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Jacobs PG, Resalat N, Hilts W, Young GM, Leitschuh J, Pinsonault J, El Youssef J, Branigan D, Gabo V, Eom J, Ramsey K, Dodier R, Mosquera-Lopez C, Wilson LM, Castle JR. Integrating metabolic expenditure information from wearable fitness sensors into an AI-augmented automated insulin delivery system: a randomised clinical trial. Lancet Digit Health 2023; 5:e607-e617. [PMID: 37543512 PMCID: PMC10557965 DOI: 10.1016/s2589-7500(23)00112-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/21/2023] [Accepted: 06/06/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Exercise can rapidly drop glucose in people with type 1 diabetes. Ubiquitous wearable fitness sensors are not integrated into automated insulin delivery (AID) systems. We hypothesised that an AID can automate insulin adjustments using real-time wearable fitness data to reduce hypoglycaemia during exercise and free-living conditions compared with an AID not automating use of fitness data. METHODS Our study population comprised of individuals (aged 21-50 years) with type 1 diabetes from from the Harold Schnitzer Diabetes Health Center clinic at Oregon Health and Science University, OR, USA, who were enrolled into a 76 h single-centre, two-arm randomised (4-block randomisation), non-blinded crossover study to use (1) an AID that detects exercise, prompts the user, and shuts off insulin during exercise using an exercise-aware adaptive proportional derivative (exAPD) algorithm or (2) an AID that automates insulin adjustments using fitness data in real-time through an exercise-aware model predictive control (exMPC) algorithm. Both algorithms ran on iPancreas comprising commercial glucose sensors, insulin pumps, and smartwatches. Participants executed 1 week run-in on usual therapy followed by exAPD or exMPC for one 12 h primary in-clinic session involving meals, exercise, and activities of daily living, and 2 free-living out-patient days. Primary outcome was time below range (<3·9 mmol/L) during the primary in-clinic session. Secondary outcome measures included mean glucose and time in range (3·9-10 mmol/L). This trial is registered with ClinicalTrials.gov, NCT04771403. FINDINGS Between April 13, 2021, and Oct 3, 2022, 27 participants (18 females) were enrolled into the study. There was no significant difference between exMPC (n=24) versus exAPD (n=22) in time below range (mean [SD] 1·3% [2·9] vs 2·5% [7·0]) or time in range (63·2% [23·9] vs 59·4% [23·1]) during the primary in-clinic session. In the 2 h period after start of in-clinic exercise, exMPC had significantly lower mean glucose (7·3 [1·6] vs 8·0 [1·7] mmol/L, p=0·023) and comparable time below range (1·4% [4·2] vs 4·9% [14·4]). Across the 76 h study, both algorithms achieved clinical time in range targets (71·2% [16] and 75·5% [11]) and time below range (1·0% [1·2] and 1·3% [2·2]), significantly lower than run-in period (2·4% [2·4], p=0·0004 vs exMPC; p=0·012 vs exAPD). No adverse events occurred. INTERPRETATION AIDs can integrate exercise data from smartwatches to inform insulin dosing and limit hypoglycaemia while improving glucose outcomes. Future AID systems that integrate exercise metrics from wearable fitness sensors may help people living with type 1 diabetes exercise safely by limiting hypoglycaemia. FUNDING JDRF Foundation and the Leona M and Harry B Helmsley Charitable Trust, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Peter G Jacobs
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Center for Health and Healing, Oregon Health and Science University, Portland, OR, USA.
| | - Navid Resalat
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Center for Health and Healing, Oregon Health and Science University, Portland, OR, USA
| | - Wade Hilts
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Center for Health and Healing, Oregon Health and Science University, Portland, OR, USA
| | - Gavin M Young
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Center for Health and Healing, Oregon Health and Science University, Portland, OR, USA
| | - Joseph Leitschuh
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Center for Health and Healing, Oregon Health and Science University, Portland, OR, USA
| | - Joseph Pinsonault
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Center for Health and Healing, Oregon Health and Science University, Portland, OR, USA
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, OR, USA
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, OR, USA
| | - Virginia Gabo
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, OR, USA
| | - Jae Eom
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, OR, USA
| | - Katrina Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics and Design Program, Oregon Health and Science University, Portland, OR, USA
| | - Robert Dodier
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Center for Health and Healing, Oregon Health and Science University, Portland, OR, USA
| | - Clara Mosquera-Lopez
- Artificial Intelligence for Medical Systems Lab, Department of Biomedical Engineering, Center for Health and Healing, Oregon Health and Science University, Portland, OR, USA
| | - Leah M Wilson
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, OR, USA
| | - Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, OR, USA
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Mosquera-Lopez C, Wilson LM, El Youssef J, Hilts W, Leitschuh J, Branigan D, Gabo V, Eom JH, Castle JR, Jacobs PG. Enabling fully automated insulin delivery through meal detection and size estimation using Artificial Intelligence. NPJ Digit Med 2023; 6:39. [PMID: 36914699 PMCID: PMC10011368 DOI: 10.1038/s41746-023-00783-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 02/16/2023] [Indexed: 03/16/2023] Open
Abstract
We present a robust insulin delivery system that includes automated meal detection and carbohydrate content estimation using machine learning for meal insulin dosing called robust artificial pancreas (RAP). We conducted a randomized, single-center crossover trial to compare postprandial glucose control in the four hours following unannounced meals using a hybrid model predictive control (MPC) algorithm and the RAP system. The RAP system includes a neural network model to automatically detect meals and deliver a recommended meal insulin dose. The meal detection algorithm has a sensitivity of 83.3%, false discovery rate of 16.6%, and mean detection time of 25.9 minutes. While there is no significant difference in incremental area under the curve of glucose, RAP significantly reduces time above range (glucose >180 mg/dL) by 10.8% (P = 0.04) and trends toward increasing time in range (70-180 mg/dL) by 9.1% compared with MPC. Time below range (glucose <70 mg/dL) is not significantly different between RAP and MPC.
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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, OR, USA.
| | - Leah M Wilson
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Wade Hilts
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Joseph Leitschuh
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Virginia Gabo
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Jae H Eom
- 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, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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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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Sun X, Rashid M, Askari MR, Cinar A. Adaptive Personalized Prior-Knowledge-Informed Model Predictive Control for Type 1 Diabetes. CONTROL ENGINEERING PRACTICE 2023; 131:105386. [PMID: 36506413 PMCID: PMC9730892 DOI: 10.1016/j.conengprac.2022.105386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
This work considers the problem of adaptive prior-informed model predictive control (MPC) formulations that explicitly incorporate prior knowledge in the model development and is robust to missing data in the output measurements. The proposed prediction model is based on a latent variables model to extract glycemic dynamics from highly-correlated data and incorporates prior knowledge of exponential stability to improve the prediction ability. Missing data structures are formulated to enable model predictions when output measurements are missing for short periods of time. Based on the latent variables model, the MPC strategy and adaptive rules are developed to automatically tune the aggressiveness of the MPC. The adaptive prior-knowledge-informed MPC is evaluated with computer simulations for the control of blood glucose concentrations in people with Type 1 diabetes (T1D) using simulated virtual patients. Due to the variability among people with T1D, the hyperparameters of the prior-knowledge-informed model are personalized to individual subjects. The percentage of time spent in the target range is 76.48% when there are no missing data and 76.52% when there are missing data episodes lasting up to 30 mins (6 samples). Incorporating the adaptive rules further improves the percentage of time in target range to 84.58% and 84.88% for cases with no missing data and missing data, respectively. The proposed adaptive prior-informed MPC formulation provides robust, effective, and safe regulation of glucose concentration in T1D despite disturbances and missing measurements.
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Affiliation(s)
- Xiaoyu Sun
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, 60616, IL, USA
| | - Mudassir Rashid
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, 60616, IL, USA
| | - Mohammad Reza Askari
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, 60616, IL, USA
| | - Ali Cinar
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, 60616, IL, USA
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, 60616, IL, USA
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Tucker AP, Erdman AG, Schreiner PJ, Ma S, Chow LS. Examining Sensor Agreement in Neural Network Blood Glucose Prediction. J Diabetes Sci Technol 2022; 16:1473-1482. [PMID: 34109837 PMCID: PMC9631521 DOI: 10.1177/19322968211018246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Successful measurements of interstitial glucose are a key component in providing effective care for patients with diabetes. Recently, there has been significant interest in using neural networks to forecast future glucose values from interstitial measurements collected by continuous glucose monitors (CGMs). While prediction accuracy continues to improve, in this work we investigated the effect of physiological sensor location on neural network blood glucose forecasting. We used clinical data from patients with Type 2 Diabetes who wore blinded FreeStyle Libre Pro CGMs (Abbott) on both their right and left arms continuously for 12 weeks. We trained patient-specific prediction algorithms to test the effect of sensor location on neural network forecasting (N = 13, Female = 6, Male = 7). In 10 of our 13 patients, we found at least one significant (P < .05) increase in forecasting error in algorithms which were tested with data taken from a different location than data which was used for training. These reported results were independent from other noticeable physiological differences between subjects (eg, height, age, weight, blood pressure) and independent from overall variance in the data. From these results we observe that CGM location can play a consequential role in neural network glucose prediction.
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Affiliation(s)
- Aaron P. Tucker
- Earl E. Bakken Medical Devices Center,
University of Minnesota, Minneapolis, MN, USA
- Aaron P. Tucker, Earl E. Bakken Medical
Devices Center, University of Minnesota, G217 Mayo Memorial Building MMC 95, 420
Delaware St., Minneapolis, MN 55455, USA.
| | - Arthur G. Erdman
- Earl E. Bakken Medical Devices Center,
University of Minnesota, Minneapolis, MN, USA
| | - Pamela J. Schreiner
- Division of Epidemiology and Community
Health, University of Minnesota, Minneapolis, MN, USA
| | - Sisi Ma
- Division of General Internal Medicine,
University of Minnesota, Minneapolis, MN, USA
| | - Lisa S. Chow
- Division of Diabetes, Endocrinology and
Metabolism, University of Minnesota, Minneapolis, MN, USA
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6
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Subcutaneous amperometric biosensors for continuous glucose monitoring in diabetes. Talanta 2022. [DOI: 10.1016/j.talanta.2022.124033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Rahmanian F, Asemani MH, Dehghani M, Mobayen S. Robust dynamic output feedback control of blood glucose level in diabetic rat with robust descriptor Kalman filter. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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8
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Mosquera-Lopez C, Jacobs PG. Incorporating Glucose Variability into Glucose Forecasting Accuracy Assessment Using the New Glucose Variability Impact Index and the Prediction Consistency Index: An LSTM Case Example. J Diabetes Sci Technol 2022; 16:7-18. [PMID: 34490793 PMCID: PMC8875041 DOI: 10.1177/19322968211042621] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In this work, we developed glucose forecasting algorithms trained and evaluated on a large dataset of free-living people with type 1 diabetes (T1D) using closed-loop (CL) and sensor-augmented pump (SAP) therapies; and we demonstrate how glucose variability impacts accuracy. We introduce the glucose variability impact index (GVII) and the glucose prediction consistency index (GPCI) to assess the accuracy of prediction algorithms. METHODS A long-short-term-memory (LSTM) neural network was designed to predict glucose up to 60 minutes in the future using continuous glucose measurements and insulin data collected from 175 people with T1D (41,318 days) and evaluated on 75 people (11,333 days) from the Tidepool Big Data Donation Dataset. LSTM was compared with two naïve forecasting algorithms as well as Ridge linear regression and a random forest using root-mean-square error (RMSE). Parkes error grid quantified clinical accuracy. Regression analysis was used to derive the GVII and GPCI. RESULTS The LSTM had highest accuracy and best GVII and GPCI. RMSE for CL was 19.8 ± 3.2 and 33.2 ± 5.4 mg/dL for 30- and 60-minute prediction horizons, respectively. RMSE for SAP was 19.6 ± 3.8 and 33.1 ± 7.3 mg/dL for 30- and 60-minute prediction horizons, respectively; 99.6% and 97.6% of predictions were within zones A+B of the Parkes error grid at 30- and 60-minute prediction horizons, respectively. Glucose variability was strongly correlated with RMSE (R≥0.64, P < 0.001); GVII and GPCI demonstrated a means to compare algorithms across datasets with different glucose variability. CONCLUSIONS The LSTM model was accurate on a large real-world free-living dataset. Glucose variability should be considered when assessing prediction accuracy using indices such as GVII and GPCI.
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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, OR, USA
- Clara Mosquera-Lopez, PhD, 3303 SW Bond Avenue, Portland, OR 97239, USA.
| | - Peter G. Jacobs
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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Lee S, Kim J, Park SW, Jin SM, Park SM. Toward a Fully Automated Artificial Pancreas System Using a Bioinspired Reinforcement Learning Design: In Silico Validation. IEEE J Biomed Health Inform 2021; 25:536-546. [PMID: 32750935 DOI: 10.1109/jbhi.2020.3002022] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The automation of insulin treatment is the most challenge aspect of glucose management for type 1 diabetes owing to unexpected exogenous events (e.g., meal intake). In this article, we propose a novel reinforcement learning (RL) based artificial intelligence (AI) algorithm for a fully automated artificial pancreas (AP) system. METHODS A bioinspired RL designing method was developed for automated insulin infusion. This method has reward functions that imply the temporal homeostatic objective and discount factors that reflect an individual specific pharmacological characteristic. The proposed method was applied to a training method using an RL algorithm and was evaluated in virtual patients from the FDA approved UVA/Padova simulator with unannounced meal intakes. RESULTS For a single-meal experiment with preprandial fasting, the trained policy demonstrated fully automated regulation in both the basal and postprandial phases. In the in silico trial with a variation of insulin sensitivity and dawn phenomenon, the policy achieved a mean glucose of 124.72 mg/dL and percentage time in the normal range of 89.56%. The layer-wise relevance propagation provides interpretable information on AI-driven decision for robustness to sensor noise, automated postprandial regulation, and insulin stacking avoidance. CONCLUSION The AP algorithm based on the bioinspired RL approach enables fully automated blood glucose control with unannounced meal intake. SIGNIFICANCE The proposed framework can be extended to other drug-based treatments for systems with significant uncertainties.
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Wilson LM, Jacobs PG, Ramsey KL, Resalat N, Reddy R, Branigan D, Leitschuh J, Gabo V, Guillot F, Senf B, El Youssef J, Steineck IIK, Tyler NS, Castle JR. Dual-Hormone Closed-Loop System Using a Liquid Stable Glucagon Formulation Versus Insulin-Only Closed-Loop System Compared With a Predictive Low Glucose Suspend System: An Open-Label, Outpatient, Single-Center, Crossover, Randomized Controlled Trial. Diabetes Care 2020; 43:2721-2729. [PMID: 32907828 DOI: 10.2337/dc19-2267] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 08/16/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the efficacy and feasibility of a dual-hormone (DH) closed-loop system with insulin and a novel liquid stable glucagon formulation compared with an insulin-only closed-loop system and a predictive low glucose suspend (PLGS) system. RESEARCH DESIGN AND METHODS In a 76-h, randomized, crossover, outpatient study, 23 participants with type 1 diabetes used three modes of the Oregon Artificial Pancreas system: 1) dual-hormone (DH) closed-loop control, 2) insulin-only single-hormone (SH) closed-loop control, and 3) PLGS system. The primary end point was percentage time in hypoglycemia (<70 mg/dL) from the start of in-clinic aerobic exercise (45 min at 60% VO2max) to 4 h after. RESULTS DH reduced hypoglycemia compared with SH during and after exercise (DH 0.0% [interquartile range 0.0-4.2], SH 8.3% [0.0-12.5], P = 0.025). There was an increased time in hyperglycemia (>180 mg/dL) during and after exercise for DH versus SH (20.8% DH vs. 6.3% SH, P = 0.038). Mean glucose during the entire study duration was DH, 159.2; SH, 151.6; and PLGS, 163.6 mg/dL. Across the entire study duration, DH resulted in 7.5% more time in target range (70-180 mg/dL) compared with the PLGS system (71.0% vs. 63.4%, P = 0.044). For the entire study duration, DH had 28.2% time in hyperglycemia vs. 25.1% for SH (P = 0.044) and 34.7% for PLGS (P = 0.140). Four participants experienced nausea related to glucagon, leading three to withdraw from the study. CONCLUSIONS The glucagon formulation demonstrated feasibility in a closed-loop system. The DH system reduced hypoglycemia during and after exercise, with some increase in hyperglycemia.
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Affiliation(s)
- Leah M Wilson
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Peter G Jacobs
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Katrina L Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics and Design Program, Oregon Health & Science University & Portland State University School of Public Health, Portland, OR
| | - Navid Resalat
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Ravi Reddy
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Joseph Leitschuh
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Virginia Gabo
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Florian Guillot
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Brian Senf
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR.,Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | | | - Nichole S Tyler
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
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11
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Measuring glucose at the site of insulin delivery with a redox-mediated sensor. Biosens Bioelectron 2020; 165:112221. [PMID: 32729464 DOI: 10.1016/j.bios.2020.112221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/22/2022]
Abstract
Automated insulin delivery systems for people with type 1 diabetes rely on an accurate subcutaneous glucose sensor and an infusion cannula that delivers insulin in response to measured glucose. Integrating the sensor with the infusion cannula would provide substantial benefit by reducing the number of devices inserted into subcutaneous tissue. We describe the sensor chemistry and a calibration algorithm to minimize impact of insulin delivery artifacts in a new glucose sensing cannula. Seven people with type 1 diabetes undergoing automated insulin delivery used two sensing cannulae whereby one delivered a rapidly-acting insulin analog and the other delivered a control phosphate buffered saline (PBS) solution with no insulin. While there was a small artifact in both conditions that increased for larger volumes, there was no difference between the artifacts in the sensing cannula delivering insulin compared with the sensing cannula delivering PBS as determined by integrating the area-under-the-curve of the sensor values following delivery of larger amounts of fluid (P = 0.7). The time for the sensor to recover from the artifact was found to be longer for larger fluid amounts compared with smaller fluid amounts (10.3 ± 8.5 min vs. 41.2 ± 78.3 s, P < 0.05). Using a smart-sampling Kalman filtering smoothing algorithm improved sensor accuracy. When using an all-point calibration on all sensors, the smart-sampling Kalman filter reduced the mean absolute relative difference from 10.9% to 9.5% and resulted in 96.7% of the data points falling within the A and B regions of the Clarke error grid. Despite a small artifact, which is likely due to dilution by fluid delivery, it is possible to continuously measure glucose in a cannula that simultaneously delivers insulin.
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Lal RA, Ekhlaspour L, Hood K, Buckingham B. Realizing a Closed-Loop (Artificial Pancreas) System for the Treatment of Type 1 Diabetes. Endocr Rev 2019; 40:1521-1546. [PMID: 31276160 PMCID: PMC6821212 DOI: 10.1210/er.2018-00174] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 02/28/2019] [Indexed: 01/20/2023]
Abstract
Recent, rapid changes in the treatment of type 1 diabetes have allowed for commercialization of an "artificial pancreas" that is better described as a closed-loop controller of insulin delivery. This review presents the current state of closed-loop control systems and expected future developments with a discussion of the human factor issues in allowing automation of glucose control. The goal of these systems is to minimize or prevent both short-term and long-term complications from diabetes and to decrease the daily burden of managing diabetes. The closed-loop systems are generally very effective and safe at night, have allowed for improved sleep, and have decreased the burden of diabetes management overnight. However, there are still significant barriers to achieving excellent daytime glucose control while simultaneously decreasing the burden of daytime diabetes management. These systems use a subcutaneous continuous glucose sensor, an algorithm that accounts for the current glucose and rate of change of the glucose, and the amount of insulin that has already been delivered to safely deliver insulin to control hyperglycemia, while minimizing the risk of hypoglycemia. The future challenge will be to allow for full closed-loop control with minimal burden on the patient during the day, alleviating meal announcements, carbohydrate counting, alerts, and maintenance. The human factors involved with interfacing with a closed-loop system and allowing the system to take control of diabetes management are significant. It is important to find a balance between enthusiasm and realistic expectations and experiences with the closed-loop system.
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Affiliation(s)
- Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Laya Ekhlaspour
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Korey Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Department of Psychiatry, Stanford University School of Medicine, Stanford, California
| | - Bruce Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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13
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Resalat N, Hilts W, Youssef JE, Tyler N, Castle JR, Jacobs PG. Adaptive Control of an Artificial Pancreas Using Model Identification, Adaptive Postprandial Insulin Delivery, and Heart Rate and Accelerometry as Control Inputs. J Diabetes Sci Technol 2019; 13:1044-1053. [PMID: 31595784 PMCID: PMC6835177 DOI: 10.1177/1932296819881467] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND People with type 1 diabetes (T1D) have varying sensitivities to insulin and also varying responses to meals and exercise. We introduce a new adaptive run-to-run model predictive control (MPC) algorithm that can be used to help people with T1D better manage their glucose levels using an artificial pancreas (AP). The algorithm adapts to individuals' different insulin sensitivities, glycemic response to meals, and adjustment during exercise as a continuous input during free-living conditions. METHODS A new insulin sensitivity adaptation (ISA) algorithm is presented that updates each patient's insulin sensitivity during nonmeal periods to reduce the error between the actual glucose levels and the process model. We further demonstrate how an adaptive learning postprandial hypoglycemia prevention algorithm (ALPHA) presented in the previous work can complement the ISA algorithm, and the algorithm can adapt in several days. We further show that if physical activity is incorporated as a continuous input (heart rate and accelerometry), performance is improved. The contribution of this work is the description of the ISA algorithm and the evaluation of how ISA, ALPHA, and incorporation of exercise metrics as a continuous input can impact glycemic control. RESULTS Incorporating ALPHA, ISA, and physical activity into the MPC improved glycemic outcome measures. The adaptive learning postprandial hypoglycemia prevention algorithm combined with ISA significantly reduced time spent in hypoglycemia by 71.7% and the total number of rescue carbs by 67.8% to 0.37% events/day/patient. Insulin sensitivity adaptation significantly reduced model-actual mismatch by 12.2% compared to an AP without ISA. Incorporating physical activity as a continuous input modestly improved time in the range 70 to 180 mg/dL during high physical activity days from 84.4% to 84.9% and reduced the percentage time in hypoglycemia by 23.8% from 2.1% to 1.6%. CONCLUSION Adapting postprandial insulin delivery, insulin sensitivity, and adapting to physical exercise in an MPC-based AP systems can improve glycemic outcomes.
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Affiliation(s)
- Navid Resalat
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Wade Hilts
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Joseph El Youssef
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR, USA
| | - Nichole Tyler
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Jessica R. Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR, USA
| | - Peter G. Jacobs
- Artificial Intelligence for Medical Systems (AIMS) Lab, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
- Peter G. Jacobs, PhD, Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave, Mailstop: 13B, Portland, OR 97239, USA.
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14
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Reddy R, Resalat N, Wilson LM, Castle JR, El Youssef J, Jacobs PG. Prediction of Hypoglycemia During Aerobic Exercise in Adults With Type 1 Diabetes. J Diabetes Sci Technol 2019; 13:919-927. [PMID: 30650997 PMCID: PMC6955453 DOI: 10.1177/1932296818823792] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Fear of exercise related hypoglycemia is a major reason why people with type 1 diabetes (T1D) do not exercise. There is no validated prediction algorithm that can predict hypoglycemia at the start of aerobic exercise. METHODS We have developed and evaluated two separate algorithms to predict hypoglycemia at the start of exercise. Model 1 is a decision tree and model 2 is a random forest model. Both models were trained using a meta-data set based on 154 observations of in-clinic aerobic exercise in 43 adults with T1D from 3 different studies that included participants using sensor augmented pump therapy, automated insulin delivery therapy, and automated insulin and glucagon therapy. Both models were validated using an entirely new validation data set with 90 exercise observations collected from 12 new adults with T1D. RESULTS Model 1 identified two critical features predictive of hypoglycemia during exercise: heart rate and glucose at the start of exercise. If heart rate was greater than 121 bpm during the first 5 min of exercise and glucose at the start of exercise was less than 182 mg/dL, it predicted hypoglycemia with 79.55% accuracy. Model 2 achieved a higher accuracy of 86.7% using additional features and higher complexity. CONCLUSIONS Models presented here can assist people with T1D to avoid exercise related hypoglycemia. The simple model 1 heuristic can be easily remembered (the 180/120 rule) and model 2 is more complex requiring computational resources, making it suitable for automated artificial pancreas or decision support systems.
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Affiliation(s)
- Ravi Reddy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Navid Resalat
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Leah M. Wilson
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon, Health & Science University, Portland, OR, USA
| | - Jessica R. Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon, Health & Science University, Portland, OR, USA
| | - Joseph El Youssef
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon, Health & Science University, Portland, OR, USA
| | - Peter G. Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
- Peter G. Jacobs, PhD, Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave, Mailstop: 13B, Portland, OR 97239, USA.
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15
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Abstract
IN BRIEF Automated insulin delivery (AID; also known as artificial pancreas) has improved the regulation of blood glucose concentrations, reduced the frequency of hyperglycemic and hypoglycemic episodes, and improved the quality of life of people with diabetes and their families. Three different types of algorithms-proportional-integral-derivative control, model predictive control, and fuzzy-logic knowledge-based systems-have been used in AID control systems. This article will highlight the foundations of these algorithms and discuss their strengths and limitations. Multivariable artificial pancreas and dual-hormone (insulin and glucagon) systems will be introduced.
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Affiliation(s)
- Ali Cinar
- Departments of Chemical and Biological Engineering and Biomedical Engineering, Engineering Center for Diabetes Research and Education, Illinois Institute of Technology, Chicago, IL
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16
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Resalat N, El Youssef J, Tyler N, Castle J, Jacobs PG. A statistical virtual patient population for the glucoregulatory system in type 1 diabetes with integrated exercise model. PLoS One 2019; 14:e0217301. [PMID: 31344037 PMCID: PMC6657828 DOI: 10.1371/journal.pone.0217301] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 05/08/2019] [Indexed: 11/18/2022] Open
Abstract
Purpose We introduce two validated single (SH) and dual hormone (DH) mathematical models that represent an in-silico virtual patient population (VPP) for type 1 diabetes (T1D). The VPP can be used to evaluate automated insulin and glucagon delivery algorithms, so-called artificial pancreas (AP) algorithms that are currently being used to help people with T1D better manage their glucose levels. We present validation results comparing these virtual patients with true clinical patients undergoing AP control and demonstrate that the virtual patients behave similarly to people with T1D. Methods A single hormone virtual patient population (SH-VPP) was created that is comprised of eight differential equations that describe insulin kinetics, insulin dynamics and carbohydrate absorption. The parameters in this model that represent insulin sensitivity were statistically sampled from a normal distribution to create a population of virtual patients with different levels of insulin sensitivity. A dual hormone virtual patient population (DH-VPP) extended this SH-VPP by incorporating additional equations to represent glucagon kinetics and glucagon dynamics. The DH-VPP is comprised of thirteen differential equations and a parameter representing glucagon sensitivity, which was statistically sampled from a normal distribution to create virtual patients with different levels of glucagon sensitivity. We evaluated the SH-VPP and DH-VPP on a clinical data set of 20 people with T1D who participated in a 3.5-day outpatient AP study. Twenty virtual patients were matched with the 20 clinical patients by total daily insulin requirements and body weight. The identical meals given during the AP study were given to the virtual patients and the identical AP control algorithm that was used to control the glucose of the virtual patients was used on the clinical patients. We compared percent time in target range (70–180 mg/dL), time in hypoglycemia (<70 mg/dL) and time in hyperglycemia (>180 mg/dL) for both the virtual patients and the actual patients. Results The subjects in the SH-VPP performed similarly vs. the actual patients (time in range: 78.1 ± 5.1% vs. 74.3 ± 8.1%, p = 0.11; time in hypoglycemia: 3.4 ± 1.3% vs. 2.8 ± 1.7%, p = 0.23). The subjects in the DH-VPP also performed similarly vs. the actual patients (time in range: 75.6 ± 5.5% vs. 71.9 ± 10.9%, p = 0.13; time in hypoglycemia: 0.9 ± 0.8% vs. 1.3 ± 1%, p = 0.19). While the VPPs tended to over-estimate the time in range relative to actual patients, the difference was not statistically significant. Conclusions We have verified that a SH-VPP and a DH-VPP performed comparably with actual patients undergoing AP control using an identical control algorithm. The SH-VPP and DH-VPP may be used as a simulator for pre-evaluation of T1D control algorithms.
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Affiliation(s)
- Navid Resalat
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Joseph El Youssef
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon, United States of America
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Nichole Tyler
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Jessica Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Peter G. Jacobs
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon, United States of America
- * E-mail:
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17
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Payne FW, Ledden B, Lamps G. Capabilities of Next-Generation Patch Pump: Improved Precision, Instant Occlusion Detection, and Dual-Hormone Therapy. J Diabetes Sci Technol 2019; 13:49-54. [PMID: 29792066 PMCID: PMC6313296 DOI: 10.1177/1932296818776028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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
Insulin pumps allow patients to attain better blood glucose control with more lifestyle flexibility. Their size and cost, however, limit their usefulness. Current CSII pumps are bulky, intrusive, and expensive. SFC Fluidics is addressing these problems by developing a new type of wearable patch pump based on the patented electro-chemiosmotic (ECO) microfluidic pumping technology. This nonmechanical pumping technology allows accurate and precise delivery of very small amounts of insulin and/or other drugs, including concentrated insulin. The pump engine is small and can be made inexpensively from injection molded parts, allowing its use in a disposable or semidisposable pod format. In addition, a single ECO pump engine can be used to deliver two drugs through independent pathways. Other features of SFC Fluidics' pod include latching safety valves that prevent accidental overdosing of insulin due to pressure changes and an instantaneous occlusion sensor that can immediately detect delivery failure at the first missed dose. These features allow for the development of a series of patch pumps that will offer users the benefit of CSII therapy in a more discreet and reliable patch pump form.
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Affiliation(s)
| | | | - Greg Lamps
- SFC Fluidics, Inc, Fayetteville, AR, USA
- Greg Lamps, MS, MBA, SFC Fluidics, Inc, 534 W Research Center Blvd, Ste 260, Fayetteville, AR 72701, USA.
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18
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Rollins DK, Mei Y. A new feedback predictive control approach for processes with time delay in the manipulated variable. Chem Eng Res Des 2018. [DOI: 10.1016/j.cherd.2018.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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19
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Castle JR, El Youssef J, Wilson LM, Reddy R, Resalat N, Branigan D, Ramsey K, Leitschuh J, Rajhbeharrysingh U, Senf B, Sugerman SM, Gabo V, Jacobs PG. Randomized Outpatient Trial of Single- and Dual-Hormone Closed-Loop Systems That Adapt to Exercise Using Wearable Sensors. Diabetes Care 2018; 41:1471-1477. [PMID: 29752345 PMCID: PMC6014543 DOI: 10.2337/dc18-0228] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/13/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Automated insulin delivery is the new standard for type 1 diabetes, but exercise-related hypoglycemia remains a challenge. Our aim was to determine whether a dual-hormone closed-loop system using wearable sensors to detect exercise and adjust dosing to reduce exercise-related hypoglycemia would outperform other forms of closed-loop and open-loop therapy. RESEARCH DESIGN AND METHODS Participants underwent four arms in randomized order: dual-hormone, single-hormone, predictive low glucose suspend, and continuation of current care over 4 outpatient days. Each arm included three moderate-intensity aerobic exercise sessions. The two primary outcomes were percentage of time in hypoglycemia (<70 mg/dL) and in a target range (70-180 mg/dL) assessed across the entire study and from the start of the in-clinic exercise until the next meal. RESULTS The analysis included 20 adults with type 1 diabetes who completed all arms. The mean time (SD) in hypoglycemia was the lowest with dual-hormone during the exercise period: 3.4% (4.5) vs. 8.3% (12.6) single-hormone (P = 0.009) vs. 7.6% (8.0) predictive low glucose suspend (P < 0.001) vs. 4.3% (6.8) current care where pre-exercise insulin adjustments were allowed (P = 0.49). Time in hypoglycemia was also the lowest with dual-hormone during the entire 4-day study: 1.3% (1.0) vs. 2.8% (1.7) single-hormone (P < 0.001) vs. 2.0% (1.5) predictive low glucose suspend (P = 0.04) vs. 3.1% (3.2) current care (P = 0.007). Time in range during the entire study was the highest with single-hormone: 74.3% (8.0) vs. 72.0% (10.8) dual-hormone (P = 0.44). CONCLUSIONS The addition of glucagon delivery to a closed-loop system with automated exercise detection reduces hypoglycemia in physically active adults with type 1 diabetes.
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Affiliation(s)
- Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Leah M Wilson
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Ravi Reddy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Navid Resalat
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Katrina Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics & Design Program, Oregon Health & Science University, Portland, OR
| | - Joseph Leitschuh
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Uma Rajhbeharrysingh
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Brian Senf
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Samuel M Sugerman
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Virginia Gabo
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
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20
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Peters TM, Haidar A. Dual-hormone artificial pancreas: benefits and limitations compared with single-hormone systems. Diabet Med 2018; 35:450-459. [PMID: 29337384 DOI: 10.1111/dme.13581] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 12/17/2022]
Abstract
Technological advances have made the artificial pancreas a reality. This has the potential to improve the lives of individuals with Type 1 diabetes by reducing the risk of hypoglycaemia, achieving better overall glucose control, and enhancing quality of life. Both single-hormone (insulin-only) and dual-hormone (insulin and glucagon) systems have been developed; however, a focused review of the relative benefits of each artificial pancreas system is needed. We reviewed studies that directly compared single- and dual-hormone systems to evaluate the efficacy of each system for preventing hypoglycaemia and maintaining glycaemic control, as well as their utility in specific situations including during exercise, overnight and during the prandial period. We observed additional benefits with the dual-hormone artificial pancreas for reducing the risk of hypoglycaemic events overall and during exercise over the study duration. The single-hormone artificial pancreas was sufficient for maintenance of euglycaemia in the overnight period and for preventing late-onset post-exercise hypoglycaemia. Future comparative studies of longer duration are required to determine whether one system is superior for improving mean glucose control, eliminating severe hypoglycaemia, or improving quality of life.
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Affiliation(s)
- T M Peters
- Division of Endocrinology and Metabolism, Faculty of Medicine
| | - A Haidar
- Division of Endocrinology and Metabolism, Faculty of Medicine
- Department of Biomedical Engineering, McGill University
- The Research Institute of the McGill University Health Centre, Montreal, Canada
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21
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Hövelmann U, Bysted BV, Mouritzen U, Macchi F, Lamers D, Kronshage B, Møller DV, Heise T. Pharmacokinetic and Pharmacodynamic Characteristics of Dasiglucagon, a Novel Soluble and Stable Glucagon Analog. Diabetes Care 2018; 41:531-537. [PMID: 29273578 DOI: 10.2337/dc17-1402] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/22/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Treatment of severe hypoglycemia outside of the hospital setting is limited to glucagon formulations requiring reconstitution before use, which may lead to erroneous or delayed glucagon administration. We compared the pharmacokinetic (PK) and pharmacodynamic (PD) characteristics and safety and tolerability of different doses of dasiglucagon, a novel soluble glucagon analog, with approved pediatric and full doses of GlucaGen in insulin-induced hypoglycemia in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS In this single-center, randomized, double-blind trial, 58 patients with type 1 diabetes received single subcutaneous injections of 0.1, 0.3, 0.6, or 1.0 mg dasiglucagon or 0.5 or 1.0 mg GlucaGen in a state of hypoglycemia (blood glucose target 55 mg/dL) induced by an intravenous insulin infusion. RESULTS Dasiglucagon demonstrated a dose-dependent and rapid increase in plasma concentrations, reaching a maximum at ∼35 min with a half-life of ∼0.5 h. Dasiglucagon rapidly increased plasma glucose (PG) by ≥20 mg/dL (9-14 min) to PG ≥70 mg/dL (within 6-10 min), similar to GlucaGen, but with a longer-lasting and greater effect on PG. All patients on both treatments reached these end points within 30 min (predefined success criteria). Both treatments were well tolerated. Nausea was the most frequent adverse event, occurring at a similar rate (44-56%). CONCLUSIONS Dasiglucagon was well tolerated and showed an early PD response similar to that of GlucaGen at corresponding doses, suggesting comparable clinical effects of the two glucagon formulations. Dasiglucagon has the potential to become an effective and reliable rescue treatment for severe hypoglycemia in a ready-to-use pen.
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22
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Yu X, Turksoy K, Rashid M, Feng J, Frantz N, Hajizadeh I, Samadi S, Sevil M, Lazaro C, Maloney Z, Littlejohn E, Quinn L, Cinar A. Model-Fusion-Based Online Glucose Concentration Predictions in People with Type 1 Diabetes. CONTROL ENGINEERING PRACTICE 2018; 71:129-141. [PMID: 29276347 PMCID: PMC5736323 DOI: 10.1016/j.conengprac.2017.10.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Accurate predictions of glucose concentrations are necessary to develop an artificial pancreas (AP) system for people with type 1 diabetes (T1D). In this work, a novel glucose forecasting paradigm based on a model fusion strategy is developed to accurately characterize the variability and transient dynamics of glycemic measurements. To this end, four different adaptive filters and a fusion mechanism are proposed for use in the online prediction of future glucose trajectories. The filter fusion mechanism is developed based on various prediction performance indexes to guide the overall output of the forecasting paradigm. The efficiency of the proposed model fusion based forecasting method is evaluated using simulated and clinical datasets, and the results demonstrate the capability and prediction accuracy of the data-based fusion filters, especially in the case of limited data availability. The model fusion framework may be used in the development of an AP system for glucose regulation in patients with T1D.
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Affiliation(s)
- Xia Yu
- School of Information Science and Engineering, Northeastern University, Shenyang 110819, PR China
| | - Kamuran Turksoy
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Mudassir Rashid
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Jianyuan Feng
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Nicole Frantz
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Iman Hajizadeh
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Sediqeh Samadi
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Mert Sevil
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Caterina Lazaro
- Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Zacharie Maloney
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
| | - Elizabeth Littlejohn
- Department of Pediatrics and Medicine, Kovler Diabetes Center, University of Chicago, Chicago, IL 60637, USA
| | - Laurie Quinn
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Ali Cinar
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL 60616, USA
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Abstract
Type 1 diabetes mellitus is a chronic state of insulin deficiency which results from destruction of beta cells by the immune system. The long term microvascular and macrovascular complications can be devastating. Since the discovery of insulin almost 100 years ago new medical therapies have improved the long-term survival for people with type 1 diabetes. Each year we come closer to discovering a cure but much work still needs to be done to eliminate this disease.
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Affiliation(s)
- Melanie Copenhaver
- Division of Pediatric Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Robert P Hoffman
- Division of Pediatric Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
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24
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Herrero P, Bondia J, Oliver N, Georgiou P. A coordinated control strategy for insulin and glucagon delivery in type 1 diabetes. Comput Methods Biomech Biomed Engin 2017; 20:1474-1482. [PMID: 28929796 DOI: 10.1080/10255842.2017.1378352] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Type 1 diabetes is an autoimmune condition characterised by a pancreatic insulin secretion deficit, resulting in high blood glucose concentrations, which can lead to micro- and macrovascular complications. Type 1 diabetes also leads to impaired glucagon production by the pancreatic α-cells, which acts as a counter-regulatory hormone to insulin. A closed-loop system for automatic insulin and glucagon delivery, also referred to as an artificial pancreas, has the potential to reduce the self-management burden of type 1 diabetes and reduce the risk of hypo- and hyperglycemia. To date, bihormonal closed-loop systems for glucagon and insulin delivery have been based on two independent controllers. However, in physiology, the secretion of insulin and glucagon in the body is closely interconnected by paracrine and endocrine associations. In this work, we present a novel biologically-inspired glucose control strategy that accounts for such coordination. An in silico study using an FDA-accepted type 1 simulator was performed to evaluate the proposed coordinated control strategy compared to its non-coordinated counterpart, as well as an insulin-only version of the controller. The proposed coordinated strategy achieves a reduction of hyperglycemia without increasing hypoglycemia, when compared to its non-coordinated counterpart.
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Affiliation(s)
- Pau Herrero
- a Centre for Bio-Inspired Technology, Institute of Biomedical Engineering , Imperial College London , London , UK
| | - Jorge Bondia
- b Institut Universitari d'Automàtica i Informàtica Industrial , Universitat Politècnica de València , València , Spain
| | - Nick Oliver
- c Charing Cross Hospital, Imperial College Healthcare NHS Trust , London , UK
| | - Pantelis Georgiou
- a Centre for Bio-Inspired Technology, Institute of Biomedical Engineering , Imperial College London , London , UK
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25
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Resalat N, El Youssef J, Reddy R, Jacobs PG. Design of a dual-hormone model predictive control for artificial pancreas with exercise model. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:2270-2273. [PMID: 28324962 DOI: 10.1109/embc.2016.7591182] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Artificial Pancreas (AP) is a new technology for helping people with type 1 diabetes to better control their glucose levels through automated delivery of insulin and optionally glucagon in response to sensed glucose levels. In a dual hormone AP, insulin and glucagon are delivered automatically to the body based on glucose sensor measurements using a control algorithm that calculates the amount of hormones to be infused. A dual-hormone MPC may deliver insulin continuously; however, it must avoid continuous delivery of glucagon because nausea can occur from too much glucagon. In this paper, we propose a novel dual-hormone (DH) switching model predictive control and compare it with a single-hormone (SH) MPC. We extended both MPCs by integrating an exercise model and compared performance with and without the exercise model included. Results were obtained on a virtual patient population undergoing a simulated exercise event using a mathematical glucoregulatory model that includes exercise. Time spent in hypoglycemia is significantly less with the DH-MPC than the SH-MPC (p=0.0022). Additionally, including the exercise model in the DH-MPC can help prevent hypoglycemia (p <; 0.001).
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Turksoy K, Frantz N, Quinn L, Dumin M, Kilkus J, Hibner B, Cinar A, Littlejohn E. Automated Insulin Delivery-The Light at the End of the Tunnel. J Pediatr 2017; 186:17-28.e9. [PMID: 28396030 DOI: 10.1016/j.jpeds.2017.02.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 02/13/2017] [Accepted: 02/20/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Kamuran Turksoy
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL
| | - Nicole Frantz
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL
| | - Laurie Quinn
- College of Nursing, University of Illinois at Chicago, Chicago, IL
| | - Magdalena Dumin
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Jennifer Kilkus
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Brooks Hibner
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Ali Cinar
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL; Biological Sciences Division, University of Chicago, Chicago, IL; Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL
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Evaluation of model complexity in model predictive control within an exercise-enabled artificial pancreas. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.ifacol.2017.08.2270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Huyett LM, Ly TT, Forlenza GP, Reuschel-DiVirgilio S, Messer LH, Wadwa RP, Gondhalekar R, Doyle FJ, Pinsker JE, Maahs DM, Buckingham BA, Dassau E. Outpatient Closed-Loop Control with Unannounced Moderate Exercise in Adolescents Using Zone Model Predictive Control. Diabetes Technol Ther 2017; 19:331-339. [PMID: 28459617 PMCID: PMC5510043 DOI: 10.1089/dia.2016.0399] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The artificial pancreas (AP) has the potential to improve glycemic control in adolescents. This article presents the first evaluation in adolescents of the Zone Model Predictive Control and Health Monitoring System (ZMPC+HMS) AP algorithms, and their first evaluation in a supervised outpatient setting with frequent exercise. MATERIALS AND METHODS Adolescents with type 1 diabetes underwent 3 days of closed-loop control (CLC) in a hotel setting with the ZMPC+HMS algorithms on the Diabetes Assistant platform. Subjects engaged in twice-daily exercise, including soccer, tennis, and bicycling. Meal size (unrestricted) was estimated and entered into the system by subjects to trigger a bolus, but exercise was not announced. RESULTS Ten adolescents (11.9-17.7 years) completed 72 h of CLC, with data on 95 ± 14 h of sensor-augmented pump (SAP) therapy before CLC as a comparison to usual therapy. The percentage of time with continuous glucose monitor (CGM) 70-180 mg/dL was 71% ± 10% during CLC, compared to 57% ± 16% during SAP (P = 0.012). Nocturnal control during CLC was safe, with 0% (0%, 0.6%) of time with CGM <70 mg/dL compared to 1.1% (0.0%, 14%) during SAP. Despite large meals (estimated up to 120 g carbohydrate), only 8.0% ± 6.9% of time during CLC was spent with CGM >250 mg/dL (16% ± 14% during SAP). The system remained connected in CLC for 97% ± 2% of the total study time. No adverse events or severe hypoglycemia occurred. CONCLUSIONS The use of the ZMPC+HMS algorithms is feasible in the adolescent outpatient environment and achieved significantly more time in the desired glycemic range than SAP in the face of unannounced exercise and large announced meal challenges.
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Affiliation(s)
- Lauren M. Huyett
- Department of Chemical Engineering, University of California Santa Barbara, Santa Barbara, California
- William Sansum Diabetes Center, Santa Barbara, California
| | - Trang T. Ly
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California
| | - Gregory P. Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Suzette Reuschel-DiVirgilio
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California
| | - Laurel H. Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - R. Paul Wadwa
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ravi Gondhalekar
- William Sansum Diabetes Center, Santa Barbara, California
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - Francis J. Doyle
- Department of Chemical Engineering, University of California Santa Barbara, Santa Barbara, California
- William Sansum Diabetes Center, Santa Barbara, California
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | | | - David M. Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bruce A. Buckingham
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, California
| | - Eyal Dassau
- Department of Chemical Engineering, University of California Santa Barbara, Santa Barbara, California
- William Sansum Diabetes Center, Santa Barbara, California
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
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Jacobs PG, El Youssef J, Reddy R, Resalat N, Branigan D, Condon J, Preiser N, Ramsey K, Jones M, Edwards C, Kuehl K, Leitschuh J, Rajhbeharrysingh U, Castle JR. Randomized trial of a dual-hormone artificial pancreas with dosing adjustment during exercise compared with no adjustment and sensor-augmented pump therapy. Diabetes Obes Metab 2016; 18:1110-1119. [PMID: 27333970 PMCID: PMC5056819 DOI: 10.1111/dom.12707] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/08/2016] [Accepted: 06/12/2016] [Indexed: 11/30/2022]
Abstract
AIMS To test whether adjusting insulin and glucagon in response to exercise within a dual-hormone artificial pancreas (AP) reduces exercise-related hypoglycaemia. MATERIALS AND METHODS In random order, 21 adults with type 1 diabetes (T1D) underwent three 22-hour experimental sessions: AP with exercise dosing adjustment (APX); AP with no exercise dosing adjustment (APN); and sensor-augmented pump (SAP) therapy. After an overnight stay and 2 hours after breakfast, participants exercised for 45 minutes at 60% of their maximum heart rate, with no snack given before exercise. During APX, insulin was decreased and glucagon was increased at exercise onset, while during SAP therapy, subjects could adjust dosing before exercise. The two primary outcomes were percentage of time spent in hypoglycaemia (<3.9 mmol/L) and percentage of time spent in euglycaemia (3.9-10 mmol/L) from the start of exercise to the end of the study. RESULTS The mean (95% confidence interval) times spent in hypoglycaemia (<3.9 mmol/L) after the start of exercise were 0.3% (-0.1, 0.7) for APX, 3.1% (0.8, 5.3) for APN, and 0.8% (0.1, 1.4) for SAP therapy. There was an absolute difference of 2.8% less time spent in hypoglycaemia for APX versus APN (p = .001) and 0.5% less time spent in hypoglycaemia for APX versus SAP therapy (p = .16). Mean time spent in euglycaemia was similar across the different sessions. CONCLUSIONS Adjusting insulin and glucagon delivery at exercise onset within a dual-hormone AP significantly reduces hypoglycaemia compared with no adjustment and performs similarly to SAP therapy when insulin is adjusted before exercise.
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Affiliation(s)
- P G Jacobs
- Department of Biomedical Engineering, Oregon Health and Science University, Portland.
| | - J El Youssef
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
| | - R Reddy
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - N Resalat
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - D Branigan
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
| | - J Condon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - N Preiser
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - K Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics and Design Program, Oregon Health and Science University, Portland
| | - M Jones
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
| | - C Edwards
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
| | - K Kuehl
- Department of Medicine, Division of Health Promotion and Sports Medicine, Human Performance Laboratory, Oregon Health and Science University, Portland
| | - J Leitschuh
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - U Rajhbeharrysingh
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - J R Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
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Lee JB, Dassau E, Gondhalekar R, Seborg DE, Pinsker JE, Doyle FJ. Enhanced Model Predictive Control (eMPC) Strategy for Automated Glucose Control. Ind Eng Chem Res 2016; 55:11857-11868. [PMID: 27942106 DOI: 10.1021/acs.iecr.6b02718] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Development of an effective artificial pancreas (AP) controller to deliver insulin autonomously to people with type 1 diabetes mellitus is a difficult task. In this paper, three enhancements to a clinically validated AP model predictive controller (MPC) are proposed that address major challenges facing automated blood glucose control, and are then evaluated by both in silico tests and clinical trials. First, the core model of insulin-blood glucose dynamics utilized in the MPC is expanded with a medically inspired personalization scheme to improve controller responses in the face of inter- and intra-individual variations in insulin sensitivity. Next, the asymmetric nature of the short-term consequences of hypoglycemia versus hyperglycemia is incorporated in an asymmetric weighting of the MPC cost function. Finally, an enhanced dynamic insulin-on-board algorithm is proposed to minimize the likelihood of controller-induced hypoglycemia following a rapid rise of blood glucose due to rescue carbohydrate load with accompanying insulin suspension. Each advancement is evaluated separately and in unison through in silico trials based on a new clinical protocol, which incorporates induced hyper- and hypoglycemia to test robustness. The advancements are also evaluated in an advisory mode (simulated) testing of clinical data. The combination of the three proposed advancements show statistically significantly improved performance over the nonpersonalized controller without any enhancements across all metrics, displaying increased time in the 70-180 mg/dL safe glycemic range (76.9 versus 68.8%) and the 80-140 mg/dL euglycemic range (48.1 versus 44.5%), without a statistically significant increase in instances of hypoglycemia. The proposed advancements provide safe control action for AP applications, personalizing and improving controller performance without the need for extensive model identification processes.
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Affiliation(s)
- Joon Bok Lee
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA; Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA; William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
| | - Eyal Dassau
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA; Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA; William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
| | - Ravi Gondhalekar
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA; William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
| | - Dale E Seborg
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA
| | - Jordan E Pinsker
- William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
| | - Francis J Doyle
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA; Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA; William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
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Embedded Control in Wearable Medical Devices: Application to the Artificial Pancreas. Processes (Basel) 2016. [DOI: 10.3390/pr4040035] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Abstract
While self-monitoring of blood glucose (SMBG) is the current standard used by people with diabetes to manage glucose levels, recent improvements in accuracy of continuous glucose monitoring (CGM) technology are making it very likely that diabetes-related treatment decisions will soon be made based on CGM values alone. Nonadjunctive use of CGM will lead to a paradigm shift in how patients manage their glucose levels and will require substantial changes in how care providers educate their patients, monitor their progress, and provide feedback to help them manage their diabetes. The approval to use CGM nonadjunctively is also a critical step in the pathway toward FDA approval of an artificial pancreas system, which is further expected to transform diabetes care for people with type 1 diabetes. In this article, we discuss how nonadjunctive CGM is expected to soon replace routine SMBG and how this new usage scenario is expected to transform health outcomes and patient care.
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Affiliation(s)
- Jessica R Castle
- Department of Medicine, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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Bally L, Thabit H, Hovorka R. Role of Dual-Hormone Closed-Loop Delivery System in the Future. Diabetes Technol Ther 2016; 18:452-4. [PMID: 27500812 DOI: 10.1089/dia.2016.0259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Lia Bally
- 1 Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge , Cambridge, United Kingdom
- 2 Department of Diabetes & Endocrinology, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
- 3 Division of Diabetes, Endocrinology, Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern , Bern, Switzerland
| | - Hood Thabit
- 1 Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge , Cambridge, United Kingdom
- 2 Department of Diabetes & Endocrinology, Cambridge University Hospitals NHS Foundation Trust , Cambridge, United Kingdom
| | - Roman Hovorka
- 1 Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge , Cambridge, United Kingdom
- 4 Department of Paediatrics, University of Cambridge , Cambridge, United Kingdom
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Daskalaki E, Diem P, Mougiakakou SG. Model-Free Machine Learning in Biomedicine: Feasibility Study in Type 1 Diabetes. PLoS One 2016; 11:e0158722. [PMID: 27441367 PMCID: PMC4956312 DOI: 10.1371/journal.pone.0158722] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 06/21/2016] [Indexed: 11/23/2022] Open
Abstract
Although reinforcement learning (RL) is suitable for highly uncertain systems, the applicability of this class of algorithms to medical treatment may be limited by the patient variability which dictates individualised tuning for their usually multiple algorithmic parameters. This study explores the feasibility of RL in the framework of artificial pancreas development for type 1 diabetes (T1D). In this approach, an Actor-Critic (AC) learning algorithm is designed and developed for the optimisation of insulin infusion for personalised glucose regulation. AC optimises the daily basal insulin rate and insulin:carbohydrate ratio for each patient, on the basis of his/her measured glucose profile. Automatic, personalised tuning of AC is based on the estimation of information transfer (IT) from insulin to glucose signals. Insulin-to-glucose IT is linked to patient-specific characteristics related to total daily insulin needs and insulin sensitivity (SI). The AC algorithm is evaluated using an FDA-accepted T1D simulator on a large patient database under a complex meal protocol, meal uncertainty and diurnal SI variation. The results showed that 95.66% of time was spent in normoglycaemia in the presence of meal uncertainty and 93.02% when meal uncertainty and SI variation were simultaneously considered. The time spent in hypoglycaemia was 0.27% in both cases. The novel tuning method reduced the risk of severe hypoglycaemia, especially in patients with low SI.
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Affiliation(s)
- Elena Daskalaki
- Diabetes Technology Research Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland
| | - Peter Diem
- Division of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital “Inselspital”, 3010 Bern, Switzerland
| | - Stavroula G. Mougiakakou
- Diabetes Technology Research Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland
- Division of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital “Inselspital”, 3010 Bern, Switzerland
- * E-mail:
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Blauw H, van Bon AC, Koops R, DeVries JH. Performance and safety of an integrated bihormonal artificial pancreas for fully automated glucose control at home. Diabetes Obes Metab 2016; 18:671-7. [PMID: 26996542 PMCID: PMC5111773 DOI: 10.1111/dom.12663] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/24/2015] [Accepted: 03/15/2016] [Indexed: 01/22/2023]
Abstract
AIMS To assess the performance and safety of an integrated bihormonal artificial pancreas system consisting of one wearable device and two wireless glucose sensor transmitters during short-term daily use at home. METHODS Adult patients with type 1 diabetes using an insulin pump were invited to enrol in this randomized crossover study. Treatment with the artificial pancreas started with a day and night in the clinical research centre, followed by 3 days at home. The control period consisted of 4 days of insulin pump therapy at home with blinded continuous glucose monitoring for data collection. Days 2-4 were predefined as the analysis period, with median glucose as the primary outcome. RESULTS A total of 10 patients completed the study. The median [interquartile range (IQR)] glucose level was similar for the two treatments [7.3 (7.0-7.6) mmol/l for the artificial pancreas vs. 7.7 (7.0-9.0) mmol/l for the control; p = 0.123]. The median (IQR) percentage of time spent in euglycaemia (3.9-10 mmol/l) was longer during use of the artificial pancreas [84.7 (82.2-87.8)% for the artificial pancreas vs. 68.5 (57.9-83.6)% for the control; p = 0.007]. Time in hypoglycaemia was 1.3 (0.2-3.2)% for the artificial pancreas and 2.4 (0.4-10.3)% for the control treatment (p = 0.139). Separate analysis of daytime and night-time showed that the improvements were mainly achieved during the night. CONCLUSIONS The results of this pilot study suggest that our integrated artificial pancreas provides better glucose control than insulin pump therapy in patients with type 1 diabetes at home and that the treatment is safe.
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Affiliation(s)
- H Blauw
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Inreda Diabetic BV, Goor, The Netherlands
| | | | - R Koops
- Inreda Diabetic BV, Goor, The Netherlands
| | - J H DeVries
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Blauw H, Keith-Hynes P, Koops R, DeVries JH. A Review of Safety and Design Requirements of the Artificial Pancreas. Ann Biomed Eng 2016; 44:3158-3172. [PMID: 27352278 PMCID: PMC5093196 DOI: 10.1007/s10439-016-1679-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/13/2016] [Indexed: 01/03/2023]
Abstract
As clinical studies with artificial pancreas systems for automated blood glucose control in patients with type 1 diabetes move to unsupervised real-life settings, product development will be a focus of companies over the coming years. Directions or requirements regarding safety in the design of an artificial pancreas are, however, lacking. This review aims to provide an overview and discussion of safety and design requirements of the artificial pancreas. We performed a structured literature search based on three search components—type 1 diabetes, artificial pancreas, and safety or design—and extended the discussion with our own experiences in developing artificial pancreas systems. The main hazards of the artificial pancreas are over- and under-dosing of insulin and, in case of a bi-hormonal system, of glucagon or other hormones. For each component of an artificial pancreas and for the complete system we identified safety issues related to these hazards and proposed control measures. Prerequisites that enable the control algorithms to provide safe closed-loop control are accurate and reliable input of glucose values, assured hormone delivery and an efficient user interface. In addition, the system configuration has important implications for safety, as close cooperation and data exchange between the different components is essential.
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Affiliation(s)
- Helga Blauw
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100 DD, Amsterdam, The Netherlands. .,Inreda Diabetic BV, Goor, The Netherlands.
| | - Patrick Keith-Hynes
- TypeZero Technologies, LLC, Charlottesville, VA, USA.,Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | | | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100 DD, Amsterdam, The Netherlands
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Trevitt S, Simpson S, Wood A. Artificial Pancreas Device Systems for the Closed-Loop Control of Type 1 Diabetes: What Systems Are in Development? J Diabetes Sci Technol 2016; 10:714-23. [PMID: 26589628 PMCID: PMC5038530 DOI: 10.1177/1932296815617968] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Closed-loop artificial pancreas device (APD) systems are externally worn medical devices that are being developed to enable people with type 1 diabetes to regulate their blood glucose levels in a more automated way. The innovative concept of this emerging technology is that hands-free, continuous, glycemic control can be achieved by using digital communication technology and advanced computer algorithms. METHODS A horizon scanning review of this field was conducted using online sources of intelligence to identify systems in development. The systems were classified into subtypes according to their level of automation, the hormonal and glycemic control approaches used, and their research setting. RESULTS Eighteen closed-loop APD systems were identified. All were being tested in clinical trials prior to potential commercialization. Six were being studied in the home setting, 5 in outpatient settings, and 7 in inpatient settings. It is estimated that 2 systems may become commercially available in the EU by the end of 2016, 1 during 2017, and 2 more in 2018. CONCLUSIONS There are around 18 closed-loop APD systems progressing through early stages of clinical development. Only a few of these are currently in phase 3 trials and in settings that replicate real life.
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Affiliation(s)
- Sara Trevitt
- NIHR Horizon Scanning Research & Intelligence Centre, University of Birmingham, Birmingham, UK
| | - Sue Simpson
- NIHR Horizon Scanning Research & Intelligence Centre, University of Birmingham, Birmingham, UK
| | - Annette Wood
- NIHR Horizon Scanning Research & Intelligence Centre, University of Birmingham, Birmingham, UK
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Forlenza GP, Buckingham B, Maahs DM. Progress in Diabetes Technology: Developments in Insulin Pumps, Continuous Glucose Monitors, and Progress towards the Artificial Pancreas. J Pediatr 2016; 169:13-20. [PMID: 26547403 PMCID: PMC6214345 DOI: 10.1016/j.jpeds.2015.10.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/03/2015] [Accepted: 10/05/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Gregory P. Forlenza
- Barbara Davis Center for Childhood Diabetes, University of
Colorado Denver, Aurora, CO
| | | | - David M. Maahs
- Barbara Davis Center for Childhood Diabetes, University of
Colorado Denver, Aurora, CO
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Castle JR, El Youssef J, Bakhtiani PA, Cai Y, Stobbe JM, Branigan D, Ramsey K, Jacobs P, Reddy R, Woods M, Ward WK. Effect of Repeated Glucagon Doses on Hepatic Glycogen in Type 1 Diabetes: Implications for a Bihormonal Closed-Loop System. Diabetes Care 2015; 38:2115-9. [PMID: 26341131 PMCID: PMC4613914 DOI: 10.2337/dc15-0754] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/10/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate subjects with type 1 diabetes for hepatic glycogen depletion after repeated doses of glucagon, simulating delivery in a bihormonal closed-loop system. RESEARCH DESIGN AND METHODS Eleven adult subjects with type 1 diabetes participated. Subjects underwent estimation of hepatic glycogen using (13)C MRS. MRS was performed at the following four time points: fasting and after a meal at baseline, and fasting and after a meal after eight doses of subcutaneously administered glucagon at a dose of 2 µg/kg, for a total mean dose of 1,126 µg over 16 h. The primary and secondary end points were, respectively, estimated hepatic glycogen by MRS and incremental area under the glucose curve for a 90-min interval after glucagon administration. RESULTS In the eight subjects with complete data sets, estimated glycogen stores were similar at baseline and after repeated glucagon doses. In the fasting state, glycogen averaged 21 ± 3 g/L before glucagon administration and 25 ± 4 g/L after glucagon administration (mean ± SEM) (P = NS). In the fed state, glycogen averaged 40 ± 2 g/L before glucagon administration and 34 ± 4 g/L after glucagon administration (P = NS). With the use of an insulin action model, the rise in glucose after the last dose of glucagon was comparable to the rise after the first dose, as measured by the 90-min incremental area under the glucose curve. CONCLUSIONS In adult subjects with well-controlled type 1 diabetes (mean A1C 7.2%), glycogen stores and the hyperglycemic response to glucagon administration are maintained even after receiving multiple doses of glucagon. This finding supports the safety of repeated glucagon delivery in the setting of a bihormonal closed-loop system.
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Affiliation(s)
- Jessica R Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Joseph El Youssef
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Parkash A Bakhtiani
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Yu Cai
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR
| | - Jade M Stobbe
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR
| | - Deborah Branigan
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
| | - Katrina Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics & Design Program, Oregon Health & Science University, Portland, OR
| | - Peter Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Ravi Reddy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Mark Woods
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR Portland State University, Portland, OR
| | - W Kenneth Ward
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR
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Jacobs PG, Resalat N, El Youssef J, Reddy R, Branigan D, Preiser N, Condon J, Castle J. Incorporating an Exercise Detection, Grading, and Hormone Dosing Algorithm Into the Artificial Pancreas Using Accelerometry and Heart Rate. J Diabetes Sci Technol 2015; 9:1175-84. [PMID: 26438720 PMCID: PMC4667295 DOI: 10.1177/1932296815609371] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In this article, we present several important contributions necessary for enabling an artificial endocrine pancreas (AP) system to better respond to exercise events. First, we show how exercise can be automatically detected using body-worn accelerometer and heart rate sensors. During a 22 hour overnight inpatient study, 13 subjects with type 1 diabetes wearing a Zephyr accelerometer and heart rate monitor underwent 45 minutes of mild aerobic treadmill exercise while controlling their glucose levels using sensor-augmented pump therapy. We used the accelerometer and heart rate as inputs into a validated regression model. Using this model, we were able to detect the exercise event with a sensitivity of 97.2% and a specificity of 99.5%. Second, from this same study, we show how patients' glucose declined during the exercise event and we present results from in silico modeling that demonstrate how including an exercise model in the glucoregulatory model improves the estimation of the drop in glucose during exercise. Last, we present an exercise dosing adjustment algorithm and describe parameter tuning and performance using an in silico glucoregulatory model during an exercise event.
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Affiliation(s)
- Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Navid Resalat
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
| | - Ravi Reddy
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
| | - Nicholas Preiser
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - John Condon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Jessica Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
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Affiliation(s)
- Jessica R Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR, USA.
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Abstract
PURPOSE OF REVIEW Autoimmune destruction of the β cells is considered the key abnormality in type 1 diabetes mellitus and insulin replacement the primary therapeutic strategy. However, a lack of insulin is accompanied by disturbances in glucagon release, which is excessive postprandially, but insufficient during hypoglycaemia. In addition, replacing insulin alone appears insufficient for adequate glucose control. This review focuses on the growing body of evidence that glucagon abnormalities contribute significantly to the pathophysiology of diabetes and on recent efforts to target the glucagon axis as adjunctive therapy to insulin replacement. RECENT FINDINGS This review discusses recent (since 2013) advances in abnormalities of glucagon regulation and their link to the pathophysiology of diabetes; new mechanisms of glucagon action and regulation; manipulation of glucagon in diabetes treatment; and analytical and systems biology tools to study glucagon regulation. SUMMARY Recent efforts 'resurrected' glucagon as a key hormone in the pathophysiology of diabetes. New studies target its abnormal regulation and action that is key for improving diabetes treatment. The progress is promising, but major questions remain, including unravelling the mechanism of loss of glucagon counterregulation in type 1 diabetes mellitus and how best to manipulate glucagon to achieve more efficient and safer glycaemic control.
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Affiliation(s)
- Leon S Farhy
- Division of Endocrinology and Metabolism, Department of Medicine and Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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Finan DA, Dassau E, Breton MD, Patek SD, McCann TW, Kovatchev BP, Doyle FJ, Levy BL, Venugopalan R. Sensitivity of the Predictive Hypoglycemia Minimizer System to the Algorithm Aggressiveness Factor. J Diabetes Sci Technol 2015; 10:104-10. [PMID: 26134834 PMCID: PMC4738202 DOI: 10.1177/1932296815593292] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Predictive Hypoglycemia Minimizer System ("Hypo Minimizer"), consisting of a zone model predictive controller (the "controller") and a safety supervision module (the "safety module"), aims to mitigate hypoglycemia by preemptively modulating insulin delivery based on continuous glucose monitor (CGM) measurements. The "aggressiveness factor," a pivotal variable in the system, governs the speed and magnitude of the controller's insulin dosing characteristics in response to changes in CGM levels. METHODS Twelve adults with type 1 diabetes were studied in closed-loop in a clinical research center for approximately 24 hours. This analysis focused primarily on the effect of the aggressiveness factor on the automated insulin-delivery characteristics of the controller, and secondarily on the glucose control results. RESULTS As aggressiveness increased from "conservative" to "medium" to "aggressive," the controller recommended less insulin (-3.3% vs -14.4% vs -19.5% relative to basal) with a higher frequency (5.3% vs 14.4% vs 20.3%) during the critical times when the CGM was reading 90-120 mg/dl and decreasing. Blood glucose analyses indicated that the most aggressive setting resulted in the most desirable combination of the least time spent <70 mg/dl and the most time spent 70-180 mg/dl, particularly in the overnight period. Hyperglycemia, diabetic ketoacidosis, or severe hypoglycemia did not occur with any of the aggressiveness values. CONCLUSION The Hypo Minimizer's controller took preemptive action to prevent hypoglycemia based on predicted changes in CGM glucose levels. The most aggressive setting was quickest to take action to reduce insulin delivery below basal and achieved the best glucose metrics.
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Affiliation(s)
| | - Eyal Dassau
- University of California, Santa Barbara, Santa Barbara, CA, USA Sansum Diabetes Research Institute, Santa Barbara, CA, USA
| | - Marc D Breton
- University of Virginia, Center for Diabetes Technology, Charlottesville, VA, USA
| | - Stephen D Patek
- University of Virginia, Center for Diabetes Technology, Charlottesville, VA, USA
| | | | - Boris P Kovatchev
- University of Virginia, Center for Diabetes Technology, Charlottesville, VA, USA
| | - Francis J Doyle
- University of California, Santa Barbara, Santa Barbara, CA, USA Sansum Diabetes Research Institute, Santa Barbara, CA, USA
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Huyett LM, Dassau E, Zisser HC, Doyle FJ. Design and Evaluation of a Robust PID Controller for a Fully Implantable Artificial Pancreas. Ind Eng Chem Res 2015; 54:10311-10321. [PMID: 26538805 PMCID: PMC4627627 DOI: 10.1021/acs.iecr.5b01237] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 06/06/2015] [Accepted: 06/09/2015] [Indexed: 11/28/2022]
Abstract
Treatment of type 1 diabetes mellitus could be greatly improved by applying a closed-loop control strategy to insulin delivery, also known as an artificial pancreas (AP). In this work, we outline the design of a fully implantable AP using intraperitoneal (IP) insulin delivery and glucose sensing. The design process utilizes the rapid glucose sensing and insulin action offered by the IP space to tune a PID controller with insulin feedback to provide safe and effective insulin delivery. The controller was tuned to meet robust performance and stability specifications. An anti-reset windup strategy was introduced to prevent dangerous undershoot toward hypoglycemia after a large meal disturbance. The final controller design achieved 78% of time within the tight glycemic range of 80-140 mg/dL, with no time spent in hypoglycemia. The next step is to test this controller design in an animal model to evaluate the in vivo performance.
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Affiliation(s)
- Lauren M Huyett
- Department of Chemical Engineering, University of California Santa Barbara , Santa Barbara, California 93106-5080, United States
| | - Eyal Dassau
- Department of Chemical Engineering, University of California Santa Barbara , Santa Barbara, California 93106-5080, United States
| | - Howard C Zisser
- Department of Chemical Engineering, University of California Santa Barbara , Santa Barbara, California 93106-5080, United States
| | - Francis J Doyle
- Department of Chemical Engineering, University of California Santa Barbara , Santa Barbara, California 93106-5080, United States
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Abstract
Artificial pancreas (AP) systems, a long-sought quest to replicate mechanically islet physiology that is lost in diabetes, are reaching the clinic, and the potential of automating insulin delivery is about to be realized. Significant progress has been made, and the safety and feasibility of AP systems have been demonstrated in the clinical research center and more recently in outpatient "real-world" environments. An iterative road map to AP system development has guided AP research since 2009, but progress in the field indicates that it needs updating. While it is now clear that AP systems are technically feasible, it remains much less certain that they will be widely adopted by clinicians and patients. Ultimately, the true success of AP systems will be defined by successful integration into the diabetes health care system and by the ultimate metric: improved diabetes outcomes.
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Du X, Durgan CJ, Matthews DJ, Motley JR, Tan X, Pholsena K, Árnadóttir L, Castle JR, Jacobs PG, Cargill RS, Ward WK, Conley JF, Herman GS. Fabrication of a Flexible Amperometric Glucose Sensor Using Additive Processes. ECS JOURNAL OF SOLID STATE SCIENCE AND TECHNOLOGY : JSS 2015; 4:P3069-P3074. [PMID: 26634186 PMCID: PMC4664458 DOI: 10.1149/2.0101504jss] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This study details the use of printing and other additive processes to fabricate a novel amperometric glucose sensor. The sensor was fabricated using a Au coated 12.7 μm thick polyimide substrate as a starting material, where micro-contact printing, electrochemical plating, chloridization, electrohydrodynamic jet (e-jet) printing, and spin coating were used to pattern, deposit, chloridize, print, and coat functional materials, respectively. We have found that e-jet printing was effective for the deposition and patterning of glucose oxidase inks with lateral feature sizes between ~5 to 1000 μm in width, and that the glucose oxidase was still active after printing. The thickness of the permselective layer was optimized to obtain a linear response for glucose concentrations up to 32 mM and no response to acetaminophen, a common interfering compound, was observed. The use of such thin polyimide substrates allow wrapping of the sensors around catheters with high radius of curvature ~250 μm, where additive and microfabrication methods may allow significant cost reductions.
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Affiliation(s)
- Xiaosong Du
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Christopher J. Durgan
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - David J. Matthews
- School of Electrical Engineering and Computer Science, Oregon State University, Corvallis, Oregon 97331, USA
| | - Joshua R. Motley
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Xuebin Tan
- School of Electrical Engineering and Computer Science, Oregon State University, Corvallis, Oregon 97331, USA
| | - Kovit Pholsena
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | - Líney Árnadóttir
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
| | | | - Peter G. Jacobs
- Pacific Diabetes Technologies, Portland, Oregon 97201, USA
- Oregon Health & Science University, Portland, Oregon 97239, USA
| | | | | | - John F. Conley
- School of Electrical Engineering and Computer Science, Oregon State University, Corvallis, Oregon 97331, USA
| | - Gregory S. Herman
- School of Chemical, Biological, and Environmental Engineering, Oregon State University, Corvallis, Oregon 97331, USA
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Bakhtiani PA, El Youssef J, Duell AK, Branigan DL, Jacobs PG, Lasarev MR, Castle JR, Ward WK. Factors affecting the success of glucagon delivered during an automated closed-loop system in type 1 diabetes. J Diabetes Complications 2015; 29:93-8. [PMID: 25264232 PMCID: PMC4281277 DOI: 10.1016/j.jdiacomp.2014.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 08/31/2014] [Accepted: 09/03/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND In bi-hormonal closed-loop systems for treatment of diabetes, glucagon sometimes fails to prevent hypoglycemia. We evaluated glucagon responses during several closed-loop studies to determine factors, such as gain factors, responsible for glucagon success and failure. METHODS We extracted data from four closed-loop studies, examining blood glucose excursions over the 50min after each glucagon dose and defining hypoglycemic failure as glucose values<60 mg/dl. Secondly, we evaluated hyperglycemic excursions within the same period, where glucose was>180 mg/dl. We evaluated several factors for association with rates of hypoglycemic failure or hyperglycemic excursion. These factors included age, weight, HbA1c, duration of diabetes, gender, automation of glucagon delivery, glucagon dose, proportional and derivative errors (PE and DE), insulin on board (IOB), night vs. day delivery, and point sensor accuracy. RESULTS We analyzed a total of 251 glucagon deliveries during 59 closed-loop experiments performed on 48 subjects. Glucagon successfully maintained glucose within target (60-180 mg/dl) in 195 (78%) of instances with 40 (16%) hypoglycemic failures and 16 (6%) hyperglycemic excursions. A multivariate logistic regression model identified PE (p<0.001), DE (p<0.001), and IOB (p<0.001) as significant determinants of success in terms of avoiding hypoglycemia. Using a model of glucagon absorption and action, simulations suggested that the success rate for glucagon would be improved by giving an additional 0.8μg/kg. CONCLUSION We conclude that glucagon fails to prevent hypoglycemia when it is given at a low glucose threshold and when glucose is falling steeply. We also confirm that high IOB significantly increases the risk for glucagon failures. Tuning of glucagon subsystem parameters may help reduce this risk.
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Affiliation(s)
- P A Bakhtiani
- Harold Schnitzer Diabetes Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - J El Youssef
- Harold Schnitzer Diabetes Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
| | - A K Duell
- Harold Schnitzer Diabetes Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - D L Branigan
- Harold Schnitzer Diabetes Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - P G Jacobs
- Department of Biomedical Engineering, Oregon Health and Science University, 33030 SW Bond Ave., Portland, OR 97239
| | - M R Lasarev
- Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - J R Castle
- Harold Schnitzer Diabetes Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - W K Ward
- Harold Schnitzer Diabetes Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239
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Pohl R, Li M, Krasner A, De Souza E. Development of stable liquid glucagon formulations for use in artificial pancreas. J Diabetes Sci Technol 2015; 9:8-16. [PMID: 25352634 PMCID: PMC4495524 DOI: 10.1177/1932296814555541] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [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
A promising approach to treat diabetes is the development of fully automated artificial/bionic pancreas systems that use both insulin and glucagon to maintain euglycemia. A physically and chemically stable liquid formulation of glucagon does not currently exist. Our goal is to develop a glucagon formulation that is stable as a clear and gel-free solution, free of fibrils and that has the requisite long-term shelf life for storage in the supply chain, short-term stability for at least 7 days at 37°C, and pump compatibility for use in a bihormonal pump. We report the development of two distinct families of stable liquid glucagon formulations which utilize surfactant or surfactant-like excipients (LMPC and DDM) to "immobilize" the glucagon in solution potentially through the formation of micelles and prevention of interaction between glucagon molecules. Data are presented that demonstrate long-term physical and chemical stability (~2 years) at 5°C, short-term stability (up to 1 month) under accelerated 37°C testing conditions, pump compatibility for up to 9 days, and adequate glucose responses in dogs and diabetic swine. These stable glucagon formulations show utility and promise for further development in artificial pancreas systems.
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