Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes

Efficacy, safety, and user experience of DIY or open-source artificial pancreas systems: a systematic review

The do-it-yourself artificial pancreas system (DIYAPS) is a patient-driven initiative with the potential to revolutionise diabetes management, automating insulin delivery with existing pumps and CGM combined with open-source algorithms. Given the considerable interest in this topic within the diabetes community, we have conducted a systematic review of DIYAPS efficacy, safety, and user experience. Following recognised procedures and reporting standards, we identified 10 eligible publications of 730 participants within the peer-reviewed literature. Overall, studies reported improvements in time in range, HbA1c (glycated haemoglobin), reduced hypoglycaemia, and improved quality of life with DIYAPS use. While results were positive, the identified studies were small, and the majority were observational and at high risk of bias. Further research including well-designed randomised trials comparing DIYAPS with appropriate comparators is recommended.

Improved Low-Glucose Predictive Alerts Based on Sustained Hypoglycemia: Model Development and Validation Study

BACKGROUND

Predictive alerts for impending hypoglycemic events enable persons with type 1 diabetes to take preventive actions and avoid serious consequences.

OBJECTIVE

This study aimed to develop a prediction model for hypoglycemic events with a low false alert rate, high sensitivity and specificity, and good generalizability to new patients and time periods.

METHODS

Performance improvement by focusing on sustained hypoglycemic events, defined as glucose values less than 70 mg/dL for at least 15 minutes, was explored. Two different modeling approaches were considered: (1) a classification-based method to directly predict sustained hypoglycemic events, and (2) a regression-based prediction of glucose at multiple time points in the prediction horizon and subsequent inference of sustained hypoglycemia. To address the generalizability and robustness of the model, two different validation mechanisms were considered: (1) patient-based validation (model performance was evaluated on new patients), and (2) time-based validation (model performance was evaluated on new time periods).

RESULTS

This study utilized data from 110 patients over 30-90 days comprising 1.6 million continuous glucose monitoring values under normal living conditions. The model accurately predicted sustained events with >97% sensitivity and specificity for both 30- and 60-minute prediction horizons. The false alert rate was kept to <25%. The results were consistent across patient- and time-based validation strategies.

CONCLUSIONS

Providing alerts focused on sustained events instead of all hypoglycemic events reduces the false alert rate and improves sensitivity and specificity. It also results in models that have better generalizability to new patients and time periods.

The effects of professional continuous glucose monitoring as an adjuvant educational tool for improving glycemic control in patients with type 2 diabetes

BACKGROUND

The study objective was to evaluate the effects of professional continuous glucose monitoring (CGM) as an adjuvant educational tool for improving glycemic control in patients with type 2 diabetes (T2D).

METHODS

We conducted a three-month quasi-experimental study with an intervention (IGr) and control group (CGr) and ex-ante and ex-post evaluations in one family medicine clinic in Mexico City. Participants were T2D patients with HbA1c > 8% attending a comprehensive diabetes care program. In addition to the program, the IGr wore a professional CGM sensor (iPro™2) during the first 7 days of the study. Following this period, IGr participants had a medical consultation for the CGM results and treatment adjustments. Additionally, they received an educational session and personalized diet plan from a dietitian. After 3 months, the IGr again wore the CGM sensor for 1 week. The primary outcome variable was HbA1c level measured at baseline and 3 months after the CGM intervention. We analyzed the effect of the intervention on HbA1c levels by estimating the differences-in-differences treatment effect (Diff-in-Diff). Additionally, baseline and three-month CGM and dietary information were recorded for the IGr and analyzed using the Student's paired t-test and mixed-effects generalized linear models to control for patients' baseline characteristics.

RESULTS

Overall, 302 T2D patients participated in the study (IGr, n = 150; control, n = 152). At the end of the three-month follow-up, we observed 0.439 mean HbA1C difference between groups (p = 0.004), with an additional decrease in HbA1c levels in the IGr compared with the CGr (Diff-in-Diff HbA1c mean of - 0.481% points, p = 0.023). Moreover, compared with the baseline, the three-month CGM patterns showed a significant increase in the percentage of time in glucose range (+ 7.25; p = 0.011); a reduction in the percentage of time above 180 mg/dl (- 6.01; p = 0.045), a decrease in glycemic variability (- 3.94, p = 0.034); and improvements in dietary patterns, shown by a reduction in total caloric intake (- 197.66 Kcal/day; p = 0.0001).

CONCLUSION

Professional CGM contributes to reducing HbA1c levels and is an adjuvant educational tool that can improve glycemic control in patients with T2D.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04667728 . Registered 16/12/2020.

Electrochemical Detection of Glucose Molecules Using Laser-Induced Graphene Sensors: A Review

This paper deals with recent progress in the use of laser-induced graphene sensors for the electrochemical detection of glucose molecules. The exponential increase in the exploitation of the laser induction technique to generate porous graphene from polymeric and other naturally occurring materials has provided a podium for researchers to fabricate flexible sensors with high dynamicity. These sensors have been employed largely for electrochemical applications due to their distinct advantages like high customization in their structural dimensions, enhanced characteristics and easy roll-to-roll production. These laser-induced graphene (LIG)-based sensors have been employed for a wide range of sensorial applications, including detection of ions at varying concentrations. Among the many pivotal electrochemical uses in the biomedical sector, the use of these prototypes to monitor the concentration of glucose molecules is constantly increasing due to the essentiality of the presence of these molecules at specific concentrations in the human body. This paper shows a categorical classification of the various uses of these sensors based on the type of materials involved in the fabrication of sensors. The first category constitutes examples where the electrodes have been functionalized with various forms of copper and other types of metallic nanomaterials. The second category includes other miscellaneous forms where the use of both pure and composite forms of LIG-based sensors has been shown. Finally, the paper concludes with some of the possible measures that can be taken to enhance the use of this technique to generate optimized sensing prototypes for a wider range of applications.

Continuous Glucose Monitoring Use in Clinical Trials for On-Market Diabetes Drugs

To the best of our knowledge, there are no published data on the historical and recent use of CGM in clinical trials of pharmacological agents used in the treatment of diabetes. We analyzed 2,032 clinical trials of 40 antihyperglycemic therapies currently on the market with a study start date between 1 January 2000 and 31 December 2019. According to ClinicalTrials.gov, 119 (5.9%) of these trials used CGM. CGM usage in clinical trials has increased over time, rising from <5% before 2005 to 12.5% in 2019. However, it is still low given its inclusion in the American Diabetes Association's latest guidelines and known limitations of A1C for assessing ongoing diabetes care.

Therapy adjustments in people with type 1 diabetes with impaired hypoglycemia awareness on multiple daily injections using real-time continuous glucose monitoring: a mechanistic analysis of the HypoDE study

INTRODUCTION

Studies have shown beneficial effects of real-time continuous glucose monitoring (rtCGM) usage on clinical outcomes. The objective of this analysis was to identify which therapy adjustments were made by people with type 1 diabetes with impaired hypoglycemia awareness during rtCGM usage enabling reductions in the number of low glucose events observed in the HypoDE (Hypoglycemia in Deutschland) study.

RESEARCH DESIGN AND METHODS

In the multicenter randomized controlled trial in people with type 1 diabetes on multiple daily injections with impaired hypoglycemia awareness, participants recorded their diabetes therapy in 7-day logbooks at baseline and at 6-month follow-up. They used rtCGM or self-monitoring of blood glucose for therapy adjustments. This mechanistic analysis looked at changes in various aspects of therapy.

RESULTS

Logbooks were completed by 70 participants in the rtCGM group and 65 participants in the control group. Participants in the rtCGM group kept their total carbohydrate consumption, daily insulin doses and distribution constant during the study. However, they reported an increased intake of rescue carbohydrates (0.8±0.6 (mean±SD) vs 1.0±0.8 intake/day; baseline-adjusted between-group difference 0.3 intake (0.1-0.5), p=0.031). The glucose threshold at which rescue carbohydrate intake was initiated was elevated from 71±13 mg/dL (3.9±0.7 mmol/L) to 79±14 mg/dL (4.4±0.8 mmol/L) (adjusted between-group difference +7.6 mg/dL (2.4-12.8) (+0.4 mmol/L (0.1-0.7)); p=0.005) in the rtCGM group. Regression analysis showed that follow-up low glucose events were associated with group allocation (p<0.001), low glucose events at baseline (p=0.016) and rescue threshold (p=0.001).

CONCLUSIONS

No major adjustments in insulin therapy were made by study participants with impaired hypoglycemia awareness; however, they were more active in preventing hypoglycemia by taking rescue carbohydrates earlier and more often.

TRIAL REGISTRATION NUMBER

NCT02671968.

Digital health and management of chronic disease: A multimodal technologies typology

This cross-sectional descriptive study aims to (1) describe the current digital technology (DT) use of people with chronic diseases (CD) by identifying different user profiles and (2) determine whether those profiles have specific characteristics regarding health-related variables and patient-doctor relationship quality (RQ). An online questionnaire assessing the uses of multiple types of DT (the Internet, mobile applications and connected devices) and several dimensions related to health and patient-doctor RQ was completed by 954 individuals living with CD. DT user groups were obtained by k-means cluster analysis and then compared using Mann-Whitney tests. The results show three profiles of DT users: (1) hyperconnected (8.9%, regular users of all DTs), (2) biconnected (19.1%, regular users of the Internet and mobile apps) and (3) hypoconnected (72%, casual users of the Internet only). The hyperconnected and biconnected groups are more empowered, more knowledgeable about their treatment and more committed to their doctors than the hypoconnected group. Nonadherence to treatment, health motivations, self-efficacy for health management and the trust dimension of the patient-doctor RQ did not differ between groups. We conclude by discussing the low use of the most recent technologies in the CD population, although these technologies seem to provide access to health information that empowers patients and leads to a better relationship with their doctors.

GLU: a software package for analysing continuously measured glucose levels in epidemiology

Continuous glucose monitors (CGM) record interstitial glucose levels 'continuously', producing a sequence of measurements for each participant (e.g. the average glucose level every 5 min over several days, both day and night). To analyse these data, researchers tend to derive summary variables such as the area under the curve (AUC), to then use in subsequent analyses. To date, a lack of consistency and transparency of precise definitions used for these summary variables has hindered interpretation, replication and comparison of results across studies. We present GLU, an open-source software package for deriving a consistent set of summary variables from CGM data. GLU performs quality control of each CGM sample (e.g. addressing missing data), derives a diverse set of summary variables (e.g. AUC and proportion of time spent in hypo-, normo- and hyper- glycaemic levels) covering six broad domains, and outputs these (with quality control information) to the user. GLU is implemented in R and is available on GitHub at https://github.com/MRCIEU/GLU. Git tag v0.2 corresponds to the version presented here.

Flash Glucose Monitoring and Patient Satisfaction: A Meta-Review of Systematic Reviews

Flash glucose monitoring (FGM) systems have been suggested to have clinical beneficial effects in patients with diabetes mellitus, although their improvements in terms of quality of life (QoL) and patients’ satisfaction are not always addressed or are considered a secondary outcome. Thus, the aim of this meta-review is to establish the benefits of FGM in terms of patients’ satisfaction and QoL in both type 1 and type 2 diabetes patients using evidence from past systematic reviews and meta-analyses. Major databases were searched for systematic reviews (with or without meta-analyses) that assessed the satisfaction or QoL of type 1 or 2 diabetes patients using FGM compared with other glucose monitoring systems. The quality of the included systematic reviews was addressed with the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool. Six systematic reviews (including two meta-analyses) were included in the meta-review. Evidence suggests that FGM systems seem to improve patients’ satisfaction and QoL compared with self-monitoring of blood glucose, although the high variability in the measurement tools, the clinical significance and the quality of the systematic reviews included do not allow us to state FGM benefits with any certainty. Further research, including high-quality randomised clinical trials, differentiating the needs of both type 1 and type 2 diabetes patients and focusing on psychosocial benefits for these patients is needed to optimise clinical decisions between patients and professionals by developing the right health technology assessment for FGM systems.

Application of Telemedicine in Diabetes Care: The Time is Now

The utilization of telemedicine solutions to reduce outpatient clinic visits and visits to physicians' offices, thus saving financial and personal resources as well as time, has gained substantial importance in recent years. The COVID19 pandemic has made it necessary to abruptly adjust outpatient care methods in various medical settings that needlessly require consultations in person to monitor and change the disease management of patients in specific risk groups. People with diabetes represent a vulnerable population who need to be protected from avoidable outpatient clinic visits, particularly in times of influenza or other pandemic outbreaks. However, the treatment and care of patients with diabetes and its comorbidities require careful and regular monitoring and therapy adjustments by medical staff. Advanced age or cognitive impairment and insufficient access to the health care system due to low socioeconomic status can complicate the use of possible alternatives to in-person consultations in outpatient clinics or physicians' offices. Telemedicine solutions may offer suitable alternatives to standard face-to-face consultations in outpatient settings and provide sufficient access to appropriate diabetes care. Nevertheless, telemedicine methods for monitoring diabetes issues are yet to find widespread use due to numerous barriers, such as a lack of acceptance and doubt about its time- and cost-effectiveness, availability, and potential technical and regulatory issues. This article offers an overview of existing applications that provide telemedicine diabetes care. Furthermore, it discusses potential ways to restructure and revolutionize diabetes outpatient care.

Glycemic variability and cardiovascular disease in patients with type 2 diabetes

Glycated hemoglobin is currently the gold standard for assessment of long-term glycemic control and response to medical treatment in patients with diabetes. Glycated hemoglobin, however, does not address fluctuations in blood glucose. Glycemic variability (GV) refers to fluctuations in blood glucose levels. Recent clinical data indicate that GV is associated with increased risk of hypoglycemia, microvascular and macrovascular complications, and mortality in patients with diabetes, independently of glycated hemoglobin level. The use of continuous glucose monitoring devices has markedly improved the assessment of GV in clinical practice and facilitated the assessment of GV as well as hypoglycemia and hyperglycemia events in patients with diabetes. We review current concepts on the definition and assessment of GV and its association with cardiovascular complications in patients with type 2 diabetes.

Continuous Glucose Monitoring in Patients With Insulinoma Treated by Endoscopic Ultrasound-Guided Ethanol Injection

OBJECTIVES

The aims of this study were to analyze the continuous glucose monitoring (CGM) profiles of patients with insulinoma before and after treatment with endoscopic ultrasound-guided ethanol injection and assess the value of CGM in curative effect evaluating.

METHODS

We included 8 patients, and CGM was performed for 3 to 5 days before and after treatment.

RESULTS

The proportion of monitoring points at which the glucose level was lower than 3.9 mmol/L after treatment decreased in patient 5 (from 4% to 3%) and patient 8 (from 30% to 12%), whereas the proportion increased in patient 1 (from 1% to 16%), patient 3 (from 5% to 23%), and patient 7 (from 7% to 63%). There was no mean significant difference between CGM values (5.75 [standard deviation, 2.49] mmol/L) and self-monitoring of blood glucose values (5.76 [standard deviation, 2.32] mmol/L) (P > 0.05). Pearson correlation analysis showed positive correlation between CGM values and self-monitoring of blood glucose values (r = 0.88, P < 0.05). Clarke Error Grid Analysis showed that 91.5% of pairs were located in areas A and B.

CONCLUSIONS

Continuous glucose monitoring is useful for detecting hypoglycemia and evaluating curative effect, but the correction of fingertip blood glucose is necessary when the blood glucose is relatively low.

Evaluation of the SPECTRUM training programme for real-time continuous glucose monitoring: A real-world multicentre prospective study in 120 adults with type 1 diabetes

AIMS

Comprehensive knowledge, specific skills and data-analysis competences are prerequisites for the successful use of continuous glucose monitoring (CGM) systems. SPECTRUM is a structured training programme for real-time CGM (rtCGM) consisting of a web-based introduction and six group sessions of 90 min each. The 'CGM-TRAIN study' evaluated the efficacy and acceptance of SPECTRUM and rtCGM systems among adults with insulin therapy.

METHODS

Participants (n = 120) were recruited from 10 German diabetes centres in which they were treated under usual care conditions. Outcome measures were rtCGM knowledge, practical skills, satisfaction with the training programme, satisfaction and acceptance of rtCGM system and glycaemic control. Data were collected at study entry, after training completion and at 6-month follow-up.

RESULTS

All participants were diagnosed with type 1 diabetes (56% women, mean age 42.4 ± 13.4 years, diabetes duration 21.6 ± 11.6 years), 110 participants completed the course. After training completion, rtCGM-specific knowledge had improved by 43% (scale: 0-40 points) from 21.2 ± 7.6 to 30.4 ± 4.5 points; p < 0.001. The knowledge-level persisted until follow-up (29.4 ± 4.5). Participants were able to master nearly all the practical requirements of the technology. In addition, rtCGM was highly accepted, and participants were motivated to use their systems continuously. HbA_1c improved slightly from 61 ± 14 mmol/mol (7.7 ± 1.3%) before training to 60 ± 14 mmol/mol (7.6 ± 1.3%) at follow-up (p = 0.04). The training programme itself was favourably rated by participants.

CONCLUSIONS

Under usual out-patient daily care conditions, the training programme SPECTRUM improved knowledge and skills about rtCGM in adults with type 1 diabetes. This was associated with a reduced HbA_1c , high satisfaction and acceptance of rtCGM (Clinical Trials Registry no.: DRKS00014380).

Impact of COVID-19 lockdown on flash and real-time glucose sensor users with type 1 diabetes in England

AIMS

People with type 1 diabetes (T1D) face the daily task of implementing self-management strategies to achieve their glycaemic goals. The UK COVID-19 lockdown has had an impact on day-to-day behaviour, which may affect diabetes self-management and outcomes. We assessed whether sensor-based outcomes pre- and during lockdown periods were different in a cohort of glucose sensor users with T1D.

METHODS

Data were collected from Freestyle Libre (FSL) or Dexcom G6 sensor users who remotely shared their data with the diabetes clinic web platform. Sensor metrics according to international consensus were analysed and compared between pre-lockdown period and 2 and 3 weeks into lockdown (periods 1 and 2).

RESULTS

Two hundred and sixty-nine T1D patients (baseline HbA1c 57 ± 14 mmol/mol) were identified as FSL (n = 190) or Dexcom G6 (n = 79) users. In patients with sensor use > 70% (N = 223), compared to pre-lockdown period percentage TIR 3.9-10 mM (TIR) significantly increased during period 1 (59.6 ± 18.2 vs. 57.5 ± 17.2%, p = 0.002) and period 2 (59.3 ± 18.3 vs. 57.5 ± 17.2%, p = 0.035). The proportion of patients achieving TIR ≥ 70% increased from 23.3% pre-lockdown to 27.8% in period 1 and 30.5% in period 2. A higher proportion also achieved the recommended time below and above range, and coefficient of variation in periods 1 and 2. Dexcom G6 users had significantly lower % time below range (< 3.9 mM) compared to FSL users during both lockdown periods (period 1: Dexcom G6 vs. FSL: 1.8% vs. 4%; period 2: 1.4% vs. 4%, p < 0.005 for both periods).

CONCLUSION

Sensor-based glycaemic outcomes in people with T1D in the current cohort improved during COVID-19 lockdown, which may be associated with positive changes in self-management strategies. Further work is required to evaluate long-term sustainability and support.

One-year experience of hybrid closed-loop system in children and adolescents with type 1 diabetes previously treated with multiple daily injections: drivers to successful outcomes

OBJECTIVE

To evaluate the effect of a 1-year hybrid closed-loop (HCL) system on glycemic control in children and adolescents with type 1 diabetes (T1D) previously treated with multiple daily injections (MDI).

METHODS

This was a 1-year observational study, as a continuation of the previous 3 months prospective study of pediatric patients with T1D conducted at Sidra Medicine in Qatar. The study enrolled individuals aged 7-18 years with T1D > 1 year, on MDI with self-monitoring of blood glucose or continuous glucose monitoring, with no prior pump experience, and with an HbA1c level < 12.5% (< 113 mmol/mol). After the first 3 months of HCL use, patients were followed at 6, 9 and 12 months, where HbA1c was obtained and pump data were collected.

RESULTS

All 30 participants (age 10.24 ± 2.6 years) who initiated HCL completed 12 months of HCL system use in Auto Mode. The participants used the sensor 88.4 ± 6.5% of the time with Auto Mode usage 85.6 ± 7.4% during 12 months of HCL system use. HbA1c decreased from 8.2 ± 1.4% (66 ± 15.3 mmol/mol) at baseline, to 6.7 ± 0.5% (50 ± 5.5 mmol/mol) at 3 months (p = 0.02) and remained stable to 7.1 ± 0.6 (54 ± 6.6 mmol/mol) at 12 months (p = 0.02). TIR (70-180 mg/dL) increased from 46.9% at baseline to 71.9% at 1 month and remained above 70% during the 12 months of HCL use.

CONCLUSION

HCL system (MiniMed 670G) in children and adolescents previously treated with MDI significantly improves glycemic outcomes (HbA1c and Time in Ranges) immediately during the first month. This improved glycemic control was maintained over the 1 year following Auto Mode initiation.

Ability of Current Machine Learning Algorithms to Predict and Detect Hypoglycemia in Patients With Diabetes Mellitus: Meta-analysis

Background

Machine learning (ML) algorithms have been widely introduced to diabetes research including those for the identification of hypoglycemia.

Objective

The objective of this meta-analysis is to assess the current ability of ML algorithms to detect hypoglycemia (ie, alert to hypoglycemia coinciding with its symptoms) or predict hypoglycemia (ie, alert to hypoglycemia before its symptoms have occurred).

Methods

Electronic literature searches (from January 1, 1950, to September 14, 2020) were conducted using the Dialog platform that covers 96 databases of peer-reviewed literature. Included studies had to train the ML algorithm in order to build a model to detect or predict hypoglycemia and test its performance. The set of 2 × 2 data (ie, number of true positives, false positives, true negatives, and false negatives) was pooled with a hierarchical summary receiver operating characteristic model.

Results

A total of 33 studies (14 studies for detecting hypoglycemia and 19 studies for predicting hypoglycemia) were eligible. For detection of hypoglycemia, pooled estimates (95% CI) of sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were 0.79 (0.75-0.83), 0.80 (0.64-0.91), 8.05 (4.79-13.51), and 0.18 (0.12-0.27), respectively. For prediction of hypoglycemia, pooled estimates (95% CI) were 0.80 (0.72-0.86) for sensitivity, 0.92 (0.87-0.96) for specificity, 10.42 (5.82-18.65) for PLR, and 0.22 (0.15-0.31) for NLR.

Conclusions

Current ML algorithms have insufficient ability to detect ongoing hypoglycemia and considerate ability to predict impeding hypoglycemia in patients with diabetes mellitus using hypoglycemic drugs with regard to diagnostic tests in accordance with the Users’ Guide to Medical Literature (PLR should be ≥5 and NLR should be ≤0.2 for moderate reliability). However, it should be emphasized that the clinical applicability of these ML algorithms should be evaluated according to patients’ risk profiles such as for hypoglycemia and its associated complications (eg, arrhythmia, neuroglycopenia) as well as the average ability of the ML algorithms. Continued research is required to develop more accurate ML algorithms than those that currently exist and to enhance the feasibility of applying ML in clinical settings.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020163682; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42020163682

A novel classification of glucose profile in pregnancy based on continuous glucose monitoring data

AIM

To investigate the glucose profile of women with and without gestational diabetes mellitus (GDM) by simultaneously analyzing several factors of continuous glucose monitoring (CGM) data.

METHODS

CGM was conducted for 2 weeks in the second trimester of pregnant women whose random blood glucose level was ≥100 mg/dl. A 75-g oral glucose tolerance test was performed around day 7, and the index of hyperglycemia, relative hypoglycemia, and indices of glucose variability were extracted from CGM data. Unsupervised hierarchical clustering was performed to categorize glucose profiles of the participants.

RESULTS

CGM data were obtained from 29 women. Glucose profiles were categorized into three clusters: low glucose levels with less glucose variability group (L group, n = 7); moderate glucose levels with moderate-to-high glucose variability group (M group, n = 18); and high glucose levels with high glucose variability group (H group, n = 4). The waveforms of the glucose profiles were very different among the three groups. Women with GDM tended to be more frequent in the H group than in the M and L groups (75.0%, 16.7%, and 14.3%, respectively; p = 0.053). Maternal age was significantly higher and the proportion of multiparous women was significantly larger in the H group compared to L group (p = 0.002 and 0.015, respectively).

CONCLUSIONS

A comprehensive analysis of CGM data could help us extract a subgroup of women with characteristics of GDM.

Comprehensive elaboration of glycemic variability in diabetic macrovascular and microvascular complications

Diabetes mellitus is the major risk factor for the development of macrovascular and microvascular complications. It is increasingly recognized that glycemic variability (GV), referring to oscillations in blood glucose levels and representing either short-term or long-term GV, is involved in the pathogenesis of diabetic complications and has emerged as a possible independent risk factor for them. In this review, we summarize the metrics and measurement of GV in clinical practice, as well as comprehensively elaborate the role and related mechanisms of GV in diabetic macrovascular and microvascular complications, aiming to provide the mechanism-based therapeutic strategies for clinicians to manage diabetes mellitus.

Glucose Variability and Time in Range in Type 2 Diabetes Treated with U-500R by Pump or Injection: CGM Findings from the VIVID Study

Background: The EValuating U-500R Infusion Versus Injection in Type 2 Diabetes Mellitus (VIVID) study compared two methods of U-500R insulin delivery, continuous subcutaneous insulin infusion (CSII) and multiple daily injection (MDI), for 26 weeks in people with type 2 diabetes (T2D) requiring high doses of insulin. To assess glycemic variability (GV) and time in range (TIR), a subset of participants performed masked continuous glucose monitoring (CGM). Methods: VIVID participants were adults who had insulin requirements of >200 but ≤600 U/day and A1C 7.5% to 12%. Participants performed masked CGM for seven consecutive days on each of three occasions: before weeks 0 (baseline), 14, and 26. The primary objective was to compare GV between CSII and MDI groups, based on change from baseline of within-day standard deviation (SD_w) of CGM glucose. Results: Of 54 participants enrolled, 41 with evaluable data were analyzed (17 and 24 in CSII and MDI groups, respectively). The CSII group had a significantly greater reduction from baseline in mean SD_w of glucose (45.0 to 38.2 mg/dL [-8.1 mg/dL]) compared with the MDI group (47.0 to 45.8 [-0.4 mg/dL]; P = 0.047). TIR 70-180 mg/dL glucose increased significantly from baseline in the CSII group only, from 59.8% to 73.1% (change +12.9%, P < 0.05), but was not significantly different between groups. There were no significant between-group differences in the endpoint mean glucose or A1C. Conclusions: In the VIVID CGM substudy of U-500R in people with T2D requiring high doses of insulin, participants using CSII significantly reduced GV compared with MDI. CSII also significantly increased TIR with no difference between groups.

Glycemic Control and Variability of Diabetes Secondary to Total Pancreatectomy Assessed by Continuous Glucose Monitoring

CONTEXT

The extent of the glycemic variability in diabetes secondary to total pancreatectomy is not fully understood.

OBJECTIVE

To evaluate glycemic variability in totally pancreatectomized (PX) patients and compare it to glycemic variability in hemoglobin A1c (HbA1c)-matched patients with long-standing type 1 diabetes (T1D).

DESIGN

A case-control study was performed.

SETTING

Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.

PATIENTS OR OTHER PARTICIPANTS

Ten PX patients (mean [SEM]: age 64.3 [9.8] years; body mass index (BMI) 34.4 [5.0] kg/m2; duration of diabetes 3 [2.8] years), 10 HbA1c-matched patients with T1D (63.9 [8.6] years; 24.6 [3.1] kg/m2; 22 [4] years), and 10 gender-, age-, and BMI-matched healthy controls. All patients were managed on multiple daily injections of insulin.

INTERVENTION

Continuous glucose monitoring (CGM) (Medtronic MiniMed iPro 2) during 12 consecutive days.

MAIN OUTCOME MEASURES

Glycemic variability.

RESULTS

HbA1c levels were similar in the PX group and the T1D group. The PX group had greater continuous overall net glycemic action per 60 minutes (CONGA60 min) compared with the T1D group (mean [SEM]: 9.5 [0.3] vs 8.3 [0.2] mmol/L, P < 0.003) and mean plasma glucose values were higher in the PX group (10.6 [0.9] vs 9.0 [0.9] mmol/L, P < 0.001), whereas coefficient of variation for plasma glucose and standard deviation of mean plasma glucose, respectively, were similar in the 2 groups. Time spent below range was not different between the PX and the T1D group (2.3 [0.8] vs 4.5 [0.8]%, P = 0.065), whereas time spent above range was higher in the PX group (51.4 [3.3] vs 37.6 [1.9]%, P < 0.001).

CONCLUSIONS

CGM-assessed glycemic variability showed higher CONGA60 min and time spent above range in our PX patients compared with HbA1c-matched T1D patients. This study is registered at www.ClinicalTrials.gov (NCT02944110).

Glycemic Variability, Oxidative Stress, and Impact on Complications Related to Type 2 Diabetes Mellitus

Chronic hyperglycemia is an established risk factor for the development of complications in both type 1 and type 2 diabetes, but glycemic variability has emerged as a possible independent risk factor for diabetes complications, possibly through oxidative stress. In this review, methods to access glycemic variability and oxidative stress, as well as their correlations, are discussed. Non-pharmacological and pharmacological strategies are also debated to achieve better glycemic control, not only by HbA1c target but also with reduced glycemic fluctuations, possibly minimizing the risk of diabetes complications.

Continuous Glucose Monitoring for Underserved and Minority Patients with Type 2 Diabetes in an Interprofessional Internal Medicine Clinic

Objective

Evaluate the impact of interprofessional continuous glucose monitoring (CGM) on glycemic control in underserved and minority patients with type 2 diabetes mellitus (T2DM).

Methods

The IRB-approved, retrospective quasi-experimental study was conducted between August 2018 and August 2019 at an internal medicine residency clinic. Adult patients with diagnosed T2DM, an indication for CGM (hyperglycemia, hypoglycemia, and/or glycemic variability), and at least 10 consecutive days of CGM data were included. Patients who were pregnant and/or missed one or more clinic appointments were excluded. Patients were followed weekly over a 14-day period during which data from the CGM sensor were downloaded and interpreted by the interprofessional team. Interventions with shared decision-making were made at each visit.

Results

Fifty-five patients were included, with a mean age of 61+11.2 years, 86% were of non-white race, and 56% were female. Average blood glucose levels decreased from 208.39 mg/dL at week 1 to 190.74 mg/dL at week 2, a 17.65 mg/dLreduction (p = 0.0281). Time within target range (70-180 mg/dL) increased by 6.16% (p = 0.0038), while time above range (>180 mg/dL) decreased by 5.5% (p = 0.0168). Average number of hypoglycemic events (readings <70 mg/dL) did not change significantly from week 1 to week 2 (2.94 vs. 3.64, p > 0.05). Of the 66 interventions made after week 1, 33% were made by the pharmacy team, 56% were made by the attending or resident physicians, and 11% were made by the dietician. Of 59 interventions made after week 2, 32% were made by the pharmacy team, 49% were made by the attending or resident physicians, and 19% were made by the dietician.

Conclusions

The interprofessional collaborative CGM service was associated with improvements in glucose control based on increased time within target range and reduced hyperglycemia, without increasing the risk of hypoglycemia or medication burden.

People with type 1 diabetes and impaired awareness of hypoglycaemia have a delayed reaction to performing a glucose scan during hypoglycaemia: a prospective observational study

AIMS

Considering that people with type 1 diabetes and impaired awareness of hypoglycaemia (IAH) have a delayed perception of hypoglycaemia, the question arises whether they perform scans later in case of hypoglycaemia than people without IAH. We assessed whether time to performing a scan after reaching hypoglycaemia while using a flash glucose monitoring (flash GM) system is different in people with IAH compared with people without IAH.

METHODS

Ninety-two people with type 1 diabetes [mean (± sd) age 42 ± 14 years, HbA1c 57 ± 9 mmol/mol] using a flash GM system for 3 months were included. Flash GM data were assessed for time until scan after reaching hypoglycaemia level 1 (< 3.9 mmol/l) and level 2 (< 3.0 mmol/l) and compared for type 1 diabetes with vs. without IAH via unpaired t-test/Mann-Whitney U test (P < 0.05).

RESULTS

Significant differences were found only for the delay between reaching hypoglycaemia and scan between people with and without IAH for Gold score [hypoglycaemia level 1: IAH 78 (51-105) min vs. without IAH 63 (42-89) min, P = 0.03; night-time hypoglycaemia level 2: IAH 140 (107-227) min vs. without IAH 96 (41-155) min, P = 0.004] and Pedersen-Bjergaard score [hypoglycaemia level 1: IAH 76 (52-97) min vs. without IAH 54 (38-71) min, P = 0.011; night-time hypoglycaemia level 1: IAH 132 (79-209) min vs. without IAH 89 (59-143) min, P = 0.011; night-time hypoglycaemia level 2: IAH 134 (66-212) min vs. without IAH 80 (37-131) min, P = 0.002). Data are shown as median (i.q.r.).

CONCLUSIONS

Time until scan after reaching hypoglycaemia might be an objective assessment tool for IAH, but needs to be investigated comprehensively in future studies.

Simple Post-Processing of Continuous Glucose Monitoring Measurements Improves Endpoints in Clinical Trials

BACKGROUND

Continuous glucose monitoring (CGM) is a powerful tool to be considered both in clinical practice and clinical trials. However, CGM has been criticized for being inaccurate for many reasons including a physiological delay. This study sought to investigate the current delay issue and propose a simple post-processing procedure.

METHOD

More than a million hours of the Dexcom G4 CGM from 472 subjects investigated in a state-of-the-art clinical trial were analyzed by time shifting the CGM measurements and comparing them to plasma glucose (PG) measurements. The resultant CGM measurements were then assessed in relation to real-world clinical research endpoints.

RESULTS

A CGM time shift of -9 minutes was optimal and reduced mean absolute relative difference (MARD) statistically significantly with 1.0% point. The MARD reduction resulted in better clinical research endpoints of hypoglycemia and postprandial glucose increments.

CONCLUSIONS

The delay in CGM is still an issue. The delay in this study was identified to be 9 minutes compared to PG. With a simple post-processing approach of time shifting the CGM measurements with -9 minutes, it was possible to obtain a statistically significantly lower MARD and subsequently obtain clinical research endpoints of improved validity.

Has subsidized continuous glucose monitoring improved outcomes in pediatric diabetes?

INTRODUCTION

In 2017, the Australian Federal Government fully subsidized continuous glucose monitoring (CGM) devices for patients under 21 years of age with T1D with the aim of reducing rates of severe hypoglycaemia (SH) and improving metabolic control. The aim of this study was to reports on metabolic outcomes in youth from a single tertiary centre.

METHODS

The study design was observational. Data were obtained on youth who commenced CGM between May 2017 and December 2019.

RESULTS

Three hundred and forty one youth who commenced CGM and had clinical outcome data for a minimum of 4 months. 301, 261, 216, 172, and 125 had outcome data out to 8, 12, 16, 20, and 24 months, respectively. Cessation occurred between 27.9% and 32.8% of patients 12 to 24 months after CGM commencement. HbA1c did not change in patients who continued to use CGM. In the 12 months prior to starting CGM the rate of severe hypoglycaemia events were 5.0 per 100 patient years. The rates of severe hypoglycaemia in those continuing to use CGM at 4, 8, 12, 16, 20, and 24 months, were 5.2, 5.1, 1.6, 6.1, 2.4, and 0 per 100 patient years, respectively.

DISCUSSION

Our experience of patients either ceasing or underusing CGM is less than reported in other cohorts but is nonetheless still high. There may have been a reduction in rates of severe hypoglycaemia over the 24 months follow up period; however, the absolute numbers of events were so low as to preclude meaningful statistical analysis.

Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies

Impaired awareness of hypoglycemia (IAH) is a reduction in the ability to recognize low blood glucose levels that would otherwise prompt an appropriate corrective therapy. Identified in approximately 25% of patients with type 1 diabetes, IAH has complex pathophysiology, and might lead to serious and potentially lethal consequences in patients with diabetes, particularly in those with more advanced disease and comorbidities. Continuous glucose monitoring systems can provide real-time glucose information and generate timely alerts on rapidly falling or low blood glucose levels. Given their improvements in accuracy, affordability and integration with insulin pump technology, continuous glucose monitoring systems are emerging as critical tools to help prevent serious hypoglycemia and mitigate its consequences in patients with diabetes. This review discusses the current knowledge on IAH and effective diagnostic methods, the relationship between hypoglycemia and cardiovascular autonomic neuropathy, a practical approach to evaluating cardiovascular autonomic neuropathy for clinicians, and recent evidence from clinical trials assessing the effects of the use of CGM technologies in patients with type 1 diabetes with IAH.

Scaling-up medical technologies using flexographic printing

Medical technologies, such as point-of-care devices and biological and chemical assays which rely on functional materials deposited on top of substrates, are in great demand due to an increase in the prevalence of diseases worldwide. A significant number of these medical technologies are still in their infancy with respect to commercialization because of the high cost, material and complexity of the conventionally available fabrication techniques. As a result, medical technologies, in broad terms, require low cost and mass production fabrication methods in order to overcome the commercialization challenges. Recently, researchers have explored the flexographic printing technique which is widely employed for food packaging and newspaper production. This technique has proved cost-effective, facile, rapid and industrially compatible fabrication technique of functional materials for various applications. In this review, we provide an account of the attempts of flexographic printing made to scale up functional materials on surfaces for biomedical applications. Firstly, we offer justification for demanding high-throughput fabrication techniques. We then present the facile working principle of the flexographic printing and its use in different medical applications, for example chronic disease monitoring devices, colorimetric sensors, electrochemical sensors, assays and drugs. Finally, we discuss challenges of the fabrication technique. The main purpose of this review is to give insights into the usefulness of flexographic printing to the health care industry.

Insulin pump therapy and continuous glucose monitoring in adults with type 2 diabetes: where are we now?

Technology in diabetes is rapidly evolving, with the aim of helping affected people to safely optimize their blood glucose control. New technologies are now considered as an essential tool for managing glycemia predominantly in people with type 1 diabetes, and clinical trials have demonstrated that in these subjects the use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems are associated with improved glycemic control along with a better quality of life. Literature regarding technologies and type 2 diabetes is relatively lacking, but innovations may have an important role also in the management of these patients. Some studies in adults with type 2 diabetes have shown benefits with the use of CGM in terms of glycemic variability and improved therapeutic adjustments. Clinical trials about CSII and CGM use in type 2 diabetes may have some pitfalls and future studies are needed to assess how these advanced systems could improve clinical outcomes and also ensure cost-effectiveness in this population. In this narrative review, we aim to highlight the most relevant studies on this topic and to focus on the potential role of new technological devices in type 2 diabetes management.

Individualization of recommendations from the international consensus on continuous glucose monitoring-derived metrics in Japanese children and adolescents with type 1 diabetes

We assessed the significance of recommendations from the international consensus on continuous glucose monitoring (CGM)-derived metrics in Japanese children and adolescents with type 1 diabetes. Eighty-five patients (age, 13.5 ± 4.7 years) who wore the FreeStyle^® Libre for a 28-day period were enrolled in this study. Seventy-three patients were treated with multiple daily injections of insulin and 12 with insulin pump therapy without using a sensor-augmented pump or a predictive low-glucose suspend-function pump. We evaluated the relationship between CGM-derived metrics: time in range (TIR: 70-180 mg/dL), time below range (TBR: <70 mg/dL), and time above range (TAR: >180 mg/dL), and laboratory-measured HbA1c and estimated HbA1c (eA1c) levels calculated from the mean glucose values. The TIR was 50.7 ± 12.2% (23-75%), TBR was 11.8 ± 5.8% (2-27%), and TAR was 37.5 ± 13.5% (9-69%). The TIR was highly correlated with HbA1c level, eA1c level, and TAR, but not with TBR. An HbA1c level of 7.0% corresponded to a TIR of 55.1% (95% CI: 53.7-56.5%), whereas a TIR of 70% corresponded to an HbA1c level of 6.1% (95% CI: 5.9-6.3%). The results of eA1c levels were similar to those observed for HbA1c levels. From these findings, we conclude that low rates of a recommended TIR of 70% may be due to less use of advanced technology and insufficient comprehensive diabetes care. Ethnic characteristics including lifestyle and eating customs may have contributed to the result. CGM-derived targets must be individualized based on ethnic characteristics, insulin treatment and diabetes care, and needs of individuals with diabetes.

Using Aptamers as a Novel Method for Determining GnRH/LH Pulsatility

Aptamers are a novel technology enabling the continuous measurement of analytes in blood and other body compartments, without the need for repeated sampling and the associated reagent costs of traditional antibody-based methodologies. Aptamers are short single-stranded synthetic RNA or DNA that recognise and bind to specific targets. The conformational changes that can occur upon aptamer–ligand binding are transformed into chemical, fluorescent, colour changes and other readouts. Aptamers have been developed to detect and measure a variety of targets in vitro and in vivo. Gonadotropin-releasing hormone (GnRH) is a pulsatile hypothalamic hormone that is essential for normal fertility but difficult to measure in the peripheral circulation. However, pulsatile GnRH release results in pulsatile luteinizing hormone (LH) release from the pituitary gland. As such, LH pulsatility is the clinical gold standard method to determine GnRH pulsatility in humans. Aptamers have recently been shown to successfully bind to and measure GnRH and LH, and this review will focus on this specific area. However, due to the adaptability of aptamers, and their suitability for incorporation into portable devices, aptamer-based technology is likely to be used more widely in the future.

Cost of Treating Skin Problems in Patients with Diabetes Who Use Insulin Pumps and/or Glucose Sensors

Background: The use of insulin pump and glucose sensor is advantageous, but unfortunately many experience skin problems. To reduce or overcome skin problems, patients use additional products or change their sets preterm. Therefore, the aim was to investigate costs related to skin problems. Materials and Methods: Two hundred sixty-three patients from four different hospitals in Denmark participated in a cross-sectional survey about skin problems related to insulin pump and/or glucose sensor use. Additional costs aside technology and diabetes treatment were calculated based on adhesives, patches, lotion, and preterm shifts of infusion or sensor sets due to skin problems. Descriptive statistics and linear regression were used. Results: The total costs for all these expenses were 11493.9 U.S. dollars (USD) in 145 pediatric patients and 4843 USD in 118 adult patients. The costs were higher in patients with, than without, skin problems and for skin problems due to the glucose sensor compared with insulin pump. Pediatric patients with eczema and/or wound due to the glucose sensor did cost 154.3 USD more, than patients without these skin problems (P < 0.01). We found a clear dose/response relationship between costs and severity of skin problems, especially in pediatric patients. Conclusions: Our data show that skin problems due to use of insulin pump and/or glucose sensor have significant costs on the Danish welfare system. This leaves an economic incentive for developing more skin-sensitive adhesive for the infusion set and sensors, at least for a certain subgroup of patients.

Flash glucose monitoring in type 1 diabetes: A comparison with self-monitoring blood glucose

AIMS/INTRODUCTION

A flash glucose monitoring (FGM) system has become available. To clarify the relationship between FGM and self-monitoring blood glucose (SMBG) values, we compared the two values after simultaneous measurement in Japanese patients with type 1 diabetes, under daily life settings.

MATERIALS AND METHODS

A total of 20 outpatients with type 1 diabetes were analyzed. When FGM and SMBG were carried out simultaneously (within ±3 min), the values were adopted and each FGM value was matched and compared with the corresponding SMBG value. In addition, we analyzed other cases of simultaneity defined as "within ±2 min," "within ±1 min" and "at the exact same time."

RESULTS

The percentage of SMBG and FGM values in the clinically acceptable zone A + B in Clarke and consensus error grid analyses were 97.9 and 99.2%, respectively. Deming regression (x-axis: FGM values, y-axis: SMBG values) determined a slope of 0.9128 (95% confidence interval 0.9008-0.9247) and an intercept of +15.94 mg/dL (95% confidence interval 14.05-17.84). FGM values were lower than SMBG values in the lower glucose range, and higher in the higher glucose range. The shorter the time lag between measurements, the higher the rate of concordance between FGM and SMBG values.

CONCLUSIONS

The results of this study provided evidence on the reliability of FGM in Japanese patients with type 1 diabetes in home conditions. Based on the results, if an abnormal glucose value is detected by FGM, SBMG should then be used to confirm the result.

Resistance to data loss from the Freestyle Libre: impact on glucose variability indices and recommendations for data analysis

Like many wearables, flash glucose monitoring relies on user compliance and is subject to missing data. As recent research is beginning to utilise glucose technologies as behaviour change tools, it is important to understand whether missing data are tolerable. Complete Freestyle Libre data files were amputed to remove 1-6 h of data both at random and over mealtimes (breakfast, lunch, and dinner). Absolute percent errors (MAPE) and intraclass correlation coefficients (ICC) were calculated to evaluate agreement and reliability. Thirty-two (91%) participants provided at least 1 complete day (24 h) of data (age: 44.8 ± 8.6 years, female: 18 (56%); mean fasting glucose: 5.0 ± 0.6 mmol/L). Mean and continuous overall net glycaemic action (CONGA) (60 min) were robust to data loss (MAPE ≤3%). Larger errors were calculated for standard deviation, coefficient of variation (CV) and mean amplitude of glycaemic excursions (MAGE) at increasing missingness (MAPE: 2%-10%, 2%-9%, and 4%-18%, respectively). ICC decreased as missing data increased, with most indicating excellent reliability (>0.9) apart from certain MAGE ICCs, which indicated good reliability (0.84-0.9). Researchers and clinicians should be aware of the potential for larger errors when reporting standard deviation, CV, and MAGE at higher rates of data loss in nondiabetic populations. But where mean and CONGA are of interest, data loss is less of a concern. Novelty: As research now utilises flash glucose monitoring as behavioural change tools in nondiabetic populations, it is important to consider the influence of missing data. Glycaemic variability indices of mean and CONGA are robust to data loss, but standard deviation, CV, and MAGE are influenced at higher rates of missingness.

A systematic review on clinical implication of continuous glucose monitoring in diabetes management

Objective

The aim of this systematic review was to evaluate the clinical implications of continuous glucose monitoring (CGM) among patients with diabetes mellitus using variables that include glycated hemoglobin (HbA1c), estimated A1c, glucose variability, and users' perspectives.

Materials and Methods

This study analyzed 17 articles that were identified and studied according to the research question criteria. PRISMA guidelines were used for identification and screening of the literature. The required data were searched using Medscape, PubMed, PROSPERO, Wiley Library, Scopus, Clinical Trial Registry, and Trip.

Results

The articles reviewed were on the use of CGM in type 1 and type 2 diabetes mellitus, which showed significant improvement in the levels of HbA1c as compared to non-CGM. The application of CGM on acute sudden onset type of adverse drug reactions (i.e., hypoglycemia) is better than fasting blood sugar or self-monitoring of blood glucose or capillary blood glucose (random blood glucose monitoring). CGM is beneficial for use in patients with type 2 diabetes mellitus including elderly patients as it gives information regarding glucose variability as well as HbA1c levels. The health-care providers require full spectrum of patients' CGM data to design a better therapeutic plan. However, the patients experienced inconvenience on wearing the device on the body for longer periods. The findings also stated the fact that more education and training is required for the patients to interpret their own glycemic data using CGM and modify their lifestyle accordingly. Use of CGM along with HbA1c has also been used to achieve better glycemic results and it allows the health care professional to guide patients in terms of their glucose level; whether they are hypoglycemic or hyperglycemic, however its use has some controversies that minimize its application.

Conclusion

The study concluded that CGM has significant potential in the management of not only patients with type 1 diabetes mellitus but also patients with type 2 diabetes mellitus in spite of the few limitations that are being improvised in the upcoming years. However, limited literature of CGM among patients with type 2 diabetes mellitus and pregnant women reduces the practice scope.

Continuous glucose monitoring for hypoglycaemia in children: Perspectives in 2020

Hypoglycaemia in children is a major risk factor for adverse neurodevelopment with rates as high as 50% in hyperinsulinaemic hypoglycaemia (HH). A key part of management relies upon timely identification and treatment of hypoglycaemia. The current standard of care for glucose monitoring is by infrequent fingerprick plasma glucose testing but this carries a high risk of missed hypoglycaemia identification. High-frequency Continuous Glucose Monitoring (CGM) offers an attractive alternative for glucose trend monitoring and glycaemic phenotyping but its utility remains largely unestablished in disorders of hypoglycaemia. Attempts to determine accuracy through correlation with plasma glucose measurements using conventional methods such as Mean Absolute Relative Difference (MARD) overestimate accuracy at hypoglycaemia. The inaccuracy of CGM in true hypoglycaemia is amplified by calibration algorithms that prioritize hyperglycaemia over hypoglycaemia with minimal objective evidence of efficacy in HH. Conversely, alternative algorithm design has significant potential for predicting hypoglycaemia to prevent neuroglycopaenia and consequent brain dysfunction in childhood disorders. Delays in the detection of hypoglycaemia, alarm fatigue, device calibration and current high cost are all barriers to the wider adoption of CGM in disorders of hypoglycaemia. However, machine learning, artificial intelligence and other computer-generated algorithms now offer significant potential for further improvement in CGM device technology and widespread application in childhood hypoglycaemia.

TIR generated by continuous glucose monitoring is associated with peripheral nerve function in type 2 diabetes

AIMS

Continuous glucose monitoring (CGM)-derived time-in-range (TIR) of 3.9-10 mmol/L is associated with diabetic retinopathy in type 2 diabetes (T2DM), but its relationship to peripheral nerve function has not been previously investigated. To explore the association between the TIR and nerve conduction study parameters in patients with T2DM, we performed a cross-sectional analysis.

METHODS

A total of 740 patients with T2DM were enrolled in this study. All of the participants were divided into tertiles according to the TIR (TIR low: ≤53%; TIR medium: 54-76%; TIR high: ≥77%). Composite Z-scores of nerve conduction velocity (CV), latency, and amplitude were calculated. The linear correlation between the TIR and composite nerve function Z-score was evaluated and risk assessment was analysed using binary logistic regression.

RESULTS

The composite Z-score of the CV and amplitude increased with higher TIR and the composite Z-score of latency significantly decreased as the TIR tertiles increased (all P trend < 0.05). After adjusting for age, diabetes duration, height, weight and other confounding factors, higher TIR was associated with a higher composite Z-score of CV (β = 0.230, P < 0.001), amplitude (β = 0.099, P = 0.010), and lower composite Z-score of latency (β = -0.172, P < 0.001). The risk of TIR tertiles and low composite Z-score of CV remained significant even after adjustment of HbA1c (TIR medium: OR = 0.48, P = 0.001; TIR high: OR = 0.41, P < 0.001).

CONCLUSIONS

Higher TIR tertiles were independently associated with better peripheral nerve function. CGM-derived TIR may be a promising approach to screen patients for further assessment of possible diabetic peripheral neuropathy.

Continuous Glucose Monitoring of Glycemic Variability During Fasting Post-Sleeve Gastrectomy

INTRODUCTION

Day-long fasting creates considerable metabolic stress that poses challenges in people with diabetes and those who have undergone bariatric surgery. Clinical knowledge of glucose fluctuations and the risks for such patients during fasting is limited.

OBJECTIVES

This study examined the effect of intermittent fasting on glucose excursions, hypoglycemia, and hyperglycemia in people with or without diabetes who had sleeve gastrectomy compared with healthy individuals.

METHODS

This open-label, prospective study compared interstitial glucose profiles measured with continuous glucose monitoring system for 72 h during fasting and non-fasting periods between four groups comprising 15 participants each: people with obesity and medicine-treated type 2 diabetes (T2D) only, obesity and T2D treated with sleeve gastrectomy, obesity without T2D treated with sleeve gastrectomy, and healthy, normal-weight non-diabetic controls.

RESULTS

The mean 72-h glucose concentration was significantly lower during the fasting period for all groups (p ≤ 0.041), with the highest glucose concentrations in the medicine-treated T2D-only group and the lowest concentrations in the sleeve gastrectomy in non-T2D group. The mean glucose profiles of all the groups showed a marked increase in interstitial glucose on breaking the fast, which was exaggerated in the two diabetes groups. The mean amplitude of glycemic excursions did not differ significantly within each group between fasting and non-fasting. No significant difference was noted in the fraction of time in the hypoglycemic range between the fasting and non-fasting periods in any group.

CONCLUSION

Intermittent fasting had no adverse effect on glycemic control in people with or without diabetes who had undergone sleeve gastrectomy.

Analysis and Testing of a Suitable Compatible Electrode's Material for Continuous Measurement of Glucose Concentration

The subject of the submitted work is the proposal of electrodes for the continual measurement of the glucose concentration for the purpose of specifying further hemodynamic parameters. The proposal includes the design of the electronic measuring system, the construction of the electrodes themselves and the functionality of the entire system, verified experimentally using various electrode materials. The proposed circuit works on the basis of micro-ammeter measuring the size of the flowing electric current and the electrochemical measurement method is used for specifying the glucose concentration. The electrode system is comprised of two electrodes embedded in a silicon tube. The solution consists of the measurement with three types of materials, which are verified by using three solutions with a precisely given concentration of glucose in the form of a mixed solution and enzyme glucose oxidase. For the testing of the proposed circuit and the selection of a suitable material, the testing did not take place on measurements in whole blood. For the construction of the electrodes, the three most frequently used materials for the construction of electrodes used in clinical practice for sensing biopotentials, specifically the materials Ag/AgCl, Cu and Au, were used. The performed experiments showed that the material Ag/AgCl, which had the greatest sensitivity for the measurement even without the enzyme, was the most suitable material for the electrode. This conclusion is supported by the performed statistical analysis. On the basis of the testing, we can come to the conclusion that even if the Ag/AgCl electrode appears to be the most suitable, showing high stability, gold-plated electrodes showed stability throughout the measurement similarly to Ag/AgCl electrodes, but did not achieve the same qualities in sensitivity and readability of the measured results.

10-Day structured initiation protocol from multiple daily injection to hybrid closed-loop system in children and adolescents with type 1 diabetes

AIM

The aim of this study was to evaluate the 10-day initiation protocol for MiniMed 670G hybrid closed-loop (HCL) system in individuals with type 1 diabetes on multiple daily injection (MDI) in achieving desirable glycemic control.

METHODS

An open-label single-arm, single-center, clinical investigation in children aged 7-18 years on MDI following a structured protocol: 2 days, HCL system assessment; 5 days, HCL system training (2-h sessions on 5 consecutive days with groups of 3-5 participants and families); 3 days, Manual Mode use of HCL system; 84 days, Auto Mode use of the HCL system, cumulating in 10 days from MDI to Auto Mode activation.

RESULTS

A total of 30 children (age 10.24 ± 2.6 years) were enrolled in the study, and all completed the planned 84 days on Auto Mode. The participants used the sensor for a median of 92% of the time and spent a median of 89% in Auto Mode. The mean HbA1c decreased from 8.2 ± 1.4% (66 ± 15.3 mmol/mol) at baseline to 6.7 ± 0.5% (50 ± 5.5 mmol/mol) at the end of the study (p = 0.017). Time in range (70-180 mg/dL) increased from 46.9 ± 18.5% at baseline to 75.6 ± 6.9% in Auto Mode (p < 0.001). This was achieved while spending 2.8% of the time below 70 mg/dL and without any severe hypoglycemia or DKA.

CONCLUSION

Children and adolescents with type 1 diabetes on MDI therapy can successfully initiate the HCL system, using a concise structured 10-day protocol.

Comparing effects of continuous glucose monitoring systems (CGMs) and self-monitoring of blood glucose (SMBG) amongst adults with type 2 diabetes mellitus: a systematic review protocol

BACKGROUND

Continuous glucose monitorings (CGMs) have been used to manage diabetes with reasonable glucose control amongst patients with type 2 diabetes (T2D) in recent decades. CGMs measure interstitial fluid glucose levels to provide information about glucose levels, which identify fluctuation that would not have been identified with conventional self-monitoring. Self-monitoring of blood glucose (SMBG) is a classical tool to measure glycaemic changes. However, the effectiveness of glucose control, hypoglycemia, weight change, quality of life and user satisfaction, are needed to evaluate and compare CGMs and SMBG amongst adults with T2D.

METHODS

The review will compare the various forms of CGM systems (i.e flash CGM, real-time CGM, retrospective CGM) versus SMBG or usual intervention regarding diabetes management amongst adults with T2D. The following databases will be searched: Cochrane Library, PubMed, EMBASE, CINAHL, PsycINFO, Scopus and grey literature (ClinicalTrials.gov, PsycEXTRA, ProQuest Dissertations, Google Scholar and Theses Global) for the identification of studies. The studies involving adults (aged ≥ 18 years old) will be included. We will only include and summarise randomised clinical trials (RCTs) with respect to authors, publication type, year, status and type of devices. Studies published in English between February 2010 and March 2020, will be included as the field of CGMs amongst T2D patients has emerged over the last decade. Primary outcomes will be HbA1c (glycosylated haemoglobin level) (mmol/L), body weight (kg), time spent with hypoglycaemia (< 70 mg/dl) or hyperglycaemia (≥ 180 mg/dl), blood pressure (< 140/90 mmHg is considered as good management) and quality of life (understanding and feeling of living situation based on culture and value system). Secondary outcome measures will be user satisfaction (patient or treatment/intervention satisfaction or satisfaction scale) and barriers (physical and mental difficulties or issues). Study selection, data extraction and risk of bias assessment will be conducted independently by at least two reviewers. A third reviewer will determine and resolve discrepancies. Moreover, the quality of the evidence of the review will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation tool (GRADE).

DISCUSSION

The review will synthesise evidence on the comparison between using CGMs and SMBG. The results will support researchers and health professionals to determine the most effective methods/technologies in the overall diabetes management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020149212.

Continuous Glucose Monitoring as a Matter of Justice

Type 1 diabetes (T1D) is a chronic illness that requires intensive lifelong management of blood glucose concentrations by means of external insulin administration. There have been substantial developments in the ways of measuring glucose levels, which is crucial to T1D self-management. Recently, continuous glucose monitoring (CGM) has allowed people with T1D to keep track of their blood glucose levels in near real-time. These devices have alarms that warn users about potentially dangerous blood glucose trends, which can often be shared with ther people. CGM is consistently associated with improved glycemic control and reduced hypoglycemia and is currently recommended by doctors. However, due to the costs of CGM, only those who qualify for hospital provision or those who can personally afford it are able to use it, which excludes many people. In this paper, I argue that unequal access to CGM results in: (1) unjust health inequalities, (2) relational injustice, (3) injustice with regard to agency and autonomy, and (4) epistemic injustice. These considerations provide prima facie moral reasons why all people with T1D should have access to CGM technology. I discuss the specific case of CGM policy in the Netherlands, which currently only provides coverage for a small group of people with T1D, and argue that, especially with additional considerations of cost-effectiveness, the Dutch government ought to include CGM in basic health care insurance for all people with T1D.

Continuous Glucose Monitoring as a Matter of Justice

Type 1 diabetes (T1D) is a chronic illness that requires intensive lifelong management of blood glucose concentrations by means of external insulin administration. There have been substantial developments in the ways of measuring glucose levels, which is crucial to T1D self-management. Recently, continuous glucose monitoring (CGM) has allowed people with T1D to keep track of their blood glucose levels in near real-time. These devices have alarms that warn users about potentially dangerous blood glucose trends, which can often be shared with ther people. CGM is consistently associated with improved glycemic control and reduced hypoglycemia and is currently recommended by doctors. However, due to the costs of CGM, only those who qualify for hospital provision or those who can personally afford it are able to use it, which excludes many people. In this paper, I argue that unequal access to CGM results in: (1) unjust health inequalities, (2) relational injustice, (3) injustice with regard to agency and autonomy, and (4) epistemic injustice. These considerations provide prima facie moral reasons why all people with T1D should have access to CGM technology. I discuss the specific case of CGM policy in the Netherlands, which currently only provides coverage for a small group of people with T1D, and argue that, especially with additional considerations of cost-effectiveness, the Dutch government ought to include CGM in basic health care insurance for all people with T1D.

Clinical Performance of Flash Glucose Monitoring System in Patients with Liver Cirrhosis and Diabetes Mellitus

Flash glucose monitoring system (FGMS) is an improved subset of continuous glucose monitoring with a recognized effectiveness on glycemic control, though validation in patients with Liver Cirrhosis (LC) is lacking. To evaluate the accuracy of FGMS in patients with Type 2 Diabetes Mellitus (DM) and LC, a prospective, case-control study was performed in 61 ambulatory patients with LC and DM (LC group, n = 31) or DM (Control group, n = 30). During 14 days, patients performed 4 assessments per day of self-monitoring of blood glucose (SMBG, reference value) followed by FGMS scanning. There were 2567 paired SMBG and FGMS values used in the accuracy analysis, with an overall mean absolute relative difference (MARD) of 12.68% in the LC group and 10.55% in the control group (p < 0,001). In patients with LC, the percentage of readings within Consensus Consensus Error Grid analysis Zone A and A + B were 80.36% and 99,26%, respectively. Sensor clinical accuracy was not affected by factors such as body mass index, age, gender, Child-Pugh score or edematoascitic decompensation. This is the first study to approach FGMS clinical accuracy in LC, revealing a potential usability of this system to monitor glycemic control in this population.

Glycemic Variability and Hypoglycemic Excursions With Continuous Glucose Monitoring Compared to Intermittently Scanned Continuous Glucose Monitoring in Adults With Highest Risk Type 1 Diabetes

BACKGROUND

The I-HART CGM study has shown that real-time continuous glucose monitoring (rtCGM) has greater beneficial impact on hypoglycemia than intermittently scanned continuous glucose monitoring (iscCGM) in adults with type 1 diabetes at high risk (Gold score ≥4 or recent severe hypoglycemia using insulin injections). In this subanalysis, we present the impact of rtCGM and iscCGM on glycemic variability (GV).

METHODS

Forty participants were recruited to this parallel group study. Following two weeks of blinded rtCGM (DexcomG4), participants were randomized to rtCGM (Dexcom G5; n = 20) or iscCGM (Freestyle Libre; n = 20) for eight weeks. An open-extension phase enabled participants on rtCGM to continue for a further eight weeks and those on iscCGM to switch to rtCGM over this period. Glycemic variability measures at baseline, 8- and 16-week endpoints were compared between groups.

RESULTS

At the eight-week endpoint, between-group differences demonstrated significant reduction in several GV measures with rtCGM compared to iscCGM (GRADE%hypoglycemia, index of glycemic control [IGC], and average daily risk range [ADRR]; P < .05). Intermittently scanned continuous glucose monitoring reduced mean average glucose and glycemic variability percentage and GRADE%hyperglycemia compared with rtCGM (P < .05). At 16 weeks, the iscCGM group switching to rtCGM showed significant improvement in GRADE%hypoglycemia, personal glycemic status, IGC, and ADRR.

CONCLUSION

Our data suggest most, but not all, GV measures improve with rtCGM compared with iscCGM, particularly those measures associated with the risk of hypoglycemia. Selecting appropriate glucose monitoring technology to address GV in this high-risk cohort is important to minimize the risk of glucose extremes and severe hypoglycemia.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03028220.

Continuous glucose monitor use with and without remote monitoring in pregnant women with type 1 diabetes: A pilot study

BACKGROUND

To examine whether continuous glucose monitoring (CGM) with remote monitoring by followers (family/friends) changes glucose management, follower interventions, and health outcomes compared to CGM alone in pregnant women with diabetes.

METHODS

We prospectively stratified first trimester pregnant women with Type 1 Diabetes to CGM Share (remote monitoring) or CGM Alone. We enrolled a main follower per woman. We retrospectively acquired data for pregnant women who did not use CGM (no CGM). We compared hemoglobin A1c (HbA1c) between groups. We compared sensor glucose, follower interventions, and gestational outcomes between CGM Alone and CGM Share. Longitudinal mixed effects models were used for analyses of changes in outcomes over time.

RESULTS

HbA1c decreased in all groups throughout pregnancy and was significantly lower over time in women using CGM Share (n = 15) compared to CGM Alone (n = 13) or no CGM (n = 8) (p = 0.0042). CGM Share users had lower median sensor glucose levels (p = 0.0331) and percent time spent >180 mg/dL (p = 0.0228) across pregnancy. There were no significant differences in maternal and fetal outcomes between groups. CGM Share followers had more alerts for hypoglycemia, but did fewer interventions.

CONCLUSIONS

In this small pilot study, use of CGM with remote monitoring improved some glycemic metrics in pregnant women with diabetes.

The changing face of paediatric diabetes

The purpose of this review is to provide an update on the changing face of paediatric type 1 diabetes and type 2 diabetes. Paediatric diabetes is on the rise, with extensive research dedicated to understanding its pathophysiology, comorbidities and complications. As obesity continues to increase among all youth, differentiating between type 1 diabetes and type 2 diabetes has become increasingly difficult but remains important for optimising treatment, anticipating complications and predicting disease risk. Novel treatments are emerging, with the ultimate goal being to achieve glycaemic control, limit weight gain, improve quality of life and reduce comorbidities. In this review, we focus on updates regarding the epidemiology, clinical presentation, comorbidities and complications of paediatric type 1 diabetes and type 2 diabetes and conclude with current and emerging treatments.