Continuous Glucose Monitoring Integration in Clinical Practice: A Stepped Guide to Data Review and Interpretation

What difference does sleep make? Continuous glucose monitoring metrics during fixed-overnight time versus sleep periods among older adults with type 1 diabetes

Hypoglycaemia during sleep is a common and clinically important issue for people living with insulin-treated diabetes. Continuous glucose monitoring devices can help to identify nocturnal hypoglycaemia and inform treatment strategies. However, sleep is generally inferred, with diabetes researchers and physicians using a fixed-overnight period as a proxy for sleep-wake status when analysing and interpretating continuous glucose monitoring data. No study to date has validated such an approach with established sleep measures. Continuous glucose monitoring and research-grade actigraphy devices were worn and sleep diaries completed for 2 weeks by 28 older adults (mean age 67 years [SD 5]; 17 (59%) women) with type 1 diabetes. Using continuous glucose monitoring data from a total of 356 nights, fixed-overnight (using the recommended period of 00:00 hours-06:00 hours) and objectively-measured sleep periods were compared. The fixed-overnight period approach missed a median 57 min per night (interquartile range: 49-64) of sleep for each participant, including five continuous glucose monitoring-detected hypoglycaemia episodes during objectively-measured sleep. Twenty-seven participants (96%) had at least 1 night with continuous glucose monitoring time-in-range and time-above-range discrepancies both ≥ 10 percentage points, a clinically significant discrepancy. The utility of fixed-overnight time continuous glucose monitoring as a proxy for sleep-awake continuous glucose monitoring is inadequate as it consistently excludes actual sleep time, obscures glycaemic patterns, and misses sensor hypoglycaemia episodes during sleep. The use of validated measures of sleep to aid interpretation of continuous glucose monitoring data is encouraged.

Continuous Glucose Monitoring for Diabetes Management During Pregnancy: Evidence, Practical Tips, and Common Pitfalls

Continuous glucose monitoring (CGM) has the potential to revolutionize diabetes management during pregnancy by providing detailed and real-time data to patients and clinicians, overcoming many of the limitations of self-monitoring of blood glucose. Although there are limited data on the role of CGM to improve pregnancy outcomes in patients with type 2 diabetes or gestational diabetes, CGM has been shown to reduce pregnancy complications in patients with type 1 diabetes. Despite the limited data in some populations, given its ease of use and recent U.S. Food and Drug Administration approval with expanding insurance coverage, CGM has gained widespread popularity among pregnant patients with all types of diabetes. It is critical for obstetric clinicians to understand how CGM can be successfully integrated into clinical practice. We present a practical, step-wise approach to CGM data interpretation that can be incorporated into diabetes management during pregnancy and common CGM pitfalls and solutions. Although technology will continue to advance with newer-generation CGM devices and diabetes technology such as automated insulin delivery (not covered here), these key principles form a basic foundation for understanding CGM technology and its utility for pregnant people.

Augmenting clinicians' analytical workflow through task-based integration of data visualizations and algorithmic insights: a user-centered design study

OBJECTIVES

To understand healthcare providers' experiences of using GlucoGuide, a mockup tool that integrates visual data analysis with algorithmic insights to support clinicians' use of patientgenerated data from Type 1 diabetes devices.

MATERIALS AND METHODS

This qualitative study was conducted in three phases. In Phase 1, 11 clinicians reviewed data using commercial diabetes platforms in a think-aloud data walkthrough activity followed by semistructured interviews. In Phase 2, GlucoGuide was developed. In Phase 3, the same clinicians reviewed data using GlucoGuide in a think-aloud activity followed by semistructured interviews. Inductive thematic analysis was used to analyze transcripts of Phase 1 and Phase 3 think-aloud activity and interview.

RESULTS

3 high level tasks, 8 sub-tasks, and 4 challenges were identified in Phase 1. In Phase 2, 3 requirements for GlucoGuide were identified. Phase 3 results suggested that clinicians found GlucoGuide easier to use and experienced a lower cognitive burden as compared to the commercial diabetes data reports that were used in Phase 1. Additionally, GlucoGuide addressed the challenges experienced in Phase 1.

DISCUSSION

The study suggests that the knowledge of analytical tasks and task-specific visualization strategies in implementing features of data interfaces can result in tools that lower the perceived burden of engaging with data. Additionally, supporting clinicians in contextualizing algorithmic insights by visual analysis of relevant data can positively influence clinicians' willingness to leverage algorithmic support.

CONCLUSION

Task-aligned tools that combine multiple data-driven approaches, such as visualization strategies and algorithmic insights, can improve clinicians' experience in reviewing device data.

Advancing elderly diabetes care: exploring the usability and acceptance of continuous glucose monitoring (CGM)

OBJECTIVES

This study aimed to evaluate the acceptability, usability, compliance, and satisfaction of Continuous Glucose Monitoring (CGM) among elderly diabetic patients.

DESIGN

Utilizing a mixed-methods approach, the study involved 30 participants, averaging 74.79 years in age. Participants wore two CGM devices, and their experiences, along with survey data, were comprehensively analyzed to gauge the effectiveness of CGM in managing diabetes.

RESULTS

The study demonstrated that -CGM- is highly usable and acceptable among elderly diabetic patients. Participants effectively utilized CGM to monitor and predict blood glucose trends, positively influencing their glucose control and lifestyle. The average adherence rate was found to be 81 %, indicating a substantial level of effective self-management and treatment decision-making.

CONCLUSION

The study recommends developing CGM educational programs tailored for the elderly, educating healthcare professionals, expanding insurance coverage for CGM, and promoting real-time CGM technology to improve usability and acceptance among the elderly.

Unveiling the interplay between rational, psychological and functional factors in continuous glucose monitoring early adoption: Novel evidence from the Dexcom ONE case in Italy

BACKGROUND

The escalating prevalence of diabetes, with its multifaceted complications, poses a pressing challenge for healthcare systems globally. In response, the advent of continuous glucose monitoring (CGM) systems, offering technological solutions for daily diabetes management, presents significant opportunities. However, the widespread adoption faces several barriers, linked both to the technological configuration of the devices and to the psychological dimension of patients. Therefore, this study aims to apply and test a theoretical model that investigates the antecedents of the intention to use Continuous Glucose Monitoring systems.

METHODS

The research model was built to unveil the impacts of psychological factors, functional components and rational constructs derived from the Technology Acceptance Model (TAM) on CGM systems sustained adoption. To ensure the comparability of results, we have collected data from people who had used Dexcom ONE Dexcom (San Diego, CA) for the first time for at least one month. Employing Structural Equation Modelling (SEM) techniques, the hypothesized relationships among constructs were assessed.

RESULTS

The analyses confirmed the positive correlation of rational factors to the Intention to Use. Subjective Norm, intended as the physicians' influence, is positively correlated with the Perceived Usefulness. Trend Arrows, albeit being negatively correlated with Perceived Usefulness, have a positive correlation on Perceived Ease Of Use, reinforcing its mediating effect towards Perceived Usefulness. Among psychological factors, Trust in the CGM technology positively correlates with Intention to Use. Health Literacy is negatively correlated to the Intention to Use.

CONCLUSIONS

These findings contribute to theoretical and managerial understanding, providing recommendations to enhance the adoption of CGM systems like Dexcom ONE.

Continuous glucose monitoring for automatic real-time assessment of eating events and nutrition: a scoping review

Background

Accurate dietary assessment remains a challenge, particularly in free-living settings. Continuous glucose monitoring (CGM) shows promise in optimizing the assessment and monitoring of ingestive activity (IA, i.e., consumption of calorie-containing foods/beverages), and it might enable administering dietary Just-In-Time Adaptive Interventions (JITAIs).

Objective

In a scoping review, we aimed to answer the following questions: (1) Which CGM approaches to automatically detect IA in (near-)real-time have been investigated? (2) How accurate are these approaches? (3) Can they be used in the context of JITAIs?

Methods

We systematically searched four databases until October 2023 and included publications in English or German that used CGM-based approaches for human (all ages) IA detection. Eligible publications included a ground-truth method as a comparator. We synthesized the evidence qualitatively and critically appraised publication quality.

Results

Of 1,561 potentially relevant publications identified, 19 publications (17 studies, total N = 311; for 2 studies, 2 publications each were relevant) were included. Most publications included individuals with diabetes, often using meal announcements and/or insulin boluses accompanying meals. Inpatient and free-living settings were used. CGM-only approaches and CGM combined with additional inputs were deployed. A broad range of algorithms was tested. Performance varied among the reviewed methods, ranging from unsatisfactory to excellent (e.g., 21% vs. 100% sensitivity). Detection times ranged from 9.0 to 45.0 min.

Conclusion

Several CGM-based approaches are promising for automatically detecting IA. However, response times need to be faster to enable JITAIs aimed at impacting acute IA. Methodological issues and overall heterogeneity among articles prevent recommending one single approach; specific cases will dictate the most suitable approach.

A systematic bibliometric analysis on the clinical practice of CGM in diabetes mellitus from 2012 to 2022

Background

Continuous glucose monitoring (CGM) has revolutionized diabetes management, but a comprehensive analysis of its clinical implementation is lacking. This study aims to explore CGM in diabetes practice over the past decade using bibliometric analysis. It will identify trends, research focal points, and provide a framework for future investigations.

Materials and methods

The Web of Science Core Collection (WOSCC) was utilized to acquire literature pertaining to the employment of continuous glucose monitoring (CGM) in diabetes that was published between the years 2012 and 2022, and to conduct a comprehensive analysis of the associated citation data. To achieve bibliometric visualization and analysis of the collated data, the bibliography package in the Rstudio(v.4.2.2), Citespace 6.2.R4, and VOS viewer were employed.

Results

A total of 3024 eligible publications were extracted from 91 countries, with the United States being the leading country in terms of the number of issued articles. Furthermore, the annual publication rate has shown a gradual increase during the past decade. Among the various journals in this field, DIABETES TECHNOLOGY & THERAPEUTICS was identified as the most highly cited one. Keyword clustering analysis of the extracted publications indicates that the research hotspots in the past decade have primarily focused on "continuous glucose monitoring", "glycemic variability", "type 1 diabetes", "hypoglycemia", and "glycemic control". Moreover, the analysis of keyword emergence reveals that "Time In Range" and "Young Adult" represent the current research frontiers for the years 2012-2022.

Conclusion

The concept of Time in Range (TIR) has garnered considerable attention as a significant area of inquiry and an emerging research trend in the clinical practice of Continuous Glucose Monitoring (CGM) for Diabetes Mellitus. Moreover, recent investigations have demonstrated a growing focus on young adults with type 1 diabetes as the research population of interest. In the foreseeable future, research endeavors will persist in the pursuit of improving glycemic management among young adults through the utilization of continuous glucose monitoring (CGM) technology, while also delving into the examination of the Time in Range metric via supplementary clinical investigations.

Patent analysis of digital sensors for continuous glucose monitoring

The high need for optimal diabetes management among an ever-increasing number of patients dictates the development and implementation of new digital sensors for continuous glucose monitoring. The purpose of this work is to systematize the global patenting trends of digital sensors for continuous glucose monitoring and analyze their effectiveness in controlling the treatment of diabetes patients of different ages and risk groups. The Lens database was used to build the patent landscape of sensors for continuous glucose monitoring. Retrospective analysis showed that the patenting of sensors for continuous glucose monitoring had positive trend over the analyzed period (2000-2022). Leading development companies are Dexcom Inc., Abbott Diabetes Care Inc., Medtronic Minimed Inc., Roche Diabetes Care Inc., Roche Diagnostics Operations Inc., Roche Diabetes Care Gmbh, and Ascensia Diabetes Care Holdings Ag, among others. Since 2006, a new approach has emerged where digital sensors are used for continuous glucose monitoring, and smartphones act as receivers for the data. Additionally, telemedicine communication is employed to facilitate this process. This opens up new opportunities for assessing the glycemic profile (glycemic curve information, quantitative assessment of the duration and amplitude of glucose fluctuations, and so on), which may contribute to improved diabetes management. A number of digital sensors for minimally invasive glucose monitoring are patented, have received FDA approval, and have been on the market for over 10 years. Their effectiveness in the clinic has been proven, and advantages and disadvantages have been clarified. Digital sensors offer a non-invasive option for monitoring blood glucose levels, providing an alternative to traditional invasive methods. This is particularly useful for patients with diabetes who require frequent monitoring, including before and after meals, during and after exercise, and in other scenarios where glucose levels can fluctuate. However, non-invasive glucose measurements can also benefit patients without diabetes, such as those following a dietary treatment plan, pregnant women, and individuals during fasting periods like Ramadan. The availability of non-invasive monitoring is especially valuable for patients in high-risk groups and across different age ranges. New world trends have been identified in the patenting of digital sensors for non-invasive glucose monitoring in interstitial skin fluid, saliva, sweat, tear fluid, and exhaled air. A number of non-invasive devices have received the CE mark approval, which confirms that the items meet European health, safety, and environmental protection standards (TensorTip Combo-Glucometer, Cnoga Medical Ltd.; SugarBEAT, Nemaura Medical; GlucoTrack, GlucoTrack Inc.), but are not FDA-approved yet. The above-mentioned sensors have characteristics that make them popular in the treatment of diabetes: they do not require implantation, do not cause an organism reaction to a foreign body, and are convenient to use. In the EU, in order to increase clinical safety and the level of transparency about medical devices, manufacturers must obtain certificates in accordance with Regulation (EU) 2017/745, taking into account the transition period. The development of systems, which include digital sensors for continuous glucose monitoring, mobile applications, and web platforms for professional analysis of glycemic control and implementation of unified glycemic assessment principles in mobile healthcare, represent promising approaches for controlling glycaemia in patients.

Correlation Between Hemoglobin Glycation Index Measured by Continuous Glucose Monitoring With Complications in Type 1 Diabetes

OBJECTIVE

HbA1C is the "gold standard" parameter to evaluate glycemic control in diabetes; however, its correlation with mean glucose is not always perfect. The objective of this study was to correlate continuous glucose monitoring (CGM)-derived hemoglobin glycation index (HGI) with microvascular complications.

METHODS

We conducted a cross-sectional study including permanent users of CGM with type 1 diabetes mellitus or latent autoimmune diabetes of the adult. HGI was estimated, and presence of microvascular complications was compared in subgroups with high or low HGI. A logistic regression analysis to assess the contribution of high HGI to chronic kidney disease (CKD) was performed.

RESULTS

In total, 52 participants who were aged 39.7 ± 14.7 years, with 73.1% women and 15.5 years (IQR, 7.5-29 years) since diagnosis, were included; 32.7% recorded diabetic retinopathy, 25% CKD, and 19.2% neuropathy. The median HbA1C was 7.6% (60 mmol/mol) and glucose management indicator (GMI) 7.0% (53 mmol/mol). The average HGI was 0.55% ± 0.66%. The measured HbA1C was higher in the group with high HGI (8.1% [65 mmol/mol] vs 6.9% [52 mmol/mol]; P < .001), whereas GMI (7.0% [53 mmol/mol] vs 7.0% [53 mmol/mol]; P = .495) and mean glucose were similar in both groups (153 mg/dL vs 153 mg/dL; P = .564). In the high HGI group, higher occurrence of CKD (P = .016) and neuropathy were observed (P = .025). High HGI was associated with increased risk of CKD (odds ratio [OR]: 5.05; 95% CI: 1.02-24.8; P = .04) after adjusting for time since diagnosis (OR: 1.09; 95% CI: 1.02-1.16; P = .008).

CONCLUSION

High HGI measured by CGM may be a useful marker for increased risk of microvascular diabetic complications.

Patient Perspectives on the Ambulatory Glucose Profile Report for Type 1 Diabetes Management in Adults: A National Online Survey

OBJECTIVES

Continuous and flash glucose monitoring devices produce data reports (e.g. ambulatory glucose profile [AGP]) that can be used by people with diabetes and health-care providers (HCPs). Clinical benefits of these reports have been published, but the patient perspective is underreported.

METHODS

We conducted an online survey for adults with type 1 diabetes (T1D) using continuous/flash glucose monitoring to understand their use and attitudes toward the AGP report. Barriers and facilitators related to digital health technology were explored.

RESULTS

The survey included 291 respondents: 63% were <40 years of age, and 65% had been living with T1D for >15 years. Nearly 80% reviewed their AGP report, with 50% often discussing it with their HCP. Support from family and HCPs was positively associated with the use of the AGP report, and there was a positive relationship between motivation and better understanding of the AGP report (odds ratio=2.61; 95% confidence interval, 1.45 to 4.71). Nearly all respondents (92%) indicated that the AGP report is important for their diabetes management, but most indicated dissatisfaction with the cost of the device. Open-ended responses suggested some concern with the complexity of information from the AGP report.

CONCLUSIONS

The online survey showed that there may be few barriers to the use of the AGP report by people with T1D, with the main barrier being its cost of the devices. Facilitators for the use of the AGP report included motivation and support from both family and the HCP. Facilitating discussion between HCPs and patients may be a strategy to improve the use and potential benefit of the AGP.

Rossitto J, Ray K, A. Dufurrena Q, Blue RS. Blood Glucose Alterations and Continuous Glucose Monitoring in Centrifuge-Simulated Spaceflight

INTRODUCTION: Sympathetic stimulation is known to be associated with transient alterations of blood glucose (BG) concentration; spaceflight acceleration may be similarly associated with alterations of BG, potentially posing a risk to diabetic individuals engaging in future spaceflight activities. Despite prior studies demonstrating diabetic subjects’ tolerance to centrifuge-simulated spaceflight, data are lacking regarding blood glucose response to hypergravity. It remains unclear whether hypergravity or associated physiological response may pose a risk to diabetics. Continuous glucose monitors (CGM) offer a means of noninvasive glucose monitoring and may be useful in spaceflight and analog environments. Here, we describe the results of continuous glucose monitoring during centrifuge-simulated spaceflight.METHODS: Subjects participated in 1–5 centrifuge-simulated spaceflight profiles (maximum +4.0 Gz, +6.0 Gx, 6.1 G resultant). Data collection included heart rate, blood pressure, electrocardiogram, continuous glucose via CGM, intermittent fingerstick BG, and postrun questionnaires regarding symptoms related to hypergravity exposure.RESULTS: CGM data were collected from 26 subjects, including 4 diabetics. While diabetic subjects had significantly higher BG compared to nondiabetics, this was not associated with any difference in symptoms or tolerance. Transient hypergravity-associated CGM glucose alterations did not affect tolerance of the centrifuge experience. CGM data were found to be reliable with occasional exceptions, including four instances of false critical low glucose alarms.DISCUSSION: While further study is necessary to better characterize CGM fidelity during hypergravity and other spaceflight-related stressors, CGM may be a feasible option for spaceflight and analog settings. As in prior studies, individuals with well-controlled diabetes appear able to tolerate the accelerations anticipated for commercial spaceflight.Ong KM, Rossitto JJ, Ray K, Dufurrena QA, Blue RS. Blood glucose alterations and continuous glucose monitoring in centrifuge-simulated spaceflight. Aerosp Med Hum Perform. 2022; 93(9):688–695.

Barriers and Facilitators to Diabetes Device Adoption for People with Type 1 Diabetes

PURPOSE OF REVIEW

Diabetes technology (insulin pumps, continuous glucose monitoring, automated insulin delivery systems) has advanced significantly and provides benefits to the user. This article reviews the current barriers to diabetes device adoption and sustained use, and outlines the known and potential facilitators for increasing and sustaining device adoption.

RECENT FINDINGS

Barriers to diabetes device adoption continue to exist at the system-, provider-, and individual-level. Known facilitators to promote sustained adoption include consistent insurance coverage, support for providers and clinics, structured education and support for technology users, and device user access to support as needed (e.g., through online resources). Systemic barriers to diabetes device adoption persist while growing evidence demonstrates the increasing benefits of newest devices and systems. There are ongoing efforts to develop evidence-based structured education programs to support device adoption and sustained use.

The Role of Retrospective Data Review in the Personal Use of Real-Time Continuous Glucose Monitoring: Perceived Impact on Quality of Life and Health Outcomes

Background: To explore whether regularly reviewing one's own retrospective continuous glucose monitoring (CGM) data might be linked with perceived quality of life (QoL) and glycemic benefits. Methods: Adults with type 1 diabetes (N = 300) or insulin-using type 2 diabetes (N = 198) using the Dexcom G5 Mobile or G6 Real-Time CGM (RT-CGM) system and receiving the weekly CLARITY summary report of their glucose data completed a survey exploring their use of the report and its perceived value and impact on QoL and glycemic outcomes. Regression analyses examined whether personal use of the report was associated with QoL, perceived glycemic outcomes, and RT-CGM metrics. Results: The majority reported that receiving and viewing the report contributed to improved hypoglycemic confidence (75.9%) and overall well-being (50.0%), reduced diabetes distress (59.3%-74.1%), and helped to improve A1C (73.1%) and reduce problems with hypoglycemia (61.8%) and chronic hyperglycemia (73.1%). Regularly reviewing the report with family or friends (positive predictor) and doing nothing with the report's information (negative predictor) were independently associated with QoL and perceived glycemic outcomes. Surprisingly, both predictors were also associated with poorer glycemic control (e.g., greater % time above range >180). Conclusions: These findings suggest that receiving a weekly RT-CGM summary report may contribute to QoL and health benefits, especially if the individual chooses to actively review and make use of the report's findings and openly reviews the findings with family or friends. Prospective studies are needed to more precisely determine how retrospective RT-CGM data summaries can best be presented and utilized effectively by adults with diabetes to enhance health outcomes.

Continuous Glucose Monitoring in Healthy Adults-Possible Applications in Health Care, Wellness, and Sports

INTRODUCTION

Continuous glucose monitoring (CGM) systems were primarily developed for patients with diabetes mellitus. However, these systems are increasingly being used by individuals who do not have diabetes mellitus. This mini review describes possible applications of CGM systems in healthy adults in health care, wellness, and sports.

RESULTS

CGM systems can be used for early detection of abnormal glucose regulation. Learning from CGM data how the intake of foods with different glycemic loads and physical activity affect glucose responses can be helpful in improving nutritional and/or physical activity behavior. Furthermore, states of stress that affect glucose dynamics could be made visible. Physical performance and/or regeneration can be improved as CGM systems can provide information on glucose values and dynamics that may help optimize nutritional strategies pre-, during, and post-exercise.

CONCLUSIONS

CGM has a high potential for health benefits and self-optimization. More scientific studies are needed to improve the interpretation of CGM data. The interaction with other wearables and combined data collection and analysis in one single device would contribute to developing more precise recommendations for users.

Comparison of two glucose-monitoring systems for use in horses

OBJECTIVE

To determine the accuracy of 2 interstitial glucose-monitoring systems (GMSs) for use in horses compared with a point-of-care (POC) glucometer and standard laboratory enzymatic chemistry method (CHEM).

ANIMALS

8 clinically normal adult horses.

PROCEDURES

One of each GMS device (Dexcom G6 and Freestyle Libre 14-day) was placed on each horse, and blood glucose concentration was measured via POC and CHEM at 33 time points and compared with simultaneous GMS readings. An oral glucose absorption test (OGAT) was performed on day 2, and glucose concentrations were measured and compared.

RESULTS

Glucose concentrations were significantly correlated with one another between all devices on days 1 to 5. Acceptable agreement was observed between Dexcom G6 and Freestyle Libre 14-day when compared with CHEM on days 1, 3, 4, and 5 with a combined mean bias of 10.45 mg/dL and 1.53 mg/dL, respectively. During dextrose-induced hyperglycemia on day 2, mean bias values for Dexcom G6 (10.49 mg/dL) and FreeStyle Libre 14-day (0.34 mg/dL) showed good agreement with CHEM.

CLINICAL RELEVANCE

Serial blood glucose measurements are used to diagnose or monitor a variety of conditions in equine medicine; advances in near-continuous interstitial glucose monitoring allow for minimally invasive glucose assessment, thereby reducing stress and discomfort to patients. Data from this study support the use of the Dexcom G6 and Freestyle Libre 14-day interstitial glucose-monitoring systems to estimate blood glucose concentrations in horses.

Do-It-Yourself Open Artificial Pancreas System in Children and Adolescents with Type 1 Diabetes Mellitus: Real-World Data

Few studies have been conducted among Asian children and adolescents with type 1 diabetes mellitus (T1DM) using do-it-yourself artificial pancreas system (DIY-APS). We evaluated real-world data of pediatric T1DM patients using DIY-APS. Data were obtained for 10 patients using a DIY-APS with algorithms. We collected sensor glucose and insulin delivery data from each participant for a period of 4 weeks. Average glycosylated hemoglobin was 6.2%±0.3%. The mean percentage of time that glucose level remained in the target range of 70 to 180 mg/dL was 82.4%±7.8%. Other parameters including time above range, time below range and mean glucose were also within the recommended level, similar to previous commercial and DIY-APS studies. However, despite meeting the target range, unadjusted gaps were still observed between the median basal setting and temporary basal insulin, which should be handled by healthcare providers.

Use of continuous glucose monitoring trend arrows in the younger population with type 1 diabetes

Early control of glycaemia is key to reduce vascular complications in individuals with Type 1 diabetes. Therefore, encouraging children and adolescents with T1DM to take responsibility for controlling glucose levels is an important yet a challenging task. The rapid expansion of continuous glucose monitoring (CGM) systems has allowed for more comprehensive analysis of glycaemia in T1D. Moreover, CGM devices have the ability to calculate rate of change in glucose levels and display the information as trend arrows. In turn, this can help to take evasive actions to return glucose levels to near physiological glycaemia, which can be highly motivating for young people with T1DM. In the absence of standardised, evidence-based guidance, this consensus document, generated by experts from the Arab Society of Paediatric Endocrinology and Diabetes and international advisors, summarises recent literature on the use of trend arrows in young people with T1DM. The use of trend arrows in different CGM systems is reviewed and their clinical significance is highlighted. Adjusting insulin doses according to trend arrows is discussed while also addressing special situations, such as exercise, fasting, nocturnal hypoglycaemia and menstruation. Adequate understanding of trend arrows should facilitate optimisation of glycaemic control in the T1D population.

Bayesian structural time series for biomedical sensor data: A flexible modeling framework for evaluating interventions

The development of mobile-health technology has the potential to revolutionize personalized medicine. Biomedical sensors (e.g., wearables) can assist with determining treatment plans for individuals, provide quantitative information to healthcare providers, and give objective measurements of health, leading to the goal of precise phenotypic correlates for genotypes. Even though treatments and interventions are becoming more specific and datasets more abundant, measuring the causal impact of health interventions requires careful considerations of complex covariate structures, as well as knowledge of the temporal and spatial properties of the data. Thus, interpreting biomedical sensor data needs to make use of specialized statistical models. Here, we show how the Bayesian structural time series framework, widely used in economics, can be applied to these data. This framework corrects for covariates to provide accurate assessments of the significance of interventions. Furthermore, it allows for a time-dependent confidence interval of impact, which is useful for considering individualized assessments of intervention efficacy. We provide a customized biomedical adaptor tool, MhealthCI, around a specific implementation of the Bayesian structural time series framework that uniformly processes, prepares, and registers diverse biomedical data. We apply the software implementation of MhealthCI to a structured set of examples in biomedicine to showcase the ability of the framework to evaluate interventions with varying levels of data richness and covariate complexity and also compare the performance to other models. Specifically, we show how the framework is able to evaluate an exercise intervention’s effect on stabilizing blood glucose in a diabetes dataset. We also provide a future-anticipating illustration from a behavioral dataset showcasing how the framework integrates complex spatial covariates. Overall, we show the robustness of the Bayesian structural time series framework when applied to biomedical sensor data, highlighting its increasing value for current and future datasets.

In this paper, we propose and describe a robust and flexible modeling framework called MhealthCI based on the Bayesian structural time series, for which we have found to excel at analyzing diverse biosensor data. While Bayesian modeling is often employed in various fields such as finance, marketing, and weather forecasting, it is rarely used in biomedicine, specifically for biosensor and wearable data relating to human health and behavior. We use and apply this framework with the goal of interpreting and quantifying the causal impact of an intervention, a widespread goal of biomedicine. We describe the diversity of data types to which it could apply, provide intuition to its mechanics, collect relevant data in various fields, provide a wrapper tool around well-known R packages that prepares and registers diverse biosensor data to be analyzed, and finally apply the method to showcase its strength in quantifying the impact of interventions.

An open source tool to compute measures of inpatient glycemic control: translating from healthcare analytics research to clinical quality improvement

Objectives

The objective of this study is to facilitate monitoring of the quality of inpatient glycemic control by providing an open-source tool to compute glucometrics. To allay regulatory and privacy concerns, the tool is usable locally; no data are uploaded to the internet.

Materials and Methods

We extended code, initially developed for healthcare analytics research, to serve the clinical need for quality monitoring of diabetes. We built an application, with a graphical interface, which can be run locally without any internet connection.

Results

We verified that our code produced results identical to prior work in glucometrics. We extended the prior work by including additional metrics and by providing user customizability. The software has been used at an academic healthcare institution.

Conclusion

We successfully translated code used for research methods into an open source, user-friendly tool which hospitals may use to expedite quality measure computation for the management of inpatients with diabetes.

American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus

OBJECTIVE

To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders.

METHODS

The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development.

MAIN OUTCOME MEASURES

Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range.

RESULTS

This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base.

RECOMMENDATIONS

Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology.

CONCLUSIONS

Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.

Clinical Application of Time in Range and Other Metrics

Time in range (TIR) and other continuous glucose monitoring (CGM)-derived metrics have been standardized in international consensus conferences. TIR correlates closely with A1C; a TIR of 70% correlates to an A1C of 6.7-7%. Evidence is emerging on the association of TIR with long-term diabetes complications, and each 10% increase in TIR shows a substantial decrease in risk for long-term complications. Application of TIR to clinical practice can be easily done with a stepped approach to the analysis and interpretation of CGM-derived metrics and the ambulatory glucose profile report. Clinician education and partnership with patients are crucial for successful implementation of TIR and all CGM-derived metrics in clinical practice.

Use of ambulatory glucose monitoring and analysis of ambulatory glucose profile in clinical practice for diabetes management; a position statement of the Arab Society of Paediatric Endocrinology and diabetes

BACKGROUND AND AIM

Diabetes mellitus imposes a significant burden around the world generally and in the Middle East and North Africa specifically. Glucose monitoring is a cornerstone of diabetes management.

METHODS

Glycated haemoglobin has always been the main metric for assessing glycaemic control, but its use is linked with multiple pitfalls. As an alternative, continuous glucose monitoring is becoming a standard of care in many countries. Intermittent scanning glucose monitoring (isCGM) has acquired a worldwide popularity and has been proven to improve glycaemic control, hypoglycaemia detection and prevention, and quality of life.

RESULTS

The most recent International Society of Paediatric and Adolescent Diabetes practice. guidelines recommended its use in young people with diabetes observing Ramadan to ensure safe fasting. At a meeting in Abu Dhabi in November 2019, the Arab Society for Paediatric. Endocrinology and Diabetes brought together a number of regional diabetes experts, patient. representatives and international expert advisors to review the evidence for isCGM and propose. guidelines for its use in the Middle East and North Africa region.

CONCLUSION

In this paper, the authors strongly recommend the use of isCGM for patients in MENA and present general recommendations and compressive specific guidance for physicians and patients, which they believe will also have wider resonance.

Telehealth Adoption Among Endocrinologists During The Covid-19 Pandemic

OBJECTIVE

Telehealth is a timely solution for delivering health care during the coronavirus disease 2019 (COVID-19) pandemic. The practice of endocrinology is suited to provide virtual care to patients with a variety of endocrine disorders. In this survey, we aimed to gauge the adoption of telehealth practices during the COVID-19 pandemic among endocrinologists in the United States (U.S.).

METHODS

This was a cross-sectional, online survey-based study. Members of the Facebook group "Endocrinologists" were invited to participate in the survey. Characteristics of respondents and their rates of adoption of telehealth were described and analyzed for statistically significant associations using the Pearson chi-square test.

RESULTS

A total of 181 physicians responded to the survey. The majority of respondents were females (75%), younger than or equal to 40 years of age (51%), employed (72%) either by a private group/hospital or by an academic setting, worked in an urban area (88.4%), and were adult endocrinologists (93%). With the COVID-19 outbreak, more than two-fifths (44.2%) of participants switched to completely virtual visits, and an additional 44.2% switched to a majority of virtual visits, with some in-person visits in the outpatient setting. Additionally, there was a significantly higher adoption rate of telehealth among endocrinologists younger than or equal to 40 years of age (P = .02) and among those who practiced in northeastern, midwestern, and the western geographic regions of the U.S. (P = .04).

CONCLUSION

The majority of the responding endocrinologists from the U.S. appeared to have swiftly adapted by using telehealth within a few weeks of COVID-19 being declared a national emergency.

ABBREVIATIONS

CMS = Centers for Medicare and Medicaid Services; COVID-19 = coronavirus disease 2019; PPE = personal protective equipment; U.S. = United States.

Continuous glucose monitoring: The achievement of 100 years of innovation in diabetes technology

Monitoring of glucose levels is essential to effective diabetes management. Over the past 100 years, there have been numerous innovations in glucose monitoring methods. The most recent advances have centered on continuous glucose monitoring (CGM) technologies. Numerous studies have demonstrated that use of continuous glucose monitoring confers significant glycemic benefits on individuals with type 1 diabetes (T1DM) and type 2 diabetes (T2DM). Ongoing improvements in accuracy and convenience of CGM devices have prompted increasing adoption of this technology. The development of standardized metrics for assessing CGM data has greatly improved and streamlined analysis and interpretation, enabling clinicians and patients to make more informed therapy modifications. However, many clinicians many be unfamiliar with current CGM and how use of these devices may help individuals with T1DM and T2DM achieve their glycemic targets. The purpose of this review is to present an overview of current CGM systems and provide guidance to clinicians for initiating and utilizing CGM in their practice settings.

Glycemic Monitoring and Management in Advanced Chronic Kidney Disease

Glucose and insulin metabolism in patients with diabetes are profoundly altered by advanced chronic kidney disease (CKD). Risk of hypoglycemia is increased by failure of kidney gluconeogenesis, impaired insulin clearance by the kidney, defective insulin degradation due to uremia, increased erythrocyte glucose uptake during hemodialysis, impaired counterregulatory hormone responses (cortisol, growth hormone), nutritional deprivation, and variability of exposure to oral antihyperglycemic agents and exogenous insulin. Patients with end-stage kidney disease frequently experience wide glycemic excursions, with common occurrences of both hypoglycemia and hyperglycemia. Assessment of glycemia by glycated hemoglobin (HbA1c) is hampered by a variety of CKD-associated conditions that can bias the measure either to the low or high range. Alternative glycemic biomarkers, such as glycated albumin or fructosamine, are not fully validated. Therefore, HbA1c remains the preferred glycemic biomarker despite its limitations. Based on observational data for associations with mortality and risks of hypoglycemia with intensive glycemic control regimens in advanced CKD, an HbA1c range of 7% to 8% appears to be the most favorable. Emerging data on the use of continuous glucose monitoring in this population suggest promise for more precise monitoring and treatment adjustments to permit fine-tuning of glycemic management in patients with diabetes and advanced CKD.

The Reference Guide to Integrate Smart Insulin Pens Into Data-Driven Diabetes Care and Education Services

PURPOSE

More than 7 million Americans who have diabetes use insulin therapy. The majority continue to use syringes and vials or traditional insulin pens to deliver their insulin doses. Using these tools to deliver insulin presents numerous challenges for both the person with diabetes and their clinicians. This article provides an in-depth introduction to a new category of insulin delivery devices and integrated management systems, referred to as smart insulin pens. The article includes information about how these integrated insulin delivery systems can reduce many of the challenges of rapid-acting insulin dosing via injection by enabling easier and more accurate dose recording, dose calculations, and sharing of diabetes management data with clinicians. This article also discusses new roles for diabetes care and education specialists in diabetes data-driven care and practice and addresses how smart insulin pens represent one of many newer digital diabetes management tools that can assist people with diabetes and their clinicians to optimally achieve and deliver quality, data-driven diabetes care.

CONCLUSIONS

Newer and simplified insulin delivery devices with their integrated management systems, such as smart insulin pens, have the potential to minimize the challenges and complexities associated with insulin injection therapy while also providing people with diabetes and their clinicians more complete and integrated data in easily transmitted reports that support more efficient data analysis.

Implementation of Continuous Glucose Monitoring in the Hospital: Emergent Considerations for Remote Glucose Monitoring During the COVID-19 Pandemic

Continuous glucose monitoring (CGM) has become a widely used tool in the ambulatory setting for monitoring glucose levels, as well as detecting uncontrolled hyperglycemia, hypoglycemia, and glycemic variability. The accuracy of some CGM systems has recently improved to the point of manufacture with factory calibration and Food and Drug Administration clearance for nonadjunctive use to dose insulin. In this commentary, we analyze the answers to six questions about what is needed to bring CGM into the hospital as a reliable, safe, and effective tool. The evidence to date indicates that CGM offers promise as an effective tool for monitoring hospitalized patients. During the current coronavirus disease 2019 crisis, we hope to provide guidance to healthcare professionals, who are seeking to reduce exposure to SARS-Cov-2, as well as preserve invaluable personal protective equipment. In this commentary, we address who, what, where, when, why, and how CGM can be adopted for inpatient use.

Diabetes Technology Use in Adults with Type 1 and Type 2 Diabetes

In the last 2 decades, diabetes technology has emerged as a branch of diabetes management thanks to the advent of continuous glucose monitoring (CGM) and increased availability of continuous subcutaneous insulin infusion systems, or insulin pumps. These tools have progressed from rudimentary instruments to sophisticated therapeutic options for advanced diabetes management. This article discusses the available CGM and insulin pump systems and the clinical benefits of their use in adults with type 1 diabetes, intensively insulin-treated type 2 diabetes, and pregnant patients with preexisting diabetes.

Optimizing Postprandial Glucose Management in Adults With Insulin-Requiring Diabetes: Report and Recommendations

Faster-acting insulins, new noninsulin drug classes, more flexible insulin-delivery systems, and improved continuous glucose monitoring devices offer unprecedented opportunities to improve postprandial glucose (PPG) management and overall care for adults with insulin-treated diabetes. These developments led the Endocrine Society to convene a working panel of diabetes experts in December 2018 to assess the current state of PPG management, identify innovative ways to improve self-management and quality of life, and align best practices to current and emerging treatment and monitoring options. Drawing on current research and collective clinical experience, we considered the following issues for the ∼200 million adults worldwide with type 1 and insulin-requiring type 2 diabetes: (i) the role of PPG management in reducing the risk of diabetes complications; (ii) barriers preventing effective PPG management; (iii) strategies to reduce PPG excursions and improve patient quality of life; and (iv) education and clinical tools to support endocrinologists in improving PPG management. We concluded that managing PPG to minimize or prevent diabetes-related complications will require elucidating fundamental questions about optimal ways to quantify and clinically assess the metabolic dysregulation and consequences of the abnormal postprandial state in diabetes and recommend research strategies to address these questions. We also identified practical strategies and tools that are already available to reduce barriers to effective PPG management, optimize use of new and emerging clinical tools, and improve patient self-management and quality of life.