The International Diabetes Closed-Loop Study: Testing Artificial Pancreas Component Interoperability

Fabrication of Multiple-Channel Electrochemical Microneedle Electrode Array via Separated Functionalization and Assembly Method

Real-time monitoring of physiological indicators inside the body is pivotal for contemporary diagnostics and treatments. Implantable electrodes can not only track specific biomarkers but also facilitate therapeutic interventions. By modifying biometric components, implantable electrodes enable in situ metabolite detection in living tissues, notably beneficial in invasive glucose monitoring, which effectively alleviates the self-blood-glucose-managing burden for patients. However, the development of implantable electrochemical electrodes, especially multi-channel sensing devices, still faces challenges: (1) The complexity of direct preparation hinders functionalized or multi-parameter sensing on a small scale. (2) The fine structure of individual electrodes results in low spatial resolution for sensor functionalization. (3) There is limited conductivity due to simple device structures and weakly conductive electrode materials (such as silicon or polymers). To address these challenges, we developed multiple-channel electrochemical microneedle electrode arrays (MCEMEAs) via a separated functionalization and assembly process. Two-dimensional microneedle (2dMN)-based and one-dimensional microneedle (1dMN)-based electrodes were prepared by laser patterning, which were then modified as sensing electrodes by electrochemical deposition and glucose oxidase decoration to achieve separated functionalization and reduce mutual interference. The electrodes were then assembled into 2dMN- and 1dMN-based multi-channel electrochemical arrays (MCEAs), respectively, to avoid damaging functionalized coatings. In vitro and in vivo results demonstrated that the as-prepared MCEAs exhibit excellent transdermal capability, detection sensitivity, selectivity, and reproducibility, which was capable of real-time, in situ glucose concentration monitoring.

Technological Advances of Wearable Device for Continuous Monitoring of In Vivo Glucose

Managing diabetes is a chronic challenge today, requiring monitoring and timely insulin injections to maintain stable blood glucose levels. Traditional clinical testing relies on fingertip or venous blood collection, which has facilitated the emergence of continuous glucose monitoring (CGM) technology to address data limitations. Continuous glucose monitoring technology is recognized for tracking long-term blood glucose fluctuations, and its development, particularly in wearable devices, has given rise to compact and portable continuous glucose monitoring devices, which facilitates the measurement of blood glucose and adjustment of medication. This review introduces the development of wearable CGM-based technologies, including noninvasive methods using body fluids and invasive methods using implantable electrodes. The advantages and disadvantages of these approaches are discussed as well as the use of microneedle arrays in minimally invasive CGM. Microneedle arrays allow for painless transdermal puncture and are expected to facilitate the development of wearable CGM devices. Finally, we discuss the challenges and opportunities and look forward to the biomedical applications and future directions of wearable CGM-based technologies in biological research.

Evidence from clinical trials on high-risk medical devices in children: a scoping review

BACKGROUND

Meeting increased regulatory requirements for clinical evaluation of medical devices marketed in Europe in accordance with the Medical Device Regulation (EU 2017/745) is challenging, particularly for high-risk devices used in children.

METHODS

Within the CORE-MD project, we performed a scoping review on evidence from clinical trials investigating high-risk paediatric medical devices used in paediatric cardiology, diabetology, orthopaedics and surgery, in patients aged 0-21 years. We searched Medline and Embase from 1st January 2017 to 9th November 2022.

RESULTS

From 1692 records screened, 99 trials were included. Most were multicentre studies performed in North America and Europe that mainly had evaluated medical devices from the specialty of diabetology. Most had enrolled adolescents and 39% of trials included both children and adults. Randomized controlled trials accounted for 38% of the sample. Other frequently used designs were before-after studies (21%) and crossover trials (20%). Included trials were mainly small, with a sample size <100 participants in 64% of the studies. Most frequently assessed outcomes were efficacy and effectiveness as well as safety.

CONCLUSION

Within the assessed sample, clinical trials on high-risk medical devices in children were of various designs, often lacked a concurrent control group, and recruited few infants and young children.

IMPACT

In the assessed sample, clinical trials on high-risk medical devices in children were mainly small, with variable study designs (often without concurrent control), and they mostly enrolled adolescents. We provide a systematic summary of methodologies applied in clinical trials of medical devices in the paediatric population, reflecting obstacles in this research area that make it challenging to conduct adequately powered randomized controlled trials. In view of changing European regulations and related concerns about shortages of high-risk medical devices for children, our findings may assist competent authorities in setting realistic requirements for the evidence level to support device conformity certification.

In-silico evaluation of an artificial pancreas achieving automatic glycemic control in patients with type 1 diabetes

Artificial pancreas (AP) is a useful tool for maintaining the blood glucose (BG) of patients with type 1 diabetes (T1D) within the euglycemic range. An intelligent controller has been developed based on general predictive control (GPC) for AP. This controller exhibits good performance with the UVA/Padova T1D mellitus simulator approved by the US Food and Drug Administration. In this work, the GPC controller was further evaluated under strict conditions, including a pump with noise and error, a CGM sensor with noise and error, a high carbohydrate intake, and a large population of 100 in-silico subjects. Test results showed that the subjects are in high risk for hypoglycemia. Thus, an insulin on board (IOB) calculator, as well as an adaptive control weighting parameter (AW) strategy, was introduced. The percentage of time spent in euglycemic range of the in-silico subjects was 86.0% ± 5.8%, and the patient group had a low risk of hypoglycemia with the GPC+IOB+AW controller. Moreover, the proposed AW strategy is more effective in hypoglycemia prevention and does not require any personalized data compared with the IOB calculator. Thus, the proposed controller realized an automatic control of the BG of patients with T1D without meal announcements and complex user interaction.

Real-World Evidence Supporting Tandem Control-IQ Hybrid Closed-Loop Success in the Medicare and Medicaid Type 1 and Type 2 Diabetes Populations

Background: The Tandem Control-IQ (CIQ) system has demonstrated significant glycemic improvements in large randomized controlled and real-world trials. Use of this system is lower in people with type 1 diabetes (T1D) government-sponsored insurance and those with type 2 diabetes (T2D). This analysis aimed to evaluate the performance of CIQ in these groups. Methods and Materials: A retrospective analysis of CIQ users was performed. Users age ≥6 years with a t:slim X2 Pump and >30 days of continuous glucose monitoring (CGM) data pre-CIQ and >30 days post-CIQ technology initiation were included. Results: A total of 4243 Medicare and 1332 Medicaid CIQ users were analyzed among whom 5075 had T1D and 500 had T2D. After starting CIQ, the Medicare beneficiaries group saw significant improvement in time in target range 70-180 mg/dL (TIR; 64% vs. 74%; P < 0.0001), glucose management index (GMI; 7.3% vs. 7.0%; P < 0.0001), and the percentage of users meeting American Diabetes Association (ADA) CGM Glucometrics Guidelines (12.8% vs. 26.3%; P < 0.0001). The Medicaid group also saw significant improvement in TIR (46% vs. 60%; P < 0.0001), GMI (7.9% vs. 7.5%; P < 0.0001), and percentage meeting ADA guidelines (5.7% vs. 13.4%; P < 0.0001). Patients with T2D and either insurance saw significant glycemic improvements. Conclusions: The CIQ system was effective in the Medicare and Medicaid groups in improving glycemic control. The T2D subgroup also demonstrated improved glycemic control with CIQ use. Glucometrics achieved in this analysis are comparable with those seen in previous randomized controlled clinical trials with the CIQ system.

Initiating hybrid closed loop: A program evaluation of an educator-led Control-IQ follow-up at a large pediatric clinic

BACKGROUND

Control-IQ (Tandem Diabetes) is a hybrid closed-loop (HCL) system that users self-initiate after completing online training. Best practices for clinical follow-up are not known. Our quality improvement objective was to evaluate the usefulness of an educator-led follow-up program for new HCL users in a type 1 diabetes pediatric clinic.

METHODS

We implemented an ''HCLCheck-in'' program, first determining when users started HCL, then having diabetes educators contact them for a follow-up call 2-weeks after start. Educators used a Clinical Tool to inform insulin dose and behavior recommendations, and used four benchmarks to determine need for further follow-up: ≥71% HCL use, ≥71% CGM use, ≥60% Time-in-Range (TIR, 70-180 mg/dL), <5% below 70 mg/dL. Family and educator satisfaction were surveyed.

RESULTS

One-hundred-twenty-three youth [mean age 13.6 ± 3.7 y, 53.7% female, mean HbA1c 7.6 ± 1.4% (60 mmol/mol)] completed an HCLCheck-in call a median (IQR) of 18(15, 21) days post-HCL start. 74 users (60%) surpassed benchmarks with 94% HCL use and 71% TIR. Of the 49 who did not, 16 completed a second call, and improved median TIR 12.5% (p = 0.03). HCL users reported high satisfaction with the program overall [median 10 (9, 10) out of 10]. Educators spent a median of 45 (32,70) minutes per user and rated satisfaction with the program as 8 (7,9.5) and the Tool as 9 (9, 10).

CONCLUSION

Our HCLCheck-in program received high satisfaction ratings and resulted in improved TIR for those initially not meeting benchmarks, suggesting users may benefit from early follow-up. Similar programs may be beneficial for other new technologies.

Review: Glucose-sensitive insulin

BACKGROUND

Hypoglycemia, the condition of low blood sugar, is a common occurance in people with diabetes using insulin therapy. Protecting against hypoglycaemia by engineering an insulin preparation that can auto-adjust its biological activity to fluctuating blood glucose levels has been pursued since the 1970s, but despite numerous publications, no system that works well enough for practical use has reached clinical practise.

SCOPE OF REVIEW

This review will summarise and scrutinise known approaches for producing glucose-sensitive insulin therapies. Notably, systems described in patent applications will be extensively covered, which has not been the case for earlier reviews of this area.

MAJOR CONCLUSIONS

The vast majority of published systems are not suitable for product development, but a few glucose-sensitive insulin concepts have recently reached clinical trials, and there is hope that glucose-sensitive insulin will become available to people with diabetes in the near future.

Digital health and diabetes: experience from India

The digitization of healthcare and its usage in the delivery of healthcare have experienced exponential growth across the world in recent times. India's fast-growing diabetes population has been exerting immense pressure on the country's healthcare infrastructure. Various innovative and evolving technologies are converging to impact the trajectory of digital health in diabetes. The diabetes community has been adopting various technologies such as connected glucose meters, continuous glucose monitoring systems, continuous subcutaneous insulin infusion, closed-loop systems, digitalization of health data, and diabetes-related apps for the prevention and management of the condition. India has provided some excellent examples in exploiting the potential of digital transformation in revamping the diabetes ecosystem. Yet, there are still various hurdles in technology development, healthcare delivery, as well as concerns related to data privacy, digital divide, policies by the government, role of stakeholders, attitude, and absorption by healthcare professionals, and hospitals. This article provides an overview of the digital diabetes technologies currently practiced in India and recommends the need for strong technology adaptation and policy interventions for an ideal roadmap of digitalization of diabetes care in the Indian milieu.

Lessons from Use of Continuous Glucose Monitoring Systems in Digital Healthcare

We live in a digital world where a variety of wearable medical devices are available. These technologies enable us to measure our health in our daily lives. It is increasingly possible to manage our own health directly through data gathered from these wearable devices. Likewise, healthcare professionals have also been able to indirectly monitor patients' health. Healthcare professionals have accepted that digital technologies will play an increasingly important role in healthcare. Wearable technologies allow better collection of personal medical data, which healthcare professionals can use to improve the quality of healthcare provided to the public. The use of continuous glucose monitoring systems (CGMS) is the most representative and desirable case in the adoption of digital technology in healthcare. Using the case of CGMS and examining its use from the perspective of healthcare professionals, this paper discusses the necessary adjustments required in clinical practices. There is a need for various stakeholders, such as medical staff, patients, industry partners, and policy-makers, to utilize and harness the potential of digital technology.

Continuous Glucose Monitoring: Review of an Innovation in Diabetes Management

Most continuous glucose monitors (CGM) provide interstitial fluid glucose trends, which reflect blood glucose trends with alarms and alerts to prevent hypoglycemia and provide better glycemic control. CGM used in conjunction with insulin pumps has changed the management of patients with insulin-dependent diabetes, mainly type 1 diabetes. CGM technology prevents the need for frequent blood glucose testing, which is often cumbersome for patients, providing them with a better alternative. CGM technology is underprescribed and therefore advantage should be taken of this technology to provide better hemoglobin A1c (HbA1c) control and decrease incidence of diabetic complications. CGM is particularly useful in patients with hypoglycemia unawareness and nocturnal hypoglycemia. CGM is currently not approved in pregnant patients, in critically ill patients and patients on dialysis. Research suggests that the benefits certainly outweigh the limitations of this technology. This review article focuses on the technical and clinical use of continuous glucose monitoring and sensor-integrated pump technology.