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Wang YY, Ying HM, Tian F, Qian XL, Zhou ZF, Zhou CC. Automated insulin delivery in children with type 1 diabetes during physical activity: a meta-analysis. J Pediatr Endocrinol Metab 2024; 37:505-515. [PMID: 38700489 DOI: 10.1515/jpem-2024-0098] [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: 02/24/2024] [Accepted: 04/18/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVES The aim of this study was to evaluate the performance of the automated insulin delivery (AID) in adolescents, and children with type 1 diabetes (T1D) during physical activity. METHODS Relevant studies were searched electronically in the Cochrane Library, PubMed, and Embase utilizing the key words "Child", "Insulin Infusion Systems", and "Diabetes Mellitus" from inception to 17th March 2024 to evaluate the performance of the AID in adolescents, and children with T1D during physical activity. RESULTS Twelve studies involving 514 patients were identified. AID did not show a beneficial effect on duration of hypoglycemia<70 mg/dL during study period (p>0.05; I2=96 %) and during the physical activity (p>0.99). Percentage of sensor glucose values in TIR was higher in AID than the non-AID pumps during study period (p<0.001; I2=94 %). The duration of hyperglycemic time was significantly decreased in AID group compared to the non-AID pumps group during study period (p<0.05; I2>50 %). CONCLUSIONS AID improved TIR and decreased the duration of hyperglycemic time, but did not appear to have a significant beneficial effect on the already low post-exercise duration of hypoglycemia achievable by open loop or sensor-augmented pumps in adolescents and children with T1D during physical activity; further research is needed to confirm the beneficial effect of AID on duration of hypoglycemia.
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Affiliation(s)
- Yuan-Yuan Wang
- Department of Endocrinology, 631689 Xixi Hospital of Hangzhou , Hangzhou, Zhejiang Province, P.R. China
| | - Hui-Min Ying
- Department of Endocrinology, 631689 Xixi Hospital of Hangzhou , Hangzhou, Zhejiang Province, P.R. China
| | - Fang Tian
- Department of Endocrinology, 631689 Xixi Hospital of Hangzhou , Hangzhou, Zhejiang Province, P.R. China
| | - Xiao-Lu Qian
- Department of Endocrinology, 631689 Xixi Hospital of Hangzhou , Hangzhou, Zhejiang Province, P.R. China
| | - Zhen-Feng Zhou
- Department of Anesthesiology, Hangzhou Women's Hospital (Hangzhou Maternity and Child Health Care Hospital, Hangzhou First People's Hospital Qianjiang New City Campus, Zhejiang Chinese Medical University), Hangzhou, P.R. China
| | - Chun-Cong Zhou
- Department of Urolithiasis and Anorectal Surgery, Ningbo No. 2 Hospital, Ningbo, Zhejiang Province, P.R. China
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2
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Lei M, Ling P, Ni Y, Chen D, Wang C, Yang D, Yang X, Xu W, Yan J. The efficacy of glucose-responsive insulin and glucagon delivery on exercise-induced hypoglycaemia among adults with type 1 diabetes mellitus: A meta-analysis of randomized controlled trials. Diabetes Obes Metab 2024; 26:1524-1528. [PMID: 38149727 DOI: 10.1111/dom.15422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 12/28/2023]
Affiliation(s)
- Mengyun Lei
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ping Ling
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Ni
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Danrui Chen
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chaofan Wang
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Daizhi Yang
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xubin Yang
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wen Xu
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jinhua Yan
- Guangdong Provincial Key Laboratory of Diabetology, Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Zimmer RT, Birnbaumer P, Sternad C, Zunner BEM, Schierbauer J, Fritsch M, Fröhlich-Reiterer E, Hofmann P, Sourij H, Aberer F, Moser O. Impact of a 4-week intensive track and field training intervention on glycaemia in adolescents with type 1 diabetes: The ChilDFiT1 study. Diabetes Obes Metab 2024; 26:631-641. [PMID: 37985360 DOI: 10.1111/dom.15352] [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: 08/03/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
AIM To investigate the safety and efficacy of track and field training compared with intensification of insulin treatment only in adolescents with type 1 diabetes (T1D). MATERIALS AND METHODS Eighteen adolescents (seven females) with T1D were included (age 15.1 ± 1.1 years, HbA1c 7.3% ± 1.0% [56.3 ± 10.9 mmol/mol]). After a 4-week observational control phase, participants were randomized to either stand-alone intensive glycaemic management (IT; telemedicine or on-site visits, three times/week) or additionally performed track and field exercise (EX; three 60-minute sessions/week) for 4 weeks. Glycaemia was assessed via continuous glucose monitoring during observational control and intervention phases. RESULTS Time in range (70-180 mg/dL; 3.9-10.0 mmol/L) significantly improved from the observational control phase to the exercise intervention phase in EX (69% ± 13% vs. 72% ± 11%, P = .049), but not in IT (59% ± 22% vs. 62% ± 16%, P = .399). Time below range 1 (54-69 mg/dL; < 3.9 mmol/L) improved in IT (3.1% ± 1.9% vs. 2.0% ± 0.8%, P = .017) and remained stable in EX (2.0% ± 1.7 vs. 1.9% ± 1.1%, P = .999). The EX group's HbA1c ameliorated preintervention to postintervention (mean difference: ΔHbA1c -0.19% ± 0.17%, P = .042), which was not seen within the IT group (ΔHbA1c -0.16% ± 0.37%, P = .40). Glucose standard deviation was reduced significantly in EX (55 ± 11 vs. 51 ± 10 mg/dL [3.1 ± 0.6 vs. 2.8 ± 0.6 mmol/L], P = .011), but not in IT (70 ± 24 vs. 63 ± 18 mg/dL [3.9 ± 1.3 vs. 3.5 ± 1.0 mmol/L], P = .186). CONCLUSION Track and field training combined with intensive glycaemic management improved glycaemia in adolescents with T1D, which was not observed in the non-exercise group.
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Affiliation(s)
- Rebecca T Zimmer
- Division of Exercise Physiology and Metabolism, BaySpo-Bayreuth Center of Sport Science, University Bayreuth, Bayreuth, Germany
| | - Philipp Birnbaumer
- Exercise Physiology, Training & Training Therapy Research Group, Institute of Human Movement Science, Sport and Health, University of Graz, Graz, Austria
| | - Christoph Sternad
- Interdisciplinary Metabolic Medicine Trials Unit, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Beate E M Zunner
- Division of Exercise Physiology and Metabolism, BaySpo-Bayreuth Center of Sport Science, University Bayreuth, Bayreuth, Germany
| | - Janis Schierbauer
- Division of Exercise Physiology and Metabolism, BaySpo-Bayreuth Center of Sport Science, University Bayreuth, Bayreuth, Germany
| | - Maria Fritsch
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Elke Fröhlich-Reiterer
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University Graz, Graz, Austria
| | - Peter Hofmann
- Exercise Physiology, Training & Training Therapy Research Group, Institute of Human Movement Science, Sport and Health, University of Graz, Graz, Austria
| | - Harald Sourij
- Interdisciplinary Metabolic Medicine Trials Unit, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Felix Aberer
- Division of Exercise Physiology and Metabolism, BaySpo-Bayreuth Center of Sport Science, University Bayreuth, Bayreuth, Germany
- Interdisciplinary Metabolic Medicine Trials Unit, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Othmar Moser
- Division of Exercise Physiology and Metabolism, BaySpo-Bayreuth Center of Sport Science, University Bayreuth, Bayreuth, Germany
- Interdisciplinary Metabolic Medicine Trials Unit, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
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Zimmer RT, Auth A, Schierbauer J, Haupt S, Wachsmuth N, Zimmermann P, Voit T, Battelino T, Sourij H, Moser O. (Hybrid) Closed-Loop Systems: From Announced to Unannounced Exercise. Diabetes Technol Ther 2023. [PMID: 38133645 DOI: 10.1089/dia.2023.0293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Physical activity and exercise have many beneficial effects on general and type 1 diabetes (T1D) specific health and are recommended for individuals with T1D. Despite these health benefits, many people with T1D still avoid exercise since glycemic management during physical activity poses substantial glycemic and psychological challenges - which hold particularly true for unannounced exercise when using an AID system. Automated insulin delivery (AID) systems have demonstrated their efficacy in improving overall glycemia and in managing announced exercise in numerous studies. They are proven to increase time in range (70-180 mg/dL) and can especially counteract nocturnal hypoglycemia, even when evening exercise was performed. AID-systems consist of a pump administering insulin as well as a CGM sensor (plus transmitter), both communicating with a control algorithm integrated into a device (insulin pump, mobile phone/smart watch). Nevertheless, without manual pre-exercise adaptions, these systems still face a significant challenge around physical activity. Automatically adapting to the rapidly changing insulin requirements during unannounced exercise and physical activity is still the Achilles' heel of current AID systems. There is an urgent need for improving current AID-systems to safely and automatically maintain glucose management without causing derailments - so that going forward, exercise announcements will not be necessary in the future. Therefore, this narrative literature review aimed to discuss technological strategies to how current AID-systems can be improved in the future and become more proficient in overcoming the hurdle of unannounced exercise. For this purpose, the current state-of-the-art therapy recommendations for AID and exercise as well as novel research approaches are presented along with potential future solutions - in order to rectify their deficiencies in the endeavor to achieve fully automated AID-systems even around unannounced exercise.
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Affiliation(s)
- Rebecca Tanja Zimmer
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Alexander Auth
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Janis Schierbauer
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Sandra Haupt
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Nadine Wachsmuth
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Paul Zimmermann
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Thomas Voit
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Bayreuth, Bavaria, Germany;
| | - Tadej Battelino
- University Children's Hospital, Ljubljana, Slovenia, Department of Endocrinology, Diabetes and Metabolism, Bohoriceva 20, Ljubljana, Slovenia, 1000
- Slovenia;
| | - Harald Sourij
- Medical University of Graz, 31475, Auenbruggerplatz 15, 8036 Graz, Graz, Austria, 8036;
| | - Othmar Moser
- University of Bayreuth, 26523, Division Exercise Physiology and Metabolism Institute of Sport Science, Universitätsstraße 30, Bayreuth, Bayern, Germany, 95440;
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Michou P, Gkiourtzis N, Christoforidis A, Kotanidou EP, Galli-Tsinopoulou A. The efficacy of automated insulin delivery systems in children and adolescents with Type 1 Diabetes Mellitus: a systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2023; 199:110678. [PMID: 37094750 DOI: 10.1016/j.diabres.2023.110678] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 04/26/2023]
Abstract
AIMS Insulin administration is the treatment of choice for people with type 1 diabetes mellitus (T1D). Technological advances have led to the development of automated insulin delivery (AID) systems, aiming to optimize the quality of life of patients with T1D. We present a systematic review and meta-analysis of the current literature about the efficacy of AID systems in children and adolescents with T1D. METHODS We conducted a systematic literature search for randomized controlled trials (RCTs) until August 8th, 2022, investigating the efficacy of AID systems in the management of patients <21 years of age with T1D. A priori subgroup and sensitivity analyses based on different settings (free-living settings, type of AID system, parallel group or crossover design) were also conducted. RESULTS In total, 26 RCTs reporting a total of 915 children and adolescents with T1D were included in the meta-analysis. AID systems revealed statistically significant differences in the main outcomes, such as the proportion of time in the target glucose range (3.9-10 mmol/L) (p<0.00001), in hypoglycemia (<3.9 mmol/L) (p=0.003) and mean proportion of HbA1C (p=0.0007) compared to control group. CONCLUSIONS According to the present meta-analysis, AID systems are superior to insulin pump therapy, sensor-augmented pumps and multiple daily insulin injections. Most of the included studies have a high risk of bias because of allocation, blinding of patients and blinding of assessment. Our sensitivity analyses showed that patients <21 years of age with T1D can use AID systems, after proper education, following their daily activities. Further RCTs examining the effect of AID systems on nocturnal hypoglycemia, under free-living settings and studies examining the effect of dual-hormone AID systems are pending.
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Affiliation(s)
- Panagiota Michou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; Department of Pediatrics, Gennimatas General Hospital of Thessaloniki, Thessaloniki, Greece, 54635.
| | - Nikolaos Gkiourtzis
- 4th Department of Pediatrics, Papageorgiou General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 56429.
| | - Athanasios Christoforidis
- 1st Department of Pediatrics, Ippokrateio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54643.
| | - Eleni P Kotanidou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; 2nd Department of Pediatrics, AHEPA University General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54636.
| | - Asimina Galli-Tsinopoulou
- Program of Postgraduate Studies Adolescent Medicine and Adolescent Health Care, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54124; 2nd Department of Pediatrics, AHEPA University General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece, 54636.
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Bassi M, Franzone D, Dufour F, Strati MF, Scalas M, Tantari G, Aloi C, Salina A, d’Annunzio G, Maghnie M, Minuto N. Automated Insulin Delivery (AID) Systems: Use and Efficacy in Children and Adults with Type 1 Diabetes and Other Forms of Diabetes in Europe in Early 2023. Life (Basel) 2023; 13:783. [PMID: 36983941 PMCID: PMC10053516 DOI: 10.3390/life13030783] [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: 02/11/2023] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Type 1 diabetes (T1D) patients' lifestyle and prognosis has remarkably changed over the years, especially after the introduction of insulin pumps, in particular advanced hybrid closed loop systems (AHCL). Emerging data in literature continuously confirm the improvement of glycemic control thanks to the technological evolution taking place in this disease. As stated in previous literature, T1D patients are seen to be more satisfied thanks to the use of these devices that ameliorate not only their health but their daily life routine as well. Limited findings regarding the use of new devices in different age groups and types of patients is their major limit. This review aims to highlight the main characteristics of each Automated Insulin Delivery (AID) system available for patients affected by Type 1 Diabetes Mellitus. Our main goal was to particularly focus on these systems' efficacy and use in different age groups and populations (i.e., children, pregnant women). Recent studies are emerging that demonstrate their efficacy and safety in younger patients and other forms of diabetes.
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Affiliation(s)
- Marta Bassi
- IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Daniele Franzone
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Francesca Dufour
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Marina Francesca Strati
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Marta Scalas
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Giacomo Tantari
- IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
| | - Concetta Aloi
- LABSIEM (Laboratory for the Study of Inborn Errors of Metabolism), Pediatric Clinic, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Alessandro Salina
- LABSIEM (Laboratory for the Study of Inborn Errors of Metabolism), Pediatric Clinic, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | | | - Mohamad Maghnie
- IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, 16126 Genoa, Italy
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Kang SL, Hwang YN, Kwon JY, Kim SM. Effectiveness and safety of a model predictive control (MPC) algorithm for an artificial pancreas system in outpatients with type 1 diabetes (T1D): systematic review and meta-analysis. Diabetol Metab Syndr 2022; 14:187. [PMID: 36494830 PMCID: PMC9733359 DOI: 10.1186/s13098-022-00962-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the effectiveness and safety of a model predictive control (MPC) algorithm for an artificial pancreas system in outpatients with type 1 diabetes. METHODS We searched PubMed, EMBASE, Cochrane Central, and the Web of Science to December 2021. The eligibility criteria for study selection were randomized controlled trials comparing artificial pancreas systems (MPC, PID, and fuzzy algorithms) with conventional insulin therapy in type 1 diabetes patients. The heterogeneity of the overall results was identified by subgroup analysis of two factors including the intervention duration (overnight and 24 h) and the follow-up periods (< 1 week, 1 week to 1 month, and > 1 month). RESULTS The meta-analysis included a total of 41 studies. Considering the effect on the percentage of time maintained in the target range between the MPC-based artificial pancreas and conventional insulin therapy, the results showed a statistically significantly higher percentage of time maintained in the target range in overnight use (10.03%, 95% CI [7.50, 12.56] p < 0.00001). When the follow-up period was considered, in overnight use, the MPC-based algorithm showed a statistically significantly lower percentage of time maintained in the hypoglycemic range (-1.34%, 95% CI [-1.87, -0.81] p < 0.00001) over a long period of use (> 1 month). CONCLUSIONS Overnight use of the MPC-based artificial pancreas system statistically significantly improved glucose control while increasing time maintained in the target range for outpatients with type 1 diabetes. Results of subgroup analysis revealed that MPC algorithm-based artificial pancreas system was safe while reducing the time maintained in the hypoglycemic range after an overnight intervention with a long follow-up period (more than 1 month).
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Affiliation(s)
- Su Lim Kang
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Yoo Na Hwang
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Ji Yean Kwon
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
| | - Sung Min Kim
- Department of Medical Device and Healthcare, Dongguk University-Seoul, 26, Pil-Dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
- Department of Medical Device Regulatory Science, Dongguk University-Seoul, 26, Pil-dong 3-Ga, Seoul, Jung-Gu 04620 Republic of Korea
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8
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Rodríguez-Sarmiento DL, León-Vargas F, García-Jaramillo M. Artificial pancreas systems: experiences from concept to commercialisation. Expert Rev Med Devices 2022; 19:877-894. [DOI: 10.1080/17434440.2022.2150546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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9
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Al-Beltagi M, Saeed NK, Bediwy AS, Elbeltagi R. Insulin pumps in children - a systematic review. World J Clin Pediatr 2022; 11:463-484. [PMID: 36439904 PMCID: PMC9685680 DOI: 10.5409/wjcp.v11.i6.463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/02/2022] [Accepted: 09/22/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Insulin pump therapy is a real breakthrough in managing diabetes Mellitus, particularly in children. It can deliver a tiny amount of insulin and decreases the need for frequent needle injections. It also helps to maintain adequate and optimal glycemic control to reduce the risk of metabolic derangements in different tissues. Children are suitable candidates for pump therapy as they need a more freestyle and proper metabolic control to ensure adequate growth and development. Therefore, children and their caregivers should have proper education and training and understand the proper use of insulin pumps to achieve successful pump therapy. The pump therapy continuously improves to enhance its performance and increase its simulation of the human pancreas. Nonetheless, there is yet a long way to reach the desired goal.
AIM To review discusses the history of pump development, its indications, types, proper use, special conditions that may enface the children and their families while using the pump, its general care, and its advantages and disadvantages.
METHODS We conducted comprehensive literature searches of electronic databases until June 30, 2022, related to pump therapy in children and published in the English language.
RESULTS We included 118 articles concerned with insulin pumps, 61 were reviews, systemic reviews, and meta-analyses, 47 were primary research studies with strong design, and ten were guidelines.
CONCLUSION The insulin pump provides fewer needles and can provide very tiny insulin doses, a convenient and more flexible way to modify the needed insulin physiologically, like the human pancreas, and can offer adequate and optimal glycemic control to reduce the risk of metabolic derangements in different tissues.
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Affiliation(s)
- Mohammed Al-Beltagi
- Department of Pediatrics, Faculty of Medicine, Tanta University, Tanta 31511, Algharbia, Egypt
- Department of Pediatrics, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Manama 26671, Manama, Bahrain
- Department of Pediatrics, University Medical Center, Dr. Sulaiman Al Habib Medical Group, Manama, Bahrain, Manama 26671, Manama, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Department of Pathology, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 12, Manama, Bahrain
- Department of Microbiology, Irish Royal College of Surgeon, Bahrain, Busaiteen 15503, Muharraq, Bahrain
| | - Adel Salah Bediwy
- Department of Chest Disease, Faculty of Medicine, Tanta University, Tanta 31527, Alghrabia, Egypt
- Department of Chest Disease, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Manama, Bahrain
| | - Reem Elbeltagi
- Department of Medicine, The Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
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10
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Ware J, Hovorka R. Closed-loop insulin delivery: update on the state of the field and emerging technologies. Expert Rev Med Devices 2022; 19:859-875. [PMID: 36331211 PMCID: PMC9780196 DOI: 10.1080/17434440.2022.2142556] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Over the last five years, closed-loop insulin delivery systems have transitioned from research-only to real-life use. A number of systems have been commercialized and are increasingly used in clinical practice. Given the rapidity of new developments in the field, understanding the capabilities and key similarities and differences of current systems can be challenging. This review aims to provide an update on the state of the field of closed-loop insulin delivery systems, including emerging technologies. AREAS COVERED We summarize key clinical safety and efficacy evidence of commercial and emerging insulin-only hybrid closed-loop systems for type 1 diabetes. A literature search was conducted and clinical trials using closed-loop systems during free-living conditions were identified to report on safety and efficacy data. We comment on emerging technologies and adjuncts for closed-loop systems, as well as non-technological priorities in closed-loop insulin delivery. EXPERT OPINION Commercial hybrid closed-loop insulin delivery systems are efficacious, consistently improving glycemic control when compared to standard therapy. Challenges remain in widespread adoption due to clinical inertia and the lack of resources to embrace technological developments by health care professionals.
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Affiliation(s)
- Julia Ware
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
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11
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Abstract
First envisioned by early diabetes clinicians, a person-centred approach to care was an aspirational goal that aimed to match insulin therapy to each individual's unique requirements. In the 100 years since the discovery of insulin, this goal has evolved to include personalised approaches to type 1 diabetes diagnosis, treatment, prevention and prediction. These advances have been facilitated by the recognition of type 1 diabetes as an autoimmune disease and by advances in our understanding of diabetes pathophysiology, genetics and natural history, which have occurred in parallel with advancements in insulin delivery, glucose monitoring and tools for self-management. In this review, we discuss how these personalised approaches have improved diabetes care and how improved understanding of pathogenesis and human biology might inform precision medicine in the future.
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Affiliation(s)
- Alice L J Carr
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
| | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
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13
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Bhutta ZA, Salam RA, Gomber A, Lewis-Watts L, Narang T, Mbanya JC, Alleyne G. A century past the discovery of insulin: global progress and challenges for type 1 diabetes among children and adolescents in low-income and middle-income countries. Lancet 2021; 398:1837-1850. [PMID: 34774146 DOI: 10.1016/s0140-6736(21)02247-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 12/11/2022]
Abstract
Type 1 diabetes is on the rise globally; however, the burden of mortality remains disproportionate in low-income and middle-income countries (LMICs). As 2021 marks 100 years since the discovery of insulin, we revisit progress, global burden of type 1 diabetes trends, and understanding of the pathogenesis and management practices related to the disease. Despite much progress, inequities in access and availability of insulin formulations persist and are reflected in differences in survival and morbidity patterns related to the disease. Some of these inequities have also been exacerbated by health-system challenges during the COVID-19 pandemic. There is a clear opportunity to improve access to insulin and related essential technologies for improved management of type 1 diabetes in LMICs, especially as a part of universal health coverage. These improvements will require concerted action and investments in human resources, community engagement, and education for the timely diagnosis and management of type 1 diabetes, as well as adequate health-care financing. Further research in LMICs, especially those in Africa, is needed to improve our understanding of the burden, risk factors, and implementation strategies for managing type 1 diabetes.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; Centre of Excellence in Women and Child Health and Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan.
| | | | - Apoorva Gomber
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Laura Lewis-Watts
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Tanya Narang
- Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada
| | - Jean Claude Mbanya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - George Alleyne
- Pan American Health Organization and Regional Office of the World Health Organization, Washington DC, USA
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14
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Moon SJ, Jung I, Park CY. Current Advances of Artificial Pancreas Systems: A Comprehensive Review of the Clinical Evidence. Diabetes Metab J 2021; 45:813-839. [PMID: 34847641 PMCID: PMC8640161 DOI: 10.4093/dmj.2021.0177] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022] Open
Abstract
Since Banting and Best isolated insulin in the 1920s, dramatic progress has been made in the treatment of type 1 diabetes mellitus (T1DM). However, dose titration and timely injection to maintain optimal glycemic control are often challenging for T1DM patients and their families because they require frequent blood glucose checks. In recent years, technological advances in insulin pumps and continuous glucose monitoring systems have created paradigm shifts in T1DM care that are being extended to develop artificial pancreas systems (APSs). Numerous studies that demonstrate the superiority of glycemic control offered by APSs over those offered by conventional treatment are still being published, and rapid commercialization and use in actual practice have already begun. Given this rapid development, keeping up with the latest knowledge in an organized way is confusing for both patients and medical staff. Herein, we explore the history, clinical evidence, and current state of APSs, focusing on various development groups and the commercialization status. We also discuss APS development in groups outside the usual T1DM patients and the administration of adjunct agents, such as amylin analogues, in APSs.
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Affiliation(s)
- Sun Joon Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Inha Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol-Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Grunberger G, Sherr J, Allende M, Blevins T, Bode B, Handelsman Y, Hellman R, Lajara R, Roberts VL, Rodbard D, Stec C, Unger J. American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus. Endocr Pract 2021; 27:505-537. [PMID: 34116789 DOI: 10.1016/j.eprac.2021.04.008] [Citation(s) in RCA: 121] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
| | - Jennifer Sherr
- Yale University School of Medicine, New Haven, Connecticut
| | - Myriam Allende
- University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | | | - Bruce Bode
- Atlanta Diabetes Associates, Atlanta, Georgia
| | | | - Richard Hellman
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - David Rodbard
- Biomedical Informatics Consultants, LLC, Potomac, Maryland
| | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | - Jeff Unger
- Unger Primary Care Concierge Medical Group, Rancho Cucamonga, California
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16
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Eckstein ML, Weilguni B, Tauschmann M, Zimmer RT, Aziz F, Sourij H, Moser O. Time in Range for Closed-Loop Systems versus Standard of Care during Physical Exercise in People with Type 1 Diabetes: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10112445. [PMID: 34072900 PMCID: PMC8198013 DOI: 10.3390/jcm10112445] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/16/2022] Open
Abstract
The aim of this systematic review and meta-analysis was to compare time in range (TIR) (70–180 mg/dL (3.9–10.0 mmol/L)) between fully closed-loop systems (CLS) and standard of care (including hybrid systems) during physical exercise in people with type 1 diabetes (T1D). A systematic literature search was conducted in EMBASE, PubMed, Cochrane Central Register of Controlled Trials, and ISI Web of Science from January 1950 until January 2020. Randomized controlled trials including studies with different CLS were compared against standard of care in people with T1D. The meta-analysis was performed using the random effects model and restricted maximum likelihood estimation method. Six randomized controlled trials involving 153 participants with T1D of all age groups were included. Due to crossover test designs, studies were included repeatedly (a–d) if CLS or physical exercise interventions were different. Applying this methodology increased the comparisons to a total number of 266 participants. TIR was higher with an absolute mean difference (AMD) of 6.18%, 95% CI: 1.99 to 10.38% in favor of CLS. In a subgroup analysis, the AMD was 9.46%, 95% CI: 2.48% to 16.45% in children and adolescents while the AMD for adults was 1.07% 95% CI: −0.81% to 2.96% in favor of CLS. In this systematic review and meta-analysis CLS moderately improved TIR in comparison to standard of care during physical exercise in people with T1D. This effect was particularly pronounced for children and adolescents showing that the use of CLS improved TIR significantly compared to standard of care.
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Affiliation(s)
- Max L. Eckstein
- Division of Exercise Physiology and Metabolism, Department of Sport Science, University of Bayreuth, 95440 Bayreuth, Germany; (M.L.E.); (R.T.Z.)
| | - Benjamin Weilguni
- Interdisciplinary Metabolic Medicine, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (B.W.); (F.A.); (H.S.)
| | - Martin Tauschmann
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Vienna, Austria;
| | - Rebecca T. Zimmer
- Division of Exercise Physiology and Metabolism, Department of Sport Science, University of Bayreuth, 95440 Bayreuth, Germany; (M.L.E.); (R.T.Z.)
| | - Faisal Aziz
- Interdisciplinary Metabolic Medicine, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (B.W.); (F.A.); (H.S.)
| | - Harald Sourij
- Interdisciplinary Metabolic Medicine, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (B.W.); (F.A.); (H.S.)
| | - Othmar Moser
- Division of Exercise Physiology and Metabolism, Department of Sport Science, University of Bayreuth, 95440 Bayreuth, Germany; (M.L.E.); (R.T.Z.)
- Interdisciplinary Metabolic Medicine, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria; (B.W.); (F.A.); (H.S.)
- Correspondence: ; Tel.: +49-(0)921-55-3465
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Palisaitis E, El Fathi A, von Oettingen JE, Haidar A, Legault L. A Meal Detection Algorithm for the Artificial Pancreas: A Randomized Controlled Clinical Trial in Adolescents With Type 1 Diabetes. Diabetes Care 2021; 44:604-606. [PMID: 33277302 DOI: 10.2337/dc20-1232] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/20/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We developed a meal detection algorithm for the artificial pancreas (AP+MDA) that detects unannounced meals and delivers automatic insulin boluses. RESEARCH DESIGN AND METHODS We conducted a randomized crossover trial in 11 adolescents aged 12-18 years with HbA1c ≥7.5% who missed one or more boluses in the past 6 months. We compared 1) continuous subcutaneous insulin infusion (CSII), 2) artificial pancreas (AP), and 3) AP+MDA. Participants underwent three 9-h interventions involving breakfast with a bolus and lunch without a bolus. RESULTS In AP+MDA, the meal detection time was 40.0 (interquartile range 40.0-57.5) min. Compared with CSII, AP+MDA decreased the 4-h postlunch incremental area under the curve (iAUC) from 24.1 ± 9.5 to 15.4 ± 8.0 h ⋅ mmol/L (P = 0.03). iAUC did not differ between AP+MDA and AP (19.6 ± 10.4 h ⋅ mmol/L, P = 0.21) or between AP and CSII (P = 0.33). The AP+MDA reduced time >10 mmol/L (58.0 ± 26.6%) compared with CSII (79.6 ± 27.5%, P = 0.02) and AP (74.2 ± 20.6%, P = 0.047). CONCLUSIONS The AP+MDA improved glucose control after an unannounced meal.
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Affiliation(s)
- Emilie Palisaitis
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Anas El Fathi
- Department of Electrical and Computer Engineering, McGill University, Montreal, Quebec, Canada
| | - Julia E von Oettingen
- Department of Pediatrics, Division of Endocrinology, Montreal Children's Hospital, Montreal, Quebec, Canada.,The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada.,The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Laurent Legault
- Department of Pediatrics, Division of Endocrinology, Montreal Children's Hospital, Montreal, Quebec, Canada .,The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Smaoui MR, Rabasa-Lhoret R, Haidar A. Development platform for artificial pancreas algorithms. PLoS One 2020; 15:e0243139. [PMID: 33332411 PMCID: PMC7746189 DOI: 10.1371/journal.pone.0243139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/17/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND AIMS Assessing algorithms of artificial pancreas systems is critical in developing automated and fault-tolerant solutions that work outside clinical settings. The development and evaluation of algorithms can be facilitated with a platform that conducts virtual clinical trials. We present in this paper a clinically validated cloud-based distributed platform that supports the development and comprehensive testing of single and dual-hormone algorithms for type 1 diabetes mellitus (T1DM). METHODS The platform is built on principles of object-oriented design and runs user algorithms in real-time virtual clinical trials utilizing a multi-threaded environment enabled by concurrent execution over a cloud infrastructure. The platform architecture isolates user algorithms located on personal machines from proprietary patient data running on the cloud. Users import a plugin into their algorithms (Matlab, Python, or Java) to connect to the platform. Once connected, users interact with a graphical interface to design experimental protocols for their trials. Protocols include trial duration in days, mealtimes and amounts, variability in mealtimes and amounts, carbohydrate counting errors, snacks, and onboard insulin levels. RESULTS The platform facilitates development by solving the ODE model in the cloud on large CPU-optimized machines, providing a 62% improvement in memory, speed and CPU utilization. Users can easily debug & modify code, test multiple strategies, and generate detailed clinical performance reports. We validated and integrated into the platform a glucoregulatory system of ordinary differential equations (ODEs) parameterized with clinical data to mimic the inter and intra-day variability of glucose responses of 15 T1DM patients. CONCLUSION The platform utilizes the validated patient model to conduct virtual clinical trials for the rapid development and testing of closed-loop algorithms for T1DM.
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Affiliation(s)
- Mohamed Raef Smaoui
- Computer Science Department, Faculty of Science, Kuwait University, Kuwait City, Kuwait
- * E-mail:
| | - Remi Rabasa-Lhoret
- Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Canada
- Institut de Recherches Cliniques de Montréal, Montréal, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, Faculty of Medicine, McGill University, Montreal, Canada
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19
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Yu X, Sun X, Zhao Y, Liu J, Li H. Fault detection of continuous glucose measurements based on modified k-medoids clustering algorithm. Neural Comput Appl 2020. [DOI: 10.1007/s00521-020-05432-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Isfahani MK, Zekri M, Marateb HR, Faghihimani E. A Hybrid Dynamic Wavelet-Based Modeling Method for Blood Glucose Concentration Prediction in Type 1 Diabetes. JOURNAL OF MEDICAL SIGNALS & SENSORS 2020; 10:174-184. [PMID: 33062609 PMCID: PMC7528985 DOI: 10.4103/jmss.jmss_62_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/12/2019] [Accepted: 01/10/2020] [Indexed: 11/07/2022]
Abstract
Background: Diabetes mellitus (DM) is a chronic disease that affects public health. The prediction of blood glucose concentration (BGC) is essential to improve the therapy of type 1 DM (T1DM). Methods: Having considered the risk of hyper- and hypo-glycemia, we provide a new hybrid modeling approach for BGC prediction based on a dynamic wavelet neural network (WNN) model, including a heuristic input selection. The proposed models include a hybrid dynamic WNN (HDWNN) and a hybrid dynamic fuzzy WNN (HDFWNN). These wavelet-based networks are designed based on dominant wavelets selected by the genetic algorithm-orthogonal least square method. Furthermore, the HDFWNN model structure is improved using fuzzy rule induction, an important innovation in the fuzzy wavelet modeling. The proposed networks are tested on real data from 12 T1DM patients and also simulated data from 33 virtual patients with an UVa/ Padova simulator, an approved simulator by the US Food and Drug Administration. Results: A comparison study is performed in terms of new glucose-based assessment metrics, such as gFIT, glucose-weighted form of ESODn (gESODn), and glucose-weighted R2 (gR2). For real patients’ data, the values of the mentioned indices are accomplished as gFIT = 0.97 ± 0.01, gESODn = 1.18 ± 0.38, and gR2 = 0.88 ± 0.07. HDFWNN, HDWNN and jump NN method showed the prediction error (root mean square error [RMSE]) of 11.23 ± 2.77 mg/dl, 10.79 ± 3.86 mg/dl and 16.45 ± 4.33 mg/dl, respectively. Conclusion: Furthermore, the generalized estimating equation and post hoc tests show that proposed models perform better compared with other proposed methods.
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Affiliation(s)
| | - Maryam Zekri
- Department of Electrical and Computer Engineering, Isfahan University of Technology, Isfahan, Iran
| | - Hamid Reza Marateb
- Department of Biomedical Engineering, Faculty of Engineering, University of Isfahan, Isfahan, Iran.,Department of Automatic Control, Biomedical Engineering Research Center, Polytechnic University of Catalonia, Barcelona Tech, Barcelona, Spain
| | - Elham Faghihimani
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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21
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Song L, Liu C, Yang W, Zhang J, Kong X, Zhang B, Chen X, Wang N, Shen D, Li Z, Jin X, Shuai Y, Wang Y. Glucose outcomes of a learning-type artificial pancreas with an unannounced meal in type 1 diabetes. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 191:105416. [PMID: 32146213 DOI: 10.1016/j.cmpb.2020.105416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/19/2020] [Accepted: 02/22/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Glycemic control with unannounced meals is the major challenge for artificial pancreas. In this study, we described the performance and safety of learning-type model predictive control (L-MPC) for artificial pancreas challenged by an unannounced meal in type 1 diabetes (T1D). METHODS This closed-loop (CL) system was tested in 29 T1D patients at one site in a 4 h inpatient open-label study. Participants used an L-MPC CL system for 6 days after 2-day system identification using open-loop (OL) insulin system. During the CL period, the L-MPC system was started from 8:00 am to noon each day. At 9:00 am, each participant consumed 50 g of carbohydrates with no prandial insulin bolus. At 9:30 am on CL-Day 4 or CL-Day 6, participants rode bicycles for 20 minutes or drank 50 ml of beer, in a random order. RESULTS As the primary outcome, TIR on CL-Day 3 was 65.2±23.3%, which was 9.8 points higher (95% CI 1.8 to 17.8; P = 0.019) than that on CL-Day 1. The time of glucose >10 mmol/L was decreased by 11.0% (95% CI -18.7 to 3.3; P = 0.007), and mean glucose level was decreased by 1.1 mmol/L (95% CI -1.1 to 0.5; P = 0.000). The total daily insulin dosage showed no significant difference (-0.1U, 95% CI -1.34 to 1.32; P = 0.982). Compared with OL-Day1 with a postprandial bolus, the TIR was increased by 13.7 points (95% CI 1.4 to 26.0; P = 0.030), the time of glucose >10 mmol/L and the mean glucose level were also decreased. Compared with the exercise day (CL-Day E, 62.0 ± 23.3%; P = 0.347) or alcohol day (CL-Day A, 64.0 ± 23.6%; P = 0.756), there was no statistically significant difference in terms of TIR, time of glucose >10 mmol/L and mean glucose level. No severe hypoglycemic events occurred and hypoglycemic episodes were not increased by using closed-loop insulin system. CONCLUSION The L-MPC CL insulin system achieved good glycemic control challenged by an unannounced meal.
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Affiliation(s)
- Lulu Song
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Changqing Liu
- College of Information Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Wenying Yang
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Jinping Zhang
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Xiaomu Kong
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Bo Zhang
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Xiaoping Chen
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Na Wang
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Dong Shen
- College of Information Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China
| | - Zhaoqing Li
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Xian Jin
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Ying Shuai
- Department of Endocrinology, China-Japan Friendship Hospital, Beijing, China
| | - Youqing Wang
- College of Information Science and Technology, Beijing University of Chemical Technology, Beijing 100029, China.
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22
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Boughton C, Allen JM, Tauschmann M, Hartnell S, Wilinska ME, Musolino G, Acerini CL, Dunger PD, Campbell F, Ghatak A, Randell T, Besser R, Trevelyan N, Elleri D, Northam E, Hood K, Scott E, Lawton J, Roze S, Sibayan J, Kollman C, Cohen N, Todd J, Hovorka R. Assessing the effect of closed-loop insulin delivery from onset of type 1 diabetes in youth on residual beta-cell function compared to standard insulin therapy (CLOuD study): a randomised parallel study protocol. BMJ Open 2020; 10:e033500. [PMID: 32169925 PMCID: PMC7069267 DOI: 10.1136/bmjopen-2019-033500] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Management of newly diagnosed type 1 diabetes (T1D) in children and adolescents is challenging for patients, families and healthcare professionals. The objective of this study is to determine whether continued intensive metabolic control using hybrid closed-loop (CL) insulin delivery following diagnosis of T1D can preserve C-peptide secretion, a marker of residual beta-cell function, compared with standard multiple daily injections (MDI) therapy. METHODS AND ANALYSIS The study adopts an open-label, multicentre, randomised, parallel design, and aims to randomise 96 participants aged 10-16.9 years, recruited within 21 days of diagnosis with T1D. Following a baseline mixed meal tolerance test (MMTT), participants will be randomised to receive 24 months treatment with conventional MDI therapy or with CL insulin delivery. A further 24-month optional extension phase will be offered to all participants to continue with the allocated treatment. The primary outcome is the between group difference in area under the stimulated C-peptide curve (AUC) of the MMTT at 12 months post diagnosis. Analyses will be conducted on an intention-to-treat basis. Key secondary outcomes are between group differences in time spent in target glucose range (3.9-10 mmol/L), glycated haemoglobin (HbA1c) and time spent in hypoglycaemia (<3.9 mmol/L) at 12 months. Secondary efficacy outcomes include between group differences in stimulated C-peptide AUC at 24 months, time spent in target glucose range, glucose variability, hypoglycaemia and hyperglycaemia as recorded by periodically applied masked continuous glucose monitoring devices, total, basal and bolus insulin dose, and change in body weight. Cognitive, emotional and behavioural characteristics of participants and parents will be evaluated, and a cost-utility analysis performed to support adoption of CL as a standard treatment modality following diagnosis of T1D. ETHICS AND DISSEMINATION Ethics approval has been obtained from Cambridge East Research Ethics Committee. The results will be disseminated by peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02871089; Pre-results.
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Affiliation(s)
- Charlotte Boughton
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Sara Hartnell
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Gianluca Musolino
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | | | - Fiona Campbell
- Children's Diabetes Centre, Leeds Children's Hospital, Leeds, UK
| | - Atrayee Ghatak
- Department of Diabetes, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Tabitha Randell
- Department of Paediatric Diabetes and Endocrinology, Nottingham Children's Hospital, Nottingham, UK
| | - Rachel Besser
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Nicola Trevelyan
- Paediatric Diabetes, Southampton Children's Hospital, Southampton, UK
| | - Daniela Elleri
- Department of Diabetes, Royal Hospital for Sick Children, Edinburgh, UK
| | - Elizabeth Northam
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Korey Hood
- Endocrinology, Stanford University School of Medicine, Stanford, California, USA
| | - Eleanor Scott
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Julia Lawton
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - Judy Sibayan
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Craig Kollman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Nate Cohen
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - John Todd
- Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
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23
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Hanaire H, Franc S, Borot S, Penfornis A, Benhamou PY, Schaepelynck P, Renard E, Guerci B, Jeandidier N, Simon C, Hannaert P, Xhaard I, Doron M, Huneker E, Charpentier G, Reznik Y. Efficacy of the Diabeloop closed-loop system to improve glycaemic control in patients with type 1 diabetes exposed to gastronomic dinners or to sustained physical exercise. Diabetes Obes Metab 2020; 22:324-334. [PMID: 31621186 DOI: 10.1111/dom.13898] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 12/12/2022]
Abstract
AIMS To compare closed-loop (CL) and open-loop (OL) systems for glycaemic control in patients with type 1 diabetes (T1D) exposed to real-life challenging situations (gastronomic dinners or sustained physical exercise). METHODS Thirty-eight adult patients with T1D were included in a three-armed randomized pilot trial (Diabeloop WP6.2 trial) comparing glucose control using a CL system with use of an OL device during two crossover 72-hour periods in one of the three following situations: large (gastronomic) dinners; sustained and repeated bouts of physical exercise (with uncontrolled food intake); or control (rest conditions). Outcomes included time in spent in the glucose ranges of 4.4-7.8 mmol/L and 3.9-10.0 mmol/L, and time in hypo- and hyperglycaemia. RESULTS Time spent overnight in the tight range of 4.4 to 7.8 mmol/L was longer with CL (mean values: 63.2% vs 40.9% with OL; P ≤ .0001). Time spent during the day in the range of 3.9 to 10.0 mmol/L was also longer with CL (79.4% vs 64.1% with OL; P ≤ .0001). Participants using the CL system spent less time during the day with hyperglycaemic excursions (glucose >10.0 mmol/L) compared to those using an OL system (17.9% vs 31.9%; P ≤ .0001), and the proportions of time spent during the day with hyperglycaemic excursions of those using the CL system in the gastronomic dinner and physical exercise subgroups were of similar magnitude to those in the control subgroup (18.1 ± 6.3%, 17.2 ± 8.1% and 18.4 ± 12.5%, respectively). Finally, times spent in hypoglycaemia were short and not significantly different among the groups. CONCLUSIONS The Diabeloop CL system is superior to OL devices in reducing hyperglycaemic excursions in patients with T1D exposed to gastronomic dinners, or exposed to physical exercise followed by uncontrolled food and carbohydrate intake.
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Affiliation(s)
- Hélène Hanaire
- Department of Diabetology, Metabolic Diseases and Nutrition, CHU Toulouse, University of Toulouse, Toulouse, France
| | - Sylvia Franc
- Department of Diabetes, Sud-Francilien Hospital, Corbeil-Essonnes, and Centre d'Etude et de Recherche pour l'Intensification du Traitement du Diabete, Evry, France
| | - Sophie Borot
- Department of Endocrinology, Metabolism, Diabetes and Nutrition, Centre Hospitalier Universitaire Jean Minjoz, Besançon, France
| | - Alfred Penfornis
- Department of Diabetes, Sud-Francilien Hospital, Corbeil-Essonnes, and Centre d'Etude et de Recherche pour l'Intensification du Traitement du Diabete, Evry, France
- University Paris-Sud, Orsay, France
| | | | - Pauline Schaepelynck
- Department of Nutrition-Endocrinology-Metabolic Disorders, Marseille University Hospital, Sainte Marguerite Hospital, Marseille, France
| | - Eric Renard
- Department of Endocrinology, Diabetes and Nutrition, Montpellier University Hospital, and Institute of Functional Genomics, CNRS, INSERM, University of Montpellier, Montpellier, France
| | - Bruno Guerci
- Endocrinology-Diabetes Care Unit, University of Lorraine, Vandoeuvre Lès Nancy, France
| | - Nathalie Jeandidier
- Department of Endocrinology, Diabetes and Nutrition, CHU of Strasbourg, Strasbourg, France
| | - Chantal Simon
- Department of Endocrinology, Diabetes and Nutrition, Centre Hospitalier Lyon Sud, Lyon, France
| | - Patrick Hannaert
- School of Medicine and Pharmacy of Poitiers, IRTOMIT, INSERM UMR 1082, Poitiers, France
| | - Ilham Xhaard
- Centre d'Etudes et de Recherches pour l'Intensification du Traitement du Diabète, Evry, France
| | - Maeva Doron
- University Grenoble Alpes, Grenoble, France
- CEA LETI MlNATEC Campus, Grenoble, France
| | | | - Guillaume Charpentier
- Department of Diabetes, Sud-Francilien Hospital, Corbeil-Essonnes, and Centre d'Etude et de Recherche pour l'Intensification du Traitement du Diabete, Evry, France
| | - Yves Reznik
- Department of Endocrinology, University of Caen Côte de Nacre Regional Hospital Centre, Caen, France
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24
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Abstract
Advances in technologies such as glucose monitors, exercise wearables, closed-loop systems, and various smartphone applications are helping many people with diabetes to be more physically active. These technologies are designed to overcome the challenges associated with exercise duration, mode, relative intensity, and absolute intensity, all of which affect glucose homeostasis in people living with diabetes. At present, optimal use of these technologies depends largely on motivation, competence, and adherence to daily diabetes care requirements. This article discusses recent technologies designed to help patients with diabetes to be more physically active, while also trying to improve glucose control around exercise.
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Affiliation(s)
- Michael C Riddell
- School of Kinesiology and Health Science, York University, Toronto, ON M3J 1P3, Canada; LMC Diabetes & Endocrinology, 1929 Bayview Avenue, Toronto, ON M4G 3E8, Canada; York University, 347 Bethune College, North York, Ontario M3J 1P3, Canada.
| | - Rubin Pooni
- School of Kinesiology and Health Science, York University, Toronto, ON M3J 1P3, Canada; York University, 347 Bethune College, North York, Ontario M3J 1P3, Canada
| | - Federico Y Fontana
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Via Casorati, 43, 37121 Verona, Italy; Team Novo Nordisk Professional Cycling Team, 2144 Hills Avenue NW, Atlanta, 30318 GA, USA. https://twitter.com/FeedYourFlock
| | - Sam N Scott
- Team Novo Nordisk Professional Cycling Team, 2144 Hills Avenue NW, Atlanta, 30318 GA, USA; Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland. https://twitter.com/SamNathanScott
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25
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Dubey SK, Alexander A, Pradhyut KS, Agrawal M, Jain R, Saha RN, Singhvi G, Saraf S, Saraf S. Recent Avenues in Novel Patient-Friendly Techniques for the Treatment of Diabetes. Curr Drug Deliv 2020; 17:3-14. [DOI: 10.2174/1567201816666191106102020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/14/2019] [Accepted: 10/15/2019] [Indexed: 12/26/2022]
Abstract
Background:
Diabetes is one of the most common chronic metabolic disorders which affect
the quality of human life worldwide. As per the WHO report, between 1980 to 2014, the number of
diabetes patients increases from 108 million to 422 million, with a global prevalence rate of 8.5% per
year. Diabetes is the prime reason behind various other diseases like kidney failure, stroke, heart disorders,
glaucoma, etc. It is recognized as the seventh leading cause of death throughout the world. The
available therapies are painful (insulin injections) and inconvenient due to higher dosing frequency.
Thus, to find out a promising and convenient treatment, extensive investigations are carried out globally
by combining novel carrier system (like microparticle, microneedle, nanocarrier, microbeads etc.) and
delivery devices (insulin pump, stimuli-responsive device, inhalation system, bioadhesive patch, insulin
pen etc.) for more precise diagnosis and painless or less invasive treatment of disease.
Objective:
The review article is made with an objective to compile information about various upcoming
and existing modern technologies developed to provide greater patient compliance and reduce the undesirable
side effect of the drug. These devices evade the necessity of daily insulin injection and offer a
rapid onset of action, which sustained for a prolonged duration of time to achieve a better therapeutic
effect.
Conclusion:
Despite numerous advantages, various commercialized approaches, like Afrezza (inhalation
insulin) have been a failure in recent years. Such results call for more potential work to develop a
promising system. The novel approaches range from the delivery of non-insulin blood glucose lowering
agents to insulin-based therapy with minimal invasion are highly desirable.
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Affiliation(s)
- Sunil Kumar Dubey
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Amit Alexander
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER GUWAHATI), Ministry of Chemicals & Fertilizers, Govt. of India, NH 37, NITS Mirza, Kamrup- 781125, Guwahati (Assam), India
| | - K. Sai Pradhyut
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Mukta Agrawal
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER GUWAHATI), Ministry of Chemicals & Fertilizers, Govt. of India, NH 37, NITS Mirza, Kamrup- 781125, Guwahati (Assam), India
| | - Rupesh Jain
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Ranendra Narayana Saha
- Department of Biotechnology, Faculty of Biotechnology, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Dubai Campus, Dubai, United Arab Emirates
| | - Gautam Singhvi
- Department of Pharmacy, Faculty of Pharmacy, Birla Institute of Technology and Science, Pilani (BITS-PILANI), Pilani Campus, Rajasthan, India
| | - Swarnlata Saraf
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, Chhattisgarh 492 010, India
| | - Shailendra Saraf
- University Institute of Pharmacy, Pt. Ravishankar Shukla University, Raipur, Chhattisgarh 492 010, India
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26
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Collard SS, Regmi PR, Hood KK, Laffel L, Weissberg‐Benchell J, Naranjo D, Barnard‐Kelly K. Exercising with an automated insulin delivery system: qualitative insight into the hopes and expectations of people with type 1 diabetes. PRACTICAL DIABETES 2020. [DOI: 10.1002/pdi.2255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Sarah S Collard
- Faculty of Health and Social SciencesBournemouth University Bournemouth UK
| | - Pramod R Regmi
- Faculty of Health and Social SciencesBournemouth University Bournemouth UK
| | - Korey K Hood
- Department of Pediatrics, Psychiatry, and Behavioral SciencesStanford University School of Medicine Stanford California USA
| | - Lori Laffel
- Joslin Diabetes CenterHarvard Medical School Boston Massachusetts USA
| | - Jill Weissberg‐Benchell
- Department of Psychiatry and Behavioral Sciences, Ann & Robert H Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Diana Naranjo
- Department of Pediatrics, Psychiatry, and Behavioral SciencesStanford University School of Medicine Stanford California USA
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27
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Haidar A. Insulin-and-Glucagon Artificial Pancreas Versus Insulin-Alone Artificial Pancreas: A Short Review. Diabetes Spectr 2019; 32:215-221. [PMID: 31462876 PMCID: PMC6695257 DOI: 10.2337/ds18-0097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IN BRIEF The advantage of the insulin-and-glucagon artificial pancreas is based on the rapid effect of subcutaneous glucagon delivery in preventing hypoglycemia compared to suspension of insulin delivery. In short-term studies, the dual-hormone artificial pancreas reduced daytime hypoglycemia, especially during exercise, compared to the insulin-alone artificial pancreas, but the insulin-alone system seemed sufficient in eliminating nocturnal hypoglycemia. The comparative benefits of the single- and dual-hormone systems for improving A1C and preventing severe hypoglycemia remain unknown.
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Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
- Division of Endocrinology and Metabolism, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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28
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Hobbs N, Hajizadeh I, Rashid M, Turksoy K, Breton M, Cinar A. Improving Glucose Prediction Accuracy in Physically Active Adolescents With Type 1 Diabetes. J Diabetes Sci Technol 2019; 13:718-727. [PMID: 30654648 PMCID: PMC6610614 DOI: 10.1177/1932296818820550] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Physical activity presents a significant challenge for glycemic control in individuals with type 1 diabetes. As accurate glycemic predictions are key to successful automated decision-making systems (eg, artificial pancreas, AP), the inclusion of additional physiological variables in the estimation of the metabolic state may improve the glucose prediction accuracy during exercise. METHODS Predictor-based subspace identification is applied to a dynamic glucose prediction model including heart rate measurements along with variables representing the carbohydrate consumption and insulin boluses. To demonstrate the improvement in prediction ability due to the additional heart rate variable, the performance of the proposed modeling technique is evaluated with (SID-HR) and without heart rate (SID-2) as an additional input using experimental data involving adolescents at ski camp. Furthermore, the performance of the proposed approach is compared to that of the metabolic state observer (MSO) model currently used in the University of Virginia AP algorithm. RESULTS The addition of heart rate in the subspace-based model (SID-HR) yields a statistically significant improvement in the root-mean-square error compared to the SID-2 model (P < .001) and the standard MSO (P < .001). Furthermore, the SID-HR model performed favorably in comparison to the SID-2 and MSO models after accounting for its increased complexity. CONCLUSIONS Directly considering the effects of physical activity levels on glycemic dynamics through the inclusion of heart rate as an additional input variable in the glucose dynamics model improves the glucose prediction accuracy. The proposed methodology could improve exercise-informed model-based predictive control algorithms in artificial pancreas systems.
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Affiliation(s)
- Nicole Hobbs
- Department of Biomedical Engineering,
Illinois Institute of Technology, Chicago, IL, USA
| | - Iman Hajizadeh
- Department of Chemical Engineering,
Illinois Institute of Technology, Chicago, IL, USA
| | - Mudassir Rashid
- Department of Chemical Engineering,
Illinois Institute of Technology, Chicago, IL, USA
| | - Kamuran Turksoy
- Department of Biomedical Engineering,
Illinois Institute of Technology, Chicago, IL, USA
| | - Marc Breton
- Center for Diabetes Technology,
University of Virginia, Charlottesville, VA, USA
| | - Ali Cinar
- Department of Biomedical Engineering,
Illinois Institute of Technology, Chicago, IL, USA
- Department of Chemical Engineering,
Illinois Institute of Technology, Chicago, IL, USA
- Ali Cinar, PhD, Illinois Institute of
Technology, Department of Chemical and Biological Engineering, 10 W 33rd St,
Chicago, IL 60616, USA.
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29
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Musolino G, Allen JM, Hartnell S, Wilinska ME, Tauschmann M, Boughton C, Campbell F, Denvir L, Trevelyan N, Wadwa P, DiMeglio L, Buckingham BA, Weinzimer S, Acerini CL, Hood K, Fox S, Kollman C, Sibayan J, Borgman S, Cheng P, Hovorka R. Assessing the efficacy, safety and utility of 6-month day-and-night automated closed-loop insulin delivery under free-living conditions compared with insulin pump therapy in children and adolescents with type 1 diabetes: an open-label, multicentre, multinational, single-period, randomised, parallel group study protocol. BMJ Open 2019; 9:e027856. [PMID: 31164368 PMCID: PMC6561428 DOI: 10.1136/bmjopen-2018-027856] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Closed-loop systems titrate insulin based on sensor glucose levels, providing novel means to reduce the risk of hypoglycaemia while improving glycaemic control. We will assess effectiveness of 6-month day-and-night closed-loop insulin delivery compared with usual care (conventional or sensor-augmented pump therapy) in children and adolescents with type 1 diabetes. METHODS AND ANALYSIS The trial adopts an open-label, multicentre, multinational (UK and USA), randomised, single-period, parallel design. Participants (n=130) are children and adolescents (aged ≥6 and <19 years) with type 1 diabetes for at least 1 year, and insulin pump use for at least 3 months with suboptimal glycaemic control (glycated haemoglobin ≥58 mmol/mol (7.5%) and ≤86 mmol/mol (10%)). After a 2-3 week run-in period, participants will be randomised to 6-month use of hybrid closed-loop insulin delivery, or to usual care. Analyses will be conducted on an intention-to-treat basis. The primary outcome is glycated haemoglobin at 6 months. Other key endpoints include time in the target glucose range (3.9-10 mmol/L, 70-180 mg/dL), mean sensor glucose and time spent above and below target. Secondary outcomes include SD and coefficient of variation of sensor glucose levels, time with sensor glucose levels <3.5 mmol/L (63 mg/dL) and <3.0 mmol/L (54 mg/dL), area under the curve of glucose <3.5 mmol/L (63 mg/dL), time with glucose levels >16.7 mmol/L (300 mg/dL), area under the curve of glucose >10.0 mmol/L (180 mg/dL), total, basal and bolus insulin dose, body mass index z-score and blood pressure. Cognitive, emotional and behavioural characteristics of participants and caregivers and their responses to the closed-loop and clinical trial will be assessed. An incremental cost-effectiveness ratio for closed-loop will be estimated. ETHICS AND DISSEMINATION Cambridge South Research Ethics Committee and Jaeb Center for Health Research Institutional Review Office approved the study. The findings will be disseminated by peer-review publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02925299; Pre-results.
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Affiliation(s)
- Gianluca Musolino
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Sara Hartnell
- Department of Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Charlotte Boughton
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Fiona Campbell
- Department of Paediatric Diabetes, Leeds Children’s Hospital, Leeds, UK
| | - Louise Denvir
- Department of Paediatric Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nicola Trevelyan
- Department of Paediatric Endocrinology and Diabetes, Southampton Children’s Hospital, Southampton General Hospital, Southampton, UK
| | - Paul Wadwa
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Linda DiMeglio
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetology, Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bruce A Buckingham
- Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
| | - Stuart Weinzimer
- Department of Pediatrics, Yale University, New Haven, Connecticut, USA
| | - Carlo L Acerini
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Korey Hood
- Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
| | - Steven Fox
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Craig Kollman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Judy Sibayan
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Sarah Borgman
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Peiyao Cheng
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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30
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Karageorgiou V, Papaioannou TG, Bellos I, Alexandraki K, Tentolouris N, Stefanadis C, Chrousos GP, Tousoulis D. Effectiveness of artificial pancreas in the non-adult population: A systematic review and network meta-analysis. Metabolism 2019; 90:20-30. [PMID: 30321535 DOI: 10.1016/j.metabol.2018.10.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/20/2018] [Accepted: 10/09/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Artificial pancreas is a technology that minimizes user input by bridging continuous glucose monitoring and insulin pump treatment, and has proven safety in the adult population. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of closed-loop (CL) systems in the glycemic control of non-adult type 1 diabetes patients in both a pairwise and network meta-analysis (NMA) context and investigate various parameters potentially affecting the outcome. METHODS Literature was systematically searched using the MEDLINE (1966-2018), Scopus (2004-2018), Cochrane Central Register of Controlled Trials (CENTRAL) (1999-2018), Clinicaltrials.gov (2008-2018) and Google Scholar (2004-2018) databases. Studies comparing the glycemic control in CL (either single- or dual-hormone) with continuous subcutaneous insulin infusion (CSII) in people with diabetes (PWD) aged <18 years old were deemed eligible. The primary outcome analysis was conducted with regard to time spent in the target glycemic range. All outcomes were evaluated in NMA in order to investigate potential between-algorithm differences. Pairwise meta-analysis and meta-regression were performed using the RevMan 5.3 and Open Meta-Analyst software. For NMA, the package pcnetmetain R 3.5.1 was used. RESULTS The meta-analysis was based on 25 studies with a total of 504 PWD. The CL group was associated with significantly higher percentage of time spent in the target glycemic range (Mean (SD): 67.59% (SD: 8.07%) in the target range and OL PWD spending 55.77% (SD: 11.73%), MD: -11.97%, 95% CI [-18.40, -5.54%]) and with lower percentages of time in hyperglycemia (MD: 3.01%, 95% CI [1.68, 4.34%]) and hypoglycemia (MD: 0.67%, 95% CI [0.21, 1.13%]. Mean glucose was also decreased in the CL group (MD: 0.75 mmol/L, 95% CI [0.18-1.33]). The NMA arm of the study showed that the bihormonal modality was superior to other algorithms and standard treatment in lowering mean glucose and increasing time spent in the target range. The DiAs platform was superior to PID in controlling hypoglycemia and mean glucose. Time in target range and mean glucose were unaffected by the confounding factors tested. CONCLUSIONS The findings of this meta-analysis suggest that artificial pancreas systems are superior to the standard sensor-augmented pump treatment of type 1 diabetes mellitus in non-adult PWD. Between-algorithm differences are also addressed, implying a superiority of the bihormonal treatment modality. Future large-scale studies are needed in the field to verify these outcomes and to determine the optimal algorithm to be used in the clinical setting.
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Affiliation(s)
- Vasilios Karageorgiou
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros G Papaioannou
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - Ioannis Bellos
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Krystallenia Alexandraki
- Clinic of Endocrine Oncology, Section of Endocrinology, Department of Pathophysiology, Laiko Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - George P Chrousos
- First Department of Pediatrics, Aghia Sophia Children's Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Biomedical Engineering Unit, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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31
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Beneyto A, Vehi J. Postprandial fuzzy adaptive strategy for a hybrid proportional derivative controller for the artificial pancreas. Med Biol Eng Comput 2018; 56:1973-1986. [PMID: 29725915 DOI: 10.1007/s11517-018-1832-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 04/19/2018] [Indexed: 11/24/2022]
Abstract
This paper presents a support fuzzy adaptive system for a hybrid proportional derivative controller that will refine its parameters during postprandial periods to enhance performance. Even though glucose controllers have improved over the last decade, tuning them and keeping them tuned are still major challenges. Changes in a patient's lifestyle, stress, exercise, or other activities may modify their blood glucose system, making it necessary to retune or change the insulin dosing algorithm. This paper presents a strategy to adjust the parameters of a proportional derivative controller using the so-called safety auxiliary feedback element loop for type 1 diabetic patients. The main parameters, such as the insulin on board limit and proportional gain are tuned using postprandial performance indexes and the information given by the controller itself. The adaptive and robust performance of the control algorithm was assessed "in silico" on a cohort of virtual patients under challenging realistic scenarios considering mixed meals, circadian variations, time-varying uncertainties, sensor errors, and other disturbances. The results showed that an adaptive strategy can significantly improve the performance of postprandial glucose control, individualizing the tuning by directly taking into account the intra-patient variability of type 1 patients. Graphical Abstract title: Postprandial glycaemia improvement via fuzzy adaptive control A fuzzy inference engine was implemented within a clinically tested artificial pancreas control system. The aim of the fuzzy system was to adapt controller parameters to improve postprandial blood glucose control while ensuring safety. Results show a significant improvement over time of the postprandial glucose response due to the adaptation, thus demonstrating the usefulness of the fuzzy adaptive system.
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Affiliation(s)
- Aleix Beneyto
- Institut d'Informàtica i Aplicacions, Universitat de Girona, Campus de Montilivi, s/n, Edifici P4, 17071, Girona, Spain
| | - Josep Vehi
- Institut d'Informàtica i Aplicacions, Universitat de Girona, Campus de Montilivi, s/n, Edifici P4, 17071, Girona, Spain. .,CIBERDEM, Girona, Spain.
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32
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Turksoy K, Hajizadeh I, Hobbs N, Kilkus J, Littlejohn E, Samadi S, Feng J, Sevil M, Lazaro C, Ritthaler J, Hibner B, Devine N, Quinn L, Cinar A. Multivariable Artificial Pancreas for Various Exercise Types and Intensities. Diabetes Technol Ther 2018; 20:662-671. [PMID: 30188192 PMCID: PMC6161329 DOI: 10.1089/dia.2018.0072] [Citation(s) in RCA: 36] [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: 11/12/2022]
Abstract
BACKGROUND Exercise challenges people with type 1 diabetes in controlling their glucose concentration (GC). A multivariable adaptive artificial pancreas (MAAP) may lessen the burden. METHODS The MAAP operates without any user input and computes insulin based on continuous glucose monitor and physical activity signals. To analyze performance, 18 60-h closed-loop experiments with 96 exercise sessions with three different protocols were completed. Each day, the subjects completed one resistance and one treadmill exercise (moderate continuous training [MCT] or high-intensity interval training [HIIT]). The primary outcome is time spent in each glycemic range during the exercise + recovery period. Secondary measures include average GC and average change in GC during each exercise modality. RESULTS The GC during exercise + recovery periods were within the euglycemic range (70-180 mg/dL) for 69.9% of the time and within a safe glycemic range for exercise (70-250 mg/dL) for 93.0% of the time. The exercise sessions are defined to begin 30 min before the start of exercise and end 2 h after start of exercise. The GC were within the severe hypoglycemia (<55 mg/dL), moderate hypoglycemia (55-70 mg/dL), moderate hyperglycemia (180-250 mg/dL), and severe hyperglycemia (>250 mg/dL) for 0.9%, 1.3%, 23.1%, and 4.8% of the time, respectively. The average GC decline during exercise differed with exercise type (P = 0.0097) with a significant difference between the MCT and resistance (P = 0.0075). To prevent large GC decreases leading to hypoglycemia, MAAP recommended carbohydrates in 59% of MCT, 50% of HIIT, and 39% of resistance sessions. CONCLUSIONS A consistent GC decline occurred in exercise and recovery periods, which differed with exercise type. The average GC at the start of exercise was above target (185.5 ± 56.6 mg/dL for MCT, 166.9 ± 61.9 mg/dL for resistance training, and 171.7 ± 41.4 mg/dL HIIT), making a small decrease desirable. Hypoglycemic events occurred in 14.6% of exercise sessions and represented only 2.22% of the exercise and recovery period.
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Affiliation(s)
- Kamuran Turksoy
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Iman Hajizadeh
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Nicole Hobbs
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Jennifer Kilkus
- Section of Endocrinology, Department of Pediatrics and Medicine, Kovler Diabetes Center, University of Chicago, Chicago, Illinois
| | - Elizabeth Littlejohn
- Section of Endocrinology, Department of Pediatrics and Medicine, Kovler Diabetes Center, University of Chicago, Chicago, Illinois
- Sparrow Medical Group/Michigan State University, Lansing, Michigan
| | - Sediqeh Samadi
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Jianyuan Feng
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Mert Sevil
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Caterina Lazaro
- Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago, Illinois
| | - Julia Ritthaler
- Division of Biological Sciences, University of Chicago, Chicago, Illinois
| | - Brooks Hibner
- Division of Biological Sciences, University of Chicago, Chicago, Illinois
| | - Nancy Devine
- Section of Endocrinology, Department of Pediatrics and Medicine, Kovler Diabetes Center, University of Chicago, Chicago, Illinois
| | - Laurie Quinn
- College of Nursing, University of Illinois at Chicago, Chicago, Illinois
| | - Ali Cinar
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, Illinois
- Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, Illinois
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Danne T, Phillip M, Buckingham BA, Jarosz-Chobot P, Saboo B, Urakami T, Battelino T, Hanas R, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Insulin treatment in children and adolescents with diabetes. Pediatr Diabetes 2018; 19 Suppl 27:115-135. [PMID: 29999222 DOI: 10.1111/pedi.12718] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/01/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Thomas Danne
- Kinder- und Jugendkrankenhaus AUF DER BULT, Diabetes-Zentrum für Kinder und Judendliche, Hannover, Germany
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Bruce A Buckingham
- Department of Pediatric Endocrinology, Stanford University, Stanford, California
| | | | - Banshi Saboo
- Department of Endocrinology, DiaCare - Advance Diabetes Care Center, Ahmedabad, India
| | - Tatsuhiko Urakami
- Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
| | - Tadej Battelino
- Department Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Ethel Codner
- Institute of Maternal and Child Research (IDMI), School of Medicine, University de Chile, Santiago, Chile
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Esposito S, Santi E, Mancini G, Rogari F, Tascini G, Toni G, Argentiero A, Berioli MG. Efficacy and safety of the artificial pancreas in the paediatric population with type 1 diabetes. J Transl Med 2018; 16:176. [PMID: 29954380 PMCID: PMC6022450 DOI: 10.1186/s12967-018-1558-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Type 1 diabetes (DM1) is one of the most common chronic diseases in childhood and requires life-long insulin therapy and continuous health care support. An artificial pancreas (AP) or closed-loop system (CLS) have been developed with the aim of improving metabolic control without increasing the risk of hypoglycaemia in patients with DM1. As the impact of APs have been studied mainly in adults, the aim of this review is to evaluate the efficacy and safety of the AP in the paediatric population with DM1. MAIN BODY The real advantage of a CLS compared to last-generation sensor-augmented pumps is the gradual modulation of basal insulin infusion in response to glycaemic variations (towards both hyperglycaemia and hypoglycaemia), which has the aim of improving the proportion of time spent in the target glucose range and reducing the mean glucose level without increasing the risk of hypoglycaemia. Some recent studies demonstrated that also in children and adolescents an AP is able to reduce the frequency of hypoglycaemic events, an important limiting factor in reaching good metabolic control, particularly overnight. However, the advantages of the AP in reducing hyperglycaemia, increasing the time spent in the target glycaemic range and thus reducing glycated haemoglobin are less clear and require more clinical trials in the paediatric population, in particular in younger children. CONCLUSIONS Although the first results from bi-hormonal CLS are promising, long-term, head-to-head studies will have to prove their superiority over insulin-only approaches. More technological progress, the availability of more fast-acting insulin, further developments of algorithms that could improve glycaemic control after meals and physical activity are the most important challenges in reaching an optimal metabolic control with the use of the AP in children and adolescents.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy.
| | - Elisa Santi
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Giulia Mancini
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Francesco Rogari
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Giorgia Tascini
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Giada Toni
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Alberto Argentiero
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Maria Giulia Berioli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
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Peters TM, Haidar A. Dual-hormone artificial pancreas: benefits and limitations compared with single-hormone systems. Diabet Med 2018; 35:450-459. [PMID: 29337384 DOI: 10.1111/dme.13581] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 12/17/2022]
Abstract
Technological advances have made the artificial pancreas a reality. This has the potential to improve the lives of individuals with Type 1 diabetes by reducing the risk of hypoglycaemia, achieving better overall glucose control, and enhancing quality of life. Both single-hormone (insulin-only) and dual-hormone (insulin and glucagon) systems have been developed; however, a focused review of the relative benefits of each artificial pancreas system is needed. We reviewed studies that directly compared single- and dual-hormone systems to evaluate the efficacy of each system for preventing hypoglycaemia and maintaining glycaemic control, as well as their utility in specific situations including during exercise, overnight and during the prandial period. We observed additional benefits with the dual-hormone artificial pancreas for reducing the risk of hypoglycaemic events overall and during exercise over the study duration. The single-hormone artificial pancreas was sufficient for maintenance of euglycaemia in the overnight period and for preventing late-onset post-exercise hypoglycaemia. Future comparative studies of longer duration are required to determine whether one system is superior for improving mean glucose control, eliminating severe hypoglycaemia, or improving quality of life.
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Affiliation(s)
- T M Peters
- Division of Endocrinology and Metabolism, Faculty of Medicine
| | - A Haidar
- Division of Endocrinology and Metabolism, Faculty of Medicine
- Department of Biomedical Engineering, McGill University
- The Research Institute of the McGill University Health Centre, Montreal, Canada
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36
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Dovc K, Macedoni M, Bratina N, Lepej D, Nimri R, Atlas E, Muller I, Kordonouri O, Biester T, Danne T, Phillip M, Battelino T. Closed-loop glucose control in young people with type 1 diabetes during and after unannounced physical activity: a randomised controlled crossover trial. Diabetologia 2017; 60:2157-2167. [PMID: 28840263 PMCID: PMC6448906 DOI: 10.1007/s00125-017-4395-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/27/2017] [Indexed: 11/21/2022]
Abstract
AIMS/HYPOTHESIS Hypoglycaemia during and after exercise remains a challenge. The present study evaluated the safety and efficacy of closed-loop insulin delivery during unannounced (to the closed-loop algorithm) afternoon physical activity and during the following night in young people with type 1 diabetes. METHODS A randomised, two-arm, open-label, in-hospital, crossover clinical trial was performed at a single site in Slovenia. The order was randomly determined using an automated web-based programme with randomly permuted blocks of four. Allocation assignment was not masked. Children and adolescents with type 1 diabetes who were experienced insulin pump users were eligible for the trial. During four separate in-hospital visits, the participants performed two unannounced exercise protocols: moderate intensity (55% of [Formula: see text]) and moderate intensity with integrated high-intensity sprints (55/80% of [Formula: see text]), using the same study device either for closed-loop or open-loop insulin delivery. We investigated glycaemic control during the exercise period and the following night. The closed-loop insulin delivery was applied from 15:00 h on the day of the exercise to 13:00 h on the following day. RESULTS Between 20 January and 16 June 2016, 20 eligible participants (9 female, mean age 14.2 ± 2.0 years, HbA1c 7.7 ± 0.6% [60.0 ± 6.6 mmol/mol]) were included in the trial and performed all trial-mandated activities. The median proportion of time spent in hypoglycaemia below 3.3 mmol/l was 0.00% for both treatment modalities (p = 0.7910). Use of the closed-loop insulin delivery system increased the proportion of time spent within the target glucose range of 3.9-10 mmol/l when compared with open-loop delivery: 84.1% (interquartile range 70.0-85.5) vs 68.7% (59.0-77.7), respectively (p = 0.0057), over the entire study period. This was achieved with significantly less insulin delivered via the closed-loop (p = 0.0123). CONCLUSIONS/INTERPRETATION Closed-loop insulin delivery was safe both during and after unannounced exercise protocols in the in-hospital environment, maintaining glucose values mostly within the target range without an increased risk of hypoglycaemia. TRIAL REGISTRATION Clinicaltrials.gov NCT02657083 FUNDING: University Medical Centre Ljubljana, Slovenian National Research Agency, and ISPAD Research Fellowship.
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Affiliation(s)
- Klemen Dovc
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, SI-1000, Ljubljana, Slovenia
| | - Maddalena Macedoni
- Department of Paediatrics-Diabetes Service Studies, University of Milan, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - Natasa Bratina
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, SI-1000, Ljubljana, Slovenia
| | - Dusanka Lepej
- Department of Pulmonology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Revital Nimri
- The Jesse and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Centre for Childhood Diabetes, Schneider Children's Medical Centre of Israel, Petah Tikva, Israel
| | - Eran Atlas
- DreaMed Diabetes Ltd, Petah Tikva, Israel
| | - Ido Muller
- DreaMed Diabetes Ltd, Petah Tikva, Israel
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Torben Biester
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Moshe Phillip
- The Jesse and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Centre for Childhood Diabetes, Schneider Children's Medical Centre of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tadej Battelino
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Bohoriceva 20, SI-1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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DeBoer MD, Cherñavvsky DR, Topchyan K, Kovatchev BP, Francis GL, Breton MD. Heart rate informed artificial pancreas system enhances glycemic control during exercise in adolescents with T1D. Pediatr Diabetes 2017; 18:540-546. [PMID: 27734563 DOI: 10.1111/pedi.12454] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the safety and performance of using a heart rate (HR) monitor to inform an artificial pancreas (AP) system during exercise among adolescents with type 1 diabetes (T1D). MATERIALS AND METHODS In a randomized, cross-over trial, adolescents with T1D age 13 - 18 years were enrolled to receive on separate days either the unmodified UVa AP (stdAP) or an AP system connected to a portable HR monitor (AP-HR) that triggered an exercise algorithm for blood glucose (BG) control. During admissions participants underwent a structured exercise regimen. Hypoglycemic events and CGM tracings were compared between the two admissions, during exercise and for the full 24-hour period. RESULTS Eighteen participants completed the trial. While number of hypoglycemic events during exercise and rest was not different between visits (0.39 AP-HR vs 0.50 stdAP), time below 70 mg dL -1 was lower on AP-HR compared to stdAP, 0.5±2.1% vs 7.4±12.5% (P = 0.028). Time with BG within 70-180 mg dL -1 was higher for the AP-HR admission vs stdAP during the exercise portion and overall (96% vs 87%, and 77% vs 74%), but these did not reach statistical significance (P = 0.075 and P = 0.366). CONCLUSIONS Heart rate signals can safely and efficaciously be integrated in a wireless AP system to inform of physical activity. While exercise contributes to hypoglycemia among adolescents, even when using an AP system, informing the system of exercise via a HR monitor improved time <70 mg dL -1 . Nonetheless, it did not significantly reduce the total number of hypoglycemic events, which were low in both groups.
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Affiliation(s)
- Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia.,Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Daniel R Cherñavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Katarina Topchyan
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Boris P Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Gary L Francis
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia.,Division of Pediatric Endocrinology, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
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Guilhem I, Penet M, Paillard A, Carpentier M, Esvant A, Lefebvre MA, Poirier JY. Manual Closed-Loop Insulin Delivery Using a Saddle Point Model Predictive Control Algorithm: Results of a Crossover Randomized Overnight Study. J Diabetes Sci Technol 2017; 11:1007-1014. [PMID: 28677416 PMCID: PMC5951001 DOI: 10.1177/1932296817717503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose was to assess the efficacy of a new closed-loop algorithm (Saddle Point Model Predictive Control, SP-MPC) in achieving nocturnal normoglycemia while reducing the risk of hypoglycemia in patients with type 1 diabetes. METHOD In this randomized crossover study, 10 adult patients (mean hemoglobin A1c 7.35 ± 1.04%) were assigned to be treated overnight by open loop using sensor-augmented pump therapy (open-loop SAP) or manual closed-loop delivery. During closed loop, insulin doses were calculated using the SP-MPC algorithm and administered as manual boluses every 15 minutes from 9:00 pm to 8:00 am. Patients consumed a self-selected meal (65-125 g of carbohydrates) at 7:00 pm accompanied by their usual prandial bolus. Blood glucose was measured every 30 minutes. The primary endpoints were the time spent in target (70-145 mg/dl) and time spent below 70 mg/dl from 11:00 pm to 8:00 am. RESULTS Time spent in target did not differ between closed-loop and open-loop SAP. The number of hypoglycemic events (<70 mg/dl) was reduced 2.8-fold in closed loop (n = 5, median = 0/patient/hour; interquartile range: 0-0.11) as compared to open-loop SAP (n = 14, median = 0.22/patient/hour, 0.02-0.22) ( P = .02). The area under the curve for sensor glucose values >145 mg/dl was significantly lower during closed-loop than during open-loop SAP ( P = .03) as well as HBGI ( P = .02). CONCLUSIONS This pilot study suggests that the use of the SP-MPC algorithm may improve mean overnight glucose control and reduce the number of hypoglycemic events as compared to SAP therapy.
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Affiliation(s)
- Isabelle Guilhem
- CHU de Rennes, Department of Endocrinology, Diabetes and Nutrition, Rennes, France
- CHU de Rennes, CIC INSERM 1414, Rennes, France
- Isabelle Guilhem, MD, MSc, service d’Endocrinologie-Diabétologie-Nutrition, CHU de Rennes, hôpital sud, 16 boulevard de Bulgarie, 35203 Rennes cedex, France.
| | - Maxime Penet
- CentraleSupélec/I.E.T.R, Hybrid System Control Team, Cesson-Sévigné, France
| | - Anaïs Paillard
- CHU de Rennes, Department of Endocrinology, Diabetes and Nutrition, Rennes, France
- CHU de Rennes, CIC INSERM 1414, Rennes, France
| | - Marc Carpentier
- CHU de Rennes, Département d’Information Médicale, Rennes, France
| | - Annabelle Esvant
- CHU de Rennes, Department of Endocrinology, Diabetes and Nutrition, Rennes, France
- CHU de Rennes, CIC INSERM 1414, Rennes, France
| | | | - Jean-Yves Poirier
- CHU de Rennes, Department of Endocrinology, Diabetes and Nutrition, Rennes, France
- CHU de Rennes, CIC INSERM 1414, Rennes, France
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Ly TT, Weinzimer SA, Maahs DM, Sherr JL, Roy A, Grosman B, Cantwell M, Kurtz N, Carria L, Messer L, von Eyben R, Buckingham BA. Automated hybrid closed-loop control with a proportional-integral-derivative based system in adolescents and adults with type 1 diabetes: individualizing settings for optimal performance. Pediatr Diabetes 2017; 18:348-355. [PMID: 27191182 DOI: 10.1111/pedi.12399] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/06/2016] [Accepted: 04/22/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Automated insulin delivery systems, utilizing a control algorithm to dose insulin based upon subcutaneous continuous glucose sensor values and insulin pump therapy, will soon be available for commercial use. The objective of this study was to determine the preliminary safety and efficacy of initialization parameters with the Medtronic hybrid closed-loop controller by comparing percentage of time in range, 70-180 mg/dL (3.9-10 mmol/L), mean glucose values, as well as percentage of time above and below target range between sensor-augmented pump therapy and hybrid closed-loop, in adults and adolescents with type 1 diabetes. METHODS We studied an initial cohort of 9 adults followed by a second cohort of 15 adolescents, using the Medtronic hybrid closed-loop system with the proportional-integral-derivative with insulin feed-back (PID-IFB) algorithm. Hybrid closed-loop was tested in supervised hotel-based studies over 4-5 days. RESULTS The overall mean percentage of time in range (70-180 mg/dL, 3.9-10 mmol/L) during hybrid closed-loop was 71.8% in the adult cohort and 69.8% in the adolescent cohort. The overall percentage of time spent under 70 mg/dL (3.9 mmol/L) was 2.0% in the adult cohort and 2.5% in the adolescent cohort. Mean glucose values were 152 mg/dL (8.4 mmol/L) in the adult cohort and 153 mg/dL (8.5 mmol/L) in the adolescent cohort. CONCLUSIONS Closed-loop control using the Medtronic hybrid closed-loop system enables adaptive, real-time basal rate modulation. Initializing hybrid closed-loop in clinical practice will involve individualizing initiation parameters to optimize overall glucose control.
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Affiliation(s)
- Trang T Ly
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA.,School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - David M Maahs
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Jennifer L Sherr
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | | | | - Lori Carria
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Laurel Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Rie von Eyben
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA
| | - Bruce A Buckingham
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA
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40
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Weisman A, Bai JW, Cardinez M, Kramer CK, Perkins BA. Effect of artificial pancreas systems on glycaemic control in patients with type 1 diabetes: a systematic review and meta-analysis of outpatient randomised controlled trials. Lancet Diabetes Endocrinol 2017; 5:501-512. [PMID: 28533136 DOI: 10.1016/s2213-8587(17)30167-5] [Citation(s) in RCA: 304] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/11/2017] [Accepted: 04/11/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Closed-loop artificial pancreas systems have been in development for several years, including assessment in numerous varied outpatient clinical trials. We aimed to summarise the efficacy and safety of artificial pancreas systems in outpatient settings and explore the clinical and technical factors that can affect their performance. METHODS We did a systematic review and meta-analysis of randomised controlled trials comparing artificial pancreas systems (insulin only or insulin plus glucagon) with conventional pump therapy (continuous subcutaneous insulin infusion [CSII] with blinded continuous glucose monitoring [CGM] or unblinded sensor-augmented pump [SAP] therapy) in adults and children with type 1 diabetes. We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies published from 1946, to Jan 1, 2017. We excluded studies not published in English, those involving pregnant women or participants who were in hospital, and those testing adjunct medications other than glucagon. The primary outcome was the mean difference in percentage of time blood glucose concentration remained in target range (3·9-10 mmol/L or 3·9-8 mmol/L, depending on the study), assessed by random-effects meta-analysis. This study is registered with PROSPERO, number 2015:CRD42015026854. FINDINGS We identified 984 reports; after exclusions, 27 comparisons from 24 studies (23 crossover and one parallel design) including a total of 585 participants (219 in adult studies, 265 in paediatric studies, and 101 in combined studies) were eligible for analysis. Five comparisons assessed dual-hormone (insulin and glucagon), two comparisons assessed both dual-hormone and single-hormone (insulin only), and 20 comparisons assessed single-hormone artificial pancreas systems. Time in target was 12·59% higher with artificial pancreas systems (95% CI 9·02-16·16; p<0·0001), from a weighted mean of 58·21% for conventional pump therapy (I2=84%). Dual-hormone artificial pancreas systems were associated with a greater improvement in time in target range compared with single-hormone systems (19·52% [95% CI 15·12-23·91] vs 11·06% [6·94 to 15·18]; p=0·006), although six of seven comparisons compared dual-hormone systems to CSII with blinded CGM, whereas 21 of 22 single-hormone comparisons had SAP as the comparator. Single-hormone studies had higher heterogeneity than dual-hormone studies (I2 79% vs 66%). Bias assessment characteristics were incompletely reported in 12 of 24 studies, no studies masked participants to the intervention assignment, and masking of outcome assessment was not done in 12 studies and was unclear in 12 studies. INTERPRETATION Artificial pancreas systems uniformly improved glucose control in outpatient settings, despite heterogeneous clinical and technical factors. FUNDING None.
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Affiliation(s)
- Alanna Weisman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Johnny-Wei Bai
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Marina Cardinez
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Caroline K Kramer
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Turksoy K, Frantz N, Quinn L, Dumin M, Kilkus J, Hibner B, Cinar A, Littlejohn E. Automated Insulin Delivery-The Light at the End of the Tunnel. J Pediatr 2017; 186:17-28.e9. [PMID: 28396030 DOI: 10.1016/j.jpeds.2017.02.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 02/13/2017] [Accepted: 02/20/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Kamuran Turksoy
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL
| | - Nicole Frantz
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL
| | - Laurie Quinn
- College of Nursing, University of Illinois at Chicago, Chicago, IL
| | - Magdalena Dumin
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Jennifer Kilkus
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Brooks Hibner
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Ali Cinar
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL; Biological Sciences Division, University of Chicago, Chicago, IL; Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL
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Use of Wearable Sensors and Biometric Variables in an Artificial Pancreas System. SENSORS 2017; 17:s17030532. [PMID: 28272368 PMCID: PMC5375818 DOI: 10.3390/s17030532] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 03/02/2017] [Accepted: 03/03/2017] [Indexed: 01/26/2023]
Abstract
An artificial pancreas (AP) computes the optimal insulin dose to be infused through an insulin pump in people with Type 1 Diabetes (T1D) based on information received from a continuous glucose monitoring (CGM) sensor. It has been recognized that exercise is a major challenge in the development of an AP system. The use of biometric physiological variables in an AP system may be beneficial for prevention of exercise-induced challenges and better glucose regulation. The goal of the present study is to find a correlation between biometric variables such as heart rate (HR), heat flux (HF), skin temperature (ST), near-body temperature (NBT), galvanic skin response (GSR), and energy expenditure (EE), 2D acceleration-mean of absolute difference (MAD) and changes in glucose concentrations during exercise via partial least squares (PLS) regression and variable importance in projection (VIP) in order to determine which variables would be most useful to include in a future artificial pancreas. PLS and VIP analyses were performed on data sets that included seven different types of exercises. Data were collected from 26 clinical experiments. Clinical results indicate ST to be the most consistently important (important for six out of seven tested exercises) variable over all different exercises tested. EE and HR are also found to be important variables over several types of exercise. We also found that the importance of GSR and NBT observed in our experiments might be related to stress and the effect of changes in environmental temperature on glucose concentrations. The use of the biometric measurements in an AP system may provide better control of glucose concentration.
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Spaic T, Driscoll M, Raghinaru D, Buckingham BA, Wilson DM, Clinton P, Chase HP, Maahs DM, Forlenza GP, Jost E, Hramiak I, Paul T, Bequette BW, Cameron F, Beck RW, Kollman C, Lum JW, Ly TT. Predictive Hyperglycemia and Hypoglycemia Minimization: In-Home Evaluation of Safety, Feasibility, and Efficacy in Overnight Glucose Control in Type 1 Diabetes. Diabetes Care 2017; 40:359-366. [PMID: 28100606 PMCID: PMC5319476 DOI: 10.2337/dc16-1794] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/22/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to determine the safety, feasibility, and efficacy of a predictive hyperglycemia and hypoglycemia minimization (PHHM) system compared with predictive low-glucose insulin suspension (PLGS) alone in overnight glucose control. RESEARCH DESIGN AND METHODS A 42-night trial was conducted in 30 individuals with type 1 diabetes in the age range 15-45 years. Participants were randomly assigned each night to either PHHM or PLGS and were blinded to the assignment. The system suspended the insulin pump on both the PHHM and PLGS nights for predicted hypoglycemia but delivered correction boluses for predicted hyperglycemia on PHHM nights only. The primary outcome was the percentage of time spent in a sensor glucose range of 70-180 mg/dL during the overnight period. RESULTS The addition of automated insulin delivery with PHHM increased the time spent in the target range (70-180 mg/dL) from 71 ± 10% during PLGS nights to 78 ± 10% during PHHM nights (P < 0.001). The average morning blood glucose concentration improved from 163 ± 23 mg/dL after PLGS nights to 142 ± 18 mg/dL after PHHM nights (P < 0.001). Various sensor-measured hypoglycemic outcomes were similar on PLGS and PHHM nights. All participants completed 42 nights with no episodes of severe hypoglycemia, diabetic ketoacidosis, or other study- or device-related adverse events. CONCLUSIONS The addition of a predictive hyperglycemia minimization component to our existing PLGS system was shown to be safe, feasible, and effective in overnight glucose control.
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Affiliation(s)
- Tamara Spaic
- St. Joseph's Health Care London, London, Ontario, Canada
| | | | | | - Bruce A Buckingham
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - Darrell M Wilson
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - Paula Clinton
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - H Peter Chase
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA.,Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Gregory P Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Emily Jost
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Irene Hramiak
- St. Joseph's Health Care London, London, Ontario, Canada
| | - Terri Paul
- St. Joseph's Health Care London, London, Ontario, Canada
| | | | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
| | | | - John W Lum
- Jaeb Center for Health Research, Tampa, FL
| | - Trang T Ly
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
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Taleb N, Emami A, Suppere C, Messier V, Legault L, Ladouceur M, Chiasson JL, Haidar A, Rabasa-Lhoret R. Efficacy of single-hormone and dual-hormone artificial pancreas during continuous and interval exercise in adult patients with type 1 diabetes: randomised controlled crossover trial. Diabetologia 2016; 59:2561-2571. [PMID: 27704167 DOI: 10.1007/s00125-016-4107-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/16/2016] [Indexed: 01/26/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to assess whether the dual-hormone (insulin and glucagon) artificial pancreas reduces hypoglycaemia compared with the single-hormone (insulin alone) artificial pancreas during two types of exercise. METHODS An open-label randomised crossover study comparing both systems in 17 adults with type 1 diabetes (age, 37.2 ± 13.6 years; HbA1c, 8.0 ± 1.0% [63.9 ± 10.2 mmol/mol]) during two exercise types on an ergocycle and matched for energy expenditure: continuous (60% [Formula: see text] for 60 min) and interval (2 min alternating periods at 85% and 50% [Formula: see text] for 40 min, with two 10 min periods at 45% [Formula: see text] at the start and end of the session). Blocked randomisation (size of four) with a 1:1:1:1 allocation ratio was computer generated. The artificial pancreas was applied from 15:30 hours until 19:30 hours; exercise was started at 18:00 hours and announced 20 min earlier to the systems. The study was conducted at the Institut de recherches cliniques de Montréal. RESULTS During single-hormone control compared with dual-hormone control, exercise-induced hypoglycaemia (plasma glucose <3.3 mmol/l with symptoms or <3.0 mmol/l regardless of symptoms) was observed in four (23.5%) vs two (11.8%) interventions (p = 0.5) for continuous exercise and in six (40%) vs one (6.25%) intervention (p = 0.07) for interval exercise. For the pooled analysis (single vs dual hormone), the median (interquartile range) percentage time spent at glucose levels below 4.0 mmol/l was 11% (0.0-46.7%) vs 0% (0-0%; p = 0.0001) and at glucose levels between 4.0 and 10.0 mmol/l was 71.4% (53.2-100%) vs 100% (100-100%; p = 0.003). Higher doses of glucagon were needed during continuous (0.126 ± 0.057 mg) than during interval exercise (0.093 ± 0.068 mg) (p = 0.03), with no reported side-effects in all interventions. CONCLUSIONS/INTERPRETATION The dual-hormone artificial pancreas outperformed the single-hormone artificial pancreas in regulating glucose levels during announced exercise in adults with type 1 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT01930110 FUNDING: : Société Francophone du Diabète and Diabète Québec.
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Affiliation(s)
- Nadine Taleb
- Institut de recherches cliniques de Montréal, 110 Avenue des Pins Ouest, Montréal, Québec, Canada, H2W 1R7
- Division of Biomedical Sciences, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Ali Emami
- Institut de recherches cliniques de Montréal, 110 Avenue des Pins Ouest, Montréal, Québec, Canada, H2W 1R7
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Corinne Suppere
- Institut de recherches cliniques de Montréal, 110 Avenue des Pins Ouest, Montréal, Québec, Canada, H2W 1R7
| | - Virginie Messier
- Institut de recherches cliniques de Montréal, 110 Avenue des Pins Ouest, Montréal, Québec, Canada, H2W 1R7
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Martin Ladouceur
- Centre de recherche du Centre hospitalier de l'université de Montréal (CRCHUM), Montréal, Québec, Canada
| | - Jean-Louis Chiasson
- Centre de recherche du Centre hospitalier de l'université de Montréal (CRCHUM), Montréal, Québec, Canada
- Montreal Diabetes Research Center, Montréal, Québec, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, Faculty of Medicine, McGill University, Montréal, Québec, Canada
- Division of Endocrinology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de recherches cliniques de Montréal, 110 Avenue des Pins Ouest, Montréal, Québec, Canada, H2W 1R7.
- Montreal Diabetes Research Center, Montréal, Québec, Canada.
- Nutrition department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada.
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Tauschmann M, Allen JM, Wilinska ME, Thabit H, Acerini CL, Dunger DB, Hovorka R. Home Use of Day-and-Night Hybrid Closed-Loop Insulin Delivery in Suboptimally Controlled Adolescents With Type 1 Diabetes: A 3-Week, Free-Living, Randomized Crossover Trial. Diabetes Care 2016; 39:2019-2025. [PMID: 27612500 PMCID: PMC5079605 DOI: 10.2337/dc16-1094] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/18/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study evaluated the feasibility, safety, and efficacy of day-and-night hybrid closed-loop insulin delivery in adolescents with type 1 diabetes under free-living conditions. RESEARCH DESIGN AND METHODS In an open-label randomized crossover study, 12 suboptimally controlled adolescents on insulin pump therapy (mean ± SD age 14.6 ± 3.1 years; HbA1c 69 ± 8 mmol/mol [8.5 ± 0.7%]; duration of diabetes 7.8 ± 3.5 years) underwent two 21-day periods in which hybrid closed-loop insulin delivery was compared with sensor-augmented insulin pump therapy in random order. During the closed-loop intervention, a model predictive algorithm automatically directed insulin delivery between meals and overnight. Participants used a bolus calculator to administer prandial boluses. RESULTS The proportion of time that sensor glucose was in the target range (3.9-10 mmol/L; primary end point) was increased during the closed-loop intervention compared with sensor-augmented insulin pump therapy by 18.8 ± 9.8 percentage points (mean ± SD; P < 0.001), the mean sensor glucose level was reduced by 1.8 ± 1.3 mmol/L (P = 0.001), and the time spent above target was reduced by 19.3 ± 11.3 percentage points (P < 0.001). The time spent with sensor glucose levels below 3.9 mmol/L was low and comparable between interventions (median difference 0.4 [interquartile range -2.2 to 1.3] percentage points; P = 0.33). Improved glucose control during closed-loop was associated with increased variability of basal insulin delivery (P < 0.001) and an increase in the total daily insulin dose (53.5 [39.5-72.1] vs. 51.5 [37.6-64.3] units/day; P = 0.006). Participants expressed positive attitudes and experience with the closed-loop system. CONCLUSIONS Free-living home use of day-and-night closed-loop in suboptimally controlled adolescents with type 1 diabetes is safe, feasible, and improves glucose control without increasing the risk of hypoglycemia. Larger and longer studies are warranted.
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Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Janet M Allen
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Malgorzata E Wilinska
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - David B Dunger
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K. .,Department of Paediatrics, University of Cambridge, Cambridge, U.K
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Evaluation of a minimally invasive glucose biosensor for continuous tissue monitoring. Anal Bioanal Chem 2016; 408:8427-8435. [PMID: 27744480 PMCID: PMC5116314 DOI: 10.1007/s00216-016-9961-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/01/2016] [Accepted: 09/19/2016] [Indexed: 12/21/2022]
Abstract
We describe here a minimally invasive glucose biosensor based on a microneedle array electrode fabricated from an epoxy-based negative photoresist (SU8 50) and designed for continuous measurement in the dermal compartment with minimal pain. These minimally invasive, continuous monitoring sensor devices (MICoMS) were produced by casting the structures in SU8 50, crosslinking and then metallising them with platinum or silver to obtain the working and reference electrodes, respectively. The metallised microneedle array electrodes were subsequently functionalised by entrapping glucose oxidase in electropolymerised polyphenol (PP) film. Sensor performance in vitro showed that glucose concentrations down to 0.5 mM could be measured with a response times (T90) of 15 s. The effect of sterilisation by Co60 irradiation was evaluated. In preparation for further clinical studies, these sensors were tested in vivo in a healthy volunteer for a period of 3-6 h. The sensor currents were compared against point measurements obtained with a commercial capillary blood glucometer. The epoxy MICoMS devices showed currents values that could be correlated with these. Graphical Abstract Microneedle arrays for continuous glucose monitoring in dermal interstitial fluid.
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Daskalaki E, Diem P, Mougiakakou SG. Model-Free Machine Learning in Biomedicine: Feasibility Study in Type 1 Diabetes. PLoS One 2016; 11:e0158722. [PMID: 27441367 PMCID: PMC4956312 DOI: 10.1371/journal.pone.0158722] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 06/21/2016] [Indexed: 11/23/2022] Open
Abstract
Although reinforcement learning (RL) is suitable for highly uncertain systems, the applicability of this class of algorithms to medical treatment may be limited by the patient variability which dictates individualised tuning for their usually multiple algorithmic parameters. This study explores the feasibility of RL in the framework of artificial pancreas development for type 1 diabetes (T1D). In this approach, an Actor-Critic (AC) learning algorithm is designed and developed for the optimisation of insulin infusion for personalised glucose regulation. AC optimises the daily basal insulin rate and insulin:carbohydrate ratio for each patient, on the basis of his/her measured glucose profile. Automatic, personalised tuning of AC is based on the estimation of information transfer (IT) from insulin to glucose signals. Insulin-to-glucose IT is linked to patient-specific characteristics related to total daily insulin needs and insulin sensitivity (SI). The AC algorithm is evaluated using an FDA-accepted T1D simulator on a large patient database under a complex meal protocol, meal uncertainty and diurnal SI variation. The results showed that 95.66% of time was spent in normoglycaemia in the presence of meal uncertainty and 93.02% when meal uncertainty and SI variation were simultaneously considered. The time spent in hypoglycaemia was 0.27% in both cases. The novel tuning method reduced the risk of severe hypoglycaemia, especially in patients with low SI.
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Affiliation(s)
- Elena Daskalaki
- Diabetes Technology Research Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland
| | - Peter Diem
- Division of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital “Inselspital”, 3010 Bern, Switzerland
| | - Stavroula G. Mougiakakou
- Diabetes Technology Research Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008 Bern, Switzerland
- Division of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital “Inselspital”, 3010 Bern, Switzerland
- * E-mail:
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Blauw H, Keith-Hynes P, Koops R, DeVries JH. A Review of Safety and Design Requirements of the Artificial Pancreas. Ann Biomed Eng 2016; 44:3158-3172. [PMID: 27352278 PMCID: PMC5093196 DOI: 10.1007/s10439-016-1679-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/13/2016] [Indexed: 01/03/2023]
Abstract
As clinical studies with artificial pancreas systems for automated blood glucose control in patients with type 1 diabetes move to unsupervised real-life settings, product development will be a focus of companies over the coming years. Directions or requirements regarding safety in the design of an artificial pancreas are, however, lacking. This review aims to provide an overview and discussion of safety and design requirements of the artificial pancreas. We performed a structured literature search based on three search components—type 1 diabetes, artificial pancreas, and safety or design—and extended the discussion with our own experiences in developing artificial pancreas systems. The main hazards of the artificial pancreas are over- and under-dosing of insulin and, in case of a bi-hormonal system, of glucagon or other hormones. For each component of an artificial pancreas and for the complete system we identified safety issues related to these hazards and proposed control measures. Prerequisites that enable the control algorithms to provide safe closed-loop control are accurate and reliable input of glucose values, assured hormone delivery and an efficient user interface. In addition, the system configuration has important implications for safety, as close cooperation and data exchange between the different components is essential.
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Affiliation(s)
- Helga Blauw
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100 DD, Amsterdam, The Netherlands. .,Inreda Diabetic BV, Goor, The Netherlands.
| | - Patrick Keith-Hynes
- TypeZero Technologies, LLC, Charlottesville, VA, USA.,Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | | | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100 DD, Amsterdam, The Netherlands
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Haidar A, Smaoui MR, Legault L, Rabasa-Lhoret R. The role of glucagon in the artificial pancreas. Lancet Diabetes Endocrinol 2016; 4:476-9. [PMID: 27138734 DOI: 10.1016/s2213-8587(16)30006-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/16/2016] [Accepted: 03/17/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, Division of Endocrinology, Faculty of Medicine, McGill University, Montréal, QC H3A 2B4, Canada.
| | - Mohamed Raef Smaoui
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC H3A 2B4, Canada; Institut de Recherches Cliniques de Montréal, Montréal, QC, Canada
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Rémi Rabasa-Lhoret
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, QC H3A 2B4, Canada; Institut de Recherches Cliniques de Montréal, Montréal, QC, Canada; Nutrition Department, Faculty of Medicine, University of Montréal, Montréal, QC, Canada; Montreal Diabetes Research Center, Montreal, QC, Canada
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