Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes

Real-World Continuous Glucose Monitoring Data from a Population with Type 1 Diabetes in South Korea: Nationwide Single-System Analysis

Background: We used continuous glucose monitoring (CGM) data to investigate glycemic outcomes in a real-world population with type 1 diabetes (T1D) from South Korea, where the widespread use of CGM and the nationwide education program began almost simultaneously. Methods: Data from Dexcom G6 users with T1D in South Korea were collected between January 2019 and January 2023. Users were included if they provided at least 90 days of glucose data and used CGM at least 70% of the days in the investigational period. The relationship between CGM utilization and glycemic metrics, including the percentage of time in range (TIR), time below range (TBR), and time above range (TAR), was assessed. The study was approved by the Institutional Review Board of Samsung Medical Center (SMC 2023-05-030). Results: A total of 2288 users were included. Mean age was 41.5 years (57% female), with average uploads of 428 days. Mean TIR was 62.4% ± 18.5%, mean TBR <70 mg/dL was 2.6% ± 2.8%, mean TAR >180 mg/dL was 35.0% ± 19.3%, mean glucose was 168.1 ± 35.8 mg/dL, mean glucose management indicator was 7.2% ± 0.9%, and mean coefficient of variation was 36.7% ± 6.0%. Users with higher CGM utilization had higher TIR (67.8% vs. 52.7%), and lower TBR <70 mg/dL (2.3% vs. 4.7%) and TAR >180 mg/dL (30.0% vs. 42.6%) than those with low CGM utilization (P < 0.001 for all). Users whose data were shared with others had higher TIR than those who did not (63.3% vs. 60.8%, P = 0.001). Conclusions: In this South Korean population, higher CGM utilization was associated with a favorably higher mean TIR, which was close to the internationally recommended target. Using its remote data-sharing feature showed beneficial impact on TIR.

Intermittently scanned continuous glucose monitoring provides no benefit over structured self-monitoring of blood glucose in type 2 diabetes not on prandial insulin, in the context of diabetes self-management education: GLucose monitoring programme SingaporE (GLiMPSE)

OBJECTIVE

We evaluated the impact of intermittently scanned continuous glucose monitoring(is-CGM)over self-monitoring of blood glucose(SMBG) in the context of diabetes self-management education (DSME) in sub-optimally controlled type 2 diabetes(T2D) in a multi-ethnicsetting.

RESEARCH DESIGN AND METHOD

Randomized-controlled, open-label trial (NCT04564911), of T2D with HbA1c ≥ 7.5-≤10 %, on oral agents with/without basal insulin was carried out. Intervention arm received 6 weeks(w) continuous is-CGM, followed by one is-CGM/month till 24w. Control arm was advised to perform 4 SMBG/day. Educationwas delivered at weeks 0, 2, 8, 16.

PRIMARY OUTCOME

Change in HbA1c from baseline at 24w. Modified intention-to-treat (mITT) analysis with linear mixed-effect model for repeated measurementswas performed.

RESULTS

176 subjects, age 55 ± 10.7 years(y), DM duration 11 ± 7.3y, BMI 27.8 ± 5.9 kg/m2, 58 % Male, 29.5 % basal insulin users were analysed. Within each arm,from baseline to 24w, mean HbA1c decreasedby -0.6 % (-6.6.mmol/mol, p-value < 0.01)and weight decreased(isCGM: -1.44 kg; SMBG: -1.25 kg, both p < 0.01). These changes were sustained to one year. However, there wasno significant difference in these parameters between arms (p-value > 0.05).

CONCLUSION

In the context of DSME, use of either SMBG or is-CGM led to improved glycaemia and reduced weight over a period of 24 weeks, sustained to one year.

Risk predictors of glycaemic control in children and adolescents with type 1 diabetes: A systematic review and meta-analysis

OBJECTIVES

To conduct systematic evaluation of the risk predictors of glycaemic control in children and adolescents with type 1 diabetes mellitus.

METHODS

Cohort studies on risk predictors of glycaemic control in children and adolescents with type 1 diabetes were retrieved from CNKI, PubMed, Web of Science, Embase databases, etc. from the construction of the repository to 3 February 2023. Literature screening was conducted according to inclusion and exclusion criteria, then data extraction of region, sample size, age, follow-up time, risk predictors, outcome indicators, etc., and quality evaluation of The Newcastle-Ottawa Scale were conducted by two researchers while the third researcher makes decisions if there are disagreements. Finally, Revman5.4 and StataMP17 were used for meta-analysis.

RESULTS

A total of 29 studies were included, and the results showed that insulin pump [Weighed mean difference (WMD) = -.48, 95% CI (-.73, -.24), p < .01], high-frequency sensor monitoring, early use of insulin pumps, prospective follow-up male, white race, large body mass index-standardised scoring, conscientiousness, agreeableness of mothers, eicosapentaenoic acid, leucine and protein (p < .05) were beneficial for reducing HbA1c levels in children and adolescents with diabetes. Ketoacidosis [WMD = .39, 95% CI (.28, .50), p < .01], selective admission, higher HbA1c level at one time (p < .01), higher glutamate decarboxylase antibody at 1 month after diagnosis, lower socio-economic status, non-living with biological parents, non-two-parent family, family disorder, family history of diabetes and high carbohydrate intake (p < .05) increased HbA1c levels in children and adolescents with diabetes.

CONCLUSION

For children and adolescents with type 1 diabetes mellitus, the use of insulin pump, high-frequency sensor monitoring, prospective follow-up, good family support and reasonable diet are conducive to blood glucose control, while selective admission and DKA are not. Disease characteristics and demographic characteristics of children are closely related to subsequent blood glucose control, and the relationship between diagnosis age and blood glucose control needs to be further explored.

Comparative Effectiveness of Hybrid Closed-Loop Automated Insulin Delivery Systems Among Patients with Type 1 Diabetes

BACKGROUND

Clinical trials have demonstrated the efficacy and safety of hybrid closed-loop (HCL) systems, yet few studies have compared outcomes in the real-world setting.

METHOD

This retrospective study analyzed patients from an academic endocrinology practice between January 1, 2018, and November 18, 2022. The inclusion criteria were diagnosis code for type I diabetes (T1D), >18 years of age, new to any HCL system [Medtronic 670G/770G (MT), Tandem Control IQ (CIQ), or Omnipod 5 (OP5)], and availability of a pump download within three months. The outcomes included %time in range (TIR) of 70 to 180 mg/dL, %time below range (TBR) <70 mg/dL at 90 days, and HbA1c for 91 to 180 days.

RESULT

Of the 176 participants, 47 were MT, 74 CIQ, and 55 OP5. Median (25%, 75%) change in HbA1c was -0.1 (-0.8, 0.3), -0.6 (-1.1, -0.15), and -0.55 (-0.98, 0)% for MT, CIQ, and OP5, respectively, (P = .04). TIR was 70 (57, 76), 67 (59, 75), and 68 (60, 76)% (P = .95) at 90 days while TBR was 2 (1, 3), 1 (0, 2), and 1 (0, 1)%, respectively, (P = .002). The %time in automated delivery was associated with TIR and change in HbA1c. After controlling other factors including %time in automated delivery, HCL type was not an independent predictor of change in HbA1c nor TIR but remained a significant predictor of TBR.

CONCLUSION

There were significant reductions in HbA1c in CIQ and OP5. TIR was similar across pumps, but TBR was highest with MT. The %time in automated delivery likely explains differences in change in HbA1c but not TBR between HCL systems.

Exploring Technology's Influence on Health Behaviours and Well-being in Type 1 Diabetes: a Review

PURPOSE OF REVIEW

Maintaining positive health behaviours promotes better health outcomes for people with type 1 diabetes (T1D). However, implementing these behaviours may also lead to additional management burdens and challenges. Diabetes technologies, including continuous glucose monitoring systems, automated insulin delivery systems, and digital platforms, are being rapidly developed and widely used to reduce these burdens. Our aim was to review recent evidence to explore the influence of these technologies on health behaviours and well-being among adults with T1D and discuss future directions.

RECENT FINDINGS

Current evidence, albeit limited, suggests that technologies applied in diabetes self-management education and support (DSME/S), nutrition, physical activity (PA), and psychosocial care areas improved glucose outcomes. They may also increase flexibility in insulin adjustment and eating behaviours, reduce carb counting burden, increase confidence in PA, and reduce mental burden. Technologies have the potential to promote health behaviours changes and well-being for people with T1D. More confirmative studies on their effectiveness and safety are needed to ensure optimal integration in standard care practices.

Insulin therapy among diabetic patients in rural communities of Sub-Saharan Africa: a perspective review

In this perspective review, we describe a brief background on the status quo of diabetes mellitus-related therapies and glycemic control among patients in rural communities in sub-Saharan Africa. The article discusses insulin therapy as well as the difficulties in obtaining insulin and oral hypoglycemic medications for diabetic patients living in sub-Saharan Africa. We wrap up our discussion with suggestions on solutions and opportunities for future research to tackle this health challenge in these impoverished communities. We conducted a literature search from PubMed and Google Scholar up until August 2023. Key words were used to generate search terms used to retrieve the required information. All types of literature with pertinent information on the current topic were included in the study. Diabetes mellitus is on the rise in sub-Saharan Africa. Several studies have reported poor glycemic control, low screening rates for diabetes mellitus, cigarette smoking, high alcohol consumption, prescription of antidiabetic therapy, and associated costs as contributors to the uptake of antidiabetic treatment. Although there is paucity of data on the extent of insulin therapy uptake and its possible modifiable contributors among the diabetic patients in the region, the anticipated increase in the number of people with diabetes on the continent makes it critical for global leaders to address the research gaps in insulin therapy among rural communities of sub-Saharan Africa, thus reducing the burden of diabetes in these populations.

Effectiveness of Insulin Pump Therapy Versus Multiple Daily Injections for Glycemic Control and Rate of Diabetic Ketoacidosis Among Children With Type 1 Diabetes Mellitus

Background Advances in pump technology and the availability of insulin analogs, as well as the results of the Diabetes Control and Complications Trial (DCCT), which established the benefit of improved glycemic control, have all contributed to the increased use of insulin pump therapy in recent years, particularly in children. Purpose This research aims to compare the impact of insulin delivery method, i.e., continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) on glycemic control and the rate of diabetic ketoacidosis (DKA) among children with type 1 diabetes mellitus in Al Ahsa, Saudi Arabia. Methods  A retrospective cohort study was carried out in a diabetic center in Al Ahsa, Saudi Arabia, over 24 months (2020-2022) among children with type I diabetes mellitus (age group 1-14 years). Results  In total, 351 patients with diabetes were induced, with 316 (90%) on MDI and 35 (10%) on CSII. After six months of diagnosis, precisely 38 (12%) of patients with diabetes on the MDI regimen experienced DKA, compared to 4 (11.4%) of those on the CSII regimen, with no statistically significant difference (P=0.918). At six months and nine months of follow-up, the average hemoglobin A1c (HbA1c) was considerably higher in diabetic patients on MDI (8.9 ± 1.7% vs. 8.2 ± 1.5% and 9.1 ± 1.6% vs. 8.0 ± 1.3%, respectively, with a significant p-value ≤0.05). Conclusion In this study, we found that patients on the MDI regimen had considerably higher HbA1c levels than patients on the CSII regimen, but there was no statistically significant difference in DKA rates between them. This is a short-term follow-up study, and we recommend that patients be followed for a longer period of time for further accurate outcomes.

Effects of hybrid closed-loop system on glycemic control and psychological aspects in persons with type 1 diabetes treated with sensor-augmented pump: A prospective single-center observational study

AIMS/INTRODUCTION

This study evaluated the effects of the Medtronic MiniMed 770G hybrid closed-loop system on glycemic control and psychological aspects in persons with type 1 diabetes mellitus.

MATERIALS AND METHODS

This 3-month prospective observational study included 22 participants with type 1 diabetes mellitus who used the Medtronic MiniMed 640G predictive low-glucose suspend system and were switched to the 770G system. Time in the range of 70-180 mg/dL and glycated hemoglobin levels were evaluated; satisfaction, emotional distress and quality of life were assessed using self-reported questionnaires, including the Diabetes Treatment Satisfaction Questionnaire Status, Problem Area in Diabetes and Diabetes Therapy-Related Quality of Life.

RESULTS

Time in the range of 70-180 mg/dL increased (63.5 ± 13.4 to 73.0 ± 10.9% [mean ± standard deviation], P = 0.0010), and time above the range of 181-250 mg/dL decreased (26.9 ± 8.9 to 19.6 ± 7.1%, P < 0.0005). Glycated hemoglobin levels decreased (7.7 ± 1.0 to 7.2 ± 0.8%, P = 0.0021). The percentage of participants with time below the range of 54-69 mg/dL <4% of readings increased from 91% to 100% (P < 0.0005). No significant changes were detected in the satisfaction, emotional distress and quality of life levels, but increased sensor calibration might be related to worsened emotional distress and quality of life.

CONCLUSIONS

The hybrid closed-loop system decreased hyperglycemia and minimized hypoglycemia, but did not improve psychological aspects compared with the predictive low-glucose suspend system, probably because sensor calibration was increased.

Addressing disparities in technology use among patients with type 1 diabetes: a review

PURPOSE OF REVIEW

The benefits of continuous glucose monitors (CGMs) and insulin pumps in the management of type 1 diabetes (T1D) are widely recognized. However, glaring disparities in access exist, particularly in marginalized and economically disadvantaged groups that stand to benefit significantly from diabetes technology use. We will review recent data describing drivers of these disparities and approaches to address the disparities.

RECENT FINDINGS

Several qualitative studies were published in recent years that have investigated the drivers of disparities reported over the past decades. These studies report that in addition to typical barriers seen in the diabetes technology, marginalized patients have unique challenges that make insulin pumps and CGMs less accessible.

SUMMARY

Barriers to technology use in these groups include stigmatization, lack of support, financial constraints, provider biases, stringent insurance policies, and clinic infrastructure. To address inequities, multifaceted strategies across community, healthcare, and provider sectors are essential. Key initiatives include enhancing public awareness, refining health policies, ensuring access to high-quality care, and emphasizing patient-centered approaches. The equitable use of technology can narrow the gap in T1D outcomes. The social and economic implications of suboptimal T1D management further underscore the urgency of these efforts for both improved health outcomes and cost-efficient care.

Advantages of sensor-augmented insulin pump therapy for pregnant women with type 1 diabetes mellitus

AIMS/INTRODUCTION

To evaluate the efficacy of sensor-augmented pump (SAP) for improving obstetric and neonatal outcomes among pregnant women with type 1 diabetes mellitus by comparing it with continuous subcutaneous insulin infusion plus self-monitoring of blood glucose (continuous subcutaneous insulin infusion [CSII]/SMBG).

MATERIALS AND METHODS

This retrospective cohort study included 40 cases of pregnancy complicated by type 1 diabetes mellitus treated with SAP (SAP group), and 29 cases of pregnancy complicated by type 1 diabetes mellitus treated with CSII/SMBG (CSII/SMBG group). The obstetric and neonatal outcomes were compared between the two groups.

RESULTS

The median of the glycoalbumin levels in the first (18.8% vs 20.9%; P < 0.05) and second (15.4% vs 18.0%; P < 0.05) trimesters, the hemoglobin A1c levels in the peripartum period (6.1% vs 6.5%; P < 0.05) and the standard deviation score of birthweights (0.36 vs 1.52; P < 0.05) were significantly lower in the SAP group than in the CSII/SMBG group. The incidence rate of large for gestational age newborns was significantly lower in the SAP group than in the CSII/SMBG group (27.5% vs 65.5%; P < 0.05). No significant differences in the incidence rates of hypertensive disorders of pregnancy, small for gestational age, respiratory distress syndrome, neonatal hypoglycemia, hypervolemia and hyperbilirubinemia were observed between the groups.

CONCLUSION

The present study showed that SAP therapy is more effective in preventing large for gestational age newborns in pregnant women with type 1 diabetes mellitus than CSII/SMBG.

Roadmap to the Effective Use of Continuous Glucose Monitoring: Innovation, Investigation, and Implementation

For 25 years, continuous glucose monitoring (CGM) has been evolving into what it is now: a key tool to both measure individuals' glycemic status and to help guide their day-to-day management of diabetes. Through a series of engineering innovations, clinical investigations, and efforts to optimize workflow implementation, the use of CGM is helping to transform diabetes care. This article presents a roadmap to the effective use of CGM that outlines past, present, and possible future advances in harnessing the potential of CGM to improve the lives of many people with diabetes, with an emphasis on ensuring that CGM technology is available to all who could benefit from its use.

Results From a Virtual Clinic for the Follow-up of Patients Using the Advanced Hybrid Closed-Loop System

BACKGROUND

Evidence regarding the implementation of medium-term strategies in advanced hybrid closed-loop (AHCL) system users is limited. Therefore, this study aimed to describe the efficacy and safety of the AHCL system in patients with type 1 diabetes (T1D) on a six-month follow-up in a virtual diabetes clinic (VDC).

METHOD

A prospective cohort of adult patients with T1D treated using the AHCL system (Mini Med 780G; Medtronic, Northridge, California) in a VDC follow-up. Standardized training and follow-up were conducted virtually. Clinical data and metabolic control outcomes were reported at baseline, and at three and six months.

RESULTS

Sixty-four patients (mean age = 42 ± 14.6 years, 65% men, 54% with graduate education) were included. Percentage time in range (%TIR) increased significantly regardless of prior therapy with intermittently scanned continuous glucose monitoring + multiple daily injections and sensor-augmented pump therapy with predictive low-glucose management after starting AHCL and persisted during the follow-up period with no hypoglycemic events. The %TIR 70 to 180 mg/dL according to socioeconomic strata was 73.4% ± 5.3%, 78.1% ± 8.1%, and 84.2% ± 7.5% for the lower, middle, and upper strata, respectively. The sensor was used more frequently in the population with a higher education level. Adherence to sensor use and SmartGuard retention were higher in patients who underwent the VDC follow-up.

CONCLUSIONS

Medium-term follow-up of users of AHCL systems in a VDC contributes to safely achieving %TIR goals. Virtual diabetes clinic follow-up favored adherence to sensor use and continuous SmartGuard use. Socioeconomic strata were associated with a better glycemic profile and education level was associated with better adherence to sensor use.

Guideline Development for Medical Device Technology: Issues for Consideration

Advances in the development of innovative medical devices and telehealth technologies create the potential to improve the quality and efficiency of diabetes care through collecting, aggregating, and interpreting relevant health data in ways that facilitate more informed decisions among all stakeholder groups. Although many medical societies publish guidelines for utilizing these technologies in clinical practice, we believe that the methodologies used for the selection and grading of the evidence should be revised. In this article, we discuss the strengths and limitations of the various types of research commonly used for evidence selection and grading and present recommendations for modifying the process to more effectively address the rapid pace of device and technology innovation and new product development.

Communication Protocols Integrating Wearables, Ingestibles, and Implantables for Closed-Loop Therapies

Body-conformal sensors and tissue interfacing robotic therapeutics enable the real-time monitoring and treatment of diabetes, wound healing, and other critical conditions. By integrating sensors and drug delivery devices, scientists and engineers have developed closed-loop drug delivery systems with on-demand therapeutic capabilities to provide just-in-time treatments that correspond to chemical, electrical, and physical signals of a target morbidity. To enable closed-loop functionality in vivo, engineers utilize various low-power means of communication that reduce the size of implants by orders of magnitude, increase device lifetime from hours to months, and ensure the secure high-speed transfer of data. In this review, we highlight how communication protocols used to integrate sensors and drug delivery devices, such as radio frequency communication (e.g., Bluetooth, near-field communication), in-body communication, and ultrasound, enable improved treatment outcomes.

Automated glycemic control with a bionic pancreas for type 1 diabetes mellitus: A systematic review and meta-analysis

BACKGROUND AND AIMS

The use of a bionic pancreas with automated insulin delivery systems to prevent complications of diabetes mellitus shows conflicting results. We aimed to comprehensively discuss the potential use of a bionic pancreas in patients with type 1 diabetes (T1D).

METHODS

A systematic database search was conducted on October 24, 2022, for articles investigating the use of a bionic pancreas in patients with T1D. The hemoglobin A1c (HbA1c) level, mean glucose level, glucose coefficient of variability, time-in-range (TIR), and adverse events were investigated.

RESULTS

Nine studies were included in this review. The data from these studies suggested that the use of a bionic pancreas could reduce the HbA1c (mean difference [MD] = -0.40% [95% confidence interval {CI} = -0.59 to -0.21], I2 = 0%, p < 0.0001) and mean glucose levels (MD = -21.06 [95% CI = -24.66 to -17.46], I2 = 45%, p < 0.00001) and improve the TIR (MD = 14.41% [95% CI = 10.99 to 17.83], I2 = 60%, p < 0.00001). The most common adverse events reported were nausea and vomiting.

CONCLUSIONS

The use of a bionic pancreas shows potential in preventing complications of T1D by improving the TIR and decreasing the HbA1c and mean glucose levels. Furthermore, serious adverse events with the use of a bionic pancreas and standard of care show insignificant results, suggesting a good safety profile.

An Opportunity for Improvement: Evaluation of Diabetes Technology Education Among Adult Endocrinology Training Programs

BACKGROUND

Despite increases in continuous glucose monitor (CGM) and insulin pump use in adults with diabetes, there is room for expansion. Technology adoption may be influenced by the training environment and fellowship education. However, little is known about adult endocrinology trainee comfort with, understanding of, or methods by which trainees receive education about diabetes technology.

METHODS

Mixed methods, sequential explanatory evaluation using survey and semi-structured interviews of endocrinology trainees and fellowship leadership in Accreditation Council for Graduate Medical Education (ACGME)-accredited adult endocrinology fellowship programs to assess trainee and leadership comfort with, perceived knowledge of, and current methods for diabetes technology education.

RESULTS

Seventy-seven respondents completed the survey. The majority of training programs have curricula for training on insulin pumps (74%) and CGM (75.3%); 52% of fellows felt curricula are adequate. First- and second-year fellows were more comfortable with CGM than insulin pump use. Only half of third-year fellows felt comfortable with starting insulin pump therapy or recommending insulin dose adjustments based on CGM rate of change arrows. Qualitative interviews identified the importance of both direct instruction and experiential learning in diabetes technology education.

CONCLUSIONS

Almost half of trainees feel that curricula for learning to use and manage insulin pumps and CGM are inadequate and feel uncomfortable with critical aspects of technology use, demonstrating the need for increased attention to trainee education in the use of diabetes technology. Based on a better understanding of current and preferred methods for instruction, this study provides direction for future development of initiatives to improve fellow education in this field.

Provision of continuous subcutaneous insulin infusion to type 1 diabetes 'frequent flyers'

A few people with type 1 diabetes undergo multiple hospital admissions for acute glycaemic events. We report on a series of five such 'frequent flyers' who were provided with continuous subcutaneous insulin infusion (CSII) therapy. Mean HbA1c decreased from 9.7 ± 2.5% (83 ± 27 mmol/mol) to 7.9 ± 0.4% (63 ± 4.7 mmol/mol) after 2-4 months. Frequency of admissions for acute glycaemic events reduced in three but increased in two patients within 6 months. Total insulin dose and body mass index decreased in some patients and satisfaction was anecdotally higher. Some, but not all, 'frequent flyers' benefited from a trial of CSII.

Racial Disparities in Diabetes Technology Adoption and Their Association with HbA1c and Diabetic Ketoacidosis

Aim

Poorer glycemic control and higher diabetic ketoacidosis (DKA) rates are seen in racial/ethnic minorities with type 1 diabetes (T1D). Use of diabetes technologies such as continuous glucose monitors (CGM), continuous subcutaneous insulin infusion (CSII) and automated insulin delivery (AID) systems has been shown to improve glycemic control and reduce DKA risk. We examined race/ethnicity differences in diabetes technology use and their relationship with HbA1c and DKA.

Methods

Data from patients aged ≥12 years with T1D for ≥1 year, receiving care from a single diabetes center, were examined. Patients were classified as Non-Hispanic White (n=3945), Non-Hispanic Black (Black, n=161), Hispanic (n=719), and Multiracial/Other (n=714). General linear models and logistic regression were used.

Results

Black (OR=0.22, 0.15-0.32) and Hispanic (OR=0.37, 0.30-0.45) patients were less likely to use diabetes technology. This disparity was greater in the pediatric population (p-interaction=0.06). Technology use associated with lower HbA1c in each race/ethnic group. Among technology users, AID use associated with lower HbA1c compared to CGM and/or CSII (HbA1c of 8.4% vs 9.2%, respectively), with the greatest difference observed for Black adult AID users. CSII use associated with a lower odds of DKA in the past year (OR=0.73, 0.54-0.99), a relationship that did not vary by race (p-interaction =0.69); this inverse association with DKA was not observed for CGM or AID.

Conclusion

Disparities in diabetes technology use, DKA, and glycemic control were apparent among Black and Hispanic patients with T1D. Differences in technology use ameliorated but did not fully account for disparities in HbA1c or DKA.

Pediatric Type 1 Diabetes: Mechanisms and Impact of Technologies on Comorbidities and Life Expectancy

Type 1 diabetes (T1D) is one of the most common chronic diseases in childhood, with a progressively increasing incidence. T1D management requires lifelong insulin treatment and ongoing health care support. The main goal of treatment is to maintain blood glucose levels as close to the physiological range as possible, particularly to avoid blood glucose fluctuations, which have been linked to morbidity and mortality in patients with T1D. Indeed, the guidelines of the International Society for Pediatric and Adolescent Diabetes (ISPAD) recommend a glycated hemoglobin (HbA1c) level < 53 mmol/mol (<7.0%) for young people with T1D to avoid comorbidities. Moreover, diabetic disease strongly influences the quality of life of young patients who must undergo continuous monitoring of glycemic values and the administration of subcutaneous insulin. In recent decades, the development of automated insulin delivery (AID) systems improved the metabolic control and the quality of life of T1D patients. Continuous subcutaneous insulin infusion (CSII) combined with continuous glucose monitoring (CGM) devices connected to smartphones represent a good therapeutic option, especially in young children. In this literature review, we revised the mechanisms of the currently available technologies for T1D in pediatric age and explored their effect on short- and long-term diabetes-related comorbidities, quality of life, and life expectation.

Islet transplantation-immunological challenges and current perspectives

Pancreatic islet transplantation is a minimally invasive procedure aiming to reverse the effects of insulin deficiency in patients with type 1 diabetes (T1D) by transplanting pancreatic beta cells. Overall, pancreatic islet transplantation has improved to a great extent, and cellular replacement will likely become the mainstay treatment. We review pancreatic islet transplantation as a treatment for T1D and the immunological challenges faced. Published data demonstrated that the time for islet cell transfusion varied between 2 and 10 h. Approximately 54% of the patients gained insulin independence at the end of the first year, while only 20% remained insulin-free at the end of the second year. Eventually, most transplanted patients return to using some form of exogenous insulin within a few years after the transplantation, which imposed the need to improve immunological factors before transplantation. We also discuss the immunosuppressive regimens, apoptotic donor lymphocytes, anti-TIM-1 antibodies, mixed chimerism-based tolerance induction, induction of antigen-specific tolerance utilizing ethylene carbodiimide-fixed splenocytes, pretransplant infusions of donor apoptotic cells, B cell depletion, preconditioning of isolated islets, inducing local immunotolerance, cell encapsulation and immunoisolation, using of biomaterials, immunomodulatory cells, etc.

Faster-acting insulin aspart reduces glycaemic variability in sensor-augmented pump treated type 1 diabetes patients

AIM

To evaluate the effect of faster aspart over glycaemic variability in type 1 diabetes (T1D) patients treated with sensor-augmented pump (SAP) in a real-world scenario.

METHODS

Observational study with SAP-treated adult T1D patients treated with faster aspart for three months. The primary endpoint was the mean amplitude of glucose excursions (MAGE).

RESULTS

Fifty patients were treated with faster aspart. Eleven patients (23%) withdrew during the follow-up mainly due to worsening of diabetes control (9 patients). Mean age was 41.2 yrs. (range 21-59) and T1D duration 22.4±10.0 yrs. Mean SAP treatment duration was 3.6±3.1 yrs. We detected a reduction of -7.0 (95% CI -1.1, -12.9; p=0.021) in MAGE at the end of the study. Other glycemic variability indices were also improved: standard deviation of mean interstitial glucose (-3mg/dl; 95% CI, -1, -5; p=0.01), CONGA4 (-2.2; 95% CI -0.3, -4.2; p=0.029), CONGA6 (-2.6; 95% CI -0.6, -4.6; p=0.011), GRADE (-0.5; 95% CI -0.1, -0.9; p=0.022), HBGI (-0.7; 95% CI -0.2, -1.3; p=0.013), J-index (-2.9; 95% CI -0.7, -5.0; p=0.011) and MODD (-5.7; 95% CI -1.7, -9.7; p=0.006). A slight reduction in mean glucose management indicator was also detected (-0.14%; 95% CI, -0.02, -0.27; -1.4mmol/mol; 95% CI -0.1, -3.3; p=0.03).

CONCLUSIONS

In SAP-treated T1D patients, faster aspart insulin was associated with reduced glycaemic variability, but also a high percentage of dropouts due to worsened glycaemic control. NCT04233203.

Switching from treatment with sensor augmented pump to hybrid closed loop system in type 1 diabetes: impact on glycemic control and neuropsychological tests in the real world

AIMS

The aim of this study is to assess in the real world the impact of initiating hybrid closed loop (HCL) on glycemic control and quality of life in patients using sensor-augmented pump (SAP).

METHODS

In this prospective study, patients using SAP changed to an HCL system in a specialized hospital. HCL devices used were Medtronic 780G®, Tandem Control-IQ® and Diabeloop® system. Glucometric data and hypoglycemia and neuropsychological tests were assessed at baseline and 3 months after initiating HCL.

RESULTS

A total of 66 consecutive patients were included (74% women, mean age 44±11 years, diabetes duration 27.2 ±11 years). Significant improvements were observed in coefficient of variation (from 35.6% to 33.1%), time in range (from 62.2 % to 73.8%), time above 180 mg/dl (from 26.9% to 18%), time below 70 mg/dl (from 3.3% to 2.1%) and time below 55 mg/dl (from 0.7% to 0.3%). In addition, significant improvements were observed in fear of hypoglycemia and grade of distress associated to treatment and to interpersonal sphere.

CONCLUSIONS

Switching from SAP to HCL system improves time in range and reduces time in hypoglycemia and glycemic variability at 3 months. These changes are accompanied by significant reduction of neuropsychological burden related to diabetes.

Metabolic Outcomes in Pediatric Patients One-Year Post-Total Pancreatectomy with Islet Autotransplantation after Early Pump Initiation

We previously published that insulin pump initiation immediately after IV insulin therapy was associated with improved post-surgical glycemic outcomes compared to multiple daily injections (MDI) in pediatric patients following a total pancreatectomy with islet autotransplantation (TPIAT). We investigated metabolic outcomes of this population at one-year post-TPIAT to assess if the improved outcomes in the early pump group were sustained over time. We retrospectively reviewed 40 patients post-TPIAT previously studied at 10-days post-surgery (15 used MDI and 25 used pump therapy immediately post-ICU, and all were discharged on pump therapy). Data analyzed included: demographics, islet equivalents per kilogram (IEQ/kg) transplanted, exogenous insulin use, and baseline vs. one-year (via mixed meal testing) HbA1c, fasting glucose, insulinogenic index, and the area under the curve (AUC) for insulin and c-peptide. More patients were off insulin at one year in the early pump group compared to the MDI group (45% vs. 13%, p = 0.07). Of all patients off insulin, 100% of the early pump users weaned off by six months post-TPIAT compared to 30% of the MDI users. Two known variables associated with favorable insulin outcomes, lower age and higher IEQ/kg, were not significantly different between groups. Fasting glucose was lower in the early pump group compared to the MDI group (median 97 vs. 122 mg/dL, p = 0.003), while AUC c-peptide was greater in early pump users at one-year post-TPIAT but did not reach significance (median 57.0 vs. 50.3 ng/mL × minutes, p = 0.14). Other metabolic outcomes did not differ between groups. Despite lower median age and higher IEQ/kg in the MDI group, the early pump group had a lower fasting glucose. Younger TPIAT age (p = 0.02) and early pump users (p = 0.04) were significantly associated with insulin independence at one year. This study was limited by sample size. Early pump use may have long-term benefits in post-TPIAT endogenous insulin secretion.

Insulin pump therapy with and without continuous glucose monitoring in pregnant women with type 1 diabetes: a prospective observational Orchestra Foundation study in Poland

AIMS

The effects of continuous subcutaneous insulin infusion (CSII) therapy with or without continuous glucose monitoring (CGM) on neonatal outcomes and glycemic outcomes of pregnant women with type 1 diabetes (T1D), living in Poland, were assessed.

METHODS

This prospective observational study enrolled women with T1D (N = 481, aged 18-45 years) who were pregnant or planned pregnancy. All used CSII therapy and a subset used CGM with CSII (CSII + CGM). Neonatal outcomes (e.g., rate of large for gestational age [LGA] delivery [birth weight > 90th percentile]) and maternal glycemia (e.g., HbA1c and percentage of time at sensor glucose ranges) were evaluated.

RESULTS

Overall HbA1c at trimesters 1, 2, and 3 was 6.8 ± 1.1% (50.9 ± 12.3 mmol/mol, N = 354), 5.8 ± 0.7% (40.1 ± 8.0 mmol/mol, N = 318), and 5.9 ± 0.7% (41.4 ± 8.0 mmol/mol, N = 255), respectively. A HbA1c target of < 6.0% (42 mmol/mol) at each trimester was achieved by 20.9% (74/354), 65.1% (207/318), and 58.0% (148/255), respectively. For women using CSII + CGM versus CSII only, HbA1c levels at trimesters 1, 2, and 3 were 6.5 ± 0.9% versus 7.1 ± 1.3% (47.8 ± 9.7 mmol/mol versus 54.3 ± 14.0 mmol/mol, p < 0.0001), 5.7 ± 0.6% versus 6.0 ± 0.9% (38.9 ± 6.5 mmol/mol versus 41.6 ± 9.3 mmol/mol, p = 0.0122), and 5.8 ± 0.6% versus 6.1 ± 0.8% (40.3 ± 6.9 mmol/mol versus 42.9 ± 9.1 mmol/mol, p = 0.0117), respectively. For the overall, CSII only, and CSII + CGM groups, rates of LGA delivery were 22.7% (74/326), 24.6% (34/138), and 21.3% (40/188), respectively.

CONCLUSIONS

Observational assessment of women with T1D using CSII therapy demonstrated low HbA1c throughout pregnancy and low rates of LGA. The addition of CGM to CSII therapy compared to CSII therapy alone was associated with some improved maternal glycemic and neonatal outcomes.

GOV IDENTIFIER

NCT01779141 (January 2013).

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

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.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Impact of continuous glucose monitoring in youth with type 1 diabetes aged 15-21 years

BACKGROUND

People with type 1 diabetes (T1D) aged <21 years are eligible for subsidised continuous glucose monitoring (CGM) products under the Australian National Diabetes Services Scheme. There are few real-world published studies to evaluate the benefits of CGM in young adults.

AIMS

To perform a real-world observation study among youth with T1D to evaluate CGM use and benefits of CGM.

METHODS

Patients at the Westmead Hospital Young Adult Diabetes Clinic aged 15-21 years who commenced CGM before July 2018 were followed for 6 months post commencement of CGM. Differences in HbA1c and glucose metrics at baseline and follow up are compared between those commencing CGM and those that did not.

RESULTS

Forty-four (38%) of 115 eligible patients commenced CGM. Demographic characteristics and baseline HbA1c did not differ significantly between those started on CGM and those that did not. At 6 months, 18 (41%) of 44 patients still used CGM, with discomfort and inconvenience the most common reasons for dropout. In CGM continuers, at 6 months compared with baseline, there was no change in HbA1c (8.2% vs 8.0%; P = 0.8), coefficient of variation of glucose (38% vs 39%; P = 0.5) or percentage time in range (52% vs 58%; P = 0.3). Six-month follow-up HbA1c in CGM non-users deteriorated significantly compared with users. Mean hypoglycaemia fear scores (worry scale) were significantly decreased from baseline at 6 months (33 vs 18; P < 0.01).

CONCLUSION

There are high rates of discontinuation in CGM use among youth with T1D. At 6 months of CGM use, there was no significant change in glycaemic control, although HbA1c in non-users deteriorated significantly. Worry of hypoglycaemia was significantly decreased among those who continued CGM.

Intermittent-scanned continuous glucose monitoring with low glucose alarms decreases hypoglycemia incidence in middle-aged adults with type 1 diabetes in real-life setting

OBJECTIVE

There is limited real-life data demonstrating that hypo-/hyperglycemic alarms added to continuous glucose monitoring (CGM) improve metabolic control in adults with type 1 diabetes (T1D). We evaluated the usefulness of switching from a flash or intermittent-scanned continuous glucose monitoring (is-CGM) device without low or higher glucose alarms to a is-CGM device with alarms to prevent hypoglycemia in adults with T1D.

METHODS

Individuals with T1D and fearful of hypoglycemia, prone to hypoglycemia unawareness, and/or experiencing severe hypoglycemia while using is-CGM Free Style Libre 1 (FSL1) were switched to FSL2 with individually-programmable low glucose alarms. The primary endpoint was the changes in % time below range (TBR%) <70 mg/dl [3.9 mmol/l] and <54 mg/dl [3.0 mmol/l] after 12 weeks on FSL2 compared with FSL1. Secondary endpoints were changes in % time in range (TIR% 70-180 mg/dl [3.9-10.0 mmol/l]), % time above range (TAR%) >180 [10.0 mmol/l], mean interstitial glucose, glycemic management indicator (GMI), interstitial glucose coefficient of variation (CV%), hemoglobin A1c, and sensor's scans/day.

RESULTS

We included 108 individuals (57.4 % men), aged 58.2 ± 17.3 [95 % CI: 55.0 to 61.5] years, with mean diabetes duration 25 ± 14.6 [95 % CI: 22.1 to 27.7] years. Among individuals, 40 (37.0 %) had hypoglycemia awareness with Clarke's score ≥4 and 19 (17.5 %) had a history of severe hypoglycemia. The median low glucose alarm threshold was 70 [IQR: 65-70] mg/dl (3.9 [IQR: 3.6-3.9] mmol/L). By comparison of first 12 weeks on FSL2 vs. last 12 weeks on FSL1, TBR% <70 mg/dl decreased from 4.5 ± 4.4 to 2.3 ± 2.8 % (p < 0.001), TBR% <54 mg/dl decreased from 1.4 ± 2.2 to 0.3 ± 0.9 % (p < 0.001). TIR% was not significantly different (51.5 ± 14.9 vs. 52.9 ± 16 % (p = 0.13)), nor was TAR% (43.8 ± 16.2 vs. 44.7 ± 16.5 % (p = 0.5)). CV% decreased from 39.4 ± 6.9 to 37.9 ± 6.1 % (p < 0.001). Those at risk for hypoglycemia (TBR >4 % and >1 %, respectively, at baseline) showed a significant decrease in the incidence of hypoglycemia <70 and <54 mg/dl (p < 0.0001). Patients' satisfaction with hypoglycemia alarms was high, since all individuals opted to pursue using individual alarm beyond the study period.

CONCLUSION

Switching from FSL1 to FSL2 with low glucose alarms reduced the frequency of hypoglycemia in middle-age adults with T1D, particularly in those who were prone to hypoglycemia awareness or severe hypoglycemia.

A Longitudinal View of Disparities in Insulin Pump Use Among Youth with Type 1 Diabetes: The SEARCH for Diabetes in Youth Study

Objective: To evaluate changes in insulin pump use over two decades in a national U.S. sample. Research Design and Methods: We used data from the SEARCH for Diabetes in Youth study to perform a serial cross-sectional analysis to evaluate changes in insulin pump use in participants <20 years old with type 1 diabetes by race/ethnicity and markers of socioeconomic status across four time periods between 2001 and 2019. Multivariable generalized estimating equations were used to assess insulin pump use. Temporal changes by subgroup were assessed through interactions. Results: Insulin pump use increased from 31.7% to 58.8%, but the disparities seen in pump use persisted and were unchanged across subgroups over time. Odds ratio for insulin pump use in Hispanic (0.57, confidence interval [95% CI] 0.45-0.73), Black (0.28, 95% CI 0.22-0.37), and Other race (0.49, 95% CI 0.32-0.76) participants were significantly lower than White participants. Those with ≤high school degree (0.39, 95% CI 0.31-0.47) and some college (0.68, 95% CI 0.58-0.79) had lower use compared to those with ≥bachelor's degree. Those with public insurance (0.84, 95% CI 0.70-1.00) had lower use than those with private insurance. Those with an annual household income <$25K (0.43, 95% CI 0.35-0.53), $25K-$49K (0.52, 95% CI 0.43-0.63), and $50K-$74K (0.79, 95% CI 0.66-0.94) had lower use compared to those with income ≥$75,000. Conclusion: Over the past two decades, there was no improvement in the racial, ethnic, and socioeconomic inequities in insulin pump use, despite an overall increase in use. Studies that evaluate barriers or test interventions to improve technology access are needed to address these persistent inequities.

A wearable, minimally-invasive, fully electrochemically-controlled feedback minisystem for diabetes management

Diabetes is a chronic disease affecting 10% of the population globally, and can lead to serious damage in the heart, kidneys, eyes, blood vessels or nerves. Commercial artificial closed-loop feedback systems can significantly improve diabetes management and save lives. However, they are large and expensive for users. Here, we demonstrate for the first time a wearable, minimally-invasive, fully electrochemically-controlled feedback minisystem for diabetes management. Both the working principles of the sensor and pump in the feedback system are based on electrochemical reactions. The smart minisystem was constructed based on integrating the thermoplastic polyurethane hollow microneedles with an electrochemical biosensing device on its outer layer and an electrochemical micropump facing the inner layer of the microneedles. The sensing device was constructed based on sputtering thin metal films through a shadow mask and electroplating Prussian blue on the surface of the microneedles, followed by the immobilization of glucose oxidase on the working electrode. The electrochemical micropump was constructed by sputtering the interdigital electrodes, followed by sealing with a thin elastic film, which was further integrated with the inner channels of the microneedles. Both the sensor and the pump were electrically powered. Via being controlled by a printed circuit board, the biosensing device monitored the levels of interstitial glucose continuously to drive the electrochemical pump to deliver insulin intelligently, in order to control blood glucose within the normal range. The closed-loop feedback system was studied for its capability in maintaining the blood glucose levels of diabetic rats under various physiological conditions. The utility of the intelligent feedback system was successfully demonstrated on diabetic rats for controlling the blood glucose levels within the normal range. The minisystem is wearable, small, cost-effective, precise, stable and painless. It is anticipated that this approach opens a new paradigm for the development of closed-loop diabetes minisystems and may lead to a compelling future for diabetes management.

Artificial intelligence for non-invasive glycaemic-events detection via ECG in a paediatric population: study protocol

Purpose

Paediatric Type 1 Diabetes (T1D) patients are at greater risk for developing severe hypo and hyperglycaemic events due to poor glycaemic control. To reduce the risk of adverse events, patients need to achieve the best possible glycaemic management through frequent blood glucose monitoring with finger prick or Continuous Glucose Monitoring (CGM) systems. However, several non-invasive techniques have been proposed aiming at exploiting changes in physiological parameters based on glucose levels. The overall objective of this study is to validate an artificial intelligence (AI) based algorithm to detect glycaemic events using ECG signals collected through non-invasive device.

Methods

This study will enrol T1D paediatric participants who already use CGM. Participants will wear an additional non-invasive wearable device for recording physiological data and respiratory rate. Glycaemic measurements driven through ECG variables are the main outcomes. Data collected will be used to design, develop and validate the personalised and generalized classifiers based on a deep learning (DL) AI algorithm, able to automatically detect hypoglycaemic events by using few ECG heartbeats recorded with wearable devices.

Results

Data collection is expected to be completed approximately by June 2023. It is expected that sufficient data will be collected to develop and validate the AI algorithm.

Conclusion

This is a validation study that will perform additional tests on a larger diabetes sample population to validate the previous pilot results that were based on four healthy adults, providing evidence on the reliability of the AI algorithm in detecting glycaemic events in paediatric diabetic patients in free-living conditions.

Trial registration

ClinicalTrials.gov identifier: NCT03936634. Registered on 11 March 2022, retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT05278143?titles=AI+for+Glycemic+Events+Detection+Via+ECG+in+a+Pediatric+Population&draw=2&rank=1.

Supplementary information

The online version contains supplementary material available at 10.1007/s12553-022-00719-x.

The Advanced Diabetes Technologies for Reduction of the Frequency of Hypoglycemia and Minimizing the Occurrence of Severe Hypoglycemia in Children and Adolescents with Type 1 Diabetes

Hypoglycemia is an often-observed acute complication in the management of children and adolescents with type 1 diabetes. It causes inappropriate glycemic outcomes and may impair the quality of life in the patients. Severe hypoglycemia with cognitive impairment, such as a convulsion and coma, is a lethal condition and is associated with later-onset cognitive impairment and brain-structural abnormalities, especially in young children. Therefore, reducing the frequency of hypoglycemia and minimizing the occurrence of severe hypoglycemia are critical issues in the management of children and adolescents with type 1 diabetes. Advanced diabetes technologies, including continuous glucose monitoring and sensor-augmented insulin pumps with low-glucose suspension systems, can reduce the frequency of hypoglycemia and the occurrence of severe hypoglycemia without aggravating glycemic control. The hybrid closed-loop system, an automated insulin delivery system, must be the most promising means to achieve appropriate glycemic control with preventing severe hypoglycemia. The use of these advanced diabetes technologies could improve glycemic outcomes and the quality of life in children and adolescents with type 1 diabetes.

[Insulin pump therapy and continuous glucose monitoring]

This Guideline represents the recommendations of the Austrian Diabetes Association (ÖDG) on the use of diabetes technology (insulin pump therapy; continuous glucose monitoring, CGM; hybrid closed-loop systems, HCL; diabetes apps) and access to these technological innovations for people with diabetes mellitus based on current scientific evidence.

Engineers in Medicine: Foster Innovation by Traversing Boundaries

Engineers play a critical role in the advancement of biomedical science and the development of diagnostic and therapeutic technologies for human well-being. The complexity of medical problems requires the synthesis of diverse knowledge systems and clinical experiences to develop solutions. Therefore, engineers in the healthcare and biomedical industries are interdisciplinary by nature to innovate technical tools in sophisticated clinical settings. In academia, engineering is usually divided into disciplines with dominant characteristics. Since biomedical engineering has been established as an independent curriculum, the term "biomedical engineers" often refers to the population from a specific discipline. In fact, engineers who contribute to medical and healthcare innovations cover a broad range of engineering majors, including electrical engineering, mechanical engineering, chemical engineering, industrial engineering, and computer sciences. This paper provides a comprehensive review of the contributions of different engineering professions to the development of innovative biomedical solutions. We use the term "engineers in medicine" to refer to all talents who integrate the body of engineering knowledge and biological sciences to advance healthcare systems.

Continuous subcutaneous insulin infusions: Closing the loop

CONTEXT

Continuous subcutaneous insulin infusions (CSIIs) and continuous glucose monitors (CGMs) have revolutionized the management of diabetes mellitus (DM). Over the last two decades the development of advanced, small, and user-friendly technology has progressed substantially, essentially closing the loop in the fasting and post-absorptive state, nearing the promise of an artificial pancreas. The momentum was mostly driven by the diabetes community itself, to improve its health and quality of life.

EVIDENCE ACQUISITION

Literature regarding CSII and CGM was reviewed.

EVIDENCE SYNTHESIS

Management of DM aims to regulate blood glucose to prevent long term micro and macrovascular complications. CSIIs combined with CGMs provide an integrated system to maintain tight glycemic control in a safe and uninterrupted fashion, while minimizing hypoglycemic events. Recent advances have allowed to 'close the loop' by better mimicking endogenous insulin secretion and glucose level regulation. Evidence supports sustained improvement in glycemic control with reduced episodes of hypoglycemia using these systems, while improving quality of life. Ongoing work in delivery algorithms with or without counterregulatory hormones will allow for further layers of regulation of the artificial pancreas.

CONCLUSION

Ongoing efforts to develop an artificial pancreas have created effective tools to improve the management of DM. CSIIs and CGMs are useful in diverse populations ranging from children to the elderly, as well as in various clinical contexts. Individually and more so together, these have had a tremendous impact in the management of DM, while avoiding treatment fatigue. However, cost and accessibility are still a hindrance to its wider application.

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

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).

Continuous Glucose Monitor, Insulin Pump, and Automated Insulin Delivery Therapies for Type 1 Diabetes: An Update on Potential for Cardiovascular Benefits

PURPOSE OF REVIEW

The incidence of type 1 diabetes (T1D) is rising in all age groups. T1D is associated with chronic microvascular and macrovascular complications but improving glycemic trends can delay the onset and slow the progression of these complications. Utilization of technological devices for diabetes management, such as continuous glucose monitors (CGM) and insulin pumps, is increasing, and these devices are associated with improvements in glycemic trends. Thus, device use may be associated with long-term prevention of T1D complications, yet few studies have investigated the direct impacts of devices on chronic complications in T1D. This review will describe common diabetes devices and combination systems, as well as review relationships between device use and cardiovascular outcomes in T1D.

RECENT FINDINGS

Findings from existing cohort and national registry studies suggest that pump use may aid in improving cardiovascular risk factors such as hypertension and dyslipidemia. Furthermore, pump users have been shown to have lower arterial stiffness and better measures of myocardial function. In registry and case-control longitudinal data, pump use has been associated with fewer cardiovascular events and reduction of cardiovascular disease (CVD) and all-cause mortality. CVD is the leading cause of morbidity and mortality in T1D. Consistent use of diabetes devices may protect against the development and progression of macrovascular complications such as CVD through improvement in glycemic trends. Existing literature is limited, but findings suggest that pump use may reduce acute cardiovascular risk factors as well as chronic cardiovascular complications and overall mortality in T1D.

Diabetestechnologie bei Kindern und Jugendlichen mit Diabetes mellitus Typ 1

Die Behandlung des Diabetes mellitus Typ 1 (T1D) im Kindes- und Jugendalter ist komplex und stellt eine Herausforderung für die betroffenen Kinder und Jugendlichen, deren Familien und das ganze Umfeld (Schule/Kindergarten) dar. Das Ziel der Diabetestherapie besteht darin, eine möglichst normoglykämische Blutzuckerkontrolle zu erreichen, um akuten und chronischen Komplikationen vorzubeugen. Laut Registerstudien können die metabolischen Therapieziele derzeit noch nicht erreicht werden, weswegen ein Risiko für Akut- und Spätkomplikationen besteht. Weitere Therapieziele sind eine normale Entwicklung, Inklusion, Flexibilität im Alltag sowie eine hohe Lebensqualität. Abgesehen von neueren Insulinanaloga gingen auch die Entwicklungen in der Diabetestechnologie in den letzten Jahren mit großen Veränderungen und Verbesserungen in der Behandlung und Lebensqualität der betroffenen Familien einher. Die Insulinpumpentherapie, die kontinuierliche Glukosemessung sowie die automatische Insulindosierung (AID) führten zu einer signifikanten Verbesserung der metabolischen Einstellung sowie einer Reduktion der schweren Hypoglykämien und Ketoazidosen. Die Diabetestechnologie entwickelt sich ständig weiter und erfordert eine umfassende Schulung und Fortbildung der betroffenen Familien, der Betreuungseinrichtungen sowie auch des multidisziplinären Behandlungsteams. Ziel sind eine Reduktion der glykämischen Variabilität und damit ein besseres Langzeitoutcome der jungen Menschen mit T1D. Die AID ist zunehmend die Therapie der Wahl bei Kindern und Jugendlichen mit T1D. Mit weiteren Innovationen im Bereich der Diabetestechnologie ist in naher Zukunft zu rechnen.

Insulin pump therapy is associated with higher rates of mild diabetic ketoacidosis compared to injection therapy: A 2-year Swedish national survey of children and adolescents with type 1 diabetes

OBJECTIVES

Diabetic ketoacidosis (DKA) in type 1 diabetes (T1D) can occur during both insulin pump therapy (continuous subcutaneous insulin infusion, CSII) and insulin injection therapy (multiple daily injections, MDI). The primary aim of this study was to compare CSII and MDI regarding DKA frequency. A secondary aim was to compare metabolic derangement between CSII and MDI at hospital admission for DKA. RESEARCH DESIGN AND METHODS: Children 0-17.99 years with established T1D admitted for DKA in Sweden from February 1, 2015 to January 31, 2017 were invited to participate. Data regarding demographics, laboratory data, CSII or MDI, and access to ketone meters and CGM were provided through questionnaires and medical records. The Swedish National Diabetes Registry (SWEDIABKIDS) was used to compare the distribution of CSII and MDI in the national population with the population admitted for DKA, using the chi-square goodness-of-fit test. Distribution of CSII and MDI was then categorized in clinical severity grades for mild (pH 7.20-7.29), moderate (pH 7.10-7.29) and severe DKA (pH <7.10).

RESULTS

The distribution of CSII at DKA admission was significantly larger than in the national pediatric population with T1D (74.7% vs. 59.7%, p = 0.002). CSII was overrepresented in mild DKA (85.2% vs. with CSII, p < 0.001), but not in moderate/severe DKA (57.9% with CSII, p = 0.82). Mean HbA1c at hospital admission was 73.9 mmol/mol with CSII and 102.7 mmol/mol with MDI.

CONCLUSIONS

CSII was associated with higher risk of mild DKA than MDI. MDI was associated with markedly higher HbA1c levels than CSII at hospital admission for DKA.

Children with type 1 diabetes in COVID-19 pandemic: Difficulties and solutions

Children/adolescents with type 1 diabetes (T1D) require holistic approach and continuous care. However, the coronavirus disease 2019 (COVID-19) pandemic has made challenges for the T1D children and their caregivers, professionals, and the healthcare system. This minireview aims to consolidate and discuss the difficulties and solutions of children with type 1 diabetes in the COVID-19 pandemic. T1D has been the most common type of diabetes in children and adolescents and the last decades has seen a rapid increase in the prevalence of T1D in youths worldwide, which deserves a public concern particularly in the COVID-19 pandemic. As reported in previous studies, T1D is a risk factor related to severe cases, while the virus may induce new-onset diabetes and serious complications. Moreover, restriction strategies influence medical availability and lifestyle, impact glycemic control and compilation management, and thus pose stress on families and health providers of youths with T1D, especially on those with certain fragile conditions. Therefore, special treatment plans are required for children provided by caregivers and the local health system. Latest health tools such as improved medical devices and telemedicine service, as well as a combined support may benefit in this period. This minireview emphasises that continued medical access and support are required to prevent deteriorated condition of children and adolescents with diabetes throughout this pandemic. Therefore, strategies are supposed to be formulated to mitigate the difficulties and stress among this group, particularly in the most at-risk population. Proposed solutions in this minireview may help individuals and the health system to overcome these problems and help youths with T1D in better diabetes management during such emergency situations.

Comparing the effectiveness of continuous subcutaneous insulin infusion with multiple daily insulin injection for patients with type 1 diabetes mellitus evaluated by retrospective continuous glucose monitoring: A real-world data analysis

Objective

Regarding the effects and practical application of insulin pumps on patients with type 1 diabetes mellitus (T1DM), the real-world evidence is limited especially concerning the incidence of hypoglycemia. This study aimed to compare the efficacy of continuous subcutaneous insulin infusion (CSII) therapy with multiple daily injection (MDI) therapy on glycemic metrics evaluated by retrospective continuous glucose monitoring (CGM) in Chinese patients with T1DM.

Methods

In total, 362 T1DM Chinese patients from the outpatient department of the Second Xiangya Hospital, Central South University, who underwent intensive insulin therapy and used a retrospective CGM system were included in this retrospective cross-sectional study. Comprehensive analysis of clinical and biological features and retrospective CGM derived-metrics was performed on the 362 enrolled T1DM patients who underwent CSII (n = 61) or MDI (n = 301) therapy (defined as 4 or more insulin injections per day).

Results

Our findings demonstrated that patients who underwent CSII therapy, compared with those who received MDI therapy, had lower levels of hemoglobin A1c (HbA1c) and fasting blood glucose; moreover, CSII therapy was associated with better glycemic outcomes in terms of increasing time in range (TIR), decreasing time above range (TAR), and achieving CGM-associated targets of TIR ≥70% and TAR <25%. However, patients who underwent CSII therapy did not experience decreasing time below range (TBR), achieving CGM-associated targets of TBR <4%, and reduction of the risk of hypoglycemia as evidenced by comparing TBR and low blood glucose index (LBGI) between the two treatment regimens. The parameters of glycemic variability, such as standard deviation of glucose (SD), mean amplitude glycemic excursion (MAGE), and large amplitude glycemic excursion (LAGE) in T1DM patients who underwent CSII therapy outperformed.

Conclusion

Our results provided further evidence that CSII therapy is safe and effective for management of Chinese T1DM patients, which was confirmed by a lower HbA1c level and better CGM-derived metrics but no demonstration of improvment in the risk of hypoglycemia. To achieve more satisfactory glycemic outcomes through the utilization of CSII therapy for Chinese T1DM patients, a strong physician-patient relationship is essential.

Insulin settings and their association with time in range in patients with type 1 diabetes users of predictive low glucose suspend (PLGS) augmented insulin pumps in Santiago, Chile

AIMS

Sensor augmented insulin pumps have become a powerful tool for managing type 1 diabetes (T1D). This study aimed to analyze the insulin pump configuration in users of predictive insulin suspension technology (PLGS).

METHODS

T1D patients on insulin pumps with PLGS (Medtronic 640G®) were enrolled. Data was obtained from medical records and pump data was downloaded for 30 days. Basal insulin, bolus calculator parameters, and PLGS operation parameters were analyzed and compared with Time in Range, Time Below Range, and Time Above Range.

RESULTS

112 patients were included, with average TIR of 73,96 % and HbA1c 7,0 % and 25 months of follow-up. Basal insulin remained similar to initial doses, with an increase of 27 % for the Dawn phenomenon. The Carbohydrate ratio was slightly more aggressive. Insulin sensitivity was 17 % less stringent than initially programmed. No differences were observed in Time in Rage according to the number of basal, ratio, and sensitivity segments. Time of insulin suspension correlated directly with Time Bellow Range.

CONCLUSIONS

Patients with good metabolic control have basal insulin programming similar to their initiation doses with less aggressive sensitivity factors. Excessive suspension time determined by PLGS could be an expression of excess insulin and increased hypoglycemia risk.

A Reinforcement Learning Based System for Blood Glucose Control without Carbohydrate Estimation in Type 1 Diabetes: In Silico Validation

Type 1 Diabetes (T1D) is a chronic autoimmune disease, which requires the use of exogenous insulin for glucose regulation. In current hybrid closed-loop systems, meal entry is manual which adds cognitive burden to the persons living with T1D. In this study, we proposed a control system based on Proximal Policy Optimisation (PPO) that controls both basal and bolus insulin infusion and only requires meal announcement, thus eliminating the need for carbohydrate estimation. We evaluated the system on a challenging meal scenario, using an open-source simulator based on the UVA/Padova 2008 model and achieved a mean Time in Range value of 65% for the adult subject cohort, while maintaining a moderate hypoglycemic and hyperglycemic risk profile. The approach shows promise and welcomes further research towards the translation to a real-life artificial pancreas. Clinical relevance- This was an in-silico analysis towards the development of an autonomous artificial pancreas system for glucose control. The proposed system show promise in eliminating the need for estimating the carbohydrate content in meals.