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Cruz P, McKee AM, Chiang HH, McGill JB, Hirsch IB, Ringenberg K, Wildes TS. Perioperative Care of Patients Using Wearable Diabetes Devices. Anesth Analg 2024:00000539-990000000-00853. [PMID: 38913575 DOI: 10.1213/ane.0000000000007115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
The increasing prevalence of diabetes mellitus has been accompanied by a rapid expansion in wearable continuous glucose monitoring (CGM) devices and insulin pumps. Systems combining these components in a "closed loop," where interstitial glucose measurement guides automated insulin delivery (AID, or closed loop) based on sophisticated algorithms, are increasingly common. While these devices' efficacy in achieving near-normoglycemia is contributing to increasing usage among patients with diabetes, the management of these patients in operative and procedural environments remains understudied with limited published guidance available, particularly regarding AID systems. With their growing prevalence, practical management advice is needed for their utilization, or for the rational temporary substitution of alternative diabetes monitoring and treatments, during surgical care. CGM devices monitor interstitial glucose in real time; however, there are potential limitations to use and accuracy in the perioperative period, and, at the present time, their use should not replace regular point-of-care glucose monitoring. Avoiding perioperative removal of CGMs when possible is important, as removal of these prescribed devices can result in prolonged interruptions in CGM-informed treatments during and after procedures, particularly AID system use. Standalone insulin pumps provide continuous subcutaneous insulin delivery without automated adjustments for glucose concentrations and can be continued during some procedures. The safe intraoperative use of AID devices in their hybrid closed-loop mode (AID mode) requires the CGM component of the system to continue to communicate valid blood glucose data, and thus introduces the additional need to ensure this portion of the system is functioning appropriately to enable intraprocedural use. AID devices revert to non-AID insulin therapy modes when paired CGMs are disconnected or when the closed-loop mode is intentionally disabled. For patients using insulin pumps, we describe procedural factors that may compromise CGM, insulin pump, and AID use, necessitating a proactive transition to an alternative insulin regimen. Procedure duration and invasiveness is an important factor as longer procedures increase the risk of stress hyperglycemia, tissue malperfusion, and device malfunction. Whether insulin pumps should be continued through procedures, or substituted by alternative insulin delivery methods, is a complex decision that requires all parties to understand potential risks and contingency plans relating to patient and procedural factors. Currently available CGMs and insulin pumps are reviewed, and practical recommendations for safe glycemic management during the phases of perioperative care are provided.
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Affiliation(s)
- Paulina Cruz
- From the Division of Endocrinology, Metabolism & Lipid Research, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Alexis M McKee
- From the Division of Endocrinology, Metabolism & Lipid Research, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Hou-Hsien Chiang
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington School of Medicine, University of Washington, Seattle, Washington
| | - Janet B McGill
- From the Division of Endocrinology, Metabolism & Lipid Research, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Irl B Hirsch
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington School of Medicine, University of Washington, Seattle, Washington
| | - Kyle Ringenberg
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Troy S Wildes
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
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Fuchs S, Caserto JS, Liu Q, Wang K, Shariati K, Hartquist CM, Zhao X, Ma M. A Glucose-Responsive Cannula for Automated and Electronics-Free Insulin Delivery. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024:e2403594. [PMID: 38639424 DOI: 10.1002/adma.202403594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/12/2024] [Indexed: 04/20/2024]
Abstract
Automated delivery of insulin based on continuous glucose monitoring is revolutionizing the way insulin-dependent diabetes is treated. However, challenges remain for the widespread adoption of these systems, including the requirement of a separate glucose sensor, sophisticated electronics and algorithms, and the need for significant user input to operate these costly therapies. Herein, a user-centric glucose-responsive cannula is reported for electronics-free insulin delivery. The cannula-made from a tough, elastomer-hydrogel hybrid membrane formed through a one-pot solvent exchange method-changes permeability to release insulin rapidly upon physiologically relevant varying glucose levels, providing simple and automated insulin delivery with no additional hardware or software. Two prototypes of the cannula are evaluated in insulin-deficient diabetic mice. The first cannula-an ends-sealed, subcutaneously inserted prototype-normalizes blood glucose levels for 3 d and controls postprandial glucose levels. The second, more translational version-a cannula with the distal end sealed and the proximal end connected to a transcutaneous injection port-likewise demonstrates tight, 3-d regulation of blood glucose levels when refilled twice daily. This proof-of-concept study may aid in the development of "smart" cannulas and next-generation insulin therapies at a reduced burden-of-care toll and cost to end-users.
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Affiliation(s)
- Stephanie Fuchs
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Julia S Caserto
- Robert Frederick Smith School of Chemical and Biomolecular Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Qingsheng Liu
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Kecheng Wang
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Kaavian Shariati
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Chase M Hartquist
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Xuanhe Zhao
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Minglin Ma
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
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3
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Phongmekhin T. Continuous glucose monitor accuracy during extracorporeal membrane oxygenation. CRIT CARE RESUSC 2024; 26:58-59. [PMID: 38690192 PMCID: PMC11056440 DOI: 10.1016/j.ccrj.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 11/03/2023] [Indexed: 05/02/2024]
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Åm MK, Teigen IA, Riaz M, Fougner AL, Christiansen SC, Carlsen SM. The artificial pancreas: two alternative approaches to achieve a fully closed-loop system with optimal glucose control. J Endocrinol Invest 2024; 47:513-521. [PMID: 37715091 PMCID: PMC10904408 DOI: 10.1007/s40618-023-02193-2] [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: 04/28/2023] [Accepted: 09/01/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Diabetes mellitus type 1 is a chronic disease that implies mandatory external insulin delivery. The patients must monitor their blood glucose levels and administer appropriate insulin boluses to keep their blood glucose within the desired range. It requires a lot of time and endeavour, and many patients struggle with suboptimal glucose control despite all their efforts. MATERIALS AND METHODS This narrative review combines existing knowledge with new discoveries from animal experiments. DISCUSSION In the last decade, artificial pancreas (AP) devices have been developed to improve glucose control and relieve patients of the constant burden of managing their disease. However, a feasible and fully automated AP is yet to be developed. The main challenges preventing the development of a true, subcutaneous (SC) AP system are the slow dynamics of SC glucose sensing and particularly the delay in effect on glucose levels after SC insulin infusions. We have previously published studies on using the intraperitoneal space for an AP; however, we further propose a novel and potentially disruptive way to utilize the vasodilative properties of glucagon in SC AP systems. CONCLUSION This narrative review presents two lesser-explored viable solutions for AP systems and discusses the potential for improvement toward a fully automated system: A) using the intraperitoneal approach for more rapid insulin absorption, and B) besides using glucagon to treat and prevent hypoglycemia, also administering micro-boluses of glucagon to increase the local SC blood flow, thereby accelerating SC insulin absorption and SC glucose sensor site dynamics.
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Affiliation(s)
- M K Åm
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway.
| | - I A Teigen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway
- Cancer Clinic, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - M Riaz
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway
- Department of Endocrinology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - A L Fougner
- Department of Engineering Cybernetics, Faculty of Information Technology and Electrical Engineering, Norwegian University of Science and Technology, Trondheim, Norway
| | - S C Christiansen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway
- Department of Endocrinology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - S M Carlsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway
- Department of Endocrinology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Hanley M, Ryan DT, Kyle E, Kavanagh EC. Radiographic appearances of a continuous glucose monitor in a patient with lipodystrophy. Radiol Case Rep 2023; 18:3287-3290. [PMID: 37520385 PMCID: PMC10375375 DOI: 10.1016/j.radcr.2023.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 08/01/2023] Open
Abstract
We report the case of a 50-year old woman with a known history of lipodystrophy. A pelvic radiograph was taken for the investigation of right hip pain. The image shown demonstrates an indeterminate artefact projected over the right iliac fossa. A previous CT renal study was reviewed, demonstrating the same device in the subcutaneous tissues of the contralateral left lower quadrant which on close inspection was consistent with a continuous glucose monitoring device. Features of lipodystrophy were also noted on review of the CT imaging. Although many devices such as vagal stimulators and prosthetic valves are easily recognized by radiologists on radiographic images, they may be less familiar with devices such as continuous glucose monitors. The aim of this case report is to familiarize radiologists with the appearances of continuous glucose monitors to allow for effective reporting.
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Cummings C, Jiang A, Sheehan A, Ferraz-Bannitz R, Puleio A, Simonson DC, Dreyfuss JM, Patti ME. Continuous glucose monitoring in patients with post-bariatric hypoglycaemia reduces hypoglycaemia and glycaemic variability. Diabetes Obes Metab 2023; 25:2191-2202. [PMID: 37046360 PMCID: PMC10807851 DOI: 10.1111/dom.15096] [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: 11/30/2022] [Revised: 04/08/2023] [Accepted: 04/09/2023] [Indexed: 04/14/2023]
Abstract
AIM To determine whether continuous glucose monitoring (CGM) can reduce hypoglycaemia in patients with post-bariatric hypoglycaemia (PBH). MATERIALS AND METHODS In an open-label, nonrandomized, pre-post design with sequential assignment, CGM data were collected in 22 individuals with PBH in two sequential phases: (i) masked (no access to sensor glucose or alarms); and (ii) unmasked (access to sensor glucose and alarms for low or rapidly declining sensor glucose). Twelve participants wore the Dexcom G4 device for a total of 28 days, while 10 wore the Dexcom G6 device for a total of 20 days. RESULTS Participants with PBH spent a lower percentage of time in hypoglycaemia over 24 hours with unmasked versus masked CGM (<3.3 mM/L, or <60 mg/dL: median [median absolute deviation {MAD}] 0.7 [0.8]% vs. 1.4 [1.7]%, P = 0.03; <3.9 mM/L, or <70 mg/dL: median [MAD] 2.9 [2.5]% vs. 4.7 [4.8]%; P = 0.04), with similar trends overnight. Sensor glucose data from the unmasked phase showed a greater percentage of time spent between 3.9 and 10 mM/L (70-180 mg/dL) (median [MAD] 94.8 [3.9]% vs. 90.8 [5.2]%; P = 0.004) and lower glycaemic variability over 24 hours (median [MAD] mean amplitude of glycaemic excursion 4.1 [0.98] vs. 4.4 [0.99] mM/L; P = 0.04). During the day, participants also spent a greater percentage of time in normoglycaemia with unmasked CGM (median [MAD] 94.2 [4.8]% vs. 90.9 [6.2]%; P = 0.005), largely due to a reduction in hyperglycaemia (>10 mM/L, or 180 mg/dL: median [MAD] 1.9 [2.2]% vs. 3.9 [3.6]%; P = 0.02). CONCLUSIONS Real-time CGM data and alarms are associated with reductions in low sensor glucose, elevated sensor glucose, and glycaemic variability. This suggests CGM allows patients to detect hyperglycaemic peaks and imminent hypoglycaemia, allowing dietary modification and self-treatment to reduce hypoglycaemia. The use of CGM devices may improve safety in PBH, particularly for patients with hypoglycaemia unawareness.
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Affiliation(s)
- Cameron Cummings
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Alex Jiang
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Amanda Sheehan
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Rafael Ferraz-Bannitz
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alexa Puleio
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Donald C. Simonson
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jonathan M. Dreyfuss
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Elian V, Popovici V, Ozon EA, Musuc AM, Fița AC, Rusu E, Radulian G, Lupuliasa D. Current Technologies for Managing Type 1 Diabetes Mellitus and Their Impact on Quality of Life-A Narrative Review. Life (Basel) 2023; 13:1663. [PMID: 37629520 PMCID: PMC10456000 DOI: 10.3390/life13081663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023] Open
Abstract
Type 1 diabetes mellitus is a chronic autoimmune disease that affects millions of people and generates high healthcare costs due to frequent complications when inappropriately managed. Our paper aimed to review the latest technologies used in T1DM management for better glycemic control and their impact on daily life for people with diabetes. Continuous glucose monitoring systems provide a better understanding of daily glycemic variations for children and adults and can be easily used. These systems diminish diabetes distress and improve diabetes control by decreasing hypoglycemia. Continuous subcutaneous insulin infusions have proven their benefits in selected patients. There is a tendency to use more complex systems, such as hybrid closed-loop systems that can modulate insulin infusion based on glycemic readings and artificial intelligence-based algorithms. It can help people manage the burdens associated with T1DM management, such as fear of hypoglycemia, exercising, and long-term complications. The future is promising and aims to develop more complex ways of automated control of glycemic levels to diminish the distress of individuals living with diabetes.
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Affiliation(s)
- Viviana Elian
- Department of Diabetes, Nutrition and Metabolic Diseases, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050471 Bucharest, Romania; (V.E.); (E.R.); (G.R.)
- Department of Diabetes, Nutrition and Metabolic Diseases, “Prof. Dr. N. C. Paulescu” National Institute of Diabetes, Nutrition and Metabolic Diseases, 030167 Bucharest, Romania
| | - Violeta Popovici
- Department of Microbiology and Immunology, Faculty of Dental Medicine, Ovidius University of Constanta, 7 Ilarie Voronca Street, 900684 Constanta, Romania
| | - Emma-Adriana Ozon
- Department of Pharmaceutical Technology and Biopharmacy, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania; (A.C.F.); (D.L.)
| | - Adina Magdalena Musuc
- Romanian Academy, “Ilie Murgulescu” Institute of Physical Chemistry, 202 Spl. Independentei, 060021 Bucharest, Romania;
| | - Ancuța Cătălina Fița
- Department of Pharmaceutical Technology and Biopharmacy, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania; (A.C.F.); (D.L.)
| | - Emilia Rusu
- Department of Diabetes, Nutrition and Metabolic Diseases, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050471 Bucharest, Romania; (V.E.); (E.R.); (G.R.)
- Department of Diabetes, N. Malaxa Clinical Hospital, 12 Vergului Street, 022441 Bucharest, Romania
| | - Gabriela Radulian
- Department of Diabetes, Nutrition and Metabolic Diseases, “Carol Davila” University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050471 Bucharest, Romania; (V.E.); (E.R.); (G.R.)
- Department of Diabetes, Nutrition and Metabolic Diseases, “Prof. Dr. N. C. Paulescu” National Institute of Diabetes, Nutrition and Metabolic Diseases, 030167 Bucharest, Romania
| | - Dumitru Lupuliasa
- Department of Pharmaceutical Technology and Biopharmacy, Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 6 Traian Vuia Street, 020945 Bucharest, Romania; (A.C.F.); (D.L.)
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Friedman JG, Coyne K, Aleppo G, Szmuilowicz ED. Beyond A1C: exploring continuous glucose monitoring metrics in managing diabetes. Endocr Connect 2023; 12:e230085. [PMID: 37071558 PMCID: PMC10305570 DOI: 10.1530/ec-23-0085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 04/19/2023]
Abstract
Hemoglobin A1c (HbA1c) has long been considered a cornerstone of diabetes mellitus (DM) management, as both an indicator of average glycemia and a predictor of long-term complications among people with DM. However, HbA1c is subject to non-glycemic influences which confound interpretation and as a measure of average glycemia does not provide information regarding glucose trends or about the occurrence of hypoglycemia and/or hyperglycemia episodes. As such, solitary use of HbA1c, without accompanying glucose data, does not confer actionable information that can be harnessed to guide targeted therapy in many patients with DM. While conventional capillary blood glucose monitoring (BGM) sheds light on momentary glucose levels, in practical use the inherent infrequency of measurement precludes elucidation of glycemic trends or reliable detection of hypoglycemia or hyperglycemia episodes. In contrast, continuous glucose monitoring (CGM) data reveal glucose trends and potentially undetected hypo- and hyperglycemia patterns that can occur between discrete BGM measurements. The use of CGM has grown significantly over the past decades as an ever-expanding body of literature demonstrates a multitude of clinical benefits for people with DM. Continually improving CGM accuracy and ease of use have further fueled the widespread adoption of CGM. Furthermore, percent time in range correlates well with HbA1c, is accepted as a validated indicator of glycemia, and is associated with the risk of several DM complications. We explore the benefits and limitations of CGM use, the use of CGM in clinical practice, and the application of CGM to advanced diabetes technologies.
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Affiliation(s)
- Jared G Friedman
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Kasey Coyne
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Emily D Szmuilowicz
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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Ramos-Levi AM, Rubio-Herrera MA, Matía-Martín P, Pérez-Ferre N, Marcuello C, Sánchez-Pernaute A, Torres-García AJ, Calle-Pascual AL. Mixed Meal Tolerance Test Versus Continuous Glucose Monitoring for an Effective Diagnosis of Persistent Post-Bariatric Hypoglycemia. J Clin Med 2023; 12:4295. [PMID: 37445330 DOI: 10.3390/jcm12134295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/31/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Gastric bypass determines an increase in incretin secretion and glucose excursions throughout the day and may sometimes entail the development of severe post-bariatric hypoglycemia (PBH). However, there is no consensus on the gold standard method for its diagnosis. In this study, we evaluated the usefulness of a mixed meal tolerance test (MMTT) and continuous glucose monitoring (CGM) for the diagnosis of PBH, defined as glucose levels <54 mg/dL (3.0 mmol/L). We found that hypoglycemia occurred in 60% of patients after the MMTT and in 75% during CGM, and it was predominantly asymptomatic. The MMTT confirmed the diagnosis of PBH in 88.9%of patients in whom surgery had been performed more than three years ago, in comparison to 36.4% in cases with a shorter postsurgical duration. CGM diagnosed nocturnal asymptomatic hypoglycemia in 70% of patients, and daytime postprandial hypoglycemia in 25% of cases. The mean duration of asymptomatic hypoglycemia was more than 30 min a day. Patients with ≥2% of their CGM readings with hypoglycemia exhibited a higher degree of glucose variability than those with <1% of the time in hypoglycemia. Our results show that the MMTT may be a useful dynamic test to confirm the occurrence of hypoglycemia in a large number of patients with persistent and recurrent PBH during long-term follow-up after gastric bypass. CGM, on its part, helps identify hypoglycemia in the real-world setting, especially nocturnal asymptomatic hypoglycemia, bringing to light that PBH is not always postprandial.
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Affiliation(s)
- Ana M Ramos-Levi
- Departament of Endocrinology and Nutrition, Hospital La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Miguel A Rubio-Herrera
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
- Faculty of Medicine, Department of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Pilar Matía-Martín
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
- Faculty of Medicine, Department of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Natalia Pérez-Ferre
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
- Faculty of Medicine, Department of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Clara Marcuello
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
| | - Andrés Sánchez-Pernaute
- Department of Surgery, Hospital Clínico San Carlos, IdISSC, Faculty of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Antonio J Torres-García
- Department of Surgery, Hospital Clínico San Carlos, IdISSC, Faculty of Medicine, Universidad Complutense, 28040 Madrid, Spain
| | - Alfonso L Calle-Pascual
- Departament of Endocrinology and Nutrition, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
- Faculty of Medicine, Department of Medicine, Universidad Complutense, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), 28040 Madrid, Spain
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Gomez LA, Toye AA, Hum RS, Kleinberg S. Simulating Realistic Continuous Glucose Monitor Time Series By Data Augmentation. J Diabetes Sci Technol 2023:19322968231181138. [PMID: 37350111 DOI: 10.1177/19322968231181138] [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: 06/24/2023]
Abstract
BACKGROUND Simulated data are a powerful tool for research, enabling benchmarking of blood glucose (BG) forecasting and control algorithms. However, expert created models provide an unrealistic view of real-world performance, as they lack the features that make real data challenging, while black-box approaches such as generative adversarial networks do not enable systematic tests to diagnose model performance. METHODS To address this, we propose a method that learns missingness and error properties of continuous glucose monitor (CGM) data collected from people with type 1 diabetes (OpenAPS, OhioT1DM, RCT, and Racial-Disparity), and then augments simulated BG data with these properties. On the task of BG forecasting, we test how well our method brings performance closer to that of real CGM data compared with current simulation practices for missing data (random dropout) and error (Gaussian noise, CGM error model). RESULTS Our methods had the smallest performance difference versus real data compared with random dropout and Gaussian noise when individually testing the effects of missing data and error on simulated BG in most cases. When combined, our approach was significantly better than Gaussian noise and random dropout for all data sets except OhioT1DM. Our error model significantly improved results on diverse data sets. CONCLUSIONS We find a significant gap between BG forecasting performance on simulated and real data, and our method can be used to close this gap. This will enable researchers to rigorously test algorithms and provide realistic estimates of real-world performance without overfitting to real data or at the expense of data collection.
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Affiliation(s)
| | | | - R Stanley Hum
- The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
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11
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Klupa T, Czupryniak L, Dzida G, Fichna P, Jarosz-Chobot P, Gumprecht J, Mysliwiec M, Szadkowska A, Bomba-Opon D, Czajkowski K, Malecki MT, Zozulinska-Ziolkiewicz DA. Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease. Diabetes Ther 2023:10.1007/s13300-023-01431-3. [PMID: 37322319 PMCID: PMC10299981 DOI: 10.1007/s13300-023-01431-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.
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Affiliation(s)
- Tomasz Klupa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland.
| | - Leszek Czupryniak
- Department of Diabetology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Dzida
- Department of Internal Diseases, Medical University of Lublin, Lublin, Poland
| | - Piotr Fichna
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Janusz Gumprecht
- Department of Internal Medicine, Diabetology and Nephrology, Medical University of Silesia, Katowice, Poland
| | - Malgorzata Mysliwiec
- Department of Pediatrics, Diabetology and Endocrinology, Medical University of Gdansk, Gdansk, Poland
| | - Agnieszka Szadkowska
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Dorota Bomba-Opon
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Czajkowski
- 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Maciej T Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
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12
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Emerson H, Guy M, McConville R. Offline reinforcement learning for safer blood glucose control in people with type 1 diabetes. J Biomed Inform 2023; 142:104376. [PMID: 37149275 DOI: 10.1016/j.jbi.2023.104376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/23/2023] [Accepted: 04/28/2023] [Indexed: 05/08/2023]
Abstract
The widespread adoption of effective hybrid closed loop systems would represent an important milestone of care for people living with type 1 diabetes (T1D). These devices typically utilise simple control algorithms to select the optimal insulin dose for maintaining blood glucose levels within a healthy range. Online reinforcement learning (RL) has been utilised as a method for further enhancing glucose control in these devices. Previous approaches have been shown to reduce patient risk and improve time spent in the target range when compared to classical control algorithms, but are prone to instability in the learning process, often resulting in the selection of unsafe actions. This work presents an evaluation of offline RL for developing effective dosing policies without the need for potentially dangerous patient interaction during training. This paper examines the utility of BCQ, CQL and TD3-BC in managing the blood glucose of the 30 virtual patients available within the FDA-approved UVA/Padova glucose dynamics simulator. When trained on less than a tenth of the total training samples required by online RL to achieve stable performance, this work shows that offline RL can significantly increase time in the healthy blood glucose range from 61.6±0.3% to 65.3±0.5% when compared to the strongest state-of-art baseline (p<0.001). This is achieved without any associated increase in low blood glucose events. Offline RL is also shown to be able to correct for common and challenging control scenarios such as incorrect bolus dosing, irregular meal timings and compression errors. The code for this work is available at: https://github.com/hemerson1/offline-glucose.
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Affiliation(s)
- Harry Emerson
- University of Bristol, 1 Cathedral Square, Bristol, BS1 5TS, United Kingdom.
| | - Matthew Guy
- University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, Hampshire, United Kingdom.
| | - Ryan McConville
- University of Bristol, 1 Cathedral Square, Bristol, BS1 5TS, United Kingdom.
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13
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Friedman JG, Cardona Matos Z, Szmuilowicz ED, Aleppo G. Use of Continuous Glucose Monitors to Manage Type 1 Diabetes Mellitus: Progress, Challenges, and Recommendations. Pharmgenomics Pers Med 2023; 16:263-276. [PMID: 37025558 PMCID: PMC10072139 DOI: 10.2147/pgpm.s374663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/25/2023] [Indexed: 04/08/2023] Open
Abstract
Type 1 diabetes (T1D) management has been revolutionized with the development and routine utilization of continuous glucose monitoring (CGM). CGM technology has allowed for the ability to track dynamic glycemic fluctuations and trends over time allowing for optimization of medical therapy and the prevention of dangerous hypoglycemic events. This review details currently-available real-time and intermittently-scanned CGM devices, clinical benefits, and challenges of CGM use, and current guidelines supporting its use in the clinical care of patients with T1D. We additionally describe future issues that will need to be addressed as CGM technology continues to evolve.
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Affiliation(s)
- Jared G Friedman
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Zulma Cardona Matos
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emily D Szmuilowicz
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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14
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Price CE, Fanelli JE, Aloi JA, Anzola SC, Vishneski SR, Saha AK, Woody CC, Segal S. Feasibility of intraoperative continuous glucose monitoring: An observational study in general surgery patients. J Clin Anesth 2023; 87:111090. [PMID: 36913777 DOI: 10.1016/j.jclinane.2023.111090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/26/2023] [Accepted: 02/22/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Perioperative hyperglycemia is associated with adverse outcomes in surgical patients, and major societies recommend intraoperative monitoring and treatment targeting glucose <180-200 mg/dL. However, compliance with these recommendations is poor, in part due to fear of unrecognized hypoglycemia. Continuous Glucose Monitors (CGMs) measure interstitial glucose with a subcutaneous electrode and can display the results on a receiver or smartphone. Historically CGMs have not been utilized for surgical patients. We investigated the use of CGM in the perioperative setting compared to current standard practices. METHOD This study evaluated the use of Abbott Freestyle Libre 2.0 and/or Dexcom G6 CGMs in a prospective cohort of 94 participants with diabetes mellitus undergoing surgery of ≥3 h duration. CGMs were placed preoperatively and compared to point of care (POC) BG checks obtained by capillary samples analyzed with a NOVA glucometer. Frequency of intraoperative blood glucose measurement was at the discretion of the anesthesia care team, with a recommendation of once per hour targeting BG of 140-180 mg/dL. Of those consented, 18 were excluded due to lost sensor data, surgery cancellation, or rescheduling to a satellite campus resulting in 76 enrolled subjects. There were zero occurrences of failure with sensor application. Paired POC BG and contemporaneous CGM readings were compared with Pearson product-moment correlation coefficients, and Bland-Altman plots. RESULTS Data for use of CGM in perioperative period was analyzed for 50 participants with Freestyle Libre 2.0, 20 participants with Dexcom G6, and 6 participants with both devices worn simultaneously. Lost sensor data occurred in 3 participants (15%) wearing Dexcom G6, 10 participants wearing Freestyle Libre 2.0 (20%) and 2 of the participants wearing both devices simultaneously. The overall agreement of the two CGM's utilized had a Pearson correlation coefficient of 0.731 in combined groups with 0.573 in Dexcom arm evaluating 84 matched pairs and 0.771 in Libre arm with 239 matched pairs. Modified Bland-Altman plot of the difference of CGM and POC BG indicated for the overall dataset a bias of -18.27 (SD 32.10). CONCLUSIONS Both Dexcom G6 and Freestyle Libre 2.0 CGMs were able to be utilized and functioned well if no sensor error occurred at time of initial warmup. CGM provided more glycemic data and further characterized glycemic trends more than individual BG readings. Required time of CGM warm up was a barrier for intraoperative use as well as unexplained sensor failure. CGMs had a fixed warm of time, 1 h for Libre 2.0 and 2 h for Dexcom G6 CGM, before glycemic data obtainable. Sensor application issues did not occur. It is anticipated that this technology could be used to improve glycemic control in the perioperative setting. Additional studies are needed to evaluate use intraoperatively and assess further if any interference from electrocautery or grounding devices may contribute to initial sensor failure. It may be beneficial in future studies to place CGM during preoperative clinic evaluation the week prior to surgery. Use of CGMs in these settings is feasible and warrants further evaluation of this technology on perioperative glycemic management.
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Affiliation(s)
- Catherine E Price
- Division of Endocrinology & Metabolism, Wake Forest School of Medicine, United States of America.
| | - Jessica E Fanelli
- Department of Anesthesiology, Wake Forest School of Medicine, United States of America
| | - Joseph A Aloi
- Division of Endocrinology & Metabolism, Wake Forest School of Medicine, United States of America.
| | - Saskia C Anzola
- Department of Anesthesiology, Wake Forest School of Medicine, United States of America.
| | - Susan R Vishneski
- Department of Anesthesiology, Wake Forest School of Medicine, United States of America.
| | - Amit K Saha
- Department of Anesthesiology, Wake Forest School of Medicine, United States of America
| | - Christopher C Woody
- Department of Internal Medicine, Wake Forest School of Medicine, United States of America.
| | - Scott Segal
- Department of Anesthesiology, Wake Forest School of Medicine, United States of America.
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15
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Szmuilowicz ED, Levy CJ, Buschur EO, Polsky S. Expert Guidance on Off-Label Use of Hybrid Closed-Loop Therapy in Pregnancies Complicated by Diabetes. Diabetes Technol Ther 2023; 25:363-373. [PMID: 36724300 DOI: 10.1089/dia.2022.0540] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Automated insulin delivery (AID) systems have established benefits in terms of glycemic control, health outcomes, and quality of life and are strongly recommended for people with type 1 diabetes outside of pregnancy. While evidence for use of investigational AID systems during pregnancy is promising, data and guidance are still needed regarding use of commercially available systems during pregnancy. Unfortunately, none of the hybrid closed-loop (HCL) systems that are currently available in the United States have glucose targets that are as aggressive as pregnancy glycemic targets, none have a pregnancy-specific algorithm, and none are approved for use during pregnancy. As such, any use of these systems during pregnancy is considered off-label in the United States and would be "assisted" by provider/user techniques. Despite these limitations, many women conceive while using clinically available HCL systems and may be hesitant to cease use during pregnancy. Achievement of strict pregnancy glycemic targets can be difficult, and it is conceivable that selective off-label use of clinically available HCL systems in some women could lead to improved glycemia. We herein offer expert guidance based on clinical experience and available case reports on how to identify appropriate candidates for HCL therapy in pregnancy, how to counsel pregnant women with diabetes on the potential risks and benefits of HCL therapy during pregnancy, and how to manage commercially available systems off-label throughout gestation in an assisted HCL approach.
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Affiliation(s)
- Emily D Szmuilowicz
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carol J Levy
- Divisions of Endocrinology and Obstetrics, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elizabeth O Buschur
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Sarit Polsky
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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16
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Brøsen JMB, Agesen RM, Kristensen PL, Alibegovic AC, Andersen HU, Beck-Nielsen H, Gustenhoff P, Hansen TK, Hedetoft C, Jensen T, Stolberg CR, Juhl CB, Lerche SS, Nørgaard K, Parving HH, Tarnow L, Thorsteinsson B, Pedersen-Bjergaard U. Effect of insulin degludec versus insulin glargine U100 on nocturnal glycaemia assessed by plasma glucose profiles in people with type 1 diabetes prone to nocturnal severe hypoglycaemia. Diabetes Obes Metab 2023; 25:1557-1565. [PMID: 36749303 DOI: 10.1111/dom.15003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
AIM To compare nocturnal glucose profiles according to hourly plasma glucose measurements during treatment with insulin degludec and insulin glargine U100 in a cohort of people with type 1 diabetes prone to nocturnal severe hypoglycaemia. MATERIALS AND METHODS The HypoDeg trial is a 2-year investigator-initiated, randomized, controlled crossover trial in 149 participants randomized to treatment with insulin degludec and insulin glargine U100 for 12 months each. The 51 participants in this predefined substudy stayed at least one night in hospital during each treatment arm for plasma glucose samples to be taken. Endpoints were glucose profiles, including mean plasma glucose, glycaemic variability and risk of hypoglycaemia. RESULTS There were no differences between treatments regarding mean plasma glucose. We saw a flatter glucose profile during insulin degludec compared with insulin glargine U100 treatment, which had a nadir at 4:00 AM, with a subsequent rise. During treatment with insulin degludec, the participants had lower glycaemic variability, with an estimated treatment difference of -4.3% (95% confidence interval [CI] -8.1 to -0.5; P < 0.05). Participants treated with insulin degludec were less likely to experience nocturnal hypoglycaemia below 3.0 mmol/L (hazard ratio 0.36 [95% CI 0.17-0.73; P < 0.05]). CONCLUSION Based on nocturnal plasma glucose measurements, treatment with insulin degludec compared with insulin glargine U100 administered in the evening results in lower glycaemic variability and lower risk of nocturnal hypoglycaemia without differences in mean plasma glucose.
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Affiliation(s)
- Julie Maria Bøggild Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Mette Agesen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lommer Kristensen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Henrik Ullits Andersen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Henning Beck-Nielsen
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Faculty of Health and Sciences, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Troels Krarup Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus, Denmark
| | | | - Tonny Jensen
- Department of Medical Endocrinology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Røn Stolberg
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Faculty of Health and Sciences, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, University Hospital South West Jutland, Esbjerg, Denmark
| | - Claus Bogh Juhl
- Faculty of Health and Sciences, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, University Hospital South West Jutland, Esbjerg, Denmark
- Steno Diabetes Center Odense, Odense, Denmark
| | - Susanne Søgaard Lerche
- Department of Diabetes and Hormonal Diseases, Lillebaelt Hospital Kolding, Kolding, Denmark
| | - Kirsten Nørgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Endocrinology, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Hans-Henrik Parving
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Medical Endocrinology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Lise Tarnow
- Steno Diabetes Center Sjaelland, Holbaek, Denmark
- Department of Clinical Research, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
| | - Birger Thorsteinsson
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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17
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Machine-Learning-Based Detection of Pressure-Induced Faults in Continuous Glucose Monitors. Ind Eng Chem Res 2023. [DOI: 10.1021/acs.iecr.2c03259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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18
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. Automated insulin delivery: benefits, challenges, and recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association. Diabetologia 2023; 66:3-22. [PMID: 36198829 PMCID: PMC9534591 DOI: 10.1007/s00125-022-05744-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 01/15/2023]
Abstract
A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialised for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organisations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organisation has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonisation of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organisations for confirmation.
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Affiliation(s)
| | | | | | - Richard M Bergenstal
- International Diabetes Center and HealthPartners Institute, Minneapolis, MN, USA
| | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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19
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Sherr JL, Heinemann L, Fleming GA, Bergenstal RM, Bruttomesso D, Hanaire H, Holl RW, Petrie JR, Peters AL, Evans M. Automated Insulin Delivery: Benefits, Challenges, and Recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association. Diabetes Care 2022; 45:3058-3074. [PMID: 36202061 DOI: 10.2337/dci22-0018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 02/03/2023]
Abstract
A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialized for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organizations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organization has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonization of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organizations for confirmation.
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Affiliation(s)
| | | | | | | | - Daniela Bruttomesso
- Unit of Metabolic Diseases, Department of Medicine, University of Padova, Padova, Italy
| | - Hélène Hanaire
- Department of Diabetology, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute of Biomedical Engineering (ZIBMT), University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
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20
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Avari P, Lumb A, Flanagan D, Rayman G, Misra S, Dhatariya K, Choudhary P. Continuous Glucose Monitoring Within Hospital: A Scoping Review and Summary of Guidelines From the Joint British Diabetes Societies for Inpatient Care. J Diabetes Sci Technol 2022; 17:611-624. [PMID: 36444418 DOI: 10.1177/19322968221137338] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Increasing numbers of people, particularly with type 1 diabetes (T1D), are using wearable technologies. That is, continuous subcutaneous insulin infusion (CSII) pumps, continuous glucose monitoring (CGM) systems, and hybrid closed-loop systems, which combine both these elements. Given over a quarter of all people admitted to hospital have diabetes, there is a need for clinical guidelines for when people using them are admitted to hospital. The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) provide a scoping review and summary of guidelines on the use of diabetes technology in people with diabetes admitted to hospital.JBDS-IP advocates enabling people who can self-manage and use their own diabetes technology to continue doing so as they would do out of hospital. Whilst people with diabetes are recommended to achieve a target of 70% time within range (3.9-10.0 mmol/L [70-180 mg/dL]), this can be very difficult to achieve whilst unwell. We therefore recommend targeting hypoglycemia prevention as a priority, keeping time below 3.9 mmol/L (70 mg/dL) at < 1%, being aware of looming hypoglycemia if glucose is between 4.0 and 5.9 mmol/L (72-106 mg/dL), and consider intervening, particularly if there is a downward CGM trend arrow.Health care organizations need clear local policies and guidance to support individuals using diabetes technologies, and ensure the relevant workforce is capable and skilled enough to ensure their safe use within the hospital setting. The current set of guidelines is divided into two parts. Part 1, which follows below, outlines the guidance for use of CGM in hospital. The second part outlines guidance for use of CSII and hybrid closed-loop in hospital.
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Affiliation(s)
- Parizad Avari
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Alistair Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Daniel Flanagan
- Department of Endocrinology, University Hospital Plymouth, Plymouth, UK
| | - Gerry Rayman
- Ipswich Diabetes Centre, East Suffolk and North East Essex Foundation Trust, Ipswich, UK
| | - Shivani Misra
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, UK
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21
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Liang Z. Mining associations between glycemic variability in awake-time and in-sleep among non-diabetic adults. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:1026830. [DOI: 10.3389/fmedt.2022.1026830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
It is often assumed that healthy people have the genuine ability to maintain tight blood glucose regulation. However, a few recent studies revealed that glucose dysregulation such as hyperglycemia may occur even in people who are considered normoglycemic by standard measures and were more prevalent than initially thought, suggesting that more investigations are needed to fully understand the within-day glucose dynamics of healthy people. In this paper, we conducted an analysis on a multi-modal dataset to examine the relationships between glycemic variability when people were awake and that when they were sleeping. The interstitial glucose levels were measured with a wearable continuous glucose monitoring (CGM) technology FreeStyle Libre 2 at every 15 min interval. In contrast to the traditional single-time-point measurements, the CGM data allow the investigation into the temporal patterns of glucose dynamics at high granularity. Sleep onset and offset timestamps were recorded daily with a Fitbit Charge 3 wristband. Our analysis leveraged the sleep data to split the glucose readings into segments of awake-time and in-sleep, instead of using fixed cut-off time points as has been done in existing literature. We combined repeated measure correlation analysis and quantitative association rules mining, together with an original post-filtering method, to identify significant and most relevant associations. Our results showed that low overall glucose in awake time was strongly correlated to low glucose in subsequent sleep, which in turn correlated to overall low glucose in the next day. Moreover, both analysis techniques identified significant associations between the minimal glucose reading in sleep and the low blood glucose index the next day. In addition, the association rules discovered in this study achieved high confidence (0.75–0.88) and lift (4.1–11.5), which implies that the proposed post-filtering method was effective in selecting quality rules.
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22
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Fellinger P, Rodewald K, Ferch M, Itariu B, Kautzky-Willer A, Winhofer Y. HbA1c and Glucose Management Indicator Discordance Associated with Obesity and Type 2 Diabetes in Intermittent Scanning Glucose Monitoring System. BIOSENSORS 2022; 12:288. [PMID: 35624589 PMCID: PMC9138367 DOI: 10.3390/bios12050288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/06/2022] [Accepted: 04/22/2022] [Indexed: 06/15/2023]
Abstract
Glucose management indicator (GMI) is frequently used as a substitute for HbA1c, especially when using telemedicine. Discordances between GMI and HbA1c were previously mostly reported in populations with type 1 diabetes (T1DM) using real-time CGM. Our aim was to investigate the accordance between GMI and HbA1c in patients with diabetes using intermittent scanning CGM (isCGM). In this retrospective cross-sectional study, patients with diabetes who used isCGM >70% of the time of the investigated time periods were included. GMI of four different time spans (between 14 and 30 days), covering a period of 3 months, reflected by the HbA1c, were investigated. The influence of clinical- and isCGM-derived parameters on the discordance was assessed. We included 278 patients (55% T1DM; 33% type 2 diabetes (T2DM)) with a mean HbA1c of 7.63%. The mean GMI of the four time periods was between 7.19% and 7.25%. On average, the absolute deviation between the four calculated GMIs and HbA1c ranged from 0.6% to 0.65%. The discordance was greater with increased BMI, a diagnosis of T2DM, and a greater difference between the most recent GMI and GMI assessed 8 to 10 weeks prior to HbA1c assessment. Our data shows that, especially in patients with increased BMI and T2DM, this difference is more pronounced and should therefore be considered when making therapeutic decisions.
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Honka H, Chuang J, D’Alessio D, Salehi M. Utility of Continuous Glucose Monitoring vs Meal Study in Detecting Hypoglycemia After Gastric Bypass. J Clin Endocrinol Metab 2022; 107:e2095-e2102. [PMID: 34935944 PMCID: PMC9016438 DOI: 10.1210/clinem/dgab913] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Indexed: 12/24/2022]
Abstract
CONTEXT Gastric bypass (GB) increases postprandial glucose excursion, which in turn can predispose to the late complication of hypoglycemia. Diagnosis remains challenging and requires documentation of symptoms associated with low glucose and relief of symptom when glucose is normalized (Whipple triad). OBJECTIVE To compare the yield of mixed meal test (MMT) and continuous glucose monitoring system (CGMS) in detecting hypoglycemia after GB. SETTING The study was conducted at General Clinical Research Unit, Cincinnati Children's Hospital (Cincinnati, OH, USA). METHODS Glucose profiles were evaluated in 15 patients with documented recurrent clinical hypoglycemia after GB, 8 matched asymptomatic GB subjects, and 9 healthy weight-matched nonoperated controls using MMT in a control setting and CGMS under free-living conditions. RESULTS Patients with prior GB had larger glucose variability during both MMT and CGMS when compared with nonsurgical controls regardless of their hypoglycemic status. Sensitivity (71 vs 47%) and specificity (100 vs 88%) of MMT in detecting hypoglycemia was superior to CGMS. CONCLUSIONS Our findings indicate that a fixed carbohydrate ingestion during MMT is a more reliable test to diagnose GB-related hypoglycemia compared with CGMS during free-living state.
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Affiliation(s)
- Henri Honka
- Division of Diabetes, University of Texas Health Science Center, San Antonio, TX 78229, USA
- Henri Honka, MD, PhD, Division of Diabetes, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, USA.
| | - Janet Chuang
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229-3026, USA
| | - David D’Alessio
- University of Cincinnati College of Medicine, Department of Medicine, Cincinnati, OH 45267, USA
| | - Marzieh Salehi
- Division of Diabetes, University of Texas Health Science Center, San Antonio, TX 78229, USA
- University of Cincinnati College of Medicine, Department of Medicine, Cincinnati, OH 45267, USA
- Bartter Research Unit, South Texas Veterans Health Care System, Audie Murphy Hospital, San Antonio, TX 78229, USA
- Correspondence: Marzieh Salehi, MD, MS, Bartter Research Unit, Audie Murphy Hospital, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229, USA.
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Marks BE, Williams KM, Sherwood JS, Putman MS. Practical aspects of diabetes technology use: Continuous glucose monitors, insulin pumps, and automated insulin delivery systems. J Clin Transl Endocrinol 2022; 27:100282. [PMID: 34917483 PMCID: PMC8666668 DOI: 10.1016/j.jcte.2021.100282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/01/2021] [Accepted: 11/27/2021] [Indexed: 02/06/2023] Open
Abstract
There have been tremendous advances in diabetes technology in the last decade. Continuous glucose monitors (CGM), insulin pumps, and automated insulin delivery (AID) systems aim to improve glycemic control while simultaneously decreasing the burden of diabetes management. Although diabetes technologies have been shown to decrease both hypoglycemia and hyperglycemia and to improve health-related quality of life in individuals with type 1 diabetes, the impact of these devices in individuals with cystic fibrosis-related diabetes (CFRD) is less clear. There are unique aspects of CFRD, including the different underlying pathophysiology and unique lived health care experience and comorbidities, that likely affect the use, efficacy, and uptake of diabetes technology in this population. Small studies suggest that CGM is accurate and may be helpful in guiding insulin therapy for individuals with CFRD. Insulin pump use has been linked to improvements in lean body mass and hemoglobin A1c among adults with CFRD. A recent pilot study highlighted the promise of AID systems in this population. This article provides an overview of practical aspects of diabetes technology use and device limitations that clinicians must be aware of in caring for individuals with CF and CFRD. Cost and limited insurance coverage remain significant barriers to wider implementation of diabetes technology use among patients with CFRD. Future studies exploring strategies to improve patient and CF provider education about these devices and studies showing the effectiveness of these technologies on health and patient-reported outcomes may lead to improved insurance coverage and increased rates of uptake and sustained use of these technologies in the CFRD community.
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Affiliation(s)
- Brynn E. Marks
- Division of Endocrinology and Diabetes, Children’s National Hospital, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Kristen M. Williams
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Columbia University Irving Medical Center, 1150 St Nicholas Avenue, New York, NY 10032, United States
| | - Jordan S. Sherwood
- Diabetes Research Center, Division of Pediatric Endocrinology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Melissa S. Putman
- Division of Endocrinology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, United States
- Diabetes Research Center, Division of Endocrinology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
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25
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Sofizadeh S, Pehrsson A, Ólafsdóttir AF, Lind M. Evaluation of Reference Metrics for Continuous Glucose Monitoring in Persons Without Diabetes and Prediabetes. J Diabetes Sci Technol 2022; 16:373-382. [PMID: 33100059 PMCID: PMC8861786 DOI: 10.1177/1932296820965599] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent guidelines have been developed for continuous glucose monitoring (CGM) metrics in persons with diabetes. To understand what glucose profiles should be judged as normal in clinical practice and glucose-lowering trials, we examined the glucose profile of healthy individuals using CGM. METHODS Persons without diabetes or prediabetes were included after passing a normal oral glucose tolerance test, two-hour value <8.9 mmol/L (160 mg/dL), fasting glucose <6.1 mmol/L (110 mg/dL), and HbA1c <6.0% (<42 mmol/mol). CGM metrics were evaluated using the Dexcom G4 Platinum. RESULTS In total, 60 persons were included, mean age was 43.0 years, 70.0% were women, mean HbA1c was 5.3% (34 mmol/mol), and mean body mass index was 25.7 kg/m2. Median and mean percent times in hypoglycemia <3.9 mmol/L (70 mg/dL) were 1.6% (IQR 0.6-3.2), and 3.2% (95% CI 2.0; 4.3), respectively. For glucose levels <3.0 mmol/L (54 mg/dL), the corresponding estimates were 0.0% (IQR 0.0-0.4) and 0.5% (95% CI 0.2; 0.8). Median and mean time-in-range (3.9-10.0 mmol/L [70-180 mg/dL]) was 97.3% (IQR 95.4-98.7) and 95.4% (95% CI 94.0; 96.8), respectively. Median and mean standard deviations were 1.04 mmol/L (IQR 0.92-1.29) and 1.15 mmol/L (95% CI 1.05; 1.24), respectively. Measures of glycemic variability (standard deviation, coefficient of variation, mean amplitude of glycemic excursions) were significantly greater during daytime compared with nighttime, whereas others did not differ. CONCLUSIONS People without prediabetes or diabetes show a non-negligible % time in hypoglycemia, median 1.6% and mean 3.2%, which needs to be accounted for in clinical practice and glucose-lowering trials. Glycemic variability measures differ day and night in this population.
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Affiliation(s)
- Sheyda Sofizadeh
- Department of Medicine, NU-Hospital
Group, Uddevalla, Sweden
- Department of Molecular and Clinical
Medicine, University of Gothenburg, Gothenburg, Sweden
- Sheyda Sofizadeh, RN, Department of
Medicine, Uddevalla Hospital, Uddevalla, 45180, Sweden.
| | | | - Arndís F. Ólafsdóttir
- Department of Medicine, NU-Hospital
Group, Uddevalla, Sweden
- Department of Molecular and Clinical
Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Lind
- Department of Medicine, NU-Hospital
Group, Uddevalla, Sweden
- Department of Molecular and Clinical
Medicine, University of Gothenburg, Gothenburg, Sweden
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26
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Newman C, Ero A, Dunne FP. Glycaemic control and novel technology management strategies in pregestational diabetes mellitus. Front Endocrinol (Lausanne) 2022; 13:1109825. [PMID: 36714590 PMCID: PMC9877346 DOI: 10.3389/fendo.2022.1109825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Pregestational diabetes (PGDM) is an increasingly common and complex condition that infers risk to both mother and infant. To prevent serious morbidity, strict glycaemic control is essential. The aim of this review is to review the glucose sensing and insulin delivering technologies currently available for women with PGDM. METHODS We reviewed online databases for articles relating to technology use in pregnancy using a combination of keywords and MeSH headings. Relevant articles are included below. RESULTS A number of technological advancements have improved care and outcomes for women with PGDM. Real time continuous glucose monitoring (rtCGM) offers clear advantages in terms of infants size and neonatal intensive care unit admissions; and further benefits are seen when combined with continuous subcutaneous insulin delivery (insulin pump) and algorithms which continuously adjust insulin levels to glucose targets (hybrid closed loop). Other advancements including flash or intermittent scanning CGM (isCGM) and stand-alone insulin pumps do not confer as many advantages for women and their infants, however they are increasingly used outside of pregnancy and many women enter pregnancy already using these devices. DISCUSSION This article offers a discussion of the most commonly used technologies in pregnancy and evaluates their current and future roles.
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Affiliation(s)
- Christine Newman
- School of Medicine, College of Medicine, Nursing and Health Science, University of Galway, Galway, Ireland
- Department of Diabetes and Endocrinology, Galway University Hospital, Galway, Ireland
- Diabetes Collaborative Clinical Trials Network, University of Galway, Galway, Ireland
- *Correspondence: Christine Newman,
| | - Adesuwa Ero
- Department of Diabetes and Endocrinology, Galway University Hospital, Galway, Ireland
| | - Fidelma P. Dunne
- School of Medicine, College of Medicine, Nursing and Health Science, University of Galway, Galway, Ireland
- Department of Diabetes and Endocrinology, Galway University Hospital, Galway, Ireland
- Diabetes Collaborative Clinical Trials Network, University of Galway, Galway, Ireland
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27
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Wang LR, Morein J, McCudden C, Sorisky A. Artifactual hypoglycemia in a patient with sickle cell anemia. CMAJ 2021; 193:E1660-E1662. [PMID: 34725113 PMCID: PMC8565976 DOI: 10.1503/cmaj.210191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Linda R Wang
- Division of Endocrinology and Metabolism, Department of Medicine (Wang, Morein, Sorisky), The Ottawa Hospital and University of Ottawa; Department of Pathology and Laboratory Medicine (McCudden), The Ottawa Hospital and University of Ottawa; Eastern Ontario Regional Laboratory Association (McCudden); Ottawa Hospital Research Institute (Sorisky), The Ottawa Hospital, Ottawa, Ont
| | - Justin Morein
- Division of Endocrinology and Metabolism, Department of Medicine (Wang, Morein, Sorisky), The Ottawa Hospital and University of Ottawa; Department of Pathology and Laboratory Medicine (McCudden), The Ottawa Hospital and University of Ottawa; Eastern Ontario Regional Laboratory Association (McCudden); Ottawa Hospital Research Institute (Sorisky), The Ottawa Hospital, Ottawa, Ont
| | - Christopher McCudden
- Division of Endocrinology and Metabolism, Department of Medicine (Wang, Morein, Sorisky), The Ottawa Hospital and University of Ottawa; Department of Pathology and Laboratory Medicine (McCudden), The Ottawa Hospital and University of Ottawa; Eastern Ontario Regional Laboratory Association (McCudden); Ottawa Hospital Research Institute (Sorisky), The Ottawa Hospital, Ottawa, Ont
| | - Alexander Sorisky
- Division of Endocrinology and Metabolism, Department of Medicine (Wang, Morein, Sorisky), The Ottawa Hospital and University of Ottawa; Department of Pathology and Laboratory Medicine (McCudden), The Ottawa Hospital and University of Ottawa; Eastern Ontario Regional Laboratory Association (McCudden); Ottawa Hospital Research Institute (Sorisky), The Ottawa Hospital, Ottawa, Ont.
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28
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Lee D, Dreyfuss JM, Sheehan A, Puleio A, Mulla CM, Patti ME. Glycemic Patterns Are Distinct in Post-Bariatric Hypoglycemia After Gastric Bypass (PBH-RYGB). J Clin Endocrinol Metab 2021; 106:2291-2303. [PMID: 33974064 PMCID: PMC8277212 DOI: 10.1210/clinem/dgab323] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Indexed: 12/12/2022]
Abstract
CONTEXT Severe hypoglycemia with neuroglycopenia, termed post-bariatric hypoglycemia (PBH). typically occurs postprandially, but it is also reported after activity or mid-nocturnally. OBJECTIVE To quantify glycemia, glycemic variability, and magnitude/duration of low sensor glucose (SG) values in patients with PBH after Roux-en-Y gastric bypass (PBH-RYGB). METHODS This retrospective analysis of data from an academic medical center included individuals with PBH-RYGB (n = 40), reactive hypoglycemia without gastrointestinal surgery (Non-Surg Hypo, n = 20), prediabetes (Pre-DM, n = 14), newly diagnosed T2D (n = 5), and healthy controls (HC, n = 38). Masked continuous glucose monitoring (Dexcom G4) was used to assess patterns over 24 hours, daytime (6 am-midnight) and nighttime (midnight-6 am). Prespecified measures included mean and median SG, variability, and percent time at thresholds of sensor glucose. RESULTS Mean and median SG were similar for PBH-RYGB and HC (mean: 99.8 ± 18.6 vs 96.9 ± 10.2 mg/dL; median: 93.0 ± 14.8 vs 94.5 ± 7.4 mg/dL). PBH-RYGB had a higher coefficient of variation (27.3 ± 6.8 vs 17.9 ± 2.4%, P < 0.0001) and range (154.5 ± 50.4 vs 112.0 ± 26.7 mg/dL, P < 0.0001). Nadir was lowest in PBH-RYGB (42.5 ± 3.7 vs HC 49.0 ± 11.9 mg/dL, P = 0.0046), with >2-fold greater time with SG < 70 mg/dL vs HC (7.7 ± 8.4 vs 3.2 ± 4.1%, P = 0.0013); these differences were greater at night (12.6 ± 16.9 vs 1.0 ± 1.5%, P < 0.0001). Non-Surg Hypo also had 4-fold greater time with SG < 70 at night vs HC (SG < 70: 4.0 ± 5.9% vs 1.0 ± 1.5%), but glycemic variability was not increased. CONCLUSION Patients with PBH-RYGB experience higher glycemic variability and frequency of SG < 70 compared to HC, especially at night. These data suggest that additional pathophysiologic mechanisms beyond prandial changes contribute to PBH.
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Affiliation(s)
- Daniel Lee
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
- Morehouse School of Medicine, Atlanta 30310, GA, USA
| | - Jonathan M Dreyfuss
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
- Harvard Medical School, Boston 02115, MA, USA
| | - Amanda Sheehan
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
| | - Alexa Puleio
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
| | - Christopher M Mulla
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
- Harvard Medical School, Boston 02115, MA, USA
- Current Affiliation for C. M. Mulla: Landstuhl Regional Medical Center, Germany
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston 02215, MA, USA
- Harvard Medical School, Boston 02115, MA, USA
- Correspondence: Mary Elizabeth Patti MD, Room 620, Joslin Diabetes Center, 1 Joslin Place, Boston MA 02215, USA.
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29
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Puglisi SC, Mackiewicz AL, Ardeshir A, Garzel LM, Christe KL. Comparison of Insulins Glargine and Degludec in Diabetic Rhesus Macaques ( Macaca mulatta) with CGM Devices. Comp Med 2021; 71:247-255. [PMID: 34034855 DOI: 10.30802/aalas-cm-20-000075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Treating and monitoring type 2 diabetes mellitus (T2DM) in NHP can be challenging. Multiple insulin and hypoglycemic therapies and management tools exist, but few studies demonstrate their benefits in a NHP clinical setting. The insulins glargine and degludec are long-acting insulins; their duration of action in humans exceeds 24 and 42 h, respectively. In the first of this study's 2 components, we evaluated whether insulin degludec could be dosed daily at equivalent units to glargine to achieve comparable blood glucose (BG) reduction in diabetic rhesus macaques (Macaca mulatta) with continuous glucose monitoring (CGM) devices. The second component assessed the accuracy of CGM devices in rhesus macaques by comparing time-stamped CGM interstitial glucose values, glucometer BG readings, and BG levels measured by using an automated clinical chemistry analyzer from samples that were collected at the beginning and end of each CGM device placement. The CGM devices collected a total of 21,637 glucose data points from 6 diabetic rhesus macaques that received glargine followed by degludec every 24 h for 1 wk each. Ultimately, glucose values averaged 29 mg/dL higher with degludec than with glargine. Glucose values were comparable between the CGM device, glucometer, and chemistry analyzer, thus validating that CGM devices as reliable for measuring BG levels in rhesus macaques. Although glargine was superior to degludec when given at the same dose (units/day), both are safe and effective treatment options. Glucose values from CGM, glucometers, and chemistry analyzers provided results that were analogous to BG values in rhesus macaques. Our report further highlights critical clinical aspects of using glargine as compared with degludec in NHP and the benefits of using CGM devices in macaques.
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Affiliation(s)
| | | | - Amir Ardeshir
- California National Primate Research Center, Davis, California
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30
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Edelman SV, Cavaiola TS, Boeder S, Pettus J. Utilizing continuous glucose monitoring in primary care practice: What the numbers mean. Prim Care Diabetes 2021; 15:199-207. [PMID: 33257275 DOI: 10.1016/j.pcd.2020.10.013] [Citation(s) in RCA: 4] [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] [Received: 06/17/2020] [Revised: 10/26/2020] [Accepted: 10/31/2020] [Indexed: 12/17/2022]
Abstract
Use of continuous glucose monitoring (CGM) has been shown to improve glycemia control, reduce hypoglycemia, lower glycemic variability and enhance quality of life for individuals with type 1 diabetes and type 2 diabetes. However, many primary care physicians may be unfamiliar with the how CGM data can interpreted and acted upon. As adoption of this technology continues to grow, primary care physicians will be challenged to integrate CGM into their clinical practices. This article is intended to provide clinicians with practical guidance in interpreting and utilizing CGM data with their patients.
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Affiliation(s)
- Steven V Edelman
- University of California San Diego and Taking Control of Your Diabetes 501c3, San Diego, CA 92161, USA.
| | - Tricia Santos Cavaiola
- Department of Medicine, Clinical and Translational Research Institute (CTRI), San Diego, CA 92161, USA.
| | - Schafer Boeder
- Department of Medicine, Clinical and Translational Research Institute (CTRI), University of California SanDiego, San Diego, CA 92161, USA.
| | - Jeremy Pettus
- Department of Medicine, Clinical and Translational Research Institute (CTRI), University of California SanDiego, San Diego, CA 92161, USA.
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Kalra S, Shaikh S, Priya G, Baruah MP, Verma A, Das AK, Shah M, Das S, Khandelwal D, Sanyal D, Ghosh S, Saboo B, Bantwal G, Ayyagari U, Gardner D, Jimeno C, Barbary NE, Hafidh KA, Bhattarai J, Minulj TT, Zufry H, Bulugahapitiya U, Murad M, Tan A, Shahjada S, Bello MB, Katulanda P, Podgorski G, AbuHelaiqa WI, Tan R, Latheef A, Govender S, Assaad-Khalil SH, Kootin-Sanwu C, Joshi A, Pathan F, Nkansah DA. Individualizing Time-in-Range Goals in Management of Diabetes Mellitus and Role of Insulin: Clinical Insights From a Multinational Panel. Diabetes Ther 2021; 12:465-485. [PMID: 33367983 PMCID: PMC7846622 DOI: 10.1007/s13300-020-00973-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023] Open
Abstract
Diabetes mellitus is a global health concern associated with significant morbidity and mortality. Inadequate control of diabetes leads to chronic complications and higher mortality rates, which emphasizes the importance of achieving glycemic targets. Although glycated hemoglobin (HbA1c) is the gold standard for measuring glycemic control, it has several limitations. Therefore, in recent years, along with the emergence of continuous glucose monitoring (CGM) technology, glycemic control modalities have moved beyond HbA1c. They encompass modern glucometrics, such as glycemic variability (GV) and time-in-range (TIR). The key advantage of these newer metrics over HbA1c is that they allow personalized diabetes management with person-centric glycemic control. Basal insulin analogues, especially second-generation basal insulins with properties such as longer duration of action and low risk of hypoglycemia, have demonstrated clinical benefits by reducing GV and improving TIR. Therefore, for more effective and accurate diabetes management, the development of an integrated approach with second-generation basal insulin and glucometrics involving GV and TIR is the need of the hour. With this objective, a multinational group of endocrinologists and diabetologists reviewed the existing recommendations on TIR, provided their clinical insights into the individualization of TIR targets, and elucidated on the role of the second-generation basal insulin analogues in addressing TIR.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India.
| | - Shehla Shaikh
- Department of Endocrinology, KGN Institute of Diabetes and Endocrinology, Mumbai, Maharashtra, India
| | - Gagan Priya
- Department of Endocrinology, Fortis Hospital, Chandigarh, Punjab, India
| | - Manas P Baruah
- Department of Endocrinology, Excel Hospital, Guwahati, Assam, India
| | - Abhyudaya Verma
- Endocrine Division, Index Medical College, Indore, Madhya Pradesh, India
| | - Ashok K Das
- Department of Endocrinology and Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Mona Shah
- HARMONY Endocrine Diabetes and Metabolic Clinic, Vadodara, Gujarat, India
| | - Sambit Das
- Department of Endocrinology, Apollo Hospitals, Bhubaneswar, Odisha, India
| | - Deepak Khandelwal
- Department of Endocrinology and Diabetes, Maharaja Agrasen Hospital, New Delhi, India
| | - Debmalya Sanyal
- Department of Endocrinology, KPC Medical College, Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department of Endocrinology and Metabolism, IPGMER, Kolkata, West Bengal, India
| | - Banshi Saboo
- Dia Care, Diabetes Care and Hormone Clinic, Ahmedabad, Gujarat, India
| | - Ganapathi Bantwal
- Department of Endocrinology, St. John's Medical College and Hospital, Bangalore, Karnataka, India
| | - Usha Ayyagari
- Department of Endocrinology, Apollo Sugar Clinics, Chennai, Tamil Nadu, India
| | - Daphne Gardner
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Cecilia Jimeno
- Department of Endocrinology, Philippine Society of Endocrinology, Diabetes and Metabolism, Manila, Philippines
| | - Nancy E Barbary
- Department of Endocrinology, Ain Shams University, Cairo, Egypt
| | - Khadijah A Hafidh
- Department of Endocrinology, Rashid Hospital-Dubai Health Authority, Dubai, UAE
| | - Jyoti Bhattarai
- Department of Endocrinology, Metro Kathmandu Hospital, Kathmandu, Nepal
| | - Tania T Minulj
- Department of Endocrinology, General Hospital Karyadi, Semarang, Indonesia
| | - Hendra Zufry
- Department of Endocrinology, General Hospital Zainoel Abidin, Aceh, Indonesia
| | | | - Moosa Murad
- Department of Internal Medicine, Indira Gandhi Memorial Hospital, Malé, Maldives
| | - Alexander Tan
- Department of Endocrinology, Sunway Medical Centre, Kuala Lumpur, Malaysia
| | - Selim Shahjada
- Department of Endocrinology, BSMMU (Bangabandhu Sheikh Mujib Medical University Hospital), Dhaka, Bangladesh
| | - Mijinyawa B Bello
- Department of Endocrinology, Gwarinpa District Hospital, Abuja, Nigeria
| | - Prasad Katulanda
- Department of Endocrinology, University of Colombo, Colombo, Sri Lanka
| | - Gracjan Podgorski
- Department of Endocrinology, Greenacres Hospital, Port Elizabeth, South Africa
| | | | - Rima Tan
- Department of Endocrinology, FEU-NRMF Medical Center, Quezon City, Philippines
| | - Ali Latheef
- Department of Endocrinology, Indira Gandhi Memorial Hospital, Malé, Maldives
| | | | | | | | - Ansumali Joshi
- Department of Endocrinology, Kathmandu Diabetes and Thyroid Center, Kathmandu, Nepal
| | - Faruque Pathan
- Department of Endocrinology, Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh
| | - Diana A Nkansah
- Department of Endocrinology, 37 Military Hospital Accra, Accra, Ghana
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32
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Fuchs S, Ernst AU, Wang LH, Shariati K, Wang X, Liu Q, Ma M. Hydrogels in Emerging Technologies for Type 1 Diabetes. Chem Rev 2020; 121:11458-11526. [DOI: 10.1021/acs.chemrev.0c01062] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Stephanie Fuchs
- Biological and Environmental Engineering, Cornell University, Ithaca, New York 14853, United States
| | - Alexander U. Ernst
- Biological and Environmental Engineering, Cornell University, Ithaca, New York 14853, United States
| | - Long-Hai Wang
- Biological and Environmental Engineering, Cornell University, Ithaca, New York 14853, United States
| | - Kaavian Shariati
- Biological and Environmental Engineering, Cornell University, Ithaca, New York 14853, United States
| | - Xi Wang
- Biological and Environmental Engineering, Cornell University, Ithaca, New York 14853, United States
| | - Qingsheng Liu
- Biological and Environmental Engineering, Cornell University, Ithaca, New York 14853, United States
| | - Minglin Ma
- Biological and Environmental Engineering, Cornell University, Ithaca, New York 14853, United States
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Galindo RJ, Umpierrez GE, Rushakoff RJ, Basu A, Lohnes S, Nichols JH, Spanakis EK, Espinoza J, Palermo NE, Awadjie DG, Bak L, Buckingham B, Cook CB, Freckmann G, Heinemann L, Hovorka R, Mathioudakis N, Newman T, O’Neal DN, Rickert M, Sacks DB, Seley JJ, Wallia A, Shang T, Zhang JY, Han J, Klonoff DC. Continuous Glucose Monitors and Automated Insulin Dosing Systems in the Hospital Consensus Guideline. J Diabetes Sci Technol 2020; 14:1035-1064. [PMID: 32985262 PMCID: PMC7645140 DOI: 10.1177/1932296820954163] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article is the work product of the Continuous Glucose Monitor and Automated Insulin Dosing Systems in the Hospital Consensus Guideline Panel, which was organized by Diabetes Technology Society and met virtually on April 23, 2020. The guideline panel consisted of 24 international experts in the use of continuous glucose monitors (CGMs) and automated insulin dosing (AID) systems representing adult endocrinology, pediatric endocrinology, obstetrics and gynecology, advanced practice nursing, diabetes care and education, clinical chemistry, bioengineering, and product liability law. The panelists reviewed the medical literature pertaining to five topics: (1) continuation of home CGMs after hospitalization, (2) initiation of CGMs in the hospital, (3) continuation of AID systems in the hospital, (4) logistics and hands-on care of hospitalized patients using CGMs and AID systems, and (5) data management of CGMs and AID systems in the hospital. The panelists then developed three types of recommendations for each topic, including clinical practice (to use the technology optimally), research (to improve the safety and effectiveness of the technology), and hospital policies (to build an environment for facilitating use of these devices) for each of the five topics. The panelists voted on 78 proposed recommendations. Based on the panel vote, 77 recommendations were classified as either strong or mild. One recommendation failed to reach consensus. Additional research is needed on CGMs and AID systems in the hospital setting regarding device accuracy, practices for deployment, data management, and achievable outcomes. This guideline is intended to support these technologies for the management of hospitalized patients with diabetes.
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Affiliation(s)
| | | | | | - Ananda Basu
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Suzanne Lohnes
- University of California San Diego Medical Center, La Jolla, CA, USA
| | | | - Elias K. Spanakis
- University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, MD, USA
| | | | - Nadine E. Palermo
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Tonya Newman
- Neal, Gerber and Eisenberg LLP, Chicago, IL, USA
| | - David N. O’Neal
- University of Melbourne Department of Medicine, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
| | | | | | | | - Amisha Wallia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | | | - Julia Han
- Diabetes Technology Society, Burlingame, CA, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Drive Room 5147, San Mateo, CA 94401, USA.
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Lundholm MD, Emanuele MA, Ashraf A, Nadeem S. Applications and pitfalls of hemoglobin A1C and alternative methods of glycemic monitoring. J Diabetes Complications 2020; 34:107585. [PMID: 32553575 DOI: 10.1016/j.jdiacomp.2020.107585] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Intensive glycemic control minimizes the risks of microvascular complications in diabetes. A1C is a convenient estimate of mean blood glucose, but is not the only marker available. The practical use and limitations of alternative markers and continuous glucose monitors are the focus of this review. METHODS PubMed and the Cochrane Library were searched for studies concerning applications or limitations of A1C, fructosamine, glycated albumin, 1,5-anhydroglucitol, skin autofluorescence, and continuous glucose monitoring. Papers reporting on strengths, limitations, or comparisons of these methods were reviewed for inclusion. RESULTS A1C reflects three months of glycemic control and is not an ideal marker in all patient populations. Fructosamine and glycated albumin reflect mean blood glucose over three weeks. 1,5-Anhydroglucitol can measure hyperglycemic excursions in days to weeks. Continuous glucose monitors provide immediate feedback for timely intervention to reduce glycemic excursions and can assess glycemic variability. Current barriers to continuous glucose monitor use include inexperience, cost, discomfort, and medication interference. CONCLUSIONS Many promising alternative glycemic markers exist. The main limitations for all alternative methods of glycemic monitoring are a lack of standardization for clinically useful cut-offs or guidelines, and a lack of long-term data on their association with complications, particularly in varied patient populations.
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Affiliation(s)
- Michelle D Lundholm
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Mary Ann Emanuele
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, IL, USA.
| | - Alina Ashraf
- Aga Khan University Medical College, Karachi, Sindh, Pakistan
| | - Sarah Nadeem
- Department of Medicine, Division of Endocrinology, Aga Khan University Hospital, Karachi, Sindh, Pakistan
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Stone JY, Bailey TS. Benefits and limitations of continuous glucose monitoring in type 1 diabetes. Expert Rev Endocrinol Metab 2020; 15:41-49. [PMID: 31928104 DOI: 10.1080/17446651.2020.1706482] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/16/2019] [Indexed: 12/14/2022]
Abstract
Introduction: Type 1 diabetes (T1D) is a chronic condition characterized by a complete deficiency in insulin production. Optimal management requires constant knowledge of glucose levels for safe and effective insulin administration. Self-monitoring of blood glucose (SMBG) using capillary blood glucose meters is cumbersome and provides limited information to guide management. Continuous glucose monitoring (CGM) technology addresses many of these gaps, but itself has limitations which have prevented people with diabetes and their clinicians from fully embracing this technology. This review covers the benefits and limitations of CGM use, and looks toward future application of this technology in the management of T1D.Areas covered: Impact of CGM on physical and psychosocial outcomes in people with T1D. Barriers to CGM uptake. Integration with insulin pumps and other technologies. Opportunities for future application.Expert opinion: CGM technology will be utilized by the majority of people with T1D and increasing numbers of people with type 2 diabetes due to improved insurance coverage and easier-to-use systems. Its use as part of artificial pancreas systems will add further utility, as it will help to protect from both hypoglycemia and hyperglycemia. People with diabetes will spend more time in range and experience fewer acute and chronic complications.
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Affiliation(s)
- Jenine Y Stone
- AMCR Institute, Escondido, CA, USA
- Vanderbilt University School of Nursing, Nashville, TN, USA
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Abstract
Regular self-monitoring of blood glucose levels, and ketones when indicated, is an essential component of type 1 diabetes (T1D) management. Although fingerstick blood glucose monitoring has been the standard of care for decades, ongoing rapid technological developments have resulted in increasingly widespread use of continuous glucose monitoring (CGM). This article reviews recommendations for self-monitoring of glucose and ketones in pediatric T1D with particular emphasis on CGM and factors that impact the accuracy and real-world use of this technology.
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Affiliation(s)
- Brynn E. Marks
- Division of Endocrinology and Diabetes, Children's National Hospital, Washington, DC, United States
- *Correspondence: Brynn E. Marks
| | - Joseph I. Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States
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Yardley JE, Rees JL, Funk DR, Toghi-Eshghi SR, Boulé NG, Senior PA. Effects of Moderate Cycling Exercise on Blood Glucose Regulation Following Successful Clinical Islet Transplantation. J Clin Endocrinol Metab 2019; 104:493-502. [PMID: 30403817 DOI: 10.1210/jc.2018-01498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/31/2018] [Indexed: 12/26/2022]
Abstract
CONTEXT Islet transplantation is effective in preventing hypoglycemia in patients with type 1 diabetes (T1D). However, it is unknown whether transplanted islets regulate plasma glucose concentrations appropriately during and after exercise in human islet transplant recipient (ITxs). OBJECTIVE To determine the effect of exercise on plasma glucose, insulin, and glucagon concentrations in ITxs compared with control subjects (CONs) without diabetes. INTERVENTION Participants completed two conditions in random order: 45 minutes of aerobic exercise (60% VO2peak) and 45 minutes of seated rest. Blood samples were drawn at baseline, immediately after exercise or rest, and every 15 minutes throughout a 60-minute recovery period. Postexercise (24 hours) interstitial glucose was monitored with continuous glucose monitoring (CGM). RESULTS Twenty-four participants (12 ITxs, 12 CONs) completed the protocol. Plasma glucose decreased more over time with exercise in ITxs compared with CONs [main effects of treatment (P = 0.019), time (P = 0.001), and group (P = 0.012)]. Plasma glucose was lower during exercise vs rest in ITxs but not CONs [treatment by group interaction (P = 0.028)]. Plasma glucose decreased more during exercise than during rest [treatment by time interaction (P = 0.001)]. One ITx and one CON experienced plasma glucose concentrations <3.5 mmol/L at the end of exercise, both of whom returned above that threshold within 15 minutes. Nocturnal CGM glucose <3.5 mmol/L was detected in two CONs but no ITxs. CONCLUSION Despite a greater plasma glucose decline during exercise in ITxs, hypoglycemia risk was similar during and after exercise in ITxs compared with CONs.
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Affiliation(s)
- Jane E Yardley
- Augustana Faculty, University of Alberta, Camrose, Alberta, Canada
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Jordan L Rees
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Deanna R Funk
- Augustana Faculty, University of Alberta, Camrose, Alberta, Canada
| | - Saeed Reza Toghi-Eshghi
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Normand G Boulé
- Alberta Diabetes Institute, Edmonton, Alberta, Canada
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Peter A Senior
- Alberta Diabetes Institute, Edmonton, Alberta, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Effect of sensor location on continuous intraperitoneal glucose sensing in an animal model. PLoS One 2018; 13:e0205447. [PMID: 30300416 PMCID: PMC6177183 DOI: 10.1371/journal.pone.0205447] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 09/25/2018] [Indexed: 12/02/2022] Open
Abstract
Background In diabetes research, the development of the artificial pancreas has been a major topic since continuous glucose monitoring became available in the early 2000’s. A prerequisite for an artificial pancreas is fast and reliable glucose sensing. However, subcutaneous continuous glucose monitoring carries the disadvantage of slow dynamics. As an alternative, we explored continuous glucose sensing in the peritoneal space, and investigated potential spatial differences in glucose dynamics within the peritoneal cavity. As a secondary outcome, we compared the glucose dynamics in the peritoneal space to the subcutaneous tissue. Material and methods Eight-hour experiments were conducted on 12 anesthetised non-diabetic pigs. Four commercially available amperometric glucose sensors (FreeStyle Libre, Abbott Diabetes Care Ltd., Witney, UK) were inserted in four different locations of the peritoneal cavity and two sensors were inserted in the subcutaneous tissue. Meals were simulated by intravenous infusions of glucose, and frequent arterial blood and intraperitoneal fluid samples were collected for glucose reference. Results No significant differences were discovered in glucose dynamics between the four quadrants of the peritoneal cavity. The intraperitoneal sensors responded faster to the glucose excursions than the subcutaneous sensors, and the time delay was significantly smaller for the intraperitoneal sensors, but we did not find significant results when comparing the other dynamic parameters.
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Wu PT, Segovia DE, Lee CC, Nguyen KL. Consistency of Continuous Ambulatory Interstitial Glucose Monitoring Sensors. BIOSENSORS-BASEL 2018; 8:bios8020049. [PMID: 29772654 PMCID: PMC6023027 DOI: 10.3390/bios8020049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/11/2018] [Accepted: 05/14/2018] [Indexed: 11/16/2022]
Abstract
AIMS The abdominal region is the most common location for continuous glucose monitor (CGM) sensor insertion. However, a paucity of post-marketing data is available to demonstrate intra-individual consistency of CGM readings at different abdominal insertion sites. METHODS Healthy adults (fasting glucose (FG) < 5.5 mmol/L; BMI < 30 kg/m²) were recruited and a CGM sensor was placed on each side of the abdomen. Postprandial and continuous 48-h interstitial glucose levels were analyzed. RESULTS There was no significant difference in the 3-h postprandial glucose (PPG) level derived from the left versus right CGM, which remained non-significant after adjusting for waist circumference or FG. Among the glucose levels recorded over 48-h, values on the left site were greater in 3.6% of the data points (p < 0.05). After adjusting for waist circumference, only 0.5% of the glucose values remained significantly greater on the left (p < 0.05). When adjusted for FG, similar results were observed. For both PPG and 48-h readings, the mean absolute relative difference was not significant between the two abdominal sites. CONCLUSIONS CGM-derived glucose measures were highly consistent between the left and right abdomen during both the postprandial and post-absorptive periods.
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Affiliation(s)
- Pei T Wu
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA 90024, USA.
| | - David E Segovia
- Department of Geriatrics, David Geffen School of Medicine at UCLA and Geriatric Research Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90095, USA.
| | - Cathy C Lee
- Department of Geriatrics, David Geffen School of Medicine at UCLA and Geriatric Research Education and Clinical Center (GRECC), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90095, USA.
| | - Kim-Lien Nguyen
- Division of Cardiology, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA 90024, USA.
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Lee I, Loew N, Tsugawa W, Lin CE, Probst D, La Belle JT, Sode K. The electrochemical behavior of a FAD dependent glucose dehydrogenase with direct electron transfer subunit by immobilization on self-assembled monolayers. Bioelectrochemistry 2017; 121:1-6. [PMID: 29291433 DOI: 10.1016/j.bioelechem.2017.12.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 12/16/2017] [Accepted: 12/16/2017] [Indexed: 10/18/2022]
Abstract
Continuous glucose monitoring (CGM) is a vital technology for diabetes patients by providing tight glycemic control. Currently, many commercially available CGM sensors use glucose oxidase (GOD) as sensor element, but this enzyme is not able to transfer electrons directly to the electrode without oxygen or an electronic mediator. We previously reported a mutated FAD dependent glucose dehydrogenase complex (FADGDH) capable of direct electron transfer (DET) via an electron transfer subunit without involving oxygen or a mediator. In this study, we investigated the electrochemical response of DET by controlling the immobilization of DET-FADGDH using 3 types of self-assembled monolayers (SAMs) with varying lengths. With the employment of DET-FADGDH and SAM, high current densities were achieved without being affected by interfering substances such as acetaminophen and ascorbic acid. Additionally, the current generated from DET-FADGDH electrodes decreased with increasing length of SAM, suggesting that the DET ability can be affected by the distance between the enzyme and the electrode. These results indicate the feasibility of controlling the immobilization state of the enzymes on the electrode surface.
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Affiliation(s)
- Inyoung Lee
- Department of Biotechnology and Life Science, Graduate School of Engineering, Tokyo University of Agriculture and Technology, 2-24-16 Naka-cho, Koganei, Tokyo 184-8588, Japan
| | - Noya Loew
- Department of Biotechnology and Life Science, Graduate School of Engineering, Tokyo University of Agriculture and Technology, 2-24-16 Naka-cho, Koganei, Tokyo 184-8588, Japan
| | - Wakako Tsugawa
- Department of Biotechnology and Life Science, Graduate School of Engineering, Tokyo University of Agriculture and Technology, 2-24-16 Naka-cho, Koganei, Tokyo 184-8588, Japan
| | - Chi-En Lin
- Harrington Program of Biomedical Engineering, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ 85287, United States
| | - David Probst
- Harrington Program of Biomedical Engineering, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ 85287, United States
| | - Jeffrey T La Belle
- Harrington Program of Biomedical Engineering, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ 85287, United States
| | - Koji Sode
- Department of Biotechnology and Life Science, Graduate School of Engineering, Tokyo University of Agriculture and Technology, 2-24-16 Naka-cho, Koganei, Tokyo 184-8588, Japan; Ultizyme International Ltd., 1-13-16 Minami, Meguro, Tokyo 152-0013, Japan; Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Chapel Hill, NC 27599, United States.
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Wang B, Sun G, Qiao W, Liu Y, Qiao J, Ye W, Wang H, Wang X, Lindquist R, Wang Y, Xiao YF. Long-term blood glucose monitoring with implanted telemetry device in conscious and stress-free cynomolgus monkeys. J Endocrinol Invest 2017; 40:967-977. [PMID: 28365864 PMCID: PMC5559582 DOI: 10.1007/s40618-017-0651-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/05/2017] [Indexed: 12/12/2022]
Abstract
AIMS Continuous blood glucose monitoring, especially long-term and remote, in diabetic patients or research is very challenging. Nonhuman primate (NHP) is an excellent model for metabolic research, because NHPs can naturally develop Type 2 diabetes mellitus (T2DM) similarly to humans. This study was to investigate blood glucose changes in conscious, moving-free cynomolgus monkeys (Macaca fascicularis) during circadian, meal, stress and drug exposure. MATERIALS AND METHODS Blood glucose, body temperature and physical activities were continuously and simultaneously recorded by implanted HD-XG telemetry device for up to 10 weeks. RESULTS AND DISCUSSION Blood glucose circadian changes in normoglycemic monkeys significantly differed from that in diabetic animals. Postprandial glucose increase was more obvious after afternoon feeding. Moving a monkey from its housing cage to monkey chair increased blood glucose by 30% in both normoglycemic and diabetic monkeys. Such increase in blood glucose declined to the pre-procedure level in 30 min in normoglycemic animals and >2 h in diabetic monkeys. Oral gavage procedure alone caused hyperglycemia in both normoglycemic and diabetic monkeys. Intravenous injection with the stress hormones, angiotensin II (2 μg/kg) or norepinephrine (0.4 μg/kg), also increased blood glucose level by 30%. The glucose levels measured by the telemetry system correlated significantly well with glucometer readings during glucose tolerance tests (ivGTT or oGTT), insulin tolerance test (ITT), graded glucose infusion (GGI) and clamp. CONCLUSION Our data demonstrate that the real-time telemetry method is reliable for monitoring blood glucose remotely and continuously in conscious, stress-free, and moving-free NHPs with the advantages highly valuable to diabetes research and drug discovery.
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Affiliation(s)
- B Wang
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - G Sun
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - W Qiao
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - Y Liu
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - J Qiao
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - W Ye
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - H Wang
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - X Wang
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - R Lindquist
- Data Sciences International, St. Paul, MN, USA
| | - Y Wang
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China
| | - Y-F Xiao
- Crown Bioscience, Inc., Taicang, Jiangsu Province, The People's Republic of China.
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Wang B, Qiao W, Ye W, Wang X, Liu Y, Wang YJ, Xiao YF. Comparison of Continuous Glucose Monitoring between Dexcom G4 Platinum and HD-XG Systems in Nonhuman Primates (Macaca Fascicularis). Sci Rep 2017; 7:9596. [PMID: 28851965 PMCID: PMC5575167 DOI: 10.1038/s41598-017-09806-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/28/2017] [Indexed: 01/26/2023] Open
Abstract
Timely knowing glucose level helps diabetic patients to manage the disease, including decisions about food, physical activity and medication. This study compared two continuous glucose monitoring systems in conscious and moving-free nonhuman primates (NHPs, Macaca fascicularis). Each normoglycemic or diabetic monkey was implanted with one Dexcom G4 Platinum subcutaneously or one HD-XG glucose sensor arterially for glucose monitoring. The glucose levels measured by both telemetry devices significantly correlated with the glucometer readings. The data of oral glucose tolerance test (oGTT) showed that the glucose levels measured by either Dexcom G4 Platinum or HD-XG transmitter were very similar to glucometer readings. However, compared to HD-XG transmitter or glucometer, Dexcom G4 Platinum detected a decreased glucose peak of ivGTT with approximately 10 min delay due to interstitial glucose far behind blood glucose change. Our data showed the advantages of the telemetry systems are: (1) consecutive data collection (day and night); (2) no bleeding; (3) no anesthesia (moving freely); (4) recording natural response without physical restriction and stress; (5) less labor intensity during ivGTT and other tests; (6) quick outcomes without lab tests. This article summarized and compared the differences of the general characteristics of two continuous glucose monitoring systems in diabetic research.
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Affiliation(s)
- Bingdi Wang
- Crown Bioscience, Inc., Taicang, Jiangsu Province, China
| | - Wei Qiao
- Crown Bioscience, Inc., Taicang, Jiangsu Province, China
| | - Weiwei Ye
- Crown Bioscience, Inc., Taicang, Jiangsu Province, China
| | - Xiaoli Wang
- Crown Bioscience, Inc., Taicang, Jiangsu Province, China
| | - Yongqiang Liu
- Crown Bioscience, Inc., Taicang, Jiangsu Province, China
| | - Yixin Jim Wang
- Crown Bioscience, Inc., Taicang, Jiangsu Province, China
| | - Yong-Fu Xiao
- Crown Bioscience, Inc., Taicang, Jiangsu Province, China.
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Forlenza GP, Argento NB, Laffel LM. Practical Considerations on the Use of Continuous Glucose Monitoring in Pediatrics and Older Adults and Nonadjunctive Use. Diabetes Technol Ther 2017; 19:S13-S20. [PMID: 28585878 PMCID: PMC5467117 DOI: 10.1089/dia.2017.0034] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Clinical use of continuous glucose monitoring (CGM) devices has grown over the past 15 years from a niche concept to becoming standard of care for patients with type 1 diabetes (T1D). With the December 2016 Food and Drug Administration approval for diabetes treatment decisions directly from CGM values (nonadjunctive use) without finger-stick confirmation, the uptake and scope of CGM use will likely further expand. With this expansion, it is important to consider the role and impact of CGM technology in specific settings and high-risk populations, such as the young and the elderly. In pediatric patients, CGM concerns include limited body surface area, difficulty keeping sensors adhered, and the role of nonadjunctive use in the school setting. In older adults, Medicare did not, until very recently, cover CGM devices and as such, their use had been limited by lack of reimbursement. As CGM use will likely expand in clinical practice given the nonadjunctive indication, guidelines and recommendations for clinical practice are warranted. In this article, we discuss recent research on CGM use in the special populations of children and older adults and provide initial guidelines for nonadjunctive use in clinical practice.
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Affiliation(s)
| | | | - Lori M. Laffel
- Pediatric, Adolescent and Young Adult Section, The Section on Clinical, Behavioral and Outcomes Research, Joslin Diabetes Center, Boston, Massachusetts
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Abstract
The use of commercially available continuous glucose monitors for diabetes management requires sensor calibrations, which until recently are exclusively performed by the patient. A new development is the implementation of factory calibration for subcutaneous glucose sensors, which eliminates the need for user calibrations and the associated blood glucose tests. Factory calibration means that the calibration process is part of the sensor manufacturing process and performed under controlled laboratory conditions. The ability to move from a user calibration to factory calibration is based on several technical requirements related to sensor stability and the robustness of the sensor manufacturing process. The main advantages of factory calibration over the conventional user calibration are: (a) more convenience for the user, since no more fingersticks are required for calibration and (b) elimination of use errors related to the execution of the calibration process, which can lead to sensor inaccuracies. The FreeStyle Libre™ and FreeStyle Libre Pro™ flash continuous glucose monitoring systems are the first commercially available sensor systems using factory-calibrated sensors. For these sensor systems, no user calibrations are required throughout the sensor wear duration.
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Affiliation(s)
- Udo Hoss
- Abbott Diabetes Care , Alameda, California
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Riemsma R, Corro Ramos I, Birnie R, Büyükkaramikli N, Armstrong N, Ryder S, Duffy S, Worthy G, Al M, Severens J, Kleijnen J. Integrated sensor-augmented pump therapy systems [the MiniMed® Paradigm™ Veo system and the Vibe™ and G4® PLATINUM CGM (continuous glucose monitoring) system] for managing blood glucose levels in type 1 diabetes: a systematic review and economic evaluation. Health Technol Assess 2016; 20:v-xxxi, 1-251. [PMID: 26933827 DOI: 10.3310/hta20170] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In recent years, meters for continuous monitoring of interstitial fluid glucose have been introduced to help people with type 1 diabetes mellitus (T1DM) to achieve better control of their disease. OBJECTIVE The objective of this project was to summarise the evidence on the clinical effectiveness and cost-effectiveness of the MiniMed(®) Paradigm™ Veo system (Medtronic Inc., Northridge, CA, USA) and the Vibe™ (Animas(®) Corporation, West Chester, PA, USA) and G4(®) PLATINUM CGM (continuous glucose monitoring) system (Dexcom Inc., San Diego, CA, USA) in comparison with multiple daily insulin injections (MDIs) or continuous subcutaneous insulin infusion (CSII), both with either self-monitoring of blood glucose (SMBG) or CGM, for the management of T1DM in adults and children. DATA SOURCES A systematic review was conducted in accordance with the principles of the Centre for Reviews and Dissemination guidance and the National Institute for Health and Care Excellence Diagnostic Assessment Programme manual. We searched 14 databases, three trial registries and two conference proceedings from study inception up to September 2014. In addition, reference lists of relevant systematic reviews were checked. In the absence of randomised controlled trials directly comparing Veo or an integrated CSII + CGM system, such as Vibe, with comparator interventions, indirect treatment comparisons were performed if possible. METHODS A commercially available cost-effectiveness model, the IMS Centre for Outcomes Research and Effectiveness diabetes model version 8.5 (IMS Health, Danbury, CT, USA), was used for this assessment. This model is an internet-based, interactive simulation model that predicts the long-term health outcomes and costs associated with the management of T1DM and type 2 diabetes. The model consists of 15 submodels designed to simulate diabetes-related complications, non-specific mortality and costs over time. As the model simulates individual patients over time, it updates risk factors and complications to account for disease progression. RESULTS Fifty-four publications resulting from 19 studies were included in the review. Overall, the evidence suggests that the Veo system reduces hypoglycaemic events more than other treatments, without any differences in other outcomes, including glycated haemoglobin (HbA1c) levels. We also found significant results in favour of the integrated CSII + CGM system over MDIs with SMBG with regard to HbA1c levels and quality of life. However, the evidence base was poor. The quality of the included studies was generally low, often with only one study comparing treatments in a specific population at a specific follow-up time. In particular, there was only one study comparing Veo with an integrated CSII + CGM system and only one study comparing Veo with a CSII + SMBG system in a mixed population. Cost-effectiveness analyses indicated that MDI + SMBG is the option most likely to be cost-effective, given the current threshold of £30,000 per quality-adjusted life-year gained, whereas integrated CSII + CGM systems and Veo are dominated and extendedly dominated, respectively, by stand-alone, non-integrated CSII with CGM. Scenario analyses did not alter these conclusions. No cost-effectiveness modelling was conducted for children or pregnant women. CONCLUSIONS The Veo system does appear to be better than the other systems considered at reducing hypoglycaemic events. However, in adults, it is unlikely to be cost-effective. Integrated systems are also generally unlikely to be cost-effective given that stand-alone systems are cheaper and, possibly, no less effective. However, evidence in this regard is generally lacking, in particular for children. Future trials in specific child, adolescent and adult populations should include longer term follow-up and ratings on the European Quality of Life-5 Dimensions scale at various time points with a view to informing improved cost-effectiveness modelling. STUDY REGISTRATION PROSPERO Registration Number CRD42014013764. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Isaac Corro Ramos
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Nasuh Büyükkaramikli
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | | | | | | | - Maiwenn Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK.,School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
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Haviland N, Walsh J, Roberts R, Bailey TS. Update on Clinical Utility of Continuous Glucose Monitoring in Type 1 Diabetes. Curr Diab Rep 2016; 16:115. [PMID: 27718171 DOI: 10.1007/s11892-016-0808-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Since the early 2000s, continuous glucose monitoring (CGM) technology has advanced to become a standard of care in the treatment of type 1 diabetes. Unfortunately, CGM use is not commonly integrated into practice. This article will review the history, technology, and need for systematic training in CGM. Additionally, it will review recent clinical trial data demonstrating the benefits that CGM offers to all people with type 1 diabetes and the clinicians who care for them.
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Affiliation(s)
- Nalani Haviland
- Advanced Metabolic Care and Research, 625 W. Citracado Pkwy, Ste 108, Escondido, CA, 92025, USA
| | - John Walsh
- Advanced Metabolic Care and Research, 625 W. Citracado Pkwy, Ste 108, Escondido, CA, 92025, USA
| | - Ruth Roberts
- Diabetes Services, Inc., 1030 West Upas St., San Diego, CA, 92103, USA
| | - Timothy S Bailey
- AMCR Institute, 625 West Citracado Parkway Suite 112, Escondido, CA, 92025, USA.
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47
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Joubert M, Baillot-Rudoni S, Catargi B, Charpentier G, Esvant A, Franc S, Guerci B, Guilhem I, Melki V, Merlen E, Penfornis A, Renard E, Riveline J, Schaepelynck P, Sola-Gazagnes A, Hanaire H. Indication, organization, practical implementation and interpretation guidelines for retrospective CGM recording: A French position statement. DIABETES & METABOLISM 2015; 41:498-508. [DOI: 10.1016/j.diabet.2015.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/06/2015] [Accepted: 07/14/2015] [Indexed: 11/15/2022]
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48
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Evans K, Richardson C, Landry A, Muileboom J, Cormack L, Lawson ML. Experience with the Enlite sensor in a multicenter pediatric study. DIABETES EDUCATOR 2014; 41:31-7. [PMID: 25512220 DOI: 10.1177/0145721714560589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this article is to outline the experience of certified diabetes educators (CDEs) using the Enlite continuous glucose monitoring sensor system in a pediatric multicenter randomized controlled trial. Continuous glucose monitoring (CGM) is becoming popular as a tool for educators and families to improve glycemic control. CGM can be a valuable educational tool to demonstrate to the user the impact of insulin dosing and effects of physical activity, food intake, and other life events such as work, illness, and stress on their glycemic control. The authors will share education tips and practical applications for diabetes educators to facilitate education and sustained use of Enlite glucose sensors in children and adolescents using insulin pump therapy. CONCLUSIONS The Enlite glucose sensor is a comfortable and user-friendly device. Improvements to both the insertion device and the Enlite glucose sensor have resulted in improved level of comfort on insertion and with ongoing wear, which may translate into greater adherence and effectiveness.
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Affiliation(s)
- Keira Evans
- Pediatric Diabetes Research Unit, London Health Sciences Centre, Children's Hospital, London, ON, Canada (Mrs Evans)
| | - Christine Richardson
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada (Mrs Richardson)
| | - Alanna Landry
- Pediatric Diabetes Program, Markham Stouffville Hospital, Stouffville, ON, Canada (Mrs Landry)
| | - Janice Muileboom
- Division of Endocrinology, McMaster Children's Hospital, Hamilton Health Sciences Centre, Hamilton, ON, Canada (Mrs Muileboom)
| | - Lynne Cormack
- Division of Endocrinology, Hospital for Sick Children, Toronto, ON, Canada (Mrs Cormack)
| | - Margaret L Lawson
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada (Dr Lawson)
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Abstract
Continuous subcutaneous insulin infusion pumps and continuous glucose monitors enable individuals with type 1 diabetes to achieve tighter blood glucose control and are critical components in a closed-loop artificial pancreas. Insulin infusion sets can fail and continuous glucose monitor sensor signals can suffer from a variety of anomalies, including signal dropout and pressure-induced sensor attenuations. In addition to hardware-based failures, software and human-induced errors can cause safety-related problems. Techniques for fault detection, safety analyses, and remote monitoring techniques that have been applied in other industries and applications, such as chemical process plants and commercial aircraft, are discussed and placed in the context of a closed-loop artificial pancreas.
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50
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Baysal N, Cameron F, Buckingham BA, Wilson DM, Chase HP, Maahs DM, Bequette BW. A novel method to detect pressure-induced sensor attenuations (PISA) in an artificial pancreas. J Diabetes Sci Technol 2014; 8:1091-6. [PMID: 25316716 PMCID: PMC4455457 DOI: 10.1177/1932296814553267] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Continuous glucose monitors (CGMs) provide real-time interstitial glucose concentrations that are essential for automated treatment of individuals with type 1 diabetes. Miscalibration, noise spikes, dropouts, or pressure applied to the site (e.g., lying on the site while sleeping) can cause inaccurate glucose signals, which could lead to inappropriate insulin dosing decisions. These studies focus on the problem of pressure-induced sensor attenuations (PISAs) that occur overnight and can cause undesirable pump shut-offs in a predictive low glucose suspend system. The algorithm presented here uses real-time CGM readings without knowledge of meals, insulin doses, activity, sensor recalibrations, or fingerstick measurements. The real-time PISA detection technique was tested on outpatient "in-home" data from a predictive low-glucose suspend trial with over 1125 nights of data. A total of 178 sets were created by using different parameters for the PISA detection algorithm to illustrate its range of available performance. The tracings were reviewed via a web-based analysis tool by an engineer with an extensive expertise on analyzing clinical datasets and ~3% of the CGM readings were marked as PISA events which were used as the gold standard. It is shown that 88.34% of the PISAs were successfully detected by the algorithm, and the percentage of false detections could be reduced to 1.70% by altering the algorithm parameters. Use of the proposed PISA detection method can result in a significant decrease in undesirable pump suspensions overnight, and may lead to lower overnight mean glucose levels while still achieving a low risk of hypoglycemia.
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Affiliation(s)
- Nihat Baysal
- Department of Chemical & Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - Fraser Cameron
- Department of Chemical & Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - Bruce A Buckingham
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, CA, USA
| | - Darrell M Wilson
- Division of Pediatric Endocrinology and Diabetes, Stanford University, Stanford, CA, USA
| | - H Peter Chase
- Barbara Davis Center for Childhood Diabetes, Aurora, CO, USA
| | - David M Maahs
- Barbara Davis Center for Childhood Diabetes, Aurora, CO, USA
| | - B Wayne Bequette
- Department of Chemical & Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
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