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Schoelwer MJ, DeBoer MD, Breton MD. Use of diabetes technology in children. Diabetologia 2024; 67:2075-2084. [PMID: 38995398 PMCID: PMC11457698 DOI: 10.1007/s00125-024-06218-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/23/2024] [Indexed: 07/13/2024]
Abstract
Children with type 1 diabetes and their caregivers face numerous challenges navigating the unpredictability of this complex disease. Although the burden of managing diabetes remains significant, new technology has eased some of the load and allowed children with type 1 diabetes to achieve tighter glycaemic management without fear of excess hypoglycaemia. Continuous glucose monitor use alone improves outcomes and is considered standard of care for paediatric type 1 diabetes management. Similarly, automated insulin delivery (AID) systems have proven to be safe and effective for children as young as 2 years of age. AID use improves not only blood glucose levels but also quality of life for children with type 1 diabetes and their caregivers and should be strongly considered for all youth with type 1 diabetes if available and affordable. Here, we review key data on the use of diabetes technology in the paediatric population and discuss management issues unique to children and adolescents.
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Affiliation(s)
| | - Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA.
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Laugesen C, Ritschel T, Ranjan AG, Hsu L, Jørgensen JB, Svensson J, Ekhlaspour L, Buckingham B, Nørgaard K. Impact of Missed and Late Meal Boluses on Glycemic Outcomes in Automated Insulin Delivery-Treated Children and Adolescents with Type 1 Diabetes: A Two-Center, Population-Based Cohort Study. Diabetes Technol Ther 2024. [PMID: 38805311 DOI: 10.1089/dia.2024.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Objective: To evaluate the impact of missed or late meal boluses (MLBs) on glycemic outcomes in children and adolescents with type 1 diabetes using automated insulin delivery (AID) systems. Research Design and Methods: AID-treated (Tandem Control-IQ or Medtronic MiniMed 780G) children and adolescents (aged 6-21 years) from Stanford Medical Center and Steno Diabetes Center Copenhagen with ≥10 days of data were included in this two-center, binational, population-based, retrospective, 1-month cohort study. The primary outcome was the association between the number of algorithm-detected MLBs and time in target glucose range (TIR; 70-180 mg/dL). Results: The study included 189 children and adolescents (48% females with a mean ± standard deviation age of 13 ± 4 years). Overall, the mean number of MLBs per day in the cohort was 2.2 ± 0.9. For each additional MLB per day, TIR decreased by 9.7% points (95% confidence interval [CI] 11.3; 8.1), and compared with the quartile with fewest MLBs (Q1), the quartile with most (Q4) had 22.9% less TIR (95% CI: 27.2; 18.6). The age-, sex-, and treatment modality-adjusted probability of achieving a TIR of >70% in Q4 was 1.4% compared with 74.8% in Q1 (P < 0.001). Conclusions: MLBs significantly impacted glycemic outcomes in AID-treated children and adolescents. The results emphasize the importance of maintaining a focus on bolus behavior to achieve a higher TIR and support the need for further research in technological or behavioral support tools to handle MLBs.
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Affiliation(s)
- Christian Laugesen
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Tobias Ritschel
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Ajenthen G Ranjan
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Liana Hsu
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - John Bagterp Jørgensen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Jannet Svensson
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Gentofte, Denmark
| | - Laya Ekhlaspour
- Division of Endocrinology, Department of Pediatrics, University of San Francisco, San Francisco, California, USA
| | - Bruce Buckingham
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Kirsten Nørgaard
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Gentofte, Denmark
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Kovatchev B, Castillo A, Pryor E, Kollar LL, Barnett CL, DeBoer MD, Brown SA. Neural-Net Artificial Pancreas: A Randomized Crossover Trial of a First-in-Class Automated Insulin Delivery Algorithm. Diabetes Technol Ther 2024; 26:375-382. [PMID: 38277161 PMCID: PMC11305265 DOI: 10.1089/dia.2023.0469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Background: Automated insulin delivery (AID) is now integral to the clinical practice of type 1 diabetes (T1D). The objective of this pilot-feasibility study was to introduce a new regulatory and clinical paradigm-a Neural-Net Artificial Pancreas (NAP)-an encoding of an AID algorithm into a neural network that approximates its action and assess NAP versus the original AID algorithm. Methods: The University of Virginia Model-Predictive Control (UMPC) algorithm was encoded into a neural network, creating its NAP approximation. Seventeen AID users with T1D were recruited and 15 participated in two consecutive 20-h hotel sessions, receiving in random order either NAP or UMPC. Their demographic characteristics were ages 22-68 years old, duration of diabetes 7-58 years, gender 10/5 female/male, White Non-Hispanic/Black 13/2, and baseline glycated hemoglobin 5.4%-8.1%. Results: The time-in-range (TIR) difference between NAP and UMPC, adjusted for entry glucose level, was 1 percentage point, with absolute TIR values of 86% (NAP) and 87% (UMPC). The two algorithms achieved similar times <70 mg/dL of 2.0% versus 1.8% and coefficients of variation of 29.3% (NAP) versus 29.1 (UMPC)%. Under identical inputs, the average absolute insulin-recommendation difference was 0.031 U/h. There were no serious adverse events on either controller. NAP had sixfold lower computational demands than UMPC. Conclusion: In a randomized crossover study, a neural-network encoding of a complex model-predictive control algorithm demonstrated similar performance, at a fraction of the computational demands. Regulatory and clinical doors are therefore open for contemporary machine-learning methods to enter the AID field. Clinical Trial Registration number: NCT05876273.
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Affiliation(s)
- Boris Kovatchev
- Address correspondence to: Boris Kovatchev, PhD, Center for Diabetes Technology, University of Virginia School of Medicine, 560 Ray C Hunt Drive, Charlottesville, VA 22903, USA
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Visentin R, Cobelli C, Sieber J, Dalla Man C. Short- and Long-Term Effects on Glucose Control of Nonadherence to Insulin Therapy in People With Type 2 Diabetes An In Silico Study. J Diabetes Sci Technol 2024; 18:309-317. [PMID: 38284154 DOI: 10.1177/19322968231223936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Strict adherence to multiple daily insulin (MDI) therapy is a cornerstone for the achievement of good glucose control in people with advanced type 2 diabetes (T2D). Here, we aim to in silico assess glucose control in T2D subjects with poor adherence to MDI therapy. METHODS We tuned the Padova T2D Simulator, originally describing early-stage T2D physiology, around advanced T2D people. One hundred in silico advanced T2D subjects were generated and equipped with optimal MDI therapy: specifically, basal and bolus insulin amounts and injection times were individualized for each subject by applying titration algorithms that iteratively update insulin dose based on glucose deviation from its target. Then, the effect of nonadhering to MDI therapy was assessed using standard glucose control metrics calculated in two 6-month 3-meal/day in silico scenarios: in Scenario 1, subjects received the optimal basal and prandial insulin bolus at each meal; in Scenario 2, subjects received optimal basal insulin and randomly delayed or skipped the prandial insulin bolus in 3 lunches during working days and 1 dinner during weekends. RESULTS A statistically significant degradation was found in all glucose control outcome metrics in Scenario 2 versus Scenario 1: e.g., percent time above 180 mg/dL increased by 22.2% and glucose management index by 0.2%. CONCLUSIONS Impaired adherence to MDI therapy in T2D leads to glucose control deteriorations in both short and long terms. Interestingly, short-term hyperglycemia seems being contrasted by residual endogenous insulin secretion, which statistically increased by 3-fold after delayed/skipped insulin boluses compared with optimal ones.
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Affiliation(s)
- Roberto Visentin
- Department of Information Engineering, University of Padua, Padua, Italy
| | - Claudio Cobelli
- Department of Woman and Child's Health, University of Padua, Padua, Italy
| | | | - Chiara Dalla Man
- Department of Information Engineering, University of Padua, Padua, Italy
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Amer BE, Yaqout YE, Abozaid AM, Afifi E, Aboelkhier MM. Does fully closed-loop automated insulin delivery improve glycaemic control in patients with type 2 diabetes? A meta-analysis of randomized controlled trials. Diabet Med 2024; 41:e15196. [PMID: 37567739 DOI: 10.1111/dme.15196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/22/2023] [Accepted: 08/09/2023] [Indexed: 08/13/2023]
Abstract
AIMS This meta-analysis investigated the efficacy and safety of fully closed-loop automated insulin delivery (AID) in patients with type 2 diabetes. MATERIALS AND METHODS We systemically searched PubMed, Scopus, Web of Science, and Cochrane Central from inception until April 26, 2023. We included randomized controlled trials (RCTs) comparing fully closed-loop AID versus conventional insulin therapy. The outcomes were pooled as the mean difference (MD) and risk ratio with 95% confidence interval (CI) in the random effect model. Our primary outcome was the proportion of time in the target glucose range (5.6-10 mmol/L, 3.9-10 mmol/L, or 3.9-8 mmol/L, depending on the study). Key secondary outcomes included the proportion of time spent in hyperglycaemia or hypoglycaemia. RESULTS We included seven RCTs (three crossover and four parallel design), compromising 390 patients. Our analysis showed that compared to the control group, fully closed-loop AID increased the proportion of time spent within the target glucose range by additional 337 min per 24 h (MD = 23.39%, 95% CI [16.64%, 30.14%], p < 0.01), additional 108 min overnight (MD = 22.40%, 95% CI [12.88%, 31.91%], p < 0.01), and additional 258 min during the daytime period (MD = 26.85%, 95% CI [21.06%, 32.63%], p < 0.01). Compared to the control group, the overall time in hyperglycaemia was shortened by 326 min per 24 h (MD = -22.67%, 95% CI [-30.87%, -14.46%], p < 0.01). There was no significant difference between the two groups in terms of overall, overnight, and daytime periods spent in hypoglycaemia. CONCLUSIONS Our meta-analysis suggests that fully closed-loop AID may improve glycaemic control in patients with type 2 diabetes, particularly for those with more challenging diabetes management. Further research is required to establish the feasibility of implementing these systems in clinical practice. [Correction added on 26 August 2023 after first online publication: Under Results, the first sentence "We included seven RCTs (three crossover and one parallel designs)" has been changed to "We included seven RCTs (three crossover and four parallel designs)".].
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Affiliation(s)
- Basma Ehab Amer
- Medical Research Group of Egypt, Negida Academy, Arlington, Massachusetts, USA
- Faculty of Medicine, Benha University, Benha, Egypt
| | - Yasmeen Essam Yaqout
- Medical Research Group of Egypt, Negida Academy, Arlington, Massachusetts, USA
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Mohamed Abozaid
- Medical Research Group of Egypt, Negida Academy, Arlington, Massachusetts, USA
- Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Eslam Afifi
- Medical Research Group of Egypt, Negida Academy, Arlington, Massachusetts, USA
- Faculty of Medicine, Benha University, Benha, Egypt
| | - Menna M Aboelkhier
- Medical Research Group of Egypt, Negida Academy, Arlington, Massachusetts, USA
- Faculty of Science, Cairo University, Cairo, Egypt
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Garcia-Tirado J, Colmegna P, Villard O, Diaz JL, Esquivel-Zuniga R, Koravi CLK, Barnett CL, Oliveri MC, Fuller M, Brown SA, DeBoer MD, Breton MD. Assessment of Meal Anticipation for Improving Fully Automated Insulin Delivery in Adults With Type 1 Diabetes. Diabetes Care 2023; 46:1652-1658. [PMID: 37478323 PMCID: PMC10465820 DOI: 10.2337/dc23-0119] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/06/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Meals are a consistent challenge to glycemic control in type 1 diabetes (T1D). Our objective was to assess the glycemic impact of meal anticipation within a fully automated insulin delivery (AID) system among adults with T1D. RESEARCH DESIGN AND METHODS We report the results of a randomized crossover clinical trial comparing three modalities of AID systems: hybrid closed loop (HCL), full closed loop (FCL), and full closed loop with meal anticipation (FCL+). Modalities were tested during three supervised 24-h admissions, where breakfast, lunch, and dinner were consumed per participant's home schedule, at a fixed time, and with a 1.5-h delay, respectively. Primary outcome was the percent time in range 70-180 mg/dL (TIR) during the breakfast postprandial period for FCL+ versus FCL. RESULTS Thirty-five adults with T1D (age 44.5 ± 15.4 years; HbA1c 6.7 ± 0.9%; n = 23 women and n = 12 men) were randomly assigned. TIR for the 5-h period after breakfast was 75 ± 23%, 58 ± 21%, and 63 ± 19% for HCL, FCL, and FCL+, respectively, with no significant difference between FCL+ and FCL. For the 2 h before dinner, time below range (TBR) was similar for FCL and FCL+. For the 5-h period after dinner, TIR was similar for FCL+ and FCL (71 ± 34% vs. 72 ± 29%; P = 1.0), whereas TBR was reduced in FCL+ (median 0% [0-0%] vs. 0% [0-0.8%]; P = 0.03). Overall, 24-h control for HCL, FCL, and FCL+ was 86 ± 10%, 77 ± 11%, and 77 ± 12%, respectively. CONCLUSIONS Although postprandial control remained optimal with hybrid AID, both fully AID solutions offered overall TIR >70% with similar or lower exposure to hypoglycemia. Anticipation did not significantly improve postprandial control in AID systems but also did not increase hypoglycemic risk when meals were delayed.
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Affiliation(s)
- Jose Garcia-Tirado
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
- University Clinic for Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital–University Hospital Bern, University of Bern, Bern, Switzerland
| | - Patricio Colmegna
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Orianne Villard
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
- Department of Diabetes Endocrinology and Metabolism, CHU Montpellier, Montpellier, France
| | - Jenny L. Diaz
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | | | | | - Mary C. Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Morgan Fuller
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Sue A. Brown
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Mark D. DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
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Pieralice S, Coppola A, Maddaloni E. Updates on Glycaemic Control Strategies: A Range of Opportunities after Total Pancreatectomy. J Clin Med 2023; 12:jcm12093306. [PMID: 37176746 PMCID: PMC10179154 DOI: 10.3390/jcm12093306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
In the past, indications for total pancreatectomy (TP) were rare, with several concerns about patients' postoperative quality of life due to exocrine and endocrine post-pancreatectomy management [...].
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Affiliation(s)
- Silvia Pieralice
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | | | - Ernesto Maddaloni
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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Michou P, Gkiourtzis N, Christoforidis A, Kotanidou EP, Galli-Tsinopoulou A. The efficacy of automated insulin delivery systems in children and adolescents with Type 1 Diabetes Mellitus: a systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2023; 199:110678. [PMID: 37094750 DOI: 10.1016/j.diabres.2023.110678] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/26/2023]
Abstract
AIMS Insulin administration is the treatment of choice for people with type 1 diabetes mellitus (T1D). Technological advances have led to the development of automated insulin delivery (AID) systems, aiming to optimize the quality of life of patients with T1D. We present a systematic review and meta-analysis of the current literature about the efficacy of AID systems in children and adolescents with T1D. METHODS We conducted a systematic literature search for randomized controlled trials (RCTs) until August 8th, 2022, investigating the efficacy of AID systems in the management of patients <21 years of age with T1D. A priori subgroup and sensitivity analyses based on different settings (free-living settings, type of AID system, parallel group or crossover design) were also conducted. RESULTS In total, 26 RCTs reporting a total of 915 children and adolescents with T1D were included in the meta-analysis. AID systems revealed statistically significant differences in the main outcomes, such as the proportion of time in the target glucose range (3.9-10 mmol/L) (p<0.00001), in hypoglycemia (<3.9 mmol/L) (p=0.003) and mean proportion of HbA1C (p=0.0007) compared to control group. CONCLUSIONS According to the present meta-analysis, AID systems are superior to insulin pump therapy, sensor-augmented pumps and multiple daily insulin injections. Most of the included studies have a high risk of bias because of allocation, blinding of patients and blinding of assessment. Our sensitivity analyses showed that patients <21 years of age with T1D can use AID systems, after proper education, following their daily activities. Further RCTs examining the effect of AID systems on nocturnal hypoglycemia, under free-living settings and studies examining the effect of dual-hormone AID systems are pending.
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Affiliation(s)
- Panagiota Michou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; Department of Pediatrics, Gennimatas General Hospital of Thessaloniki, Thessaloniki, Greece, 54635.
| | - Nikolaos Gkiourtzis
- 4th Department of Pediatrics, Papageorgiou General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 56429.
| | - Athanasios Christoforidis
- 1st Department of Pediatrics, Ippokrateio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54643.
| | - Eleni P Kotanidou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; 2nd Department of Pediatrics, AHEPA University General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54636.
| | - Asimina Galli-Tsinopoulou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; 2nd Department of Pediatrics, AHEPA University General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54636.
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Kang SL, Hwang YN, Kwon JY, Kim SM. Effectiveness and safety of a model predictive control (MPC) algorithm for an artificial pancreas system in outpatients with type 1 diabetes (T1D): systematic review and meta-analysis. Diabetol Metab Syndr 2022; 14:187. [PMID: 36494830 PMCID: PMC9733359 DOI: 10.1186/s13098-022-00962-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the effectiveness and safety of a model predictive control (MPC) algorithm for an artificial pancreas system in outpatients with type 1 diabetes. METHODS We searched PubMed, EMBASE, Cochrane Central, and the Web of Science to December 2021. The eligibility criteria for study selection were randomized controlled trials comparing artificial pancreas systems (MPC, PID, and fuzzy algorithms) with conventional insulin therapy in type 1 diabetes patients. The heterogeneity of the overall results was identified by subgroup analysis of two factors including the intervention duration (overnight and 24 h) and the follow-up periods (< 1 week, 1 week to 1 month, and > 1 month). RESULTS The meta-analysis included a total of 41 studies. Considering the effect on the percentage of time maintained in the target range between the MPC-based artificial pancreas and conventional insulin therapy, the results showed a statistically significantly higher percentage of time maintained in the target range in overnight use (10.03%, 95% CI [7.50, 12.56] p < 0.00001). When the follow-up period was considered, in overnight use, the MPC-based algorithm showed a statistically significantly lower percentage of time maintained in the hypoglycemic range (-1.34%, 95% CI [-1.87, -0.81] p < 0.00001) over a long period of use (> 1 month). CONCLUSIONS Overnight use of the MPC-based artificial pancreas system statistically significantly improved glucose control while increasing time maintained in the target range for outpatients with type 1 diabetes. Results of subgroup analysis revealed that MPC algorithm-based artificial pancreas system was safe while reducing the time maintained in the hypoglycemic range after an overnight intervention with a long follow-up period (more than 1 month).
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Affiliation(s)
- Su Lim Kang
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Yoo Na Hwang
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Ji Yean Kwon
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Sung Min Kim
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
- Department of Medical Device Regulatory Science, Dongguk University-Seoul, 26, Pil-dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
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Rankin D, Kimbell B, Hovorka R, Lawton J. Adolescents' and their parents' experiences of using a closed-loop system to manage type 1 diabetes in everyday life: qualitative study. Chronic Illn 2022; 18:742-756. [PMID: 33472409 PMCID: PMC9643806 DOI: 10.1177/1742395320985924] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Type 1 diabetes can have life-shattering consequences for adolescents and parents. A closed-loop system is a cutting-edge technology which automatically regulates glucose to reduce the burden of diabetes management. We explored adolescents' and parents' experiences of using this technology to understand how it affects their biographies and everyday lives. METHODS In-depth interviews with 18 adolescents newly diagnosed with type 1 diabetes and 21 parents after ≥12 months experience using closed-loop technology. Data were analysed thematically. RESULTS Participants reported very few disruptions to their lives when using a closed-loop. Reports of family conflict were minimal as the closed-loop enabled dietary flexibility and glucose levels to be checked effortlessly. Adolescents described doing 'normal' activities without worrying about high/low glucose, and parents reported allowing them to do so unsupervised because the closed-loop would regulate their glucose and keep them safe. Some adolescents expressed concerns about the visibility of components and, to avoid stigma, described curtailing activities such as swimming. Participants described how the closed-loop enabled adolescents to be in control of, or create distance from, diabetes. DISCUSSION The closed-loop has life-enhancing consequences for both adolescents and parents and helps to reduce the biographical disruption of type 1 diabetes in this age group.
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Affiliation(s)
- D Rankin
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - B Kimbell
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - R Hovorka
- Wellcome Trust - Medical Research Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - J Lawton
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Rodríguez-Sarmiento DL, León-Vargas F, García-Jaramillo M. Artificial pancreas systems: experiences from concept to commercialisation. Expert Rev Med Devices 2022; 19:877-894. [DOI: 10.1080/17434440.2022.2150546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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12
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Templer S. Closed-Loop Insulin Delivery Systems: Past, Present, and Future Directions. Front Endocrinol (Lausanne) 2022; 13:919942. [PMID: 35733769 PMCID: PMC9207329 DOI: 10.3389/fendo.2022.919942] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/06/2022] [Indexed: 12/16/2022] Open
Abstract
Closed-loop (artificial pancreas) systems for automated insulin delivery have been likened to the holy grail of diabetes management. The first iterations of glucose-responsive insulin delivery were pioneered in the 1960s and 1970s, with the development of systems that used venous glucose measurements to dictate intravenous infusions of insulin and dextrose in order to maintain normoglycemia. Only recently have these bulky, bedside technologies progressed to miniaturized, wearable devices. These modern closed-loop systems use interstitial glucose sensing, subcutaneous insulin pumps, and increasingly sophisticated algorithms. As the number of commercially available hybrid closed-loop systems has grown, so too has the evidence supporting their efficacy. Future challenges in closed-loop technology include the development of fully closed-loop systems that do not require user input for meal announcements or carbohydrate counting. Another evolving avenue in research is the addition of glucagon to mitigate the risk of hypoglycemia and allow more aggressive insulin dosing.
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Garcia-Tirado J, Diaz JL, Esquivel-Zuniga R, Koravi CLK, Corbett JP, Dawson M, Wakeman C, Barnett CL, Oliveri MC, Myers H, Krauthause K, Breton MD, DeBoer MD. Advanced Closed-Loop Control System Improves Postprandial Glycemic Control Compared With a Hybrid Closed-Loop System Following Unannounced Meal. Diabetes Care 2021; 44:dc210932. [PMID: 34400480 DOI: 10.2337/dc21-0932] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/16/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Meals are a major hurdle to glycemic control in type 1 diabetes (T1D). Our objective was to test a fully automated closed-loop control (CLC) system in the absence of announcement of carbohydrate ingestion among adolescents with T1D, who are known to commonly omit meal announcement. RESEARCH DESIGN AND METHODS Eighteen adolescents with T1D (age 15.6 ± 1.7 years; HbA1c 7.4 ± 1.5%; 9 females/9 males) participated in a randomized crossover clinical trial comparing our legacy hybrid CLC system (Unified Safety System Virginia [USS]-Virginia) with a novel fully automated CLC system (RocketAP) during two 46-h supervised admissions (each with one announced and one unannounced dinner), following 2 weeks of data collection. Primary outcome was the percentage time-in-range 70-180 mg/dL (TIR) following the unannounced meal, with secondary outcomes related to additional continuous glucose monitoring-based metrics. RESULTS Both TIR and time-in-tight-range 70-140 mg/dL (TTR) were significantly higher using RocketAP than using USS-Virginia during the 6 h following the unannounced meal (83% [interquartile range 64-93] vs. 53% [40-71]; P = 0.004 and 49% [41-59] vs. 27% [22-36]; P = 0.002, respectively), primarily driven by reduced time-above-range (TAR >180 mg/dL: 17% [1.3-34] vs. 47% [28-60]), with no increase in time-below-range (TBR <70 mg/dL: 0% median for both). RocketAP also improved control following the announced meal (mean difference TBR: -0.7%, TIR: +7%, TTR: +6%), overall (TIR: +5%, TAR: -5%, TTR: +8%), and overnight (TIR: +7%, TTR: +19%, TAR: -5%). RocketAP delivered less insulin overall (78 ± 23 units vs. 85 ± 20 units, P = 0.01). CONCLUSIONS A new fully automated CLC system with automatic prandial dosing was proven to be safe and feasible and outperformed our legacy USS-Virginia in an adolescent population with and without meal announcement.
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Affiliation(s)
- Jose Garcia-Tirado
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Jenny L Diaz
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | | | - John P Corbett
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Martha Dawson
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Christian Wakeman
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Mary C Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Helen Myers
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
- Department of Pediatrics, University of Virginia, Charlottesville, VA
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14
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Schoelwer MJ, Kanapka LG, Wadwa RP, Breton MD, Ruedy KJ, Ekhlaspour L, Forlenza GP, Cobry EC, Messer LH, Cengiz E, Jost E, Carria L, Emory E, Hsu LJ, Weinzimer SA, Buckingham BA, Lal RA, Oliveri MC, Kollman CC, Dokken BB, Cherñavvsky DR, Beck RW, DeBoer MD. Predictors of Time-in-Range (70-180 mg/dL) Achieved Using a Closed-Loop Control System. Diabetes Technol Ther 2021; 23:475-481. [PMID: 33689454 PMCID: PMC8252894 DOI: 10.1089/dia.2020.0646] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Studies of closed-loop control (CLC) in patients with type 1 diabetes (T1D) consistently demonstrate improvements in glycemic control as measured by increased time-in-range (TIR) 70-180 mg/dL. However, clinical predictors of TIR in users of CLC systems are needed. Materials and Methods: We analyzed data from 100 children aged 6-13 years with T1D using the Tandem Control-IQ CLC system during a randomized trial or subsequent extension phase. Continuous glucose monitor data were collected at baseline and during 12-16 weeks of CLC use. Participants were stratified into quartiles of TIR on CLC to compare clinical characteristics. Results: TIR for those in the first, second, third, and fourth quartiles was 54%, 65%, 71%, and 78%, respectively. Lower baseline TIR was associated with lower TIR on CLC (r = 0.69, P < 0.001). However, lower baseline TIR was also associated with greater improvement in TIR on CLC (r = -0.81, P < 0.001). During CLC, participants in the highest versus lowest TIR-quartile administered more user-initiated boluses daily (8.5 ± 2.8 vs. 5.8 ± 2.6, P < 0.001) and received fewer automated boluses (3.5 ± 1.0 vs. 6.0 ± 1.6, P < 0.001). Participants in the lowest (vs. the highest) TIR-quartile received more insulin per body weight (1.13 ± 0.27 vs. 0.87 ± 0.20 U/kg/d, P = 0.008). However, in a multivariate model adjusting for baseline TIR, user-initiated boluses and insulin-per-body-weight were no longer significant. Conclusions: Higher baseline TIR is the strongest predictor of TIR on CLC in children with T1D. However, lower baseline TIR is associated with the greatest improvement in TIR. As with open-loop systems, user engagement is important for optimal glycemic control.
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Affiliation(s)
- Melissa J. Schoelwer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | | | - R. Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | | | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Erin C. Cobry
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laurel H. Messer
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eda Cengiz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emily Jost
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lori Carria
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emma Emory
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Liana J. Hsu
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Stuart A. Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bruce A. Buckingham
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Rayhan A. Lal
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Mary Clancy Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Craig C. Kollman
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | | | - Daniel R. Cherñavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Mark D. DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Address correspondence to: Mark D. DeBoer, MD, MSc, MCR, Center for Diabetes Technology, University of Virginia, CFA Institute Building, 560 Ray C Hunt Drive, Charlottesville, VA 22903, USA
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15
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Messer LH, Berget C, Ernst A, Towers L, Slover RH, Forlenza GP. Initiating hybrid closed loop: A program evaluation of an educator-led Control-IQ follow-up at a large pediatric clinic. Pediatr Diabetes 2021; 22:586-593. [PMID: 33502062 PMCID: PMC8252603 DOI: 10.1111/pedi.13183] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/13/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Control-IQ (Tandem Diabetes) is a hybrid closed-loop (HCL) system that users self-initiate after completing online training. Best practices for clinical follow-up are not known. Our quality improvement objective was to evaluate the usefulness of an educator-led follow-up program for new HCL users in a type 1 diabetes pediatric clinic. METHODS We implemented an ''HCLCheck-in'' program, first determining when users started HCL, then having diabetes educators contact them for a follow-up call 2-weeks after start. Educators used a Clinical Tool to inform insulin dose and behavior recommendations, and used four benchmarks to determine need for further follow-up: ≥71% HCL use, ≥71% CGM use, ≥60% Time-in-Range (TIR, 70-180 mg/dL), <5% below 70 mg/dL. Family and educator satisfaction were surveyed. RESULTS One-hundred-twenty-three youth [mean age 13.6 ± 3.7 y, 53.7% female, mean HbA1c 7.6 ± 1.4% (60 mmol/mol)] completed an HCLCheck-in call a median (IQR) of 18(15, 21) days post-HCL start. 74 users (60%) surpassed benchmarks with 94% HCL use and 71% TIR. Of the 49 who did not, 16 completed a second call, and improved median TIR 12.5% (p = 0.03). HCL users reported high satisfaction with the program overall [median 10 (9, 10) out of 10]. Educators spent a median of 45 (32,70) minutes per user and rated satisfaction with the program as 8 (7,9.5) and the Tool as 9 (9, 10). CONCLUSION Our HCLCheck-in program received high satisfaction ratings and resulted in improved TIR for those initially not meeting benchmarks, suggesting users may benefit from early follow-up. Similar programs may be beneficial for other new technologies.
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Affiliation(s)
- Laurel H. Messer
- School of Medicine, Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverDenverColoradoUSA
| | - Cari Berget
- School of Medicine, Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverDenverColoradoUSA
| | - Ashlee Ernst
- School of Medicine, Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverDenverColoradoUSA
| | - Lindsey Towers
- School of Medicine, Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverDenverColoradoUSA
| | - Robert H. Slover
- School of Medicine, Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverDenverColoradoUSA
| | - Gregory P. Forlenza
- School of Medicine, Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverDenverColoradoUSA
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16
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Isganaitis E, Raghinaru D, Ambler-Osborn L, Pinsker JE, Buckingham BA, Wadwa RP, Ekhlaspour L, Kudva YC, Levy CJ, Forlenza GP, Beck RW, Kollman C, Lum JW, Brown SA, Laffel LM. Closed-Loop Insulin Therapy Improves Glycemic Control in Adolescents and Young Adults: Outcomes from the International Diabetes Closed-Loop Trial. Diabetes Technol Ther 2021; 23:342-349. [PMID: 33216667 PMCID: PMC8080922 DOI: 10.1089/dia.2020.0572] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective: To assess the efficacy and safety of closed-loop control (CLC) insulin delivery system in adolescents and young adults with type 1 diabetes. Research Design and Methods: Prespecified subanalysis of outcomes in adolescents and young adults aged 14-24 years old with type 1 diabetes in a previously published 6-month multicenter randomized trial. Participants were randomly assigned 2:1 to CLC (Tandem Control-IQ) or sensor augmented pump (SAP, various pumps+Dexcom G6 CGM) and followed for 6 months. Results: Mean age of the 63 participants was 17 years, median type 1 diabetes duration was 7 years, and mean baseline HbA1c was 8.1%. All 63 completed the trial. Time in range (TIR) increased by 13% with CLC versus decreasing by 1% with SAP (adjusted treatment group difference = +13% [+3.1 h/day]; 95% confidence interval [CI] 9-16, P < 0.001), which largely reflected a reduction in time >180 mg/dL (adjusted difference -12% [-2.9 h/day], P < 0.001). Time <70 mg/dL decreased by 1.6% with CLC versus 0.3% with SAP (adjusted difference -0.7% [-10 min/day], 95% CI -1.0% to -0.2%, P = 0.002). CLC use averaged 89% of the time for 6 months. The mean adjusted difference in HbA1c after 6 months was 0.30% in CLC versus SAP (95% CI -0.67 to +0.08, P = 0.13). There was one diabetic ketoacidosis episode in the CLC group. Conclusions: CLC use for 6 months was substantial and associated with improved TIR and reduced hypoglycemia in adolescents and young adults with type 1 diabetes. Thus, CLC has the potential to improve glycemic outcomes in this challenging age group. The clinical trial was registered with ClinicalTrials.gov (NCT03563313).
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Affiliation(s)
- Elvira Isganaitis
- Research Division, Department of Pediatrics, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Louise Ambler-Osborn
- Research Division, Department of Pediatrics, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Bruce A. Buckingham
- Pediatric Endocrinology and Diabetes, Stanford Children's Health, Stanford, California, USA
| | - R. Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laya Ekhlaspour
- Pediatric Endocrinology and Diabetes, Stanford Children's Health, Stanford, California, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Carol J. Levy
- Department of Medicine, Endocrinology, Diabetes and Bone Diseases, Mount Sinai Diabetes Center, New York, New York, USA
| | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Craig Kollman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - John W. Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Sue A. Brown
- Endocrinology and Metabolism Division, Department of Medicine, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Lori M. Laffel
- Research Division, Department of Pediatrics, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
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17
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Fuchs J, Hovorka R. Benefits and Challenges of Current Closed-Loop Technologies in Children and Young People With Type 1 Diabetes. Front Pediatr 2021; 9:679484. [PMID: 33996702 PMCID: PMC8119627 DOI: 10.3389/fped.2021.679484] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022] Open
Abstract
Recent advances in diabetes technology have led to the development of closed-loop insulin delivery systems for the management of type 1 diabetes. Several such systems are now commercially available for children and young people. While all available systems have been shown to improve glycaemic control and quality of life in this population, qualitative data also highlights the challenges in using closed-loop systems, which vary among different pediatric age-groups. Very young children require systems that are able to cope with low insulin doses and significant glycaemic variability due to their high insulin sensitivity and unpredictable eating and exercise patterns. Adolescents' compliance is often related to size and number of devices, usability of the systems, need for calibrations, and their ability to interact with the system. Given the speed of innovations, understanding the capabilities and key similarities and differences of current systems can be challenging for healthcare professionals, caregivers and young people with type 1 diabetes alike. The aim of this review is to summarize the key evidence on currently available closed-loop systems for children and young people with type 1 diabetes, as well as commenting on user experience, where real-world data are available. We present findings on a system-basis, as well as identifying specific challenges in different pediatric age-groups and commenting on how current systems might address these. Finally, we identify areas for future research with regards to closed-loop technology tailored for pediatric use and how these might inform reimbursement and alleviate disease burden.
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Affiliation(s)
- Julia Fuchs
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
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18
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O'Malley G, Messer LH, Levy CJ, Pinsker JE, Forlenza GP, Isganaitis E, Kudva YC, Ekhlaspour L, Raghinaru D, Lum J, Brown SA. Clinical Management and Pump Parameter Adjustment of the Control-IQ Closed-Loop Control System: Results from a 6-Month, Multicenter, Randomized Clinical Trial. Diabetes Technol Ther 2021; 23:245-252. [PMID: 33155824 PMCID: PMC8114941 DOI: 10.1089/dia.2020.0472] [Citation(s) in RCA: 6] [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] [Indexed: 12/20/2022]
Abstract
Background: Data are limited on the need for and benefits of pump setting optimization with automated insulin delivery. We examined clinical management of a closed-loop control (CLC) system and its relationship to glycemic outcomes. Materials and Methods: We analyzed personal parameter adjustments in 168 participants in a 6-month multicenter trial of CLC with Control-IQ versus sensor-augmented pump (SAP) therapy. Preset parameters (BR = basal rates, CF = correction factors, CR = carbohydrate ratios) were optimized at randomization, 2 and 13 weeks, for safety issues, participant concerns, or initiation by participants' usual diabetes care team. Time in range (TIR 70-180 mg/dL) was compared in the week before and after parameter changes. Results: In 607 encounters for parameter changes, there were fewer adjustments for CLC than SAP (3.4 vs. 4.1/participant). Adjustments involved BR (CLC 69%, SAP 80%), CR (CLC 68%, SAP 50%), CF (CLC 44%, SAP 41%), and overnight parameters (CLC 62%, SAP 75%). TIR before and after adjustments was 71.2% and 71.3% for CLC and 61.0% and 62.9% for SAP. The highest baseline HbA1c CLC subgroup had the largest TIR improvement (51.2% vs. 57.7%). When a CR was made more aggressive in the CLC group, postprandial time >180 mg/dL was 43.1% before the change and 36.0% after the change. The median postprandial time <70 mg/dL before making CR less aggressive was 1.8%, and after the change was 0.7%. Conclusions: No difference in TIR was detected with parameter changes overall, but they may have an effect in higher HbA1c subgroups or following user-directed boluses, suggesting that changes may matter more in suboptimal control or during discrete periods of the day. Clinical Trials Registration number: NCT03563313.
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Affiliation(s)
- Grenye O'Malley
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Laurel H. Messer
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Carol J. Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | | | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Elvira Isganaitis
- Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Dan Raghinaru
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - John Lum
- Jaeb Center for Health Research, Tampa, Florida, USA
- Address correspondence to: John Lum, MS, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647, USA
| | - Sue A. Brown
- Division of Endocrinology, Department of Medicine, Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
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19
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Palisaitis E, El Fathi A, von Oettingen JE, Haidar A, Legault L. A Meal Detection Algorithm for the Artificial Pancreas: A Randomized Controlled Clinical Trial in Adolescents With Type 1 Diabetes. Diabetes Care 2021; 44:604-606. [PMID: 33277302 DOI: 10.2337/dc20-1232] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/20/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We developed a meal detection algorithm for the artificial pancreas (AP+MDA) that detects unannounced meals and delivers automatic insulin boluses. RESEARCH DESIGN AND METHODS We conducted a randomized crossover trial in 11 adolescents aged 12-18 years with HbA1c ≥7.5% who missed one or more boluses in the past 6 months. We compared 1) continuous subcutaneous insulin infusion (CSII), 2) artificial pancreas (AP), and 3) AP+MDA. Participants underwent three 9-h interventions involving breakfast with a bolus and lunch without a bolus. RESULTS In AP+MDA, the meal detection time was 40.0 (interquartile range 40.0-57.5) min. Compared with CSII, AP+MDA decreased the 4-h postlunch incremental area under the curve (iAUC) from 24.1 ± 9.5 to 15.4 ± 8.0 h ⋅ mmol/L (P = 0.03). iAUC did not differ between AP+MDA and AP (19.6 ± 10.4 h ⋅ mmol/L, P = 0.21) or between AP and CSII (P = 0.33). The AP+MDA reduced time >10 mmol/L (58.0 ± 26.6%) compared with CSII (79.6 ± 27.5%, P = 0.02) and AP (74.2 ± 20.6%, P = 0.047). CONCLUSIONS The AP+MDA improved glucose control after an unannounced meal.
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Affiliation(s)
- Emilie Palisaitis
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Anas El Fathi
- Department of Electrical and Computer Engineering, McGill University, Montreal, Quebec, Canada
| | - Julia E von Oettingen
- Department of Pediatrics, Division of Endocrinology, Montreal Children's Hospital, Montreal, Quebec, Canada.,The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada.,The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Laurent Legault
- Department of Pediatrics, Division of Endocrinology, Montreal Children's Hospital, Montreal, Quebec, Canada .,The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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20
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Kimbell B, Rankin D, Ashcroft NL, Varghese L, Allen JM, Boughton CK, Campbell F, Ghatak A, Randell T, Besser RE, Trevelyan N, Hovorka R, Lawton J. What Training, Support, and Resourcing Do Health Professionals Need to Support People Using a Closed-Loop System? A Qualitative Interview Study with Health Professionals Involved in the Closed Loop from Onset in Type 1 Diabetes (CLOuD) Trial. Diabetes Technol Ther 2020; 22:468-475. [PMID: 32048877 PMCID: PMC7262645 DOI: 10.1089/dia.2019.0466] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: We explored health professionals' views about the training, support, and resourcing needed to support people using closed-loop technology in routine clinical care to help inform the development of formal guidance. Methods: Interviews were conducted with health professionals (n = 22) delivering the Closed Loop from Onset in Type 1 Diabetes (CLOuD) trial after they had ≥6 months' experience of supporting participants using a closed-loop system. Data were analyzed descriptively. Results: Interviewees described how, compared with other insulin regimens, teaching and supporting individuals to use a closed-loop system could be initially more time-consuming. However, they also noted that after an initial adjustment period, users had less need for initiating contact with the clinical team compared with people using pumps or multiple daily injections. Interviewees highlighted how a lessened need for ad hoc clinical input could result in new challenges; specifically, they had fewer opportunities to reinforce users' diabetes knowledge and skills and detect potential psychosocial problems. They also observed heightened anxiety among some parents due to the constant availability of data and unrealistic expectations about the system's capabilities. Interviewees noted that all local diabetes teams should be empowered to deliver closed-loop system care, but stressed that health professionals supporting closed-loop users in routine care will need comprehensive technology training and standardized clinical guidance. Conclusion: These findings constitute an important starting point for the development of formal guidance to support the rollout of closed-loop technology. Our recommendations, if actioned, will help limit the potential additional burden of introducing closed-loop systems in routine clinical care and help inform appropriate user education and support.
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Affiliation(s)
- Barbara Kimbell
- Usher Institute, Medical School, University of Edinburgh, Edinburgh, United Kingdom
- Address correspondence to: Barbara Kimbell, BSc (Hons), MSc, PhD, Usher Institute, Medical School, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, United Kingdom
| | - David Rankin
- Usher Institute, Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - Nicole L. Ashcroft
- Wellcome Trust–Medical Research Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | | | - Janet M. Allen
- Wellcome Trust–Medical Research Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Charlotte K. Boughton
- Wellcome Trust–Medical Research Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | | | - Atrayee Ghatak
- Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | | | - Rachel E.J. Besser
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | - Roman Hovorka
- Wellcome Trust–Medical Research Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Julia Lawton
- Usher Institute, Medical School, University of Edinburgh, Edinburgh, United Kingdom
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21
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Abstract
Technological innovations have fundamentally changed diabetes care. Insulin pump use and continuous glucose monitoring are associated with improved glycemic control along with a better quality of life; automated insulin-dosing advisors facilitate and improve decision making. Glucose-responsive automated insulin delivery enables the highest targets for time in range, lowest rate and duration of hypoglycemia, and favorable quality of life. Clear targets for time in ranges and a standard visualization of the data will help the diabetes technology to be used more efficiently. Decision support systems within and integrated cloud environment will further simplify, unify, and improve modern routine diabetes care.
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Affiliation(s)
- Klemen Dovc
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, Ljubljana SI-1000, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, Ljubljana SI-1000, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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22
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Abstract
The advent of insulin pump therapy marked an important milestone in diabetes treatment in the past few decades and has become the tipping point for the development of automated insulin delivery systems (AID). Standalone insulin pump systems have evolved over the course of years and have been replaced by modern high-technology insulin pumps with continuous glucose monitor interface allowing real-time insulin dose adjustment to optimize treatment. This review summarizes evidence from AID studies conducted in children with type 1 diabetes and discusses the outlook for future generation AID systems from a pediatric treatment perspective.
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Affiliation(s)
- Eda Cengiz
- Yale School of Medicine, 333 Cedar Street, PO Box 208064, New Haven, CT 06520, USA; Bahçeşehir Üniversitesi, Istanbul, Turkey.
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23
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Toffanin C, Kozak M, Sumnik Z, Cobelli C, Petruzelkova L. In Silico Trials of an Open-Source Android-Based Artificial Pancreas: A New Paradigm to Test Safety and Efficacy of Do-It-Yourself Systems. Diabetes Technol Ther 2020; 22:112-120. [PMID: 31769699 DOI: 10.1089/dia.2019.0375] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: Safety data on Do-It-Yourself Artificial Pancreas Systems are missing. The most widespread in Europe is the AndroidAPS implementation of the OpenAPS algorithm. We used the UVA/Padova Type 1 Diabetes Simulator to in silico test safety and efficacy of this algorithm in different scenarios. Methods: We tested five configurations of the AndroidAPS algorithm differing in aggressiveness and patient's interaction with the system. All configurations were tested with insulin sensitivity variation of ±30%. The most promising configurations were tested in real-life scenarios: over- and underestimated bolus by 50%, bolus delivered 15 min before meal, and late bolus delivered 15 min after meal. Continuous Glucose Monitoring (CGM) time in ranges (TIRs) metrics were used to assess the glycemic control. Results: In silico testing showed that open-source closed-loop system AndroidAPS works effectively and safely. The best results were reached if AndroidAPS algorithm worked with microboluses and when half of calculated bolus was issued (mean glycemia 131 mg/dL, SD 27 mg/dL, TIR 91%, time between 54 and 70 mg/dL <1%, and low blood glucose index even <1). The meal bolus over- and underestimation as well as late bolus did not affect the TIR and, importantly, the time between 54 and 70 mg/dL. Conclusion: In silico testing proved that AndroidAPS implementation of the OpenAPS algorithm is safe and effective, and it showed a great potential to be tested in prospective home setting study.
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Affiliation(s)
- Chiara Toffanin
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Milos Kozak
- CLOSED LOOP Systems, Prague, Czech Republic, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Paediatrics, Motol University Hospital, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Lenka Petruzelkova
- Department of Paediatrics, Motol University Hospital, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
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24
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Messer LH, Berget C, Forlenza GP. A Clinical Guide to Advanced Diabetes Devices and Closed-Loop Systems Using the CARES Paradigm. Diabetes Technol Ther 2019; 21:462-469. [PMID: 31140878 PMCID: PMC6653788 DOI: 10.1089/dia.2019.0105] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Laurel H. Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
- Address correspondence to: Laurel H. Messer, RN, MPH, CDE, Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, 1775 Aurora CT MS A140, Aurora, CO 80045
| | - Cari Berget
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
| | - Gregory P. Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
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25
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Abstract
Over the past 50 years, the diabetes technology field progressed remarkably through self-monitoring of blood glucose (SMBG), continuous subcutaneous insulin infusion (CSII), risk and variability analysis, mathematical models and computer simulation of the human metabolic system, real-time continuous glucose monitoring (CGM), and control algorithms driving closed-loop control systems known as the "artificial pancreas" (AP). This review follows these developments, beginning with an overview of the functioning of the human metabolic system in health and in diabetes and of its detailed quantitative network modeling. The review continues with a brief account of the first AP studies that used intravenous glucose monitoring and insulin infusion, and with notes about CSII and CGM-the technologies that made possible the development of contemporary AP systems. In conclusion, engineering lessons learned from AP research, and the clinical need for AP systems to prove their safety and efficacy in large-scale clinical trials, are outlined.
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Affiliation(s)
- Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia 22908
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26
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Lawton J, Blackburn M, Rankin D, Allen J, Campbell F, Leelarathna L, Tauschmann M, Thabit H, Wilinska ME, Hovorka R. The impact of using a closed-loop system on food choices and eating practices among people with Type 1 diabetes: a qualitative study involving adults, teenagers and parents. Diabet Med 2019; 36:753-760. [PMID: 30575114 PMCID: PMC6510609 DOI: 10.1111/dme.13887] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2018] [Indexed: 01/11/2023]
Abstract
AIMS We explored whether, how and why moving onto and using a hybrid day-and-night closed-loop system affected people's food choices and dietary practices to better understand the impact of this technology on everyday life and inform recommendations for training and support given to future users. METHODS Twenty-four adults, adolescents and parents were interviewed before commencing use of the closed-loop system and following its 3-month use. Data were analysed thematically and longitudinally. RESULTS While participants described preparing and/or eating similar meals to those consumed prior to using a closed-loop, many described feeling more normal and less burdened by diabetes in dietary situations. Individuals also noted how the use of this technology could lead to deskilling (less precise carbohydrate counting) and less healthy eating (increased snacking and portion sizes and consumption of fatty, energy-dense foods) because of the perceived ability of the system to deal with errors in carbohydrate counting and address small rises in blood glucose without a corrective dose needing to be administered. CONCLUSIONS While there may be quality-of-life benefits to using a closed-loop, individuals might benefit from additional nutritional and behavioural education to help promote healthy eating. Refresher training in carbohydrate counting may also be necessary to help ensure that users are able to undertake diabetes management in situations where the technology might fail or that they take a break from using it.
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Affiliation(s)
- J. Lawton
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - M. Blackburn
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - D. Rankin
- Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
| | - J. Allen
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | | | - L. Leelarathna
- Manchester Diabetes CentreManchester University NHS Foundation Trust and University of ManchesterManchester Academic Health Science CentreManchesterUK
| | - M. Tauschmann
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | - H. Thabit
- Manchester Diabetes CentreManchester University NHS Foundation Trust and University of ManchesterManchester Academic Health Science CentreManchesterUK
| | - M. E. Wilinska
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
| | - R. Hovorka
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Department of PaediatricsUniversity of CambridgeCambridgeUK
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Lawton J, Blackburn M, Rankin D, Allen JM, Campbell FM, Leelarathna L, Tauschmann M, Thabit H, Wilinska ME, Elleri D, Hovorka R. Participants' Experiences of, and Views About, Daytime Use of a Day-and-Night Hybrid Closed-Loop System in Real Life Settings: Longitudinal Qualitative Study. Diabetes Technol Ther 2019; 21:119-127. [PMID: 30720338 PMCID: PMC6434584 DOI: 10.1089/dia.2018.0306] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To explore individuals' experiences of daytime use of a day-and-night hybrid closed-loop system, their information and support needs, and their views about how future systems could be improved. RESEARCH DESIGN AND METHODS Twenty-four adults, adolescents, and parents were interviewed before using a hybrid day-and-night closed-loop system and 3 months later, data were analyzed thematically. RESULTS Participants praised the closed loop's ability to respond to high and low blood glucose in ways which extended beyond their own capabilities and to act as a safety net and mop up errors, such as when a mealtime bolus was forgotten or unplanned activity was undertaken. Participants also described feeling less burdened by diabetes as a consequence and more able to lead flexible, spontaneous lives. Contrary to their initial expectations, and after trust in the system had been established, most individuals wanted opportunities to collaborate with the closed loop to optimize its effectiveness. Such individuals expressed a need to communicate information, such as when routines changed or to indicate different intensities of physical activity. While individuals valued frequent contact with staff in the initial month of use, most felt that their long-term support needs would be no greater than when using an insulin pump. CONCLUSIONS While participants reported substantial benefits to using the closed loop during the day, they also identified ways in which the technology could be refined and education and training tailored to optimize effective use. Our findings suggest that mainstreaming this technology will not necessarily lead to increased demands on clinical staff.
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Affiliation(s)
- Julia Lawton
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
- Address correspondence to: Julia Lawton, PhD, Usher Institute of Population Health Sciences and Informatics, Medical School, University of Edinburgh, Edinburgh EH8 9AG, United Kingdom
| | - Maxine Blackburn
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - David Rankin
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Janet M. Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | | | - Lalantha Leelarathna
- Manchester Diabetes Center, Manchester Academic Health Science Center, Manchester University NHS Foundation Trust, University of Manchester, Manchester, United Kingdom
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Hood Thabit
- Manchester Diabetes Center, Manchester Academic Health Science Center, Manchester University NHS Foundation Trust, University of Manchester, Manchester, United Kingdom
| | - Malgorzata E. Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Daniela Elleri
- Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
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28
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Anderson SM, Dassau E, Raghinaru D, Lum J, Brown SA, Pinsker JE, Church MM, Levy C, Lam D, Kudva YC, Buckingham B, Forlenza GP, Wadwa RP, Laffel L, Doyle FJ, DeVries JH, Renard E, Cobelli C, Boscari F, Del Favero S, Kovatchev BP. The International Diabetes Closed-Loop Study: Testing Artificial Pancreas Component Interoperability. Diabetes Technol Ther 2019; 21:73-80. [PMID: 30649925 PMCID: PMC6354594 DOI: 10.1089/dia.2018.0308] [Citation(s) in RCA: 10] [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] [Indexed: 01/18/2023]
Abstract
BACKGROUND Use of artificial pancreas (AP) requires seamless interaction of device components, such as continuous glucose monitor (CGM), insulin pump, and control algorithm. Mobile AP configurations also include a smartphone as computational hub and gateway to cloud applications (e.g., remote monitoring and data review and analysis). This International Diabetes Closed-Loop study was designed to demonstrate and evaluate the operation of the inControl AP using different CGMs and pump modalities without changes to the user interface, user experience, and underlying controller. METHODS Forty-three patients with type 1 diabetes (T1D) were enrolled at 10 clinical centers (7 United States, 3 Europe) and 41 were included in the analyses (39% female, >95% non-Hispanic white, median T1D duration 16 years, median HbA1c 7.4%). Two CGMs and two insulin pumps were tested by different study participants/sites using the same system hub (a smartphone) during 2 weeks of in-home use. RESULTS The major difference between the system components was the stability of their wireless connections with the smartphone. The two sensors achieved similar rates of connectivity as measured by percentage time in closed loop (75% and 75%); however, the two pumps had markedly different closed-loop adherence (66% vs. 87%). When connected, all system configurations achieved similar glycemic outcomes on AP control (73% [mean] time in range: 70-180 mg/dL, and 1.7% [median] time <70 mg/dL). CONCLUSIONS CGMs and insulin pumps can be interchangeable in the same Mobile AP system, as long as these devices achieve certain levels of reliability and wireless connection stability.
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Affiliation(s)
- Stacey M. Anderson
- Center for Diabetes Technology, Department of Medicine, University of Virginia
- Address correspondence to: Stacey M. Anderson, MD, Center for Diabetes Technology, Department of Medicine, University of Virginia, PO Box 400888, Charlottesville, VA 22903
| | - Eyal Dassau
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
- Sansum Diabetes Research Institute, Santa Barbara, California
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | | | - John Lum
- Jaeb Center for Health Research, Tampa, Florida
| | - Sue A. Brown
- Center for Diabetes Technology, Department of Medicine, University of Virginia
| | | | - Mei Mei Church
- Sansum Diabetes Research Institute, Santa Barbara, California
| | - Carol Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - David Lam
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Yogish C. Kudva
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bruce Buckingham
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - R. Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Lori Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Francis J. Doyle
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - J. Hans DeVries
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- INSERM 1411 Clinical Investigation Center, Institute of Functional Genomics, UMR CNRS 5203/INSERM U1191, University of Montpellier, Montpellier, France
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Simone Del Favero
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Boris P. Kovatchev
- Center for Diabetes Technology, Department of Medicine, University of Virginia
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29
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Karageorgiou V, Papaioannou TG, Bellos I, Alexandraki K, Tentolouris N, Stefanadis C, Chrousos GP, Tousoulis D. Effectiveness of artificial pancreas in the non-adult population: A systematic review and network meta-analysis. Metabolism 2019; 90:20-30. [PMID: 30321535 DOI: 10.1016/j.metabol.2018.10.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/20/2018] [Accepted: 10/09/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Artificial pancreas is a technology that minimizes user input by bridging continuous glucose monitoring and insulin pump treatment, and has proven safety in the adult population. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of closed-loop (CL) systems in the glycemic control of non-adult type 1 diabetes patients in both a pairwise and network meta-analysis (NMA) context and investigate various parameters potentially affecting the outcome. METHODS Literature was systematically searched using the MEDLINE (1966-2018), Scopus (2004-2018), Cochrane Central Register of Controlled Trials (CENTRAL) (1999-2018), Clinicaltrials.gov (2008-2018) and Google Scholar (2004-2018) databases. Studies comparing the glycemic control in CL (either single- or dual-hormone) with continuous subcutaneous insulin infusion (CSII) in people with diabetes (PWD) aged <18 years old were deemed eligible. The primary outcome analysis was conducted with regard to time spent in the target glycemic range. All outcomes were evaluated in NMA in order to investigate potential between-algorithm differences. Pairwise meta-analysis and meta-regression were performed using the RevMan 5.3 and Open Meta-Analyst software. For NMA, the package pcnetmetain R 3.5.1 was used. RESULTS The meta-analysis was based on 25 studies with a total of 504 PWD. The CL group was associated with significantly higher percentage of time spent in the target glycemic range (Mean (SD): 67.59% (SD: 8.07%) in the target range and OL PWD spending 55.77% (SD: 11.73%), MD: -11.97%, 95% CI [-18.40, -5.54%]) and with lower percentages of time in hyperglycemia (MD: 3.01%, 95% CI [1.68, 4.34%]) and hypoglycemia (MD: 0.67%, 95% CI [0.21, 1.13%]. Mean glucose was also decreased in the CL group (MD: 0.75 mmol/L, 95% CI [0.18-1.33]). The NMA arm of the study showed that the bihormonal modality was superior to other algorithms and standard treatment in lowering mean glucose and increasing time spent in the target range. The DiAs platform was superior to PID in controlling hypoglycemia and mean glucose. Time in target range and mean glucose were unaffected by the confounding factors tested. CONCLUSIONS The findings of this meta-analysis suggest that artificial pancreas systems are superior to the standard sensor-augmented pump treatment of type 1 diabetes mellitus in non-adult PWD. Between-algorithm differences are also addressed, implying a superiority of the bihormonal treatment modality. Future large-scale studies are needed in the field to verify these outcomes and to determine the optimal algorithm to be used in the clinical setting.
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Affiliation(s)
- Vasilios Karageorgiou
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros G Papaioannou
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Ioannis Bellos
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Krystallenia Alexandraki
- Clinic of Endocrine Oncology, Section of Endocrinology, Department of Pathophysiology, Laiko Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - George P Chrousos
- First Department of Pediatrics, Aghia Sophia Children's Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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30
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Kovatchev B. Automated closed-loop control of diabetes: the artificial pancreas. Bioelectron Med 2018; 4:14. [PMID: 32232090 PMCID: PMC7098217 DOI: 10.1186/s42234-018-0015-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/08/2018] [Indexed: 12/28/2022] Open
Abstract
The incidence of Diabetes Mellitus is on the rise worldwide, which exerts enormous health toll on the population and enormous pressure on the healthcare systems. Now, almost hundred years after the discovery of insulin in 1921, the optimization problem of diabetes is well formulated as maintenance of strict glycemic control without increasing the risk for hypoglycemia. External insulin administration is mandatory for people with type 1 diabetes; various medications, as well as basal and prandial insulin, are included in the daily treatment of type 2 diabetes. This review follows the development of the Diabetes Technology field which, since the 1970s, progressed remarkably through continuous subcutaneous insulin infusion (CSII), mathematical models and computer simulation of the human metabolic system, real-time continuous glucose monitoring (CGM), and control algorithms driving closed-loop control systems known as the "artificial pancreas" (AP). All of these developments included significant engineering advances and substantial bioelectronics progress in the sensing of blood glucose levels, insulin delivery, and control design. The key technologies that enabled contemporary AP systems are CSII and CGM, both of which became available and sufficiently portable in the beginning of this century. This powered the quest for wearable home-use AP, which is now under way with prototypes tested in outpatient studies during the past 6 years. Pivotal trials of new AP technologies are ongoing, and the first hybrid closed-loop system has been approved by the FDA for clinical use. Thus, the closed-loop AP is well on its way to become the digital-age treatment of diabetes.
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Affiliation(s)
- Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, P.O. Box 400888, Charlottesville, VA 22908 USA
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Buckingham BA, Christiansen MP, Forlenza GP, Wadwa RP, Peyser TA, Lee JB, O'Connor J, Dassau E, Huyett LM, Layne JE, Ly TT. Performance of the Omnipod Personalized Model Predictive Control Algorithm with Meal Bolus Challenges in Adults with Type 1 Diabetes. Diabetes Technol Ther 2018; 20:585-595. [PMID: 30070928 PMCID: PMC6114075 DOI: 10.1089/dia.2018.0138] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND This study assessed the safety and performance of the Omnipod® personalized model predictive control (MPC) algorithm using an investigational device in adults with type 1 diabetes in response to overestimated and missed meal boluses and extended boluses for high-fat meals. MATERIALS AND METHODS A supervised 54-h hybrid closed-loop (HCL) study was conducted in a hotel setting after a 7-day outpatient open-loop run-in phase. Adults aged 18-65 years with type 1 diabetes and HbA1c 6.0%-10.0% were eligible. Primary endpoints were percentage time in hypoglycemia <70 mg/dL and hyperglycemia ≥250 mg/dL. Glycemic responses for 4 h to a 130% overestimated bolus and a missed meal bolus were compared with a 100% bolus for identical meals, respectively. The 12-h postprandial responses to a high-fat meal were compared using either a standard or extended bolus. RESULTS Twelve subjects participated in the study, with (mean ± standard deviation): age 35.4 ± 14.1 years, diabetes duration 16.5 ± 9.3 years, HbA1c 7.7 ± 0.9%, and total daily dose 0.58 ± 0.19 U/kg. Outcomes for the 54-h HCL period were mean glucose 153 ± 15 mg/dL, percentage time <70 mg/dL [median (interquartile range)]: 0.0% (0.0-1.2%), 70-180 mg/dL: 76.1% ± 8.0%, and ≥250 mg/dL: 4.5% ± 3.6%. After both the 100% and 130% boluses, postprandial percentage time <70 mg/dL was 0.0% (0.0-0.0%) (P = 0.50). After the 100% and missed boluses, postprandial percentage time ≥250 mg/dL was 0.2% ± 0.6% and 10.3% ± 16.5%, respectively (P = 0.06). Postprandial percentages time ≥250 mg/dL and <70 mg/dL were similar with standard or extended boluses for a high-fat meal. CONCLUSIONS The Omnipod personalized MPC algorithm performed well and was safe during day and night use in response to overestimated, missed, and extended meal boluses in adults with type 1 diabetes.
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Affiliation(s)
- Bruce A. Buckingham
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Address correspondence to:Bruce A. Buckingham, MDDivision of Endocrinology and DiabetesStanford School of Medicine780 Welch RoadPalo Alto, CA 94305
| | | | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - R. Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | | | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | | | | | - Trang T. Ly
- Insulet Corporation, Billerica, Massachusetts
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32
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Majeed W, Thabit H. Closed-loop insulin delivery: current status of diabetes technologies and future prospects. Expert Rev Med Devices 2018; 15:579-590. [PMID: 30027775 DOI: 10.1080/17434440.2018.1503530] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Type 1 diabetes is characterised by destruction of pancreatic beta cells, leading to insulin deficiency and hyperglycaemia. The mainstay of treatment remains lifelong insulin therapy as a sustainable cure has as yet proven elusive. The burden of daily management of type 1 diabetes has contributed to suboptimal outcomes for people living with the condition. Innovative technological approaches have been shown to improve glycaemic and patient-related outcomes. AREAS COVERED We discuss recent advances in technologies in type 1 diabetes including closed-loop systems, also known as the 'artificial pancreas. Its various components, technical aspects and limitations are reviewed. We also discuss its advent into clinical practice, and other systems in development. Evidence from clinical studies are summarised. EXPERT COMMENTARY The recent approval of a hybrid closed-loop system for clinical use highlights the significant progress made in this field. Results from clinical studies have shown safety and glycaemic benefit, however challenges remain around improving performance and acceptability. More data is required to establish long-term clinical efficacy and cost-effectiveness, to fulfil the expectations of people with type 1 diabetes.
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Affiliation(s)
- Waseem Majeed
- a Manchester Academic Health Science Centre , Manchester University Hospitals NHS Foundation Trust , Manchester , UK
| | - Hood Thabit
- a Manchester Academic Health Science Centre , Manchester University Hospitals NHS Foundation Trust , Manchester , UK.,b Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
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33
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Forlenza GP, Cameron FM, Ly TT, Lam D, Howsmon DP, Baysal N, Kulina G, Messer L, Clinton P, Levister C, Patek SD, Levy CJ, Wadwa RP, Maahs DM, Bequette BW, Buckingham BA. Fully Closed-Loop Multiple Model Probabilistic Predictive Controller Artificial Pancreas Performance in Adolescents and Adults in a Supervised Hotel Setting. Diabetes Technol Ther 2018; 20:335-343. [PMID: 29658779 PMCID: PMC5963546 DOI: 10.1089/dia.2017.0424] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Initial Food and Drug Administration-approved artificial pancreas (AP) systems will be hybrid closed-loop systems that require prandial meal announcements and will not eliminate the burden of premeal insulin dosing. Multiple model probabilistic predictive control (MMPPC) is a fully closed-loop system that uses probabilistic estimation of meals to allow for automated meal detection. In this study, we describe the safety and performance of the MMPPC system with announced and unannounced meals in a supervised hotel setting. RESEARCH DESIGN AND METHODS The Android phone-based AP system with remote monitoring was tested for 72 h in six adults and four adolescents across three clinical sites with daily exercise and meal challenges involving both three announced (manual bolus by patient) and six unannounced (no bolus by patient) meals. Safety criteria were predefined. Controller aggressiveness was adapted daily based on prior hypoglycemic events. RESULTS Mean 24-h continuous glucose monitor (CGM) was 157.4 ± 14.4 mg/dL, with 63.6 ± 9.2% of readings between 70 and 180 mg/dL, 2.9 ± 2.3% of readings <70 mg/dL, and 9.0 ± 3.9% of readings >250 mg/dL. Moderate hyperglycemia was relatively common with 24.6 ± 6.2% of readings between 180 and 250 mg/dL, primarily within 3 h after a meal. Overnight mean CGM was 139.6 ± 27.6 mg/dL, with 77.9 ± 16.4% between 70 and 180 mg/dL, 3.0 ± 4.5% <70 mg/dL, 17.1 ± 14.9% between 180 and 250 mg/dL, and 2.0 ± 4.5%> 250 mg/dL. Postprandial hyperglycemia was more common for unannounced meals compared with announced meals (4-h postmeal CGM 197.8 ± 44.1 vs. 140.6 ± 35.0 mg/dL; P < 0.001). No participants met safety stopping criteria. CONCLUSIONS MMPPC was safe in a supervised setting despite meal and exercise challenges. Further studies are needed in a less supervised environment.
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Affiliation(s)
| | - Faye M. Cameron
- Department of Chemical and Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York
| | - Trang T. Ly
- Division of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - David Lam
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Daniel P. Howsmon
- Department of Chemical and Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York
| | - Nihat Baysal
- Department of Chemical and Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York
| | - Georgia Kulina
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Laurel Messer
- Division of Pediatric Endocrinology, Barbara Davis Center, Aurora, Colorado
| | - Paula Clinton
- Division of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - Camilla Levister
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Stephen D. Patek
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Carol J. Levy
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - R. Paul Wadwa
- Division of Pediatric Endocrinology, Barbara Davis Center, Aurora, Colorado
| | - David M. Maahs
- Division of Pediatric Endocrinology, Barbara Davis Center, Aurora, Colorado
- Division of Pediatric Endocrinology, Stanford University, Palo Alto, California
| | - B. Wayne Bequette
- Department of Chemical and Biomedical Engineering, Rensselaer Polytechnic Institute, Troy, New York
| | - Bruce A. Buckingham
- Division of Pediatric Endocrinology, Stanford University, Palo Alto, California
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Bekiari E, Kitsios K, Thabit H, Tauschmann M, Athanasiadou E, Karagiannis T, Haidich AB, Hovorka R, Tsapas A. Artificial pancreas treatment for outpatients with type 1 diabetes: systematic review and meta-analysis. BMJ 2018; 361:k1310. [PMID: 29669716 PMCID: PMC5902803 DOI: 10.1136/bmj.k1310] [Citation(s) in RCA: 254] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of artificial pancreas treatment in non-pregnant outpatients with type 1 diabetes. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, Cochrane Library, and grey literature up to 2 February 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials in non-pregnant outpatients with type 1 diabetes that compared the use of any artificial pancreas system with any type of insulin based treatment. Primary outcome was proportion (%) of time that sensor glucose level was within the near normoglycaemic range (3.9-10 mmol/L). Secondary outcomes included proportion (%) of time that sensor glucose level was above 10 mmol/L or below 3.9 mmol/L, low blood glucose index overnight, mean sensor glucose level, total daily insulin needs, and glycated haemoglobin. The Cochrane Collaboration risk of bias tool was used to assess study quality. RESULTS 40 studies (1027 participants with data for 44 comparisons) were included in the meta-analysis. 35 comparisons assessed a single hormone artificial pancreas system, whereas nine comparisons assessed a dual hormone system. Only nine studies were at low risk of bias. Proportion of time in the near normoglycaemic range (3.9-10.0 mmol/L) was significantly higher with artificial pancreas use, both overnight (weighted mean difference 15.15%, 95% confidence interval 12.21% to 18.09%) and over a 24 hour period (9.62%, 7.54% to 11.7%). Artificial pancreas systems had a favourable effect on the proportion of time with sensor glucose level above 10 mmol/L (-8.52%, -11.14% to -5.9%) or below 3.9 mmol/L (-1.49%, -1.86% to -1.11%) over 24 hours, compared with control treatment. Robustness of findings for the primary outcome was verified in sensitivity analyses, by including only trials at low risk of bias (11.64%, 9.1% to 14.18%) or trials under unsupervised, normal living conditions (10.42%, 8.63% to 12.2%). Results were consistent in a subgroup analysis both for single hormone and dual hormone artificial pancreas systems. CONCLUSIONS Artificial pancreas systems are an efficacious and safe approach for treating outpatients with type 1 diabetes. The main limitations of current research evidence on artificial pancreas systems are related to inconsistency in outcome reporting, small sample size, and short follow-up duration of individual trials.
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Affiliation(s)
- Eleni Bekiari
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Konstantinos Kitsios
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Eleni Athanasiadou
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Thomas Karagiannis
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Department of Hygiene and Epidemiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Apostolos Tsapas
- Clinical Research and Evidence Based Medicine Unit, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
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Gingras V, Smaoui MR, Cameli C, Messier V, Ladouceur M, Legault L, Rabasa-Lhoret R. Impact of erroneous meal insulin bolus with dual-hormone artificial pancreas using a simplified bolus strategy - A randomized controlled trial. Sci Rep 2018; 8:2621. [PMID: 29422651 PMCID: PMC5805693 DOI: 10.1038/s41598-018-20785-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 01/22/2018] [Indexed: 01/12/2023] Open
Abstract
Postprandial glucose control remains challenging for patients with type 1 diabetes (T1D). A simplified meal bolus approach with a dual-hormone (insulin and glucagon) closed-loop system (DH-CLS) has been tested; yet, the impact of categorization errors with this strategy is unknown. The objective was to compare, in a randomized controlled inpatient trial, DH-CLS with the simplified meal bolus approach for two different meals properly categorized or overestimated. We tested, in patients with T1D, the simplified strategy with two standardized breakfasts (n = 10 per meal) adequately categorized or overestimated: (1) 75 g and (2) 45 g of carbohydrate. No difference was observed for percentage of time <4.0 mmol/L over a 4-hour post-meal period (primary outcome; median [IQR]: 0[0-0] vs. 0[0-0] for both comparisons, p = 0.47 and 0.31 for the 75 g and 45 g meals, respectively). Despite higher meal insulin boluses with overestimation for both meals (9.2 [8.2-9.6] vs. 8.1 [7.3-9.1] U and 8.4 [7.2-10.4] vs. 4.8 [3.7-5.6] U; p < 0.05), mean glycemia, percentage of time in target range and glucagon infusion did not differ. Additional scenarios were tested in silico with comparable results. These results suggest that the DH-CLS with a simplified meal bolus calculation is probably able to avoid hypoglycemia in the event of meal size misclassification.
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Affiliation(s)
- Véronique Gingras
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Mohamed Raef Smaoui
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Charlotte Cameli
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Université de Rennes 1, Rennes, France
| | - Virginie Messier
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
| | - Martin Ladouceur
- Research Center of the Université de Montréal Hospital Center (CRCHUM), Montreal, Quebec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada.
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada.
- Université de Rennes 1, Rennes, France.
- Montreal Diabetes Research Center (MDRC), Montreal, Quebec, Canada.
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Gingras V, Taleb N, Roy-Fleming A, Legault L, Rabasa-Lhoret R. The challenges of achieving postprandial glucose control using closed-loop systems in patients with type 1 diabetes. Diabetes Obes Metab 2018; 20:245-256. [PMID: 28675686 PMCID: PMC5810921 DOI: 10.1111/dom.13052] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/27/2017] [Accepted: 06/29/2017] [Indexed: 01/17/2023]
Abstract
For patients with type 1 diabetes, closed-loop delivery systems (CLS) combining an insulin pump, a glucose sensor and a dosing algorithm allowing a dynamic hormonal infusion have been shown to improve glucose control when compared with conventional therapy. Yet, reducing glucose excursion and simplification of prandial insulin doses remain a challenge. The objective of this literature review is to examine current meal-time strategies in the context of automated delivery systems in adults and children with type 1 diabetes. Current challenges and considerations for post-meal glucose control will also be discussed. Despite promising results with meal detection, the fully automated CLS has yet failed to provide comparable glucose control to CLS with carbohydrate-matched bolus in the post-meal period. The latter strategy has been efficient in controlling post-meal glucose using different algorithms and in various settings, but at the cost of a meal carbohydrate counting burden for patients. Further improvements in meal detection algorithms or simplified meal-priming boluses may represent interesting avenues. The greatest challenges remain in regards to the pharmacokinetic and dynamic profiles of available rapid insulins as well as sensor accuracy and lag-time. New and upcoming faster acting insulins could provide important benefits. Multi-hormone CLS (eg, dual-hormone combining insulin with glucagon or pramlintide) and adjunctive therapy (eg, GLP-1 and SGLT2 inhibitors) also represent promising options. Meal glucose control with the artificial pancreas remains an important challenge for which the optimal strategy is still to be determined.
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Affiliation(s)
- Véronique Gingras
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Nadine Taleb
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of biomedical sciences, Université de Montréal, Montreal, Quebec, Canada
| | - Amélie Roy-Fleming
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Legault
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de Recherches Cliniques de Montréal, Montreal, Quebec, Canada
- Department of nutrition, Université de Montréal, Montreal, Quebec, Canada
- Montreal Diabetes Research Center (MDRC), Montreal, Quebec, Canada
- Research Center of the Université de Montréal Hospital Center (CRCHUM), Montreal, Quebec, Canada
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Messer LH, Forlenza GP, Wadwa RP, Weinzimer SA, Sherr JL, Hood KK, Buckingham BA, Slover RH, Maahs DM. The dawn of automated insulin delivery: A new clinical framework to conceptualize insulin administration. Pediatr Diabetes 2018; 19:14-17. [PMID: 28656656 DOI: 10.1111/pedi.12535] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/29/2017] [Accepted: 03/29/2017] [Indexed: 01/19/2023] Open
Affiliation(s)
- Laurel H Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
| | - Gregory P Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
| | - R Paul Wadwa
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
| | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer L Sherr
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Korey K Hood
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Bruce A Buckingham
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Robert H Slover
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, Colorado
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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DeBoer MD, Cherñavvsky DR, Topchyan K, Kovatchev BP, Francis GL, Breton MD. Heart rate informed artificial pancreas system enhances glycemic control during exercise in adolescents with T1D. Pediatr Diabetes 2017; 18:540-546. [PMID: 27734563 DOI: 10.1111/pedi.12454] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the safety and performance of using a heart rate (HR) monitor to inform an artificial pancreas (AP) system during exercise among adolescents with type 1 diabetes (T1D). MATERIALS AND METHODS In a randomized, cross-over trial, adolescents with T1D age 13 - 18 years were enrolled to receive on separate days either the unmodified UVa AP (stdAP) or an AP system connected to a portable HR monitor (AP-HR) that triggered an exercise algorithm for blood glucose (BG) control. During admissions participants underwent a structured exercise regimen. Hypoglycemic events and CGM tracings were compared between the two admissions, during exercise and for the full 24-hour period. RESULTS Eighteen participants completed the trial. While number of hypoglycemic events during exercise and rest was not different between visits (0.39 AP-HR vs 0.50 stdAP), time below 70 mg dL -1 was lower on AP-HR compared to stdAP, 0.5±2.1% vs 7.4±12.5% (P = 0.028). Time with BG within 70-180 mg dL -1 was higher for the AP-HR admission vs stdAP during the exercise portion and overall (96% vs 87%, and 77% vs 74%), but these did not reach statistical significance (P = 0.075 and P = 0.366). CONCLUSIONS Heart rate signals can safely and efficaciously be integrated in a wireless AP system to inform of physical activity. While exercise contributes to hypoglycemia among adolescents, even when using an AP system, informing the system of exercise via a HR monitor improved time <70 mg dL -1 . Nonetheless, it did not significantly reduce the total number of hypoglycemic events, which were low in both groups.
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Affiliation(s)
- Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia.,Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Daniel R Cherñavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Katarina Topchyan
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Boris P Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Gary L Francis
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia.,Division of Pediatric Endocrinology, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
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Gildersleeve R, Riggs SL, Cherñavvsky DR, Breton MD, DeBoer MD. Improving the Safety and Functionality of an Artificial Pancreas System for Use in Younger Children: Input from Parents and Physicians. Diabetes Technol Ther 2017; 19:660-674. [PMID: 28854339 DOI: 10.1089/dia.2017.0150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Artificial pancreas (AP) systems have initially been designed for and tested in teens and adults, but there is evidence that an AP system with additional support and safety systems could greatly benefit younger children with type 1 diabetes (T1D). SUBJECTS AND METHODS Five pediatric endocrinologists and 15 parents of children aged 5-8 years with T1D participated in a total of four focus groups. Focus groups investigated current diabetes technology use and acceptance, as well as possible modifications to the current adult AP system, which would allow for safe and successful use in younger children. Modifications discussed include child-specific functionality for input tasks, safety features, and monitoring capabilities. RESULTS Participant suggestions included the following: passcodes for differential access to AP features by parents, ancillary caregivers, and the child; preset early, intermediate, and advanced child access categories; maximal customization for general and alarm settings; simplified meal screens utilizing the AP' corrective blood glucose (BG) ability; automated exercise mode; spoken and dictated messaging capabilities; emergency contacts; treatment instructions for the child and caregiver; remote monitoring website and application; animated continuous glucose monitor BG trace; gamification, such as rewarding diabetes-friendly behaviors; and comprehensive training of all individuals involved in the child's diabetes care. CONCLUSION Parents and physicians were eager for AP applications to be available for younger children, but stressed that a modified system could better serve this group's needs for safety and improved diabetes-related communication. The diverse and emerging needs of 5-8-year olds require flexible and customizable systems for T1D management.
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Affiliation(s)
- Rachel Gildersleeve
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Sara L Riggs
- 2 Department of Industrial Engineering, Clemson University , Clemson, South Carolina
| | - Daniel R Cherñavvsky
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 3 TypeZero Technologies, Inc. , Charlottesville, Virginia
| | - Marc D Breton
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 3 TypeZero Technologies, Inc. , Charlottesville, Virginia
| | - Mark D DeBoer
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 4 Department of Pediatrics, Division of Pediatric Endocrinology, University of Virginia , Charlottesville, Virginia
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Messer LH, Calhoun P, Buckingham B, Wilson D, Hramiak I, Ly T, Driscoll M, Clinton P, Maahs DM. In-home nighttime predictive low glucose suspend experience in children and adults with type 1 diabetes. Pediatr Diabetes 2017; 18:332-339. [PMID: 27125223 PMCID: PMC5086306 DOI: 10.1111/pedi.12395] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/25/2016] [Accepted: 04/06/2016] [Indexed: 01/15/2023] Open
Abstract
Overnight predictive low glucose suspend (PLGS) reduces hypoglycemia across all ages; however, there are no reports on behavior or experience differences across age groups, especially in pediatrics. As run-in for a subsequent randomized clinical trial (RCT), 127 subjects (50% male) ages 4-45 yr utilized the experimental PLGS system nightly for 5-10 nights (PLGS active phase). We analyzed the number of blood glucose (BG) checks and boluses given per age group. During the subsequent 42 night RCT phase, we analyzed sensor use, skin reactions, errors, and reasons why the experimental system was not used. In 821 nights of active PLGS, subjects ages 4-6 yr (and their parents) tested BG levels 75% of nights compared with 65% of nights (7-10 yr), 53% of nights (11-14 yr), 33% of nights (15-25 yr), and 28% of nights (26-45 yr), respectively (p < 0.001). Likewise, youngest subjects (and parents) administered insulin boluses 56% of nights during active PLGS use compared with 48%, 33%, 20%, and 25%, respectively (p < 0.001). This was unrelated to study requirements. During the RCT phase, subjects 4-6 yr experienced more frequent and severe skin reactions (p = 0.02), while adult subjects (26-45 yr) wore individual sensors a median of 26 h longer than the youngest subjects (p < 0.001). Technical problems with the sensor (errors, miscalibrations, etc.), traveling, and BG levels >270 at bedtime (study requirement) were primary contributors to non-system use. Understanding the different use patterns and challenges in pediatrics and adolescence is needed to direct patient education to optimize use of PLGS and future artificial pancreas systems.
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Affiliation(s)
- Laurel H. Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, 1775 Aurora Court, MS A-140 Bldg M20-2403, Aurora, CO 80045
| | - Peter Calhoun
- Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647
| | - Bruce Buckingham
- Professor, Pediatrics, Division of Endocrinology and Diabetes, Stanford School of Medicine, 780 Welch Road, Room CJ320H, MC 5776, Palo Alto, CA 94305
| | - Darrell Wilson
- Professor, Pediatrics, Division of Endocrinology and Diabetes, Stanford School of Medicine, 780 Welch Road, Room CJ320H, MC 5776, Palo Alto, CA 94305
| | - Irene Hramiak
- Chair/Chief, Division of Endocrinology & Metabolism, St Joseph's Health Care, London, 268 Grosvenor St Rm B5-130, London ON N6A 4V2
| | - Trang Ly
- Clinical Assistant Professor, Pediatric Endocrinologist, Division of Endocrinology and Diabetes, Stanford School of Medicine, 780 Welch Road, Room CJ320H, MC 5776, Palo Alto, CA 94305
| | - Marsha Driscoll
- Diabetes Clinical Trials Unit, St. Joseph's Health Care London, 268 Grosvenor Street Rm B5-632, London, Ontario N6A 4V2
| | - Paula Clinton
- Division of Endocrinology and Diabetes, Stanford School of Medicine, 780 Welch Road, Room CJ320H, MC 5776, Palo Alto, CA 94305
| | - David M. Maahs
- Associate Professor of Pediatrics, Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, 1775 Aurora Court, MS A-140, Aurora, CO 80045
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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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DeBoer MD, Breton MD, Wakeman C, Schertz EM, Emory EG, Robic JL, Kollar LL, Kovatchev BP, Cherñavvsky DR. Performance of an Artificial Pancreas System for Young Children with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:293-298. [PMID: 28426239 DOI: 10.1089/dia.2016.0424] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Young children 5-8 years old with type 1 diabetes (T1D) exhibit clear needs for improved glycemic control but may be limited in their ability to safely interact with an artificial pancreas system. Our goal was to evaluate the safety and performance of an artificial pancreas (AP) system among young children with T1D. RESEARCH DESIGN AND METHODS In a randomized, crossover trial, children with T1D age 5-8 years were enrolled to receive on separate study periods (in random order) either the UVa AP using the DiAs Control Platform software with child-resistant lock-out screens (followed as an out-patient admission) or their usual insulin pump+continuous glucose monitor (CGM) care at home. Hypoglycemic events and CGM tracings were compared between the two 68-h study periods. All analyses were adjusted for level of physical activity as tracked using Fitbit devices. RESULTS Twelve participants (median age 7 years, n = 6 males) completed the trial. Compared to home care, the AP admission resulted in increased time with blood glucose (BG) 70-180 mg/dL (73% vs. 47%) and lower mean BG (152 mg/dL vs. 190 mg/dL), both P < 0.001 after adjustment for activity. Occurrence of hypoglycemia was similar between sessions without differences in time <70 mg/dL (AP 1.1% ± 1.1%; home 1.6% ± 1.2%). There were no adverse events during the AP or home study periods. CONCLUSIONS Use of an AP in young children was safe and resulted in improved mean BG without increased hypoglycemia. This suggests that AP use in young children is safe and improves overall diabetes control. ClinicalTrials.gov registration number: NCT02750267.
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Affiliation(s)
- Mark D DeBoer
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 2 Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia , Charlottesville, Virginia
| | - Marc D Breton
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Christian Wakeman
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Elaine M Schertz
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Emma G Emory
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Jessica L Robic
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Laura L Kollar
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Boris P Kovatchev
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Daniel R Cherñavvsky
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 3 TypeZero Technologies, Inc., Charlottesville, Virginia
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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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Parkin CG, Homberg A, Hinzmann R. 8th Annual Symposium on Self-Monitoring of Blood Glucose (SMBG): April 16-18, 2015, Republic of Malta. Diabetes Technol Ther 2015; 17:832-50. [PMID: 26496678 PMCID: PMC4649720 DOI: 10.1089/dia.2015.0325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
International experts in the fields of diabetes, diabetes technology, endocrinology, mobile health, sport science, and regulatory issues gathered for the 8(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG) with a focus on personalized diabetes management. The aim of this meeting was to facilitate new collaborations and research projects to improve the lives of people with diabetes. The 2015 meeting comprised a comprehensive scientific program, parallel interactive workshops, and two keynote lectures.
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Bjornstad P, Maahs DM. Diabetes Complications in Childhood Diabetes-New Biomarkers and Technologies. CURRENT PEDIATRICS REPORTS 2015; 3:177-186. [PMID: 26425403 DOI: 10.1007/s40124-015-0081-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A major challenge in preventing vascular complications in diabetes is the inability to identify high-risk patients at an early stage, emphasizing the importance of discovering new risk factors, technologies and therapeutic targets to reduce the development and progression of complications. Promising biomarkers which may improve risk stratification and serve as therapeutic targets, include: uric acid, insulin sensitivity, copeptin, SGLT-2 and Klotho/FGF-23. Non-invasive measures of macrovasuclar disease in youth, include: 1) pulse wave velocity to examine arterial stiffness; 2) carotid intima-media thickness to evaluate arterial thickness; 3) cardiac MRI to investigate cardiac function and structure. Novel microvascular measures include: GFR by iohexol clearance using filter paper to directly measure GFR, retinal vascular geometry to predict early retinal changes and corneal confocal microscopy to improve detection of early nerve loss to better predict diabetic neuropathy. Herein we will review technologies, novel biomarkers, and therapeutic targets in relation to vascular complications of diabetes.
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States ; Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - David M Maahs
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, United States ; Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, United States
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