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Hannah KL, Nemlekar PM, Johnson ML, Cherñavvsky DR, Norman GJ. Continuous Glucose Monitoring and Reduced Diabetes-Related Hospitalizations in Patients with Type 2 Diabetes and CKD. Kidney360 2024; 5:515-521. [PMID: 38356161 DOI: 10.34067/kid.0000000000000396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/07/2024] [Indexed: 02/16/2024]
Abstract
Key Points
Patients with diabetes and CKD have a heightened risk of glycemic variability, which can lead to severe hypoglycemic or hyperglycemic events, potentially resulting in hospitalization.This study describes the results of a retrospective claims analysis of people with insulin-requiring type 2 diabetes and stage 3–5 CKD who initiated continuous glucose monitoring.Continuous glucose monitoring could help patients with type 2 diabetes and CKD control their glucose and avoid potentially dangerous glycemic events.
Background
There is a heightened risk of glycemic variability in patients with diabetes and CKD. This glycemic variability could lead to hypoglycemic or hyperglycemic crises. We hypothesized that initiation of continuous glucose monitoring (CGM), which provides a glucose measurement every 1–5 minutes, could reduce the incidence of hospitalizations for patients with type 2 diabetes (T2D) and CKD.
Methods
A retrospective analysis of US administrative claims data from the Optum Clinformatics database was conducted. People with T2D, using insulin, not receiving dialysis, and living with stage 3–5 CKD who initiated CGM between January 1, 2016, and March 31, 2022, were identified. National Drug Codes and Healthcare Common Coding Procedure System codes were used to identify CGM device use, and International Classification of Diseases 10th revision codes were used to identify CKD diagnosis and categorize health care encounters. Rates of diabetes-related hospitalizations were obtained, and multivariable logistic regression analyses revealed predictors of hypoglycemic and hyperglycemic encounters.
Results
A total of 8,959 insulin-using patients with T2D and CKD were identified. Most were White (72.3%), had Medicare insurance coverage (82.2%), were using intensive insulin (91.3%), and had stage 3 CKD (86.0%). After CGM initiation, rates of hospitalizations for hyperglycemia or hypoglycemia decreased by 18.2% and 17.0%, respectively (P < 0.0001 for both). The proportion hospitalized with at least one hypoglycemic or hyperglycemic event also significantly decreased after CGM initiation. Significant predictors of both hypoglycemic and hyperglycemic encounters included a previous encounter of that type, age 30–59 years and depression (for hypoglycemia), and age 30–49 years and neuropathy (for hyperglycemia). Use of CGM or glucagon-like peptide-1 receptor agonists was significantly protective against hypoglycemic encounters.
Conclusions
Initiation of CGM was associated with significant reductions in diabetes-related hospitalizations among insulin-using individuals with T2D and moderate-to-severe CKD. CGM could help patients with T2D and CKD control their glucose and avoid potentially dangerous glycemic events.
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DeBoer MD, Valdez R, Corbett JP, Krauthause K, Wakeman CA, Luke AS, Oliveri MC, Cherñavvsky DR, Patek SD. Effect of an Automated Advice Algorithm (CloudConnect) on Adolescent-Parent Diabetes-Specific Communication and Glycemic Management: A Randomized Trial. Diabetes Ther 2023; 14:899-913. [PMID: 37027118 PMCID: PMC10080500 DOI: 10.1007/s13300-023-01401-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/22/2023] [Indexed: 04/08/2023] Open
Abstract
INTRODUCTION Because adolescence is a time of difficult management of Type 1 diabetes (T1D) in part from adolescent-parent shared responsibility of T1D management, our objective was to assess the effects of a decision support system (DSS) CloudConnect on T1D-related communication between adolescents and their parents and on glycemic management. METHODS We followed 86 participants including 43 adolescents with T1D (not on automated insulin delivery systems, AID) and their parents/care-giver for a 12-week intervention of UsualCare + CGM or CloudConnect, which included a Weekly Report of automated T1D advice, including insulin dose adjustments, based on data from continuous glucose monitors (CGM), Fitbit and insulin use. Primary outcome was T1D-specific communication and secondary outcomes were hemoglobin A1c, time-in-target range (TIR) 70-180 mg/dl, and additional psychosocial scales. RESULTS Adolescents and parents reported a similar amount of T1D-related communication in both the UsualCare + CGM or CloudConnect groups and had similar levels of final HbA1c. Overall blood glucose time in range 70-180 mg/dl and time below 70 mg/dl were not different between groups. Parents but not children in the CloudConnect group reported less T1D-related conflict; however, compared to the UsualCare + CGM group, adolescents and parents in the CloudConnect reported a more negative tone of T1D-related communication. Adolescent-parent pairs in the CloudConnect group reported more frequent changes in insulin dose. There were no differences in T1D quality of life between groups. CONCLUSIONS While feasible, the CloudConnect DSS system did not increase T1D communication or provide improvements in glycemic management. Further efforts are needed to improve T1D management in adolescents with T1D not on AID systems.
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Affiliation(s)
- Mark D. DeBoer
- Division of Pediatric Endocrinology and Center for Diabetes Technology, University of Virginia, School of Medicine, PO Box 800386, Charlottesville, VA 22908 USA
- Department of Pediatrics, University of Virginia, Charlottesville, VA USA
| | - Rupa Valdez
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA USA
- Department of Engineering Systems and Environment, University of Virginia, Charlottesville, VA USA
| | - John P. Corbett
- Division of Pediatric Endocrinology and Center for Diabetes Technology, University of Virginia, School of Medicine, PO Box 800386, Charlottesville, VA 22908 USA
| | - Katie Krauthause
- Division of Pediatric Endocrinology and Center for Diabetes Technology, University of Virginia, School of Medicine, PO Box 800386, Charlottesville, VA 22908 USA
| | - Christian A. Wakeman
- Division of Pediatric Endocrinology and Center for Diabetes Technology, University of Virginia, School of Medicine, PO Box 800386, Charlottesville, VA 22908 USA
| | - Alexander S. Luke
- Division of Pediatric Endocrinology and Center for Diabetes Technology, University of Virginia, School of Medicine, PO Box 800386, Charlottesville, VA 22908 USA
| | - Mary C. Oliveri
- Division of Pediatric Endocrinology and Center for Diabetes Technology, University of Virginia, School of Medicine, PO Box 800386, Charlottesville, VA 22908 USA
| | - Daniel R. Cherñavvsky
- Division of Pediatric Endocrinology and Center for Diabetes Technology, University of Virginia, School of Medicine, PO Box 800386, Charlottesville, VA 22908 USA
- Department of Engineering Systems and Environment, University of Virginia, Charlottesville, VA USA
| | - Stephen D. Patek
- Division of Pediatric Endocrinology and Center for Diabetes Technology, University of Virginia, School of Medicine, PO Box 800386, Charlottesville, VA 22908 USA
- Department of Engineering Systems and Environment, University of Virginia, Charlottesville, VA USA
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Schoelwer MJ, Kanapka LG, Wadwa RP, Breton MD, Ruedy KJ, Ekhlaspour L, Forlenza GP, Cobry EC, Messer LH, Cengiz E, Jost E, Carria L, Emory E, Hsu LJ, Weinzimer SA, Buckingham BA, Lal RA, Oliveri MC, Kollman CC, Dokken BB, Cherñavvsky DR, Beck RW, DeBoer MD. Predictors of Time-in-Range (70-180 mg/dL) Achieved Using a Closed-Loop Control System. Diabetes Technol Ther 2021; 23:475-481. [PMID: 33689454 PMCID: PMC8252894 DOI: 10.1089/dia.2020.0646] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Studies of closed-loop control (CLC) in patients with type 1 diabetes (T1D) consistently demonstrate improvements in glycemic control as measured by increased time-in-range (TIR) 70-180 mg/dL. However, clinical predictors of TIR in users of CLC systems are needed. Materials and Methods: We analyzed data from 100 children aged 6-13 years with T1D using the Tandem Control-IQ CLC system during a randomized trial or subsequent extension phase. Continuous glucose monitor data were collected at baseline and during 12-16 weeks of CLC use. Participants were stratified into quartiles of TIR on CLC to compare clinical characteristics. Results: TIR for those in the first, second, third, and fourth quartiles was 54%, 65%, 71%, and 78%, respectively. Lower baseline TIR was associated with lower TIR on CLC (r = 0.69, P < 0.001). However, lower baseline TIR was also associated with greater improvement in TIR on CLC (r = -0.81, P < 0.001). During CLC, participants in the highest versus lowest TIR-quartile administered more user-initiated boluses daily (8.5 ± 2.8 vs. 5.8 ± 2.6, P < 0.001) and received fewer automated boluses (3.5 ± 1.0 vs. 6.0 ± 1.6, P < 0.001). Participants in the lowest (vs. the highest) TIR-quartile received more insulin per body weight (1.13 ± 0.27 vs. 0.87 ± 0.20 U/kg/d, P = 0.008). However, in a multivariate model adjusting for baseline TIR, user-initiated boluses and insulin-per-body-weight were no longer significant. Conclusions: Higher baseline TIR is the strongest predictor of TIR on CLC in children with T1D. However, lower baseline TIR is associated with the greatest improvement in TIR. As with open-loop systems, user engagement is important for optimal glycemic control.
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Affiliation(s)
- Melissa J. Schoelwer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | | | - R. Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | | | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory P. Forlenza
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Erin C. Cobry
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Laurel H. Messer
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eda Cengiz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emily Jost
- Barbara Davis Center for Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Lori Carria
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emma Emory
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Liana J. Hsu
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Stuart A. Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bruce A. Buckingham
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Rayhan A. Lal
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Mary Clancy Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Craig C. Kollman
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | | | - Daniel R. Cherñavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida, USA
| | - Mark D. DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Address correspondence to: Mark D. DeBoer, MD, MSc, MCR, Center for Diabetes Technology, University of Virginia, CFA Institute Building, 560 Ray C Hunt Drive, Charlottesville, VA 22903, USA
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Bisio A, Brown SA, McFadden R, Pajewski M, Yu PL, DeBoer M, Schoelwer MJ, Bonner HG, Wakeman CA, Cherñavvsky DR, Gonder-Frederick L. Sleep and diabetes-specific psycho-behavioral outcomes of a new automated insulin delivery system in young children with type 1 diabetes and their parents. Pediatr Diabetes 2021; 22:495-502. [PMID: 33289242 DOI: 10.1111/pedi.13164] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/03/2020] [Accepted: 11/11/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Data on the use of Control-IQ, the latest FDA-approved automated insulin delivery (AID) system for people with T1D 6 years of age or older is still scarce, particularly regarding nonglycemic outcomes. Children with T1D and their parents are at higher risk for sleep disturbances. This study assesses sleep, psycho-behavioral and glycemic outcomes of AID compared to sensor-augmented pump therapy (SAP) therapy in young children with T1D and their parents. METHODS Thirteen parents and their young children (ages 7-10) on insulin pump therapy were enrolled. Children completed an initial 4-week study with SAP using their own pump and a study CGM followed by a 4-week phase of AID. Sleep outcomes for parents and children were evaluated through actigraphy watches. Several questionnaires were administered at baseline and at the end of each study phase. CGM data were used to assess glycemic outcomes. RESULTS Actigraphy data did not show any significant change from SAP to AID, except a reduction of number of parental awakenings during the night (p = 0.036). Parents reported statistically significant improvements in Pittsburgh Sleep Quality Index total score (p = 0.009), Hypoglycemia Fear Survey total score (p = 0.011), diabetes-related distress (p = 0.032), and depression (p = 0.023). While on AID, time in range (70-180 mg/dL) significantly increased compared to SAP (p < 0.001), accompanied by a reduction in hyperglycemia (p = 0.001). CONCLUSIONS These results suggest that use of AID has a positive impact on glycemic outcomes in young children as well as sleep and diabetes-specific quality of life outcomes in their parents.
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Affiliation(s)
- Alessandro Bisio
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Sue A Brown
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA.,Department of Medicine, Division of Endocrinology and Metabolism, University of Virginia, Charlottesville, Virginia, USA
| | - Ryan McFadden
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Michael Pajewski
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Pearl L Yu
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA.,Sleep Disorder Center, University of Virginia, Charlottesville, Virginia, USA
| | - Mark DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA.,Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Melissa J Schoelwer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA.,Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Heather G Bonner
- Sleep Disorder Center, University of Virginia, Charlottesville, Virginia, USA
| | - Christian A Wakeman
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Daniel R Cherñavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA.,Department of Psychiatry, University of Virginia, Charlottesville, Virginia, USA
| | - Linda Gonder-Frederick
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA.,Department of Psychiatry, University of Virginia, Charlottesville, Virginia, USA
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Schoelwer MJ, Robic JL, Gautier T, Fabris C, Carr K, Clancy-Oliveri M, Brown SA, Anderson SM, DeBoer MD, Cherñavvsky DR, Breton MD. Safety and Efficacy of Initializing the Control-IQ Artificial Pancreas System Based on Total Daily Insulin in Adolescents with Type 1 Diabetes. Diabetes Technol Ther 2020; 22:594-601. [PMID: 32119790 DOI: 10.1089/dia.2019.0471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective: To assess the safety and efficacy of a simplified initialization for the Tandem t:slim X2 Control-IQ hybrid closed-loop system, using parameters based on total daily insulin ("MyTDI") in adolescents with type 1 diabetes under usual activity and during periods of increased exercise. Research Design and Methods: Adolescents with type 1 diabetes 12-18 years of age used Control-IQ for 5 days at home using their usual parameters. Upon arrival at a 60-h ski camp, participants were randomized to either continue Control-IQ using their home settings or to reinitialize Control-IQ with MyTDI parameters. Control-IQ use continued for 5 days following camp. The effect of MyTDI on continuous glucose monitoring outcomes were analyzed using repeated measures analysis of variance (ANOVA): baseline, camp, and at home. Results: Twenty participants were enrolled and completed the study; two participants were excluded from the analysis due to absence from ski camp (1) and illness (1). Time in range was similar between both groups at home and camp. A tendency to higher time <70 mg/dL in the MyTDI group was present but only during camp (median 3.8% vs. 1.4%, P = 0.057). MyTDI users with bolus/TDI ratios >40% tended to show greater time in the euglycemic range improvements between baseline and home than users with ratios <40% (+16.3% vs. -9.0%, P = 0.012). All participants maintained an average of 95% time in closed loop (84.1%-100%). Conclusions: MyTDI is a safe, effective, and easy way to determine insulin parameters for use in the Control-IQ artificial pancreas. Future modifications to account for the influence of carbohydrate intake on MyTDI calculations might further improve time in range.
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Affiliation(s)
- Melissa J Schoelwer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
- Department of Pediatrics, University of Virginia
| | - Jessica L Robic
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Thibault Gautier
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Chiara Fabris
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Kelly Carr
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Mary Clancy-Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Sue A Brown
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
- Division of Endocrinology, Department of Medicine, University of Virginia
| | - Stacey M Anderson
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
- Division of Endocrinology, Department of Medicine, University of Virginia
| | - Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Daniel R Cherñavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
- Dexcom, Inc., San Diego, California
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
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Breton MD, Cherñavvsky DR, Forlenza GP, DeBoer MD, Robic J, Wadwa RP, Messer LH, Kovatchev BP, Maahs DM. Closed-Loop Control During Intense Prolonged Outdoor Exercise in Adolescents With Type 1 Diabetes: The Artificial Pancreas Ski Study. Diabetes Care 2017; 40:1644-1650. [PMID: 28855239 PMCID: PMC5711335 DOI: 10.2337/dc17-0883] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/04/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Intense exercise is a major challenge to the management of type 1 diabetes (T1D). Closed-loop control (CLC) systems (artificial pancreas) improve glycemic control during limited intensity and short duration of physical activity (PA). However, CLC has not been tested during extended vigorous outdoor exercise common among adolescents. RESEARCH DESIGN AND METHODS Skiing presents unique metabolic challenges: intense prolonged PA, cold, altitude, and stress/fear/excitement. In a randomized controlled trial, 32 adolescents with T1D (ages 10-16 years) participated in a 5-day ski camp (∼5 h skiing/day) at two sites: Wintergreen, VA, and Breckenridge, CO. Participants were randomized to the University of Virginia CLC system or remotely monitored sensor-augmented pump (RM-SAP). The CLC and RM-SAP groups were coarsely paired by age and hemoglobin A1c (HbA1c). All subjects were remotely monitored 24 h per day by the study physicians and clinical team. RESULTS Compared with physician-monitored open loop, percent time in range (70-180 mg/dL) improved using CLC: 71.3 vs. 64.7% (+6.6% [95% CI 1-12]; P = 0.005), with maximum effect late at night. Hypoglycemia exposure and carbohydrate treatments were improved overall (P = 0.001 and P = 0.007) and during the daytime with strong ski level effects (P = 0.0001 and P = 0.006); ski/snowboard proficiency was balanced between groups but with a very strong site effect: naive in Virginia and experienced in Colorado. There was no adverse event associated with CLC; the participants' feedback was overwhelmingly positive. CONCLUSIONS CLC in adolescents with T1D improved glycemic control and reduced exposure to hypoglycemia during prolonged intensive winter sport activities, despite the added challenges of cold and altitude.
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Affiliation(s)
- Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | - Gregory P Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Jessica Robic
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - R Paul Wadwa
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Laurel H Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Boris P Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - David M Maahs
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO.,Department of Pediatrics, Stanford University, Stanford, CA
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DeBoer MD, Cherñavvsky DR, Topchyan K, Kovatchev BP, Francis GL, Breton MD. Heart rate informed artificial pancreas system enhances glycemic control during exercise in adolescents with T1D. Pediatr Diabetes 2017; 18:540-546. [PMID: 27734563 DOI: 10.1111/pedi.12454] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the safety and performance of using a heart rate (HR) monitor to inform an artificial pancreas (AP) system during exercise among adolescents with type 1 diabetes (T1D). MATERIALS AND METHODS In a randomized, cross-over trial, adolescents with T1D age 13 - 18 years were enrolled to receive on separate days either the unmodified UVa AP (stdAP) or an AP system connected to a portable HR monitor (AP-HR) that triggered an exercise algorithm for blood glucose (BG) control. During admissions participants underwent a structured exercise regimen. Hypoglycemic events and CGM tracings were compared between the two admissions, during exercise and for the full 24-hour period. RESULTS Eighteen participants completed the trial. While number of hypoglycemic events during exercise and rest was not different between visits (0.39 AP-HR vs 0.50 stdAP), time below 70 mg dL -1 was lower on AP-HR compared to stdAP, 0.5±2.1% vs 7.4±12.5% (P = 0.028). Time with BG within 70-180 mg dL -1 was higher for the AP-HR admission vs stdAP during the exercise portion and overall (96% vs 87%, and 77% vs 74%), but these did not reach statistical significance (P = 0.075 and P = 0.366). CONCLUSIONS Heart rate signals can safely and efficaciously be integrated in a wireless AP system to inform of physical activity. While exercise contributes to hypoglycemia among adolescents, even when using an AP system, informing the system of exercise via a HR monitor improved time <70 mg dL -1 . Nonetheless, it did not significantly reduce the total number of hypoglycemic events, which were low in both groups.
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Affiliation(s)
- Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia.,Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Daniel R Cherñavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Katarina Topchyan
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Boris P Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Gary L Francis
- Division of Endocrinology, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia.,Division of Pediatric Endocrinology, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
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8
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Gildersleeve R, Riggs SL, Cherñavvsky DR, Breton MD, DeBoer MD. Improving the Safety and Functionality of an Artificial Pancreas System for Use in Younger Children: Input from Parents and Physicians. Diabetes Technol Ther 2017; 19:660-674. [PMID: 28854339 DOI: 10.1089/dia.2017.0150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Artificial pancreas (AP) systems have initially been designed for and tested in teens and adults, but there is evidence that an AP system with additional support and safety systems could greatly benefit younger children with type 1 diabetes (T1D). SUBJECTS AND METHODS Five pediatric endocrinologists and 15 parents of children aged 5-8 years with T1D participated in a total of four focus groups. Focus groups investigated current diabetes technology use and acceptance, as well as possible modifications to the current adult AP system, which would allow for safe and successful use in younger children. Modifications discussed include child-specific functionality for input tasks, safety features, and monitoring capabilities. RESULTS Participant suggestions included the following: passcodes for differential access to AP features by parents, ancillary caregivers, and the child; preset early, intermediate, and advanced child access categories; maximal customization for general and alarm settings; simplified meal screens utilizing the AP' corrective blood glucose (BG) ability; automated exercise mode; spoken and dictated messaging capabilities; emergency contacts; treatment instructions for the child and caregiver; remote monitoring website and application; animated continuous glucose monitor BG trace; gamification, such as rewarding diabetes-friendly behaviors; and comprehensive training of all individuals involved in the child's diabetes care. CONCLUSION Parents and physicians were eager for AP applications to be available for younger children, but stressed that a modified system could better serve this group's needs for safety and improved diabetes-related communication. The diverse and emerging needs of 5-8-year olds require flexible and customizable systems for T1D management.
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Affiliation(s)
- Rachel Gildersleeve
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Sara L Riggs
- 2 Department of Industrial Engineering, Clemson University , Clemson, South Carolina
| | - Daniel R Cherñavvsky
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 3 TypeZero Technologies, Inc. , Charlottesville, Virginia
| | - Marc D Breton
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 3 TypeZero Technologies, Inc. , Charlottesville, Virginia
| | - Mark D DeBoer
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 4 Department of Pediatrics, Division of Pediatric Endocrinology, University of Virginia , Charlottesville, Virginia
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DeBoer MD, Breton MD, Wakeman C, Schertz EM, Emory EG, Robic JL, Kollar LL, Kovatchev BP, Cherñavvsky DR. Performance of an Artificial Pancreas System for Young Children with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:293-298. [PMID: 28426239 DOI: 10.1089/dia.2016.0424] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Young children 5-8 years old with type 1 diabetes (T1D) exhibit clear needs for improved glycemic control but may be limited in their ability to safely interact with an artificial pancreas system. Our goal was to evaluate the safety and performance of an artificial pancreas (AP) system among young children with T1D. RESEARCH DESIGN AND METHODS In a randomized, crossover trial, children with T1D age 5-8 years were enrolled to receive on separate study periods (in random order) either the UVa AP using the DiAs Control Platform software with child-resistant lock-out screens (followed as an out-patient admission) or their usual insulin pump+continuous glucose monitor (CGM) care at home. Hypoglycemic events and CGM tracings were compared between the two 68-h study periods. All analyses were adjusted for level of physical activity as tracked using Fitbit devices. RESULTS Twelve participants (median age 7 years, n = 6 males) completed the trial. Compared to home care, the AP admission resulted in increased time with blood glucose (BG) 70-180 mg/dL (73% vs. 47%) and lower mean BG (152 mg/dL vs. 190 mg/dL), both P < 0.001 after adjustment for activity. Occurrence of hypoglycemia was similar between sessions without differences in time <70 mg/dL (AP 1.1% ± 1.1%; home 1.6% ± 1.2%). There were no adverse events during the AP or home study periods. CONCLUSIONS Use of an AP in young children was safe and resulted in improved mean BG without increased hypoglycemia. This suggests that AP use in young children is safe and improves overall diabetes control. ClinicalTrials.gov registration number: NCT02750267.
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Affiliation(s)
- Mark D DeBoer
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 2 Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia , Charlottesville, Virginia
| | - Marc D Breton
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Christian Wakeman
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Elaine M Schertz
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Emma G Emory
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Jessica L Robic
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Laura L Kollar
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Boris P Kovatchev
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Daniel R Cherñavvsky
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 3 TypeZero Technologies, Inc., Charlottesville, Virginia
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Ly TT, Buckingham BA, DeSalvo DJ, Shanmugham S, Satin-Smith M, DeBoer MD, Oliveri MC, Schertz E, Breton MD, Cherñavvsky DR. Day-and-Night Closed-Loop Control Using the Unified Safety System in Adolescents With Type 1 Diabetes at Camp. Diabetes Care 2016; 39:e106-7. [PMID: 27271182 PMCID: PMC5878678 DOI: 10.2337/dc16-0817] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 04/25/2016] [Indexed: 02/03/2023]
Affiliation(s)
- Trang T Ly
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia
| | - Bruce A Buckingham
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - Daniel J DeSalvo
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - Satya Shanmugham
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - Marta Satin-Smith
- Children's Hospital of The King's Daughters, Norfolk, VA Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VA
| | - Mark D DeBoer
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
| | - Mary C Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Elaine Schertz
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA
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Cherñavvsky DR, DeBoer MD, Keith-Hynes P, Mize B, McElwee M, Demartini S, Dunsmore SF, Wakeman C, Kovatchev BP, Breton MD. Use of an artificial pancreas among adolescents for a missed snack bolus and an underestimated meal bolus. Pediatr Diabetes 2016; 17:28-35. [PMID: 25348683 DOI: 10.1111/pedi.12230] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/15/2014] [Accepted: 09/22/2014] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the safety and performance of the artificial pancreas (AP) in adolescents with type 1 diabetes (T1D) following insulin omission for food. RESEARCH DESIGN AND METHODS In a randomized, cross-over trial, adolescents with T1D aged 13-18 yr were enrolled in a randomized, cross-over trial. On separate days, received either usual care (UC) through their home insulin pump or used an AP system (Diabetes Assistant platform, continuous glucose monitor, and insulin pump). Approximately 1 h after admission, participants in both groups received an unannounced snack of 30 g carbohydrate, and 4 h later they received an 80 g lunch, for which both groups only received 75% of the calculated insulin dose to cover carbohydrates. On the UC day (but not the AP day), they received their full high blood glucose (BG) correction factor at lunch. Each admission lasted approximately 8 h. RESULTS A total of 16 participants completed the trial. On the AP day (compared to UC), mean BG was lower (197 ± 10 vs. 235 ± 14 mg/dL) and time in range 70-180 mg/dL was higher (43% ± 7 vs. 19% ± 7) (both p < 0.05) overall; these results held in the time following the snack and meal (also p < 0.05). During the trial, there were no differences between groups in the rate of hypoglycemia <70 mg/dL. CONCLUSIONS The AP provided improvements in short-term glycemic control without increases in hypoglycemia following missed insulin for food in adolescents. Thus, the AP partly compensates for missed insulin boluses for food, a common occurrence in adolescent diabetes care. Further testing is needed in longer-term settings.
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Affiliation(s)
- Daniel R Cherñavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Mark D DeBoer
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA.,Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Patrick Keith-Hynes
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Benton Mize
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Molly McElwee
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Susan Demartini
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA.,Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Spencer F Dunsmore
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Christian Wakeman
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Boris P Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | - Marc D Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
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Wadams H, Cherñavvsky DR, Lteif A, Basu A, Kovatchev BP, Kudva YC, DeBoer MD. Closed-loop control for pediatric Type 1 diabetes mellitus. ACTA ACUST UNITED AC 2015. [DOI: 10.2217/dmt.14.48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Kidney morphogenesis is accomplished by the coordinated interaction of molecular signals that culminate in the production of an organ that is architecturally and functionally ready for extrauterine, free life. In humans, nephrogenesis is completed before birth. However the kidney continues to mature both from a functional and anatomical point of view. Throughout its development, the kidney is susceptible to a variety of injurious agents. This brief review considers the basic mechanisms of kidney organogenesis and functional maturation. To illustrate some concepts, the renal alterations caused by interference with a normal regulatory system, the renin-angiotensin system is discussed.
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Affiliation(s)
- R A Gomez
- University of Virginia School of Medicine, Charlottesville 22908, USA.
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