Insulin dose adjustments recommendations were compared among physicians and with the automated ED-DSS. The primary endpoints were the percentage of comparison points for which there was agreement on the trend of insulin dose adjustments. Results: The proportion of agreement and disagreement in the direction of insulin dose adjustment among physicians was statistically noninferior to the proportion of agreement and disagreement observed between ED-DSS and physicians for basal rate, carbohydrate-to insulin ratio, and correction factor (P < 0.001 and P ≤ 0.004 for all three parameters for agreement and disagreement, respectively). The ED-DSS magnitude of insulin dose change was consistently lower than that proposed by the physicians. Conclusions: Recommendations for insulin dose adjustments made by automatization did not differ significantly from recommendations given by expert physicians regarding the direction of change. These results highlight the potential utilization of ED-DSS as a useful clinical tool to manage insulin titration and dose adjustments.
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Affiliation(s)
- Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Amir Tirosh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
- Division of Endocrinology, Diabetes and Metabolism, Dalia and David Arabov Endocrinology and Diabetes Research Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ido Muller
- DreaMed Diabetes Ltd., Petah Tikva, Israel
| | | | - Ivana Kraljevic
- Department of Endocrinology and Diabetes, UHC Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Montserrat Martín Alonso
- Department of Pediatrics, Children's Endocrinology Unit, University Hospital of Salamanca, Spain
| | - Tanja Milicic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Banshi Saboo
- Dia Care Diabetes Care and Hormone Clinic, Ahmedabad, Gujarat, India
| | - Asma Deeb
- Pediatric Endocrine Division, Sheikh Shakhbout Medical City and Khalifa University, Abu Dhabi, United Arab Emirates
| | - Athanasios Christoforidis
- 1st Pediatric Department, Aristotle University of Thessaloniki, Hippokratio General Hospital, Thessaloniki, Greece
| | - Marieke den Brinker
- Division of Pediatric Endocrinology and Diabetology, Department of Pediatrics, Antwerp University Hospital and University of Antwerp, Antwerpen, Belgium
| | - Lutgarda Bozzetto
- Department of Clinical Medicine and Surgery, University of Naples "Federico II," Naples, Italy
| | | | - Michal Krcma
- Diabetes and Endocrinology Unit, Department of Internal Medicine, University Hospital Pilsen, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Rosa Anna Rabini
- Department of Diabetology, Hospital Mazzoni, Ascoli Piceno, Italy
| | - Shadi Tabba
- Department of Pediatric Endocrinology, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | | | - Giulio Maltoni
- Unit of Pediatrics, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elisa Giani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Idit Dotan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
- Rabin Medical Center, Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
| | - Idit F Liberty
- Department of Medicine and Diabetes Unit, Soroka Medical Center, Faculty of Health Sciences, Beer Sheva, Israel
| | - Yoel Toledano
- Division of Maternal Fetal Medicine, Helen Schneider Women's Hospital, Rabin Medical Center, Endocrinology Clinic, Petah Tikva, Israel
| | - Olga Kordonouri
- Diabetes Center for Children and Adolescents, Children's Hospital AUF DER BULT, Hannover, Germany
| | - Natasa Bratina
- Department of Endocrinology, Diabetes and Metabolic Diseases, UMC-University Children's Hospital Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Klemen Dovc
- Department of Endocrinology, Diabetes and Metabolic Diseases, UMC-University Children's Hospital Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Torben Biester
- Diabetes Center for Children and Adolescents, Children's Hospital AUF DER BULT, Hannover, Germany
| | - Eran Atlas
- DreaMed Diabetes Ltd., Petah Tikva, Israel
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
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18
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Kong YW, Venkatesh N, Paldus B, Lee MH, Zhu JJ, Sawyer M, Chakrabarti A, Uren C, MacIsaac RJ, Jenkins AJ, O'Neal DN. Upload and Review of Insulin Pump and Glucose Sensor Data by Adults with Type 1 Diabetes: A Clinic Audit. Diabetes Technol Ther 2022; 24:531-534. [PMID: 35167376 DOI: 10.1089/dia.2021.0558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Devices have facilitated improvement in glycemia in individuals with type 1 diabetes mellitus (T1DM), but self-management remains key. It is unclear whether people review their device data before clinic appointment. We assessed this by a survey. T1DM adults using glucose sensors and/or insulin pumps attending an Australian public hospital (diabetes clinics >4 months) were prospectively surveyed. The percentage who uploaded and reviewed their data was determined and their interest in education facilitating understanding of their device data was assessed. Of 138 adults (100% participation rate), 79% uploaded and 32% reviewed their device data before their clinic appointments. Individuals using pumps with sensors were most likely to review their data. Median HbA1c levels were lower in those who did versus did not review their device data (50.8 vs. 61.8 mmol/mol, P = 0.0001). Most (89%) were interested in education. Although diabetes technology has improved glycemia in T1DM, the benefits may be maximized through device-specific education programs enhancing self-management.
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Affiliation(s)
- Yee Wen Kong
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Nisha Venkatesh
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Barbora Paldus
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Melissa H Lee
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Jasmine J Zhu
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Matthew Sawyer
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Anindita Chakrabarti
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Christopher Uren
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Richard J MacIsaac
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - Alicia J Jenkins
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - David N O'Neal
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Australia
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19
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Ahn DT. Automated Bolus Calculators and Connected Insulin Pens: A Smart Combination for Multiple Daily Injection Insulin Therapy. J Diabetes Sci Technol 2022; 16:605-609. [PMID: 34933594 PMCID: PMC9294589 DOI: 10.1177/19322968211062624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Although automated bolus calculators (ABCs) have become a mainstay in insulin pump therapy, they have not achieved similar levels of adoption by persons with diabetes (PWD) using multiple daily injections of insulin (MDI). Only a small number of blood glucose meters (BGMs) have incorporated ABC functionality and the proliferation of unregulated ABC smartphone apps raised safety concerns and eventually led to Food and Drug Administration (FDA)-mandated regulatory oversight for these types of apps. With the recent introduction of smartphone-connected insulin pens, manufacturer-supported companion ABC apps may offer an ideal solution for PWD and health care professionals that reduces errors of mental math when calculating bolus insulin dosing, increases the quality of diabetes data reporting, and improves glycemic outcomes.
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Affiliation(s)
- David T Ahn
- Mary & Dick Allen Diabetes
Center, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
- David Ahn, MD, Mary & Dick
Allen Diabetes Center, Hoag Memorial Hospital Presbyterian, 520
Superior Avenue, Suite 150, Newport Beach, CA 92663, USA.
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20
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Pinheiro SL, Bastos M, Barros L, Melo M, Paiva I. Flash glucose monitoring and glycemic control in type 1 diabetes with subcutaneous insulin infusion. Acta Diabetol 2022; 59:509-515. [PMID: 34786633 DOI: 10.1007/s00592-021-01827-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
AIMS To analyze the association between scan frequency and glycemic measures in continuous subcutaneous insulin infusion (CSII) treated type 1 diabetes (T1DM) adults. METHODS This retrospective study included 140 patients (> 18 years) with T1DM who used flash glucose monitoring (FGM). For each patient, we analyzed the Ambulatory Glucose Profile data over a period of 90 days. Data regarding glucose management indicator (GMI), time above, below and within range (TIR) and coefficient of variation (CV) were correlated with the number of daily scans. The effect of each additional test on glucose parameters was also evaluated. RESULTS Users performed a mean of 8.6 ± 4.4 scans per day. There was an inverse correlation between scanning frequency and GMI (r = - 0.431, p < 0.001), CV (r = - 0.440, p < 0.001), time above and below range (r = - 0.446, p < 0.001 and r = - 0.200, p = 0.018, respectively). The number of daily scans correlated positively with TIR (r = 0.554, p < 0.001). For each additional scan per day, the mean GMI decreased 0.09% and TIR increased 1.60%. CONCLUSIONS In patients with T1DM and CSII, higher rates of scanning correlated with improved glycemic markers, including reduced GMI and CV and increased TIR. For each test performed, there was a significant effect on the improvement of all glucose parameters.
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Affiliation(s)
- Sara Lomelino Pinheiro
- Department of Endocrinology, Instituto Português de Oncologia de Lisboa, Lisbon, Portugal.
| | - Margarida Bastos
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Luísa Barros
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Isabel Paiva
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
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21
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Riddell MC, Shakeri D, Scott SN. A Brief Review on the Evolution of Technology in Exercise and Sport in Type 1 Diabetes: Past, Present, and Future. Diabetes Technol Ther 2022; 24:289-298. [PMID: 34809493 DOI: 10.1089/dia.2021.0427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
One hundred years ago, insulin was first used to successfully lower blood glucose levels in young people living with what was then called juvenile diabetes. While insulin was not a cure for diabetes, it allowed individuals to resume a near normal life and have some freedom to eat more liberally and gain the strength they needed to live a more active lifestyle. Since then, a number of therapeutic and technical advances have arisen to further improve the health and wellbeing of individuals living with type 1 diabetes, allowing many to participate in sport at the local, regional, national or international level of competition. This review and commentary highlights some of the key advances in diabetes management in sport over the last 100 years since the discovery of insulin.
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Affiliation(s)
- Michael C Riddell
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Canada
| | - Dorsa Shakeri
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Canada
| | - Sam N Scott
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, University of Bern, Bern, Switzerland
- Team Novo Nordisk Professional Cycling Team, Atlanta, Georgia, USA
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22
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Tyler NS, Mosquera-Lopez C, Young GM, El Youssef J, Castle JR, Jacobs PG. Quantifying the impact of physical activity on future glucose trends using machine learning. iScience 2022; 25:103888. [PMID: 35252806 PMCID: PMC8889374 DOI: 10.1016/j.isci.2022.103888] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 11/19/2021] [Accepted: 02/04/2022] [Indexed: 01/21/2023] Open
Abstract
Prevention of hypoglycemia (glucose <70 mg/dL) during aerobic exercise is a major challenge in type 1 diabetes. Providing predictions of glycemic changes during and following exercise can help people with type 1 diabetes avoid hypoglycemia. A unique dataset representing 320 days and 50,000 + time points of glycemic measurements was collected in adults with type 1 diabetes who participated in a 4-arm crossover study evaluating insulin-pump therapies, whereby each participant performed eight identically designed in-clinic exercise studies. We demonstrate that even under highly controlled conditions, there is considerable intra-participant and inter-participant variability in glucose outcomes during and following exercise. Participants with higher aerobic fitness exhibited significantly lower minimum glucose and steeper glucose declines during exercise. Adaptive, personalized machine learning (ML) algorithms were designed to predict exercise-related glucose changes. These algorithms achieved high accuracy in predicting the minimum glucose and hypoglycemia during and following exercise sessions, for all fitness levels.
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Affiliation(s)
- Nichole S. Tyler
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering Oregon Health & Science University Portland, OR 97232, USA,Corresponding author
| | - Clara Mosquera-Lopez
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering Oregon Health & Science University Portland, OR 97232, USA
| | - Gavin M. Young
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering Oregon Health & Science University Portland, OR 97232, USA
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology Oregon Health & Science University Portland, OR 97239, USA
| | - Jessica R. Castle
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology Oregon Health & Science University Portland, OR 97239, USA
| | - Peter G. Jacobs
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering Oregon Health & Science University Portland, OR 97232, USA
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23
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Abstract
The goal of diabetes treatment is to maintain good glycemic control, prevent the development and progression of diabetic complications, and ensure the same quality of life and life expectancy as healthy people. Hemoglobin A1c (HbA1c) is used as an index of glycemic control, but strict glycemic control using HbA1c as an index may lead to severe hypoglycemia and cardiovascular death. Glycemic variability (GV), such as excessive hyperglycemia and hypoglycemia, is associated with diabetic vascular complications and has been recognized as an important index of glycemic control. Here, we reviewed the definition and evaluated the clinical usefulness of GV, and its relationship with diabetic complications and therapeutic strategies to reduce GV.
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Affiliation(s)
- Yoshiki Kusunoki
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Japan
| | - Kosuke Konishi
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Japan
| | - Taku Tsunoda
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Japan
| | - Hidenori Koyama
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Japan
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24
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Pinsker JE, Church MM, Brown SA, Voelmle MK, Bode BW, Narron B, Huyett LM, Lee JB, O'Connor J, Benjamin E, Dumais B, Ly TT. Clinical Evaluation of a Novel CGM-Informed Bolus Calculator with Automatic Glucose Trend Adjustment. Diabetes Technol Ther 2022; 24:18-25. [PMID: 34491825 PMCID: PMC8783627 DOI: 10.1089/dia.2021.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Expert opinion guidelines and limited data from clinical trials recommend adjustment to bolus insulin doses based on continuous glucose monitor (CGM) trend data, yet minimal evidence exists to support this approach. We performed a clinical evaluation of a novel CGM-informed bolus calculator (CIBC) with automatic insulin bolus dose adjustment based on CGM trend used with sensor-augmented pump therapy. Materials and Methods: In this multicenter, outpatient study, participants 6-70 years of age with type 1 diabetes (T1D) used the Omnipod® 5 System in Manual Mode, first for 7 days without a connected CGM (standard bolus calculator, SBC, phase 1) and then for 7 days with a connected CGM using the CIBC (CIBC phase 2). The integrated bolus calculator used stored pump settings plus user-estimated meal size and/or either a manually entered capillary glucose value (SBC phase) or an imported current CGM value and trend (CIBC phase) to recommend a bolus amount. The CIBC automatically increased or decreased the suggested bolus amount based on the CGM trend. Results: Twenty-five participants, (mean ± standard deviation) 27 ± 15 years of age, with T1D duration 12 ± 9 years and A1C 7.0% ± 0.9% completed the study. There were significantly fewer sensor readings <70 mg/dL 4 h postbolus with the CIBC compared to the SBC (2.1% ± 2.0% vs. 2.8 ± 2.7, P = 0.03), while percent of sensor readings >180 and 70-180 mg/dL remained the same. There was no difference in insulin use or number of boluses given between the two phases. Conclusion: The CIBC was safe when used with the Omnipod 5 System in Manual Mode, with fewer hypoglycemic readings in the postbolus period compared to the SBC. This trial was registered at ClinicalTrials.gov (NCT04320069).
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Affiliation(s)
- Jordan E. Pinsker
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Mei Mei Church
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Sue A. Brown
- Division of Endocrinology, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Mary K. Voelmle
- Division of Endocrinology, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Bruce W. Bode
- Atlanta Diabetes Associates, Atlanta, Georgia, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Brooke Narron
- Atlanta Diabetes Associates, Atlanta, Georgia, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Lauren M. Huyett
- Insulet Corporation, Acton, Massachusetts, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Joon Bok Lee
- Insulet Corporation, Acton, Massachusetts, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Jason O'Connor
- Insulet Corporation, Acton, Massachusetts, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Eric Benjamin
- Insulet Corporation, Acton, Massachusetts, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Bonnie Dumais
- Insulet Corporation, Acton, Massachusetts, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
| | - Trang T. Ly
- Insulet Corporation, Acton, Massachusetts, USA
- Results of this study were presented in abstract form at the 14th International Conference on Advanced Technologies & Treatments for Diabetes, June 2021
- Address correspondence to: Trang T. Ly, MBBS, FRACP, PhD, Insulet Corporation, 100 Nagog Park, Acton, MA 01720, USA
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25
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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26
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Bisio A, Anderson S, Norlander L, O'Malley G, Robic J, Ogyaadu S, Hsu L, Levister C, Ekhlaspour L, Lam DW, Levy C, Buckingham B, Breton MD. Impact of a Novel Diabetes Support System on a Cohort of Individuals With Type 1 Diabetes Treated With Multiple Daily Injections: A Multicenter Randomized Study. Diabetes Care 2022; 45:186-193. [PMID: 34794973 PMCID: PMC8753765 DOI: 10.2337/dc21-0838] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/27/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Achieving optimal glycemic control for many individuals with type 1 diabetes (T1D) remains challenging, even with the advent of newer management tools, including continuous glucose monitoring (CGM). Modern management of T1D generates a wealth of data; however, use of these data to optimize glycemic control remains limited. We evaluated the impact of a CGM-based decision support system (DSS) in patients with T1D using multiple daily injections (MDI). RESEARCH DESIGN AND METHODS The studied DSS included real-time dosing advice and retrospective therapy optimization. Adults and adolescents (age >15 years) with T1D using MDI were enrolled at three sites in a 14-week randomized controlled trial of MDI + CGM + DSS versus MDI + CGM. All participants (N = 80) used degludec basal insulin and Dexcom G5 CGM. CGM-based and patient-reported outcomes were analyzed. Within the DSS group, ad hoc analysis further contrasted active versus nonactive DSS users. RESULTS No significant differences were detected between experimental and control groups (e.g., time in range [TIR] +3.3% with CGM vs. +4.4% with DSS). Participants in both groups reported lower HbA1c (-0.3%; P = 0.001) with respect to baseline. While TIR may have improved in both groups, it was statistically significant only for DSS; the same was apparent for time spent <60 mg/dL. Active versus nonactive DSS users showed lower risk of and exposure to hypoglycemia with system use. CONCLUSIONS Our DSS seems to be a feasible option for individuals using MDI, although the glycemic benefits associated with use need to be further investigated. System design, therapy requirements, and target population should be further refined prior to use in clinical care.
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Affiliation(s)
- Alessandro Bisio
- 1Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA
| | - Stacey Anderson
- 1Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA
| | | | | | - Jessica Robic
- 1Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA
| | | | - Liana Hsu
- 2School of Medicine, Stanford University, Stanford, CA
| | | | | | - David W Lam
- 3Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carol Levy
- 3Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Marc D Breton
- 1Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA
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27
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Hughes J, Gautier T, Colmegna P, Fabris C, Breton MD. Replay Simulations with Personalized Metabolic Model for Treatment Design and Evaluation in Type 1 Diabetes. J Diabetes Sci Technol 2021; 15:1326-1336. [PMID: 33218280 PMCID: PMC8655285 DOI: 10.1177/1932296820973193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The capacity to replay data collected in real life by people with type 1 diabetes mellitus (T1DM) would lead to individualized (vs population) assessment of treatment strategies to control blood glucose and possibly true personalization. Patek et al introduced such a technique, relying on regularized deconvolution of a population glucose homeostasis model to estimate a residual additive signal and reproduce the experimental data; therefore, allowing the subject-specific replay of what-if scenarios by altering the model inputs (eg, insulin). This early method was shown to have a limited domain of validity. We propose and test in silico a similar approach and extend the method applicability. METHODS A subject-specific model personalization of insulin sensitivity and meal-absorption parameters is performed. The University of Virginia (UVa)/Padova T1DM simulator is used to generate experimental scenarios and test the ability of the methodology to accurately reproduce changes in glucose concentration to alteration in meal and insulin inputs. Method performance is assessed by comparing true (UVa/Padova simulator) and replayed glucose traces, using the mean absolute relative difference (MARD) and the Clarke error grid analysis (CEGA). RESULTS Model personalization led to a 9.08 and 6.07 decrease in MARD over a prior published method of replaying altered insulin scenarios for basal and bolus changes, respectively. Replay simulations achieved high accuracy, with MARD <10% and more than 95% of readings falling in the CEGA A-B zones for a wide range of interventions. CONCLUSIONS In silico studies demonstrate that the proposed method for replay simulation is numerically and clinically valid over broad changes in scenario inputs, indicating possible use in treatment optimization.
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Affiliation(s)
- Jonathan Hughes
- Center for Diabetes Technology,
University of Virginia, Charlottesville, VA, USA
| | - Thibault Gautier
- Center for Diabetes Technology,
University of Virginia, Charlottesville, VA, USA
| | - Patricio Colmegna
- Center for Diabetes Technology,
University of Virginia, Charlottesville, VA, USA
| | - Chiara Fabris
- Center for Diabetes Technology,
University of Virginia, Charlottesville, VA, USA
| | - Marc D Breton
- Center for Diabetes Technology,
University of Virginia, Charlottesville, VA, USA
- Marc D Breton, PhD, Center for Diabetes
Technology, University of Virginia, 560 Ray C Hunt Dr, Charlottesville, VA
22903, USA.
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28
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Fabris C, Gautier T, Breton M. Automated Adaptation of Insulin Treatment in Type 1 Diabetes. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:5039-5042. [PMID: 34892339 DOI: 10.1109/embc46164.2021.9630191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Individuals with type 1 diabetes (T1D) need life-long insulin therapy to compensate for the lack of endogenous insulin due to the autoimmune damage to pancreatic beta-cells. Treatment is based on basal and bolus insulin, to cover fasting and postprandial periods, respectively, according to three insulin dosing parameters: basal rate (BR), carbohydrate-to-insulin ratio (CR), and correction factor (CF). Suboptimal BR, CR, and CF profiles leading to incorrect insulin dosing may be the cause of undesired glycemic events, which carry dangerous short-term and long-term effects. Therefore, correct tuning of these parameters is of the utmost importance. In this work, we propose a new algorithm to optimize insulin dosing parameters in individuals with T1D who use a continuous glucose monitor and an insulin pump. The algorithm was tested using the University of Virginia/Padova T1D Simulator and led to an improvement in the quality of glycemic control. Future efforts will be devoted to test the algorithm in human clinical trials.
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29
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Avari P, Leal Y, Herrero P, Wos M, Jugnee N, Arnoriaga-Rodríguez M, Thomas M, Liu C, Massana Q, Lopez B, Nita L, Martin C, Fernández-Real JM, Oliver N, Fernández-Balsells M, Reddy M. Safety and Feasibility of the PEPPER Adaptive Bolus Advisor and Safety System: A Randomized Control Study. Diabetes Technol Ther 2021; 23:175-186. [PMID: 33048581 DOI: 10.1089/dia.2020.0301] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: The Patient Empowerment through Predictive Personalized Decision Support (PEPPER) system provides personalized bolus advice for people with type 1 diabetes. The system incorporates an adaptive insulin recommender system (based on case-based reasoning, an artificial intelligence methodology), coupled with a safety system, which includes predictive glucose alerts and alarms, predictive low-glucose suspend, personalized carbohydrate recommendations, and dynamic bolus insulin constraint. We evaluated the safety and efficacy of the PEPPER system compared to a standard bolus calculator. Methods: This was an open-labeled multicenter randomized controlled crossover study. Following 4-week run-in, participants were randomized to PEPPER/Control or Control/PEPPER in a 1:1 ratio for 12 weeks. Participants then crossed over after a washout period. The primary end-point was percentage time in range (TIR, 3.9-10.0 mmol/L [70-180 mg/dL]). Secondary outcomes included glycemic variability, quality of life, and outcomes on the safety system and insulin recommender. Results: Fifty-four participants on multiple daily injections (MDI) or insulin pump completed the run-in period, making up the intention-to-treat analysis. Median (interquartile range) age was 41.5 (32.3-49.8) years, diabetes duration 21.0 (11.5-26.0) years, and HbA1c 61.0 (58.0-66.1) mmol/mol. No significant difference was observed for percentage TIR between the PEPPER and Control groups (62.5 [52.1-67.8] % vs. 58.4 [49.6-64.3] %, respectively, P = 0.27). For quality of life, participants reported higher perceived hypoglycemia with the PEPPER system despite no objective difference in time spent in hypoglycemia. Conclusions: The PEPPER system was safe, but did not change glycemic outcomes, compared to control. There is wide scope for integrating PEPPER into routine diabetes management for pump and MDI users. Further studies are required to confirm overall effectiveness. Clinical trial registration: ClinicalTrials.gov NCT03849755.
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Affiliation(s)
- Parizad Avari
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Yenny Leal
- Diabetes, Endocrinology and Nutrition Unit, Hospital Universitari Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Pau Herrero
- Department of Electrical and Electronic Engineering, Imperial College London, London, United Kingdom
| | - Marzena Wos
- Diabetes, Endocrinology and Nutrition Unit, Hospital Universitari Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Narvada Jugnee
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - María Arnoriaga-Rodríguez
- Diabetes, Endocrinology and Nutrition Unit, Hospital Universitari Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Maria Thomas
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Chengyuan Liu
- Department of Electrical and Electronic Engineering, Imperial College London, London, United Kingdom
- Centre for Aerospace Manufactuiring, University of Nottingham, London, United Kingdom
| | - Quim Massana
- eXiT Research Group, Institut d'Informàtica i Aplicacions, University of Girona, Girona, Spain
| | - Beatriz Lopez
- eXiT Research Group, Institut d'Informàtica i Aplicacions, University of Girona, Girona, Spain
| | - Lucian Nita
- Department of Research & Development, RomSoft SRL, Iasi, Romania
| | - Clare Martin
- School of Engineering, Computing, and Mathematics, Oxford Brookes University, Oxford, United Kingdom
| | - José Manuel Fernández-Real
- Diabetes, Endocrinology and Nutrition Unit, Hospital Universitari Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain
- CIBEROBN Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, Spain
| | - Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Mercè Fernández-Balsells
- Diabetes, Endocrinology and Nutrition Unit, Hospital Universitari Dr. Josep Trueta, Institut d'Investigació Biomèdica de Girona, Girona, Spain
| | - Monika Reddy
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
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30
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Sun B, Huang S, Zhou J. Perspectives of Antidiabetic Drugs in Diabetes With Coronavirus Infections. Front Pharmacol 2021; 11:592439. [PMID: 33584268 PMCID: PMC7878391 DOI: 10.3389/fphar.2020.592439] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022] Open
Abstract
Diabetes mellitus (DM) increases the risk of viral infections especially during the period of poor glycemic controls. Emerging evidence has reported that DM is one of the most common comorbidities in the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection, also referred to as COVID-19. Moreover, the management and therapy are complex for individuals with diabetes who are acutely unwell with suspected or confirmed COVID-19. Here, we review the role of antidiabetic agents, mainly including insulin, metformin, pioglitazone, dipeptidyl peptidase-4 (DPP4) inhibitors, sodium-glucose cotransporter 2 (SGLT2) inhibitors, and glucagon-like peptide 1 (GLP-1) receptor agonists in DM patients with coronavirus infection, addressing the clinical therapeutic choices for these subjects.
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Affiliation(s)
- Bao Sun
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Shiqiong Huang
- Department of Pharmacy, The First Hospital of Changsha, Changsha, China
| | - Jiecan Zhou
- Institute of Clinical Medicine, The First Affiliated Hospital, University of South China, Hengyang, China
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31
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Wang H, Zhou Y, Zhai X, Ding B, Jing T, Su X, Li H, Ma J. Evaluating Glycemic Control During Basalin or Lantus Administration in Adults With Controlled Type 2 Diabetes Mellitus Using Continuous Glucose Monitoring. Front Endocrinol (Lausanne) 2021; 12:754820. [PMID: 34917025 PMCID: PMC8670238 DOI: 10.3389/fendo.2021.754820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
AIM This study aims at evaluating glycemic control during Basalin or Lantus administration in adults with controlled type 2 diabetes mellitus using continuous glucose monitoring system (CGM). METHODS 47 patients with well-controlled T2DM using both Basalin and oral hypoglycemic drugs were recruited. CGM were applied from day 1 to day 3 with the unchanged dose of Basalin and then removed from day 4. A washout was performed with Lantus at the same dose as Basalin from day 4 to day 10. Then patients were continued to install the CGM under Lantus administration from day 11 to day 13. Variables of CGM, such as the area under the curve (AUC) for both hyperglycemia and hypoglycemia, 24h mean blood glucose (24h MBG), 24h standard deviation of blood glucose (24h SDBG), 24h mean amplitude of glycemic excursion (24h MAGE), PT (percentage of time), and time in range (TIR), were calculated and compared between Basalin group and Lantus group. RESULTS The group of Lantus showed lower 24h MBG (p<0.01), 24h MAGE (p<0.05), and lower 24h SDBG (p<0.01) than the Basalin group. Lantus-treated patients had a lower PT and AUC when the cut-off point for blood glucose was 10 mmol/L (p<0.05) and 13.9 mmol/L (p<0.05), respectively. In this study, no patient developed symptomatic hypoglycemia, few hypoglycemia was observed and there was no difference of hypoglycemia between the two groups. CONCLUSION In patients with well-controlled T2DM who were treated with insulin glargine, Lantus group showed lower MBG, GV, and lower PT (BG > 10.0 mmol/L, BG > 13.9 mmol/L) than Basalin group. In summary, for T2DM population with HbA1c ≤ 7%, Lantus may be a better choice compared with Basalin.
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Affiliation(s)
| | | | | | | | | | | | - Huiqin Li
- *Correspondence: Jianhua Ma, ; Huiqin Li,
| | - Jianhua Ma
- *Correspondence: Jianhua Ma, ; Huiqin Li,
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32
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Corbett JP, Breton MD, Patek SD. A Multiple Hypothesis Approach to Estimating Meal Times in Individuals With Type 1 Diabetes. J Diabetes Sci Technol 2021; 15:141-146. [PMID: 31640408 PMCID: PMC7782995 DOI: 10.1177/1932296819883267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION It is important to have accurate information regarding when individuals with type 1 diabetes have eaten and taken insulin to reconcile those events with their blood glucose levels throughout the day. Insulin pumps and connected insulin pens provide records of when the user injected insulin and how many carbohydrates were recorded, but it is often unclear when meals occurred. This project demonstrates a method to estimate meal times using a multiple hypothesis approach. METHODS When an insulin dose is recorded, multiple hypotheses were generated describing variations of when the meal in question occurred. As postprandial glucose values informed the model, the posterior probability of the truth of each hypothesis was evaluated, and from these posterior probabilities, an expected meal time was found. This method was tested using simulation and a clinical data set (n = 11) and with either uniform or normally distributed (μ = 0, σ = 10 or 20 minutes) prior probabilities for the hypothesis set. RESULTS For the simulation data set, meals were estimated with an average error of -0.77 (±7.94) minutes when uniform priors were used and -0.99 (±8.55) and -0.88 (±7.84) for normally distributed priors (σ = 10 and 20 minutes). For the clinical data set, the average estimation error was 0.02 (±30.87), 1.38 (±21.58), and 0.04 (±27.52) for the uniform priors and normal priors (σ = 10 and 20 minutes). CONCLUSION This technique could be used to help advise physicians about the meal time insulin dosing behaviors of their patients and potentially influence changes in their treatment strategy.
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Affiliation(s)
- John P. Corbett
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
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33
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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34
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Kushner T, Breton MD, Sankaranarayanan S. Multi-Hour Blood Glucose Prediction in Type 1 Diabetes: A Patient-Specific Approach Using Shallow Neural Network Models. Diabetes Technol Ther 2020; 22:883-891. [PMID: 32324062 DOI: 10.1089/dia.2020.0061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Considering current insulin action profiles and the nature of glycemic responses to insulin, there is an acute need for longer term, accurate, blood glucose predictions to inform insulin dosing schedules and enable effective decision support for the treatment of type 1 diabetes (T1D). However, current methods achieve acceptable accuracy only for prediction horizons of up to 1 h, whereas typical postprandial excursions and insulin action profiles last 4-6 h. In this study, we present models for prediction horizons of 60-240 min developed by leveraging "shallow" neural networks, allowing for significantly lower complexity compared with related approaches. Methods: Patient-specific neural network-based predictive models are developed and tested on previously collected data from a cohort of 24 subjects with T1D. Models are designed to avoid serious pitfalls through incorporating essential physiological knowledge into model structure. Patient-specific models were generated to predict glucose 60, 90, 120, 180, and 240 min ahead, and a "transfer learning" approach to improve accuracy for patients where data are limited. Finally, we determined subgroup characteristics that result in higher model accuracy overall. Results: Root mean squared error was 28 ± 4, 33 ± 4, 38 ± 6, 40 ± 8, and 43 ± 12 mg/dL for 60, 90, 120, 180, and 240 min, respectively. For all prediction horizons, at least 93% of predictions were clinically acceptable by the Clarke error grid. Variance of historic continuous glucose monitor (CGM) values was a strong predictor for the need of transfer learning approaches. Conclusions: A shallow neural network, using features extracted from past CGM data and insulin logs, can achieve multi-hour glucose predictions with satisfactory accuracy. Models are patient specific, learnt on readily available data without the need for additional tests, and improve accuracy while lowering complexity compared with related approaches, paving the way for new advisory and closed loop algorithms able to encompass most of the insulin action timeframe.
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Affiliation(s)
- Taisa Kushner
- Department of Computer Science, University of Colorado Boulder, Boulder, Colorado, USA
- IQ Biology, Biofrontiers Institute, University of Colorado Boulder, Boulder, Colorado, USA
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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35
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Ozaslan B, Patek SD, Breton MD. Impact of Daily Physical Activity as Measured by Commonly Available Wearables on Mealtime Glucose Control in Type 1 Diabetes. Diabetes Technol Ther 2020; 22:742-748. [PMID: 32105515 PMCID: PMC7591370 DOI: 10.1089/dia.2019.0517] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Objective: In contrast with exercise, or structured physical activity (PA), glycemic disturbances due to daily unstructured PA in patients with type 1 diabetes (T1D) is largely underresearched, with limited information on treatment recommendations. We present results from retrospective analysis of data collected under patients' free-living conditions that illuminate the association between PA, as measured by an off-the-shelf activity tracker, and postprandial blood glucose control. Research Design and Methods: Data from 37 patients with T1D during two clinical studies with identical data collection protocols were analyzed retrospectively: 4 weeks of continuous glucose monitoring, carbohydrate intake, insulin injections, and PA (assessed through wearable activity tracker) were collected in free-living conditions. Five-hour glucose area under curves (GAUCs) following the last-bolused meal of every day were computed to assess postprandial glucose excursions, and their relation with corresponding antecedent PA was analyzed using linear mixed-effects regression models, accounting for meal, insulin, and current glycemic state. Results: Datasets yielded 845 days of data from 37 subjects (22.8 ± 11.6 days/subject); postmeal GAUC was negatively associated with total daily PA measured by step count (P = 0.025), and total time spent performing higher than light-intensity PA (P = 0.042). Patients with higher median total daily PA exhibited lower average postprandial GAUC (P < 0.01). Additional analyses indicated that daily PA likely presents an immediate and delayed impact on glucose control. Conclusion: Daily PA assessed by commonly available sensors is significantly associated with glycemic exposure after an evening meal, indicating that quantitative assessment of PA may be useful in mealtime treatment decisions.
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Affiliation(s)
- Basak Ozaslan
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | | | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
- Address correspondence to: Marc D. Breton, PhD, Center for Diabetes Technology Research, Department of Psychiatric & Neurobehavioral Sciences, P.O. Box 400888, Charlottesville, VA 22908-4888
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36
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Fathi AE, Kearney RE, Palisaitis E, Boulet B, Haidar A. A Model-Based Insulin Dose Optimization Algorithm for People With Type 1 Diabetes on Multiple Daily Injections Therapy. IEEE Trans Biomed Eng 2020; 68:1208-1219. [PMID: 32915722 DOI: 10.1109/tbme.2020.3023555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Multiple daily injections (MDI) therapy is the most common treatment for type 1 diabetes (T1D) including basal insulin doses to keep glucose levels constant during fasting conditions and bolus insulin doses with meals. Optimal insulin dosing is critical to achieving satisfactory glycemia but is challenging due to inter- and intra-individual variability. Here, we present a novel model-based iterative algorithm that optimizes insulin doses using previous-day glucose, insulin, and meal data. METHODS Our algorithm employs a maximum-a-posteriori method to estimate parameters of a model describing the effects of changes in basal-bolus insulin doses. Then, parameter estimates, their confidence intervals, and the goodness of fit, are combined to generate new recommendations. We assessed our algorithm in three ways. First, a clinical data set of 150 days (15 participants) were used to evaluate the proposed model and the estimation method. Second, 60-day simulations were performed to demonstrate the efficacy of the algorithm. Third, a sample 6-day clinical experiment is presented and discussed. RESULTS The model fitted the clinical data well with a root-mean-square-error of 1.75 mmol/L. Simulation results showed an improvement in the time in target (3.9-10 mmol/L) from 64% to 77% and a decrease in the time in hypoglycemia (< 3.9 mmol/L) from 8.1% to 3.8%. The clinical experiment demonstrated the feasibility of the algorithm. CONCLUSION Our algorithm has the potential to improve glycemic control in people with T1D using MDI. SIGNIFICANCE This work is a step forward towards a decision support system that improves their quality of life.
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El Fathi A, Palisaitis E, von Oettingen JE, Krishnamoorthy P, Kearney RE, Legault L, Haidar A. A pilot non-inferiority randomized controlled trial to assess automatic adjustments of insulin doses in adolescents with type 1 diabetes on multiple daily injections therapy. Pediatr Diabetes 2020; 21:950-959. [PMID: 32418302 DOI: 10.1111/pedi.13052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/15/2020] [Accepted: 05/11/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Multiple daily injections (MDI) therapy for type 1 diabetes involves basal and bolus insulin doses. Non-optimal insulin doses contribute to the lack of satisfactory glycemic control. We aimed to evaluate the feasibility of an algorithm that optimizes daily basal and bolus doses using glucose monitoring systems for MDI therapy users. METHODS We performed a pilot, non-inferiority, randomized, parallel study at a diabetes camp comparing basal-bolus insulin dose adjustments made by camp physicians (PA) and a learning algorithm (LA), in children and adolescents on MDI therapy. Participants wore a glucose sensor and underwent 11 days of daily dose adjustments in either arm. Algorithm adjustments were reviewed and approved by a physician. The last 7 days were examined for outcomes. RESULTS Twenty-one youths (age 13.3 [SD, 3.7] years; 13 females; HbA1c 8.6% [SD, 1.8]) were randomized to either group (LA [n = 10] or PA [n = 11]). The algorithm made 293 adjustments with a 92% acceptance rate from the camp physicians. In the last 7 days, the time in target glucose (3.9-10 mmol/L) in LA (39.5%, SD, 20.7) was similar to PA (38.4%, SD, 15.6) (P = .89). The number of hypoglycemic events per day in LA (0.3, IQR, [0.1-0.6]) was similar to PA (0.2, IQR, [0.0-0.4]) (P = .42). There was no incidence of severe hypoglycemia nor ketoacidosis. CONCLUSIONS In this pilot study, glycemic outcomes in the LA group were similar to the PA group. This algorithm has the potential to facilitate MDI therapy, and longer and larger studies are warranted.
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Affiliation(s)
- Anas El Fathi
- Department of Electrical and Computer Engineering, McGill University, Montreal, Canada
| | - Emilie Palisaitis
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Julia E von Oettingen
- Montreal Children's Hospital, Pediatric Endocrinology, Montréal, Canada.,The Research Institute of McGill University Health Center, Montréal, Canada
| | | | - Robert E Kearney
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Laurent Legault
- Montreal Children's Hospital, Pediatric Endocrinology, Montréal, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Canada.,The Research Institute of McGill University Health Center, Montréal, Canada
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Ash GI, Stults-Kolehmainen M, Busa MA, Gregory R, Garber CE, Liu J, Gerstein M, Casajus JA, Gonzalez-Aguero A, Constantinou D, Geistlinger M, Guppy FM, Pigozzi F, Pitsiladis YP. Establishing a Global Standard for Wearable Devices in Sport and Fitness: Perspectives from the New England Chapter of the American College of Sports Medicine Members. Curr Sports Med Rep 2020; 19:45-49. [PMID: 32028347 DOI: 10.1249/jsr.0000000000000680] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The recent explosion of wearable technology and the associated concerns prompted the International Federation of Sports Medicine (FIMS) to create a quality assurance standard for wearable devices, which provides commissioned testing of marketing claims and endorsement of commercial wearables that test favorably. An open forum as announced in the conference advertising was held at the Annual Meeting of the New England Regional Chapter of the American College of Sports Medicine (NEACSM) November 7 to 8, 2019, in Providence, Rhode Island, USA for attending NEACSM members to voice their input on the process. Herein, we report the proceedings. The round table participants perceived the quality assurance standard to be important, but identified some practical process challenges that included the broad scope and complexity of the device universe, the need for a multiphase testing pathway, and the associated fees for product evaluation. The participants also supported the evaluation of device data analysis, behavioral influences, and user experience in the overall evaluation. Looking forward, the FIMS quality assurance standard faces the challenge of balancing these broader perspectives with practical constraints of budget, facilities, time, and human resources.
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Affiliation(s)
| | | | - Michael A Busa
- Institute for Applied Life Sciences, University of Massachusetts Amherst, Amherst, MA
| | - Robert Gregory
- Department of Health and Movement Sciences, Southern Connecticut State University, New Haven, CT
| | - Carol Ewing Garber
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY
| | - Jason Liu
- Program in Computational Biology & Bioinformatics, Department of Molecular Biophysics & Biochemistry, Department of Computer Science, and Department of Statistics & Data Science, Yale University, New Haven, CT
| | - Mark Gerstein
- Program in Computational Biology & Bioinformatics, Department of Molecular Biophysics & Biochemistry, Department of Computer Science, and Department of Statistics & Data Science, Yale University, New Haven, CT
| | | | | | | | | | - Fergus M Guppy
- Centre for Stress and Age-related Disease, School of Pharmacy and Biomolecular Sciences (PaBS), University of Brighton, Brighton, UNITED KINGDOM
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Advanced Diabetes Management Using Artificial Intelligence and Continuous Glucose Monitoring Sensors. SENSORS 2020; 20:s20143870. [PMID: 32664432 PMCID: PMC7412387 DOI: 10.3390/s20143870] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/07/2020] [Accepted: 07/07/2020] [Indexed: 12/21/2022]
Abstract
Wearable continuous glucose monitoring (CGM) sensors are revolutionizing the treatment of type 1 diabetes (T1D). These sensors provide in real-time, every 1-5 min, the current blood glucose concentration and its rate-of-change, two key pieces of information for improving the determination of exogenous insulin administration and the prediction of forthcoming adverse events, such as hypo-/hyper-glycemia. The current research in diabetes technology is putting considerable effort into developing decision support systems for patient use, which automatically analyze the patient's data collected by CGM sensors and other portable devices, as well as providing personalized recommendations about therapy adjustments to patients. Due to the large amount of data collected by patients with T1D and their variety, artificial intelligence (AI) techniques are increasingly being adopted in these decision support systems. In this paper, we review the state-of-the-art methodologies using AI and CGM sensors for decision support in advanced T1D management, including techniques for personalized insulin bolus calculation, adaptive tuning of bolus calculator parameters and glucose prediction.
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Zhou Z, Sun B, Huang S, Zhu C, Bian M. Glycemic variability: adverse clinical outcomes and how to improve it? Cardiovasc Diabetol 2020; 19:102. [PMID: 32622354 PMCID: PMC7335439 DOI: 10.1186/s12933-020-01085-6] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/02/2020] [Indexed: 12/26/2022] Open
Abstract
Glycemic variability (GV), defined as an integral component of glucose homoeostasis, is emerging as an important metric to consider when assessing glycemic control in clinical practice. Although it remains yet no consensus, accumulating evidence has suggested that GV, representing either short-term (with-day and between-day variability) or long-term GV, was associated with an increased risk of diabetic macrovascular and microvascular complications, hypoglycemia, mortality rates and other adverse clinical outcomes. In this review, we summarize the adverse clinical outcomes of GV and discuss the beneficial measures, including continuous glucose monitoring, drugs, dietary interventions and exercise training, to improve it, aiming at better addressing the challenging aspect of blood glucose management.
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Affiliation(s)
- Zheng Zhou
- Department of Chinese Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Bao Sun
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410000, China.,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, 410000, China
| | - Shiqiong Huang
- Department of Pharmacy, The First Hospital of Changsha, Changsha, 410005, China
| | - Chunsheng Zhu
- Department of Chinese Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
| | - Meng Bian
- Department of Chinese Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
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Tyler NS, Mosquera-Lopez CM, Wilson LM, Dodier RH, Branigan DL, Gabo VB, Guillot FH, Hilts WW, El Youssef J, Castle JR, Jacobs PG. An artificial intelligence decision support system for the management of type 1 diabetes. Nat Metab 2020; 2:612-619. [PMID: 32694787 PMCID: PMC7384292 DOI: 10.1038/s42255-020-0212-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 04/23/2020] [Indexed: 11/08/2022]
Abstract
Type 1 diabetes (T1D) is characterized by pancreatic beta cell dysfunction and insulin depletion. Over 40% of people with T1D manage their glucose through multiple injections of long-acting basal and short-acting bolus insulin, so-called multiple daily injections (MDI)1,2. Errors in dosing can lead to life-threatening hypoglycaemia events (<70 mg dl-1) and hyperglycaemia (>180 mg dl-1), increasing the risk of retinopathy, neuropathy, and nephropathy. Machine learning (artificial intelligence) approaches are being harnessed to incorporate decision support into many medical specialties. Here, we report an algorithm that provides weekly insulin dosage recommendations to adults with T1D using MDI therapy. We employ a unique virtual platform3 to generate over 50,000 glucose observations to train a k-nearest neighbours4 decision support system (KNN-DSS) to identify causes of hyperglycaemia or hypoglycaemia and determine necessary insulin adjustments from a set of 12 potential recommendations. The KNN-DSS algorithm achieves an overall agreement with board-certified endocrinologists of 67.9% when validated on real-world human data, and delivers safe recommendations, per endocrinologist review. A comparison of inter-physician-recommended adjustments to insulin pump therapy indicates full agreement of 41.2% among endocrinologists, which is consistent with previous measures of inter-physician agreement (41-45%)5. In silico3,6 benchmarking using a platform accepted by the United States Food and Drug Administration for evaluation of artificial pancreas technologies indicates substantial improvement in glycaemic outcomes after 12 weeks of KNN-DSS use. Our data indicate that the KNN-DSS allows for early identification of dangerous insulin regimens and may be used to improve glycaemic outcomes and prevent life-threatening complications in people with T1D.
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Affiliation(s)
- Nichole S Tyler
- Artificial Intelligence for Medical Systems (AIMS) Lab, Oregon Health & Science University, Portland, OR, USA.
| | - Clara M Mosquera-Lopez
- Artificial Intelligence for Medical Systems (AIMS) Lab, Oregon Health & Science University, Portland, OR, USA
| | - Leah M Wilson
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Robert H Dodier
- Artificial Intelligence for Medical Systems (AIMS) Lab, Oregon Health & Science University, Portland, OR, USA
| | - Deborah L Branigan
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Virginia B Gabo
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Florian H Guillot
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Wade W Hilts
- Artificial Intelligence for Medical Systems (AIMS) Lab, Oregon Health & Science University, Portland, OR, USA
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Peter G Jacobs
- Artificial Intelligence for Medical Systems (AIMS) Lab, Oregon Health & Science University, Portland, OR, USA.
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Abstract
BACKGROUND Advances in pump technology have increased the popularity of this treatment modality among patients with type 1 diabetes and recently also among patients with type 2 diabetes. AREAS OF UNCERTAINTY Four decades after the incorporation of the insulin pump in clinical use, questions regarding its efficacy, occurrence rate of short-term complications as hypoglycemia and diabetes ketoacidosis, timing of pump initiation, and selected populations for use remain unanswered. DATA SOURCES A review of the literature was performed using the PubMed database to identify all articles published up till December 2018, with the search terms including insulin pump therapy/continuous subcutaneous insulin delivery. The Cochrane database was searched for meta-analysis evaluating controlled randomized trials. Consensuses guidelines published by the International Society for Pediatric and Adolescent Diabetes, American Diabetes Association, and Advanced Technologies and Treatments for Diabetes year books were additionally reviewed for relevant cited articles. THERAPEUTIC ADVANCES Insulin pump therapy offers flexible management of diabetes. It enables adjustment of basal insulin to daily requirements and circadian needs, offers more precise treatment for meals and physical activity, and, when integrated with continuous glucose monitoring, allows glucose responsive insulin delivery. The ability to download and transmit data for analysis allow for treatment optimization. Newer pumps are simple to operate and increase user experience. Studies support the efficacy of pump therapy in improving glycemic control and reducing the occurrence of hypoglycemia without increasing episodes of diabetes ketoacidosis. They also improve quality of life. Recent evidence suggests a role for pump therapy in reducing microvascular and macrovascular diabetes-related complications. CONCLUSIONS Insulin pump therapy appears to be effective and safe in people with T1D regardless of age. Future advancements will include incorporation of closed loop and various decision support systems to aid and improve metabolic control and quality of life.
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Tyler NS, Jacobs PG. Artificial Intelligence in Decision Support Systems for Type 1 Diabetes. SENSORS (BASEL, SWITZERLAND) 2020; 20:E3214. [PMID: 32517068 PMCID: PMC7308977 DOI: 10.3390/s20113214] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 12/16/2022]
Abstract
Type 1 diabetes (T1D) is a chronic health condition resulting from pancreatic beta cell dysfunction and insulin depletion. While automated insulin delivery systems are now available, many people choose to manage insulin delivery manually through insulin pumps or through multiple daily injections. Frequent insulin titrations are needed to adequately manage glucose, however, provider adjustments are typically made every several months. Recent automated decision support systems incorporate artificial intelligence algorithms to deliver personalized recommendations regarding insulin doses and daily behaviors. This paper presents a comprehensive review of computational and artificial intelligence-based decision support systems to manage T1D. Articles were obtained from PubMed, IEEE Xplore, and ScienceDirect databases. No time period restrictions were imposed on the search. After removing off-topic articles and duplicates, 562 articles were left to review. Of those articles, we identified 61 articles for comprehensive review based on algorithm evaluation using real-world human data, in silico trials, or clinical studies. We grouped decision support systems into general categories of (1) those which recommend adjustments to insulin and (2) those which predict and help avoid hypoglycemia. We review the artificial intelligence methods used for each type of decision support system, and discuss the performance and potential applications of these systems.
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Affiliation(s)
| | - Peter G. Jacobs
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR 97239, USA;
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Fabris C, Kovatchev B. The closed‐loop artificial pancreas in 2020. Artif Organs 2020; 44:671-679. [DOI: 10.1111/aor.13704] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Chiara Fabris
- Center for Diabetes Technology University of Virginia Charlottesville VA USA
| | - Boris Kovatchev
- Center for Diabetes Technology University of Virginia Charlottesville VA USA
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45
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Fabris C, Nass RM, Pinnata J, Carr KA, Koravi CLK, Barnett CL, Oliveri MC, Anderson SM, Chernavvsky DR, Breton MD. The Use of a Smart Bolus Calculator Informed by Real-time Insulin Sensitivity Assessments Reduces Postprandial Hypoglycemia Following an Aerobic Exercise Session in Individuals With Type 1 Diabetes. Diabetes Care 2020; 43:799-805. [PMID: 32144167 PMCID: PMC10026354 DOI: 10.2337/dc19-1675] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/18/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Insulin dosing in type 1 diabetes (T1D) is oftentimes complicated by fluctuating insulin requirements driven by metabolic and psychobehavioral factors impacting individuals' insulin sensitivity (IS). In this context, smart bolus calculators that automatically tailor prandial insulin dosing to the metabolic state of a person can improve glucose management in T1D. RESEARCH DESIGN AND METHODS Fifteen adults with T1D using continuous glucose monitors (CGMs) and insulin pumps completed two 24-h admissions in a hotel setting. During the admissions, participants engaged in an early afternoon 45-min aerobic exercise session, after which they received a standardized dinner meal. The dinner bolus was computed using a standard bolus calculator or smart bolus calculator informed by real-time IS estimates. Glucose control was assessed in the 4 h following dinner using CGMs and was compared between the two admissions. RESULTS The IS-informed bolus calculator allowed for a reduction in postprandial hypoglycemia as quantified by the low blood glucose index (2.02 vs. 3.31, P = 0.006) and percent time <70 mg/dL (8.48% vs. 15.18%, P = 0.049), without increasing hyperglycemia (high blood glucose index: 3.13 vs. 2.09, P = 0.075; percent time >180 mg/dL: 13.24% vs. 10.42%, P = 0.5; percent time >250 mg/dL: 2.08% vs. 1.19%, P = 0.317). In addition, the number of hypoglycemia rescue treatments was reduced from 12 to 7 with the use of the system. CONCLUSIONS The study shows that the proposed IS-informed bolus calculator is safe and feasible in adults with T1D, appropriately reducing postprandial hypoglycemia following an exercise-induced IS increase.
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Affiliation(s)
- Chiara Fabris
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Ralf M Nass
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Jennifer Pinnata
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Kelly A Carr
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | | | - Mary C Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Stacey M Anderson
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Daniel R Chernavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
- Dexcom, Inc., Charlottesville, VA
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
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47
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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48
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Fabris C, Ozaslan B, Breton MD. Continuous Glucose Monitors and Activity Trackers to Inform Insulin Dosing in Type 1 Diabetes: The University of Virginia Contribution. SENSORS 2019; 19:s19245386. [PMID: 31817678 PMCID: PMC6961036 DOI: 10.3390/s19245386] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/11/2023]
Abstract
Objective: Suboptimal insulin dosing in type 1 diabetes (T1D) is frequently associated with time-varying insulin requirements driven by various psycho-behavioral and physiological factors influencing insulin sensitivity (IS). Among these, physical activity has been widely recognized as a trigger of altered IS both during and following the exercise effort, but limited indication is available for the management of structured and (even more) unstructured activity in T1D. In this work, we present two methods to inform insulin dosing with biosignals from wearable sensors to improve glycemic control in individuals with T1D. Research Design and Methods: Continuous glucose monitors (CGM) and activity trackers are leveraged by the methods. The first method uses CGM records to estimate IS in real time and adjust the insulin dose according to a person’s insulin needs; the second method uses step count data to inform the bolus calculation with the residual glucose-lowering effects of recently performed (structured or unstructured) physical activity. The methods were tested in silico within the University of Virginia/Padova T1D Simulator. A standard bolus calculator and the proposed “smart” systems were deployed in the control of one meal in presence of increased/decreased IS (Study 1) and following a 1-hour exercise bout (Study 2). Postprandial glycemic control was assessed in terms of time spent in different glycemic ranges and low/high blood glucose indices (LBGI/HBGI), and compared between the dosing strategies. Results: In Study 1, the CGM-informed system allowed to reduce exposure to hypoglycemia in presence of increased IS (percent time < 70 mg/dL: 6.1% versus 9.9%; LBGI: 1.9 versus 3.2) and exposure to hyperglycemia in presence of decreased IS (percent time > 180 mg/dL: 14.6% versus 18.3%; HBGI: 3.0 versus 3.9), tending toward optimal control. In Study 2, the step count-informed system allowed to reduce hypoglycemia (percent time < 70 mg/dL: 3.9% versus 13.4%; LBGI: 1.7 versus 3.2) at the cost of a minor increase in exposure to hyperglycemia (percent time > 180 mg/dL: 11.9% versus 7.5%; HBGI: 2.4 versus 1.5). Conclusions: We presented and validated in silico two methods for the smart dosing of prandial insulin in T1D. If seen within an ensemble, the two algorithms provide alternatives to individuals with T1D for improving insulin dosing accommodating a large variety of treatment options. Future work will be devoted to test the safety and efficacy of the methods in free-living conditions.
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Vettoretti M, Battocchio C, Sparacino G, Facchinetti A. Development of an Error Model for a Factory-Calibrated Continuous Glucose Monitoring Sensor with 10-Day Lifetime. SENSORS (BASEL, SWITZERLAND) 2019; 19:E5320. [PMID: 31816886 PMCID: PMC6928894 DOI: 10.3390/s19235320] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/29/2019] [Accepted: 12/01/2019] [Indexed: 12/14/2022]
Abstract
Factory-calibrated continuous glucose monitoring (FC-CGM) sensors are new devices used in type 1 diabetes (T1D) therapy to measure the glucose concentration almost continuously for 10-14 days without requiring any in vivo calibration. Understanding and modelling CGM errors is important when designing new tools for T1D therapy. Available literature CGM error models are not suitable to describe the FC-CGM sensor error, since their domain of validity is limited to 12-h time windows, i.e., the time between two consecutive in vivo calibrations. The aim of this paper is to develop a model of the error of FC-CGM sensors. The dataset used contains 79 FC-CGM traces collected by the Dexcom G6 sensor. The model is designed to dissect the error into its three main components: effect of plasma-interstitium kinetics, calibration error, and random measurement noise. The main novelties are the model extension to cover the entire sensor lifetime and the use of a new single-step identification procedure. The final error model, which combines a first-order linear dynamic model to describe plasma-interstitium kinetics, a second-order polynomial model to describe calibration error, and an autoregressive model to describe measurement noise, proved to be suitable to describe FC-CGM sensor errors, in particular improving the estimation of the physiological time-delay.
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Affiliation(s)
| | | | | | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, 35131 Padova, Italy; (M.V.); (C.B.); (G.S.)
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Camerlingo N, Vettoretti M, Del Favero S, Cappon G, Sparacino G, Facchinetti A. A Real-Time Continuous Glucose Monitoring-Based Algorithm to Trigger Hypotreatments to Prevent/Mitigate Hypoglycemic Events. Diabetes Technol Ther 2019; 21:644-655. [PMID: 31335191 DOI: 10.1089/dia.2019.0139] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: The standard treatment for hypoglycemia recommended by the American Diabetes Association (ADA) suggests patients with diabetes to take small amounts of carbohydrates, the so-called hypotreatments (HTs), as soon as blood glucose concentration goes below 70 mg/dL. However, prevention, or at least mitigation, of hypoglycemic events could be achieved by triggering HTs ahead of time thanks to the use of the predictive capabilities of suitable real-time algorithms fed by continuous glucose monitoring (CGM) sensor data. Materials and Methods: The algorithm proposed in this article to trigger HTs for preventing forthcoming hypoglycemic events is based on the computation of the "dynamic risk", there is a nonlinear function combining current glycemia with its rate-of-change, both provided by CGM. A comparison of performance of the proposed algorithm against the ADA guidelines is made, in silico, on datasets of 100 virtual patients undergoing a single-meal experiment, with induced postmeal hypoglycemia, generated by the UVA/Padova type 1 diabetes simulator. Results: On noise-free CGM data, the proposed algorithm reduces the time spent in hypoglycemia, on median [25th-75th percentiles] from 36 [29-43] to 0 [0-11] min (P < 0.0001), with a concomitant decrease of the post-treatment rebound (PTR) in glucose concentration, on median [25th-75th percentiles] from 136 [121-148] to 121 [116-127] mg/dL (P < 0.0001). On noisy CGM data, there is still a reduction of both time spent in hypoglycemia from 41 [28-49] min to 25 [0-41] min (P < 0.0001) and PTR from 174 [146-189] mg/dL to 137 [123-151] mg/dL (P < 0.0001). Conclusions: The potentiality of the new algorithm in generating preventive HTs, which can allow significant reduction of hypoglycemia without concomitant increase of hyperglycemia, suggests its further development and test in silico, for example, simulating both insulin pump and multiple-daily-injection therapies.
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Affiliation(s)
- Nunzio Camerlingo
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Martina Vettoretti
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Simone Del Favero
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Giacomo Cappon
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, Padova, Italy
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