Improved Glycemic Control through Continuous Glucose Sensor-Augmented Insulin Pump Therapy: Prospective Results from a Community and Academic Practice Patient Registry

Background

Conducted by highly experienced investigators with abundant time and resources, phase III studies of continuous glucose sensing (CGS) may lack generalizability to everyday clinical practice.

Method

Community or academic practices in six Central and Eastern European or Mediterranean countries prospectively established an anonymized registry of consecutive patients with type 1 insulin-dependent diabetes mellitus starting CGS-augmented insulin pump therapy with the Paradigm^® X22 (Medtronic MiniMed, Northridge, CA) under everyday conditions, without prior CGS with another device. We compared glycosylated hemoglobin (GHb) values before and after 3 months of CGS and assessed relationships between insulin therapy variables and glycemia-related variables at weeks 1, 4, and 12 of CGS.

Results

Of 102 enrolled patients, 85 (83%) with complete weeks 1, 4, and 12 sensor data and baseline/3-month GHb data were evaluable. Evaluable patients were ∼54% male and ∼75% adult (mean age, 33.2 ± 16.9 years) with longstanding diabetes and high personal/family education levels. Mean GHb declined significantly after 3 months of CGS (7.55 ± 1.33% at baseline to 6.81 ± 1.08% after 12 weeks, 0.74% absolute decrease, P < 0.001). The absolute GHb reduction correlated significantly (P < 0.0005) with baseline GHb: larger absolute reductions tended to occur when baseline levels were higher. An increased basal insulin dose as a percentage of the total daily insulin dose and a decreased daily bolus count from week 1 to week 12 of CGS predicted GHb improvement from baseline to week 12.

Conclusions

CGS-augmented insulin pump therapy appears to improve glycemic control in type 1 diabetes in varied everyday practice settings.     

Insulin Pump Safety Meeting: Summary Report

Diabetes Technology Society convened a panel of insulin pump experts in Bethesda, Maryland, on November 12, 2008, at the request of the Food and Drug Administration. The group consisted of physicians, nurses, diabetes educators, and engineers from across the United States. The panel members (1) discussed safety features of insulin pump therapy and (2) recommended adjustments to current insulin pump design and use to enhance overall safety. Software and hardware features of insulin pumps were analyzed from engineering, medical, nursing, and pump-user perspectives. The meeting was divided into four sections: (1) Engineering Safety—Designing Software and Hardware for Insulin Pump Therapy; (2) Patient Safety—Selecting Patients and Clinical Settings for Insulin Pump Use; (3) Clinical Safety—Determining and Delivering Insulin Dosages Using Insulin Pump Therapy; and (4) Personal Experiences—A Panel Discussion about Insulin Pump Safety. Six aspects of insulin pump technology were noted to present potential safety problems: (1) software, (2) wireless communication, (3) hardware, (4) alarms, (5) human factors, and (6) bolus-dose calculation. There was consensus among meeting participants that insulin pump therapy is beneficial in patients of all ages and that insulin pump safety must be assured through careful regulation.     

A Prospective Evaluation of Insulin Dosing Recommendations in Patients with Type 1 Diabetes at Near Normal Glucose Control: Bolus Dosing

Background

Current bolus insulin dosing recommendations are based on retrospective studies of patients with Type 1 diabetes in whom the glucose control was not intensely established. Using continuous glucose monitoring (CGM), we prospectively studied these recommendations in patients treated with continuous subcutaneous insulin infusion.

Methods

Thirty subjects were studied over a mean of two weeks of continuous glucose monitoring with near daily insulin adjustments. First a basal glucose goal was achieved of <5% of values <70 mg/dL and <20%>, 170mg/dL. Then bolus dosing factors; Insulin to Carbohydrate Ratio (g of meal carbohydrates/unit of insulin, ICR) and Correction Factor (mg/dL fall in blood glucose/unit of insulin, CF); were established for each meal time to a goal of ± 20% of premeal glucose (ICR) or 80-120 mg/dL (CF) by the fourth post bolus hour.

Results

All treatment goals were achieved in each subject. Modification of formulas from ICR = 450/Total Daily Dose (TDD) to ICR = (217/TDD) + 3 and from CF = 1700/TDD to CF = (1076/TDD) + 12 more closely matched observed results than published formulas. There was no significant difference in each factor with time of day. There was a highly significant relationship between ICR and CF, ICR*4.44 = CF (r = 0.9, p < 0.0005), total basal dose (TBD) and TDD.

Conclusions

Current formulas need to be modified to provide higher insulin bolus doses. The interrelationships between ICR, CF, TBD and TDD suggest that any change in one may require a change in the others.     

A Prospective Evaluation of Insulin Dosing Recommendations in Patients with Type 1 Diabetes at Near Normal Glucose Control: Basal Dosing

Background

Current basal insulin dosing recommendations are based on retrospective studies of Type 1 patients with diabetes in whom the glucose control was not intensely established. Using continuous glucose monitoring (CGM) we prospectively studied these recommendations in patients treated with continuous subcutaneous insulin infusion.

Methods

With CGM 30 subjects were titrated with daily insulin adjustments to achieve a basal glucose targets of <5% of values <70 mg/dl and <20%, >170mg/dl. The basal rate during meal time was studied by a sequential daily single meal omission until the glucose goals were achieved.

Results

Glucose targets were achieved in all subjects. The observed ratios of total basal dose (TBD) to total daily dose and TBD to weight, in kilograms, were 0.384 and 0.185, respectively. Previously reported formulas for estimating the TBD resulted in significantly higher values than we observed. The difference between the maximum to the minimum hourly basal insulin infusion rate was more than 100% and the peak rate was reached by 0200 hours in 73% of subjects. During the post study observation period in which there was no further study intervention and in those subjects with baseline A1C >6.9%, the A1C decreased 0.45 % (p = 0.0110) in a mean of 12.8 weeks.

Conclusions

Current literature overestimates TBD dose and underestimates the degree and the time of onset of the dawn phenomenon. Maintaining near normal glycemia in the ambulatory setting may be achieved in selected Type 1 patients for at least two weeks and maybe longer.     

A Novel Insulin Combination of Insulin Degludec and Insulin Aspart Achieves a More Stable Overnight Glucose Profile than Insulin Glargine: Results from Continuous Glucose Monitoring in a Proof-of-Concept Trial

Purpose

Insulin degludec coformulated with insulin aspart (as IDegAsp) can cover 24 h basal insulin and postprandial insulin requirements after a main meal with one injection. We compared glycemic stability following IDegAsp or insulin glargine (IGlar) given before the evening meal in patients with type 2 diabetes.

Methods

A subset of 112 insulin-naïve type 2 diabetes patients from a randomized, parallel-group trial (IDegAsp versus IGlar, each added to metformin) underwent 72 h continuous interstitial glucose (IG) monitoring after 16 weeks of treatment. End points included mean IG concentrations, 2 h postprandial IG increments and postprandial peak, IG fluctuation (summed area above and below mean IG), within-subject coefficient of variation (day-to-day variation) in mean nocturnal IG, and episodes of low (<3.5 mmol/liter) and high (>10 mmol/liter) IG. Values were derived for the entire 72 h, with the nocturnal interval (0001–0559 h) also assessed.

Results

The postdinner IG increment observed with IGlar did not occur with IDegAsp [IDegAsp - IGlar, -1.42 (-2.15, -0.70) mmol/liter]. Nocturnal IG fluctuation was 21% lower with IDegAsp [IDegAsp/IGlar, 0.79 (0.66, 0.96) mmol/liter], with 48% fewer nocturnal high IG episodes [ratio IDegAsp/IGlar, 0.52 (0.32, 0.87)].

Conclusions

IDegAsp given with the evening meal reduces postdinner glucose excursion and provides more stable nocturnal glycemia as compared with IGlar.J Diabetes Sci Technol 2013;7(5):1328–1336     

Treatment Intensification and Blood Glucose Control Among Hospitalized Diabetic Patients

Background Hyperglycemia is common among diabetic inpatients, and has been linked to adverse outcomes. However, antihyperglycemic treatment is seldom intensified in noncritical care patients, and the relationship between intensification frequency and glucose control is poorly understood. We evaluated the relationship between treatment intensification and changes in blood glucose in hospitalized diabetic patients. Design We retrospectively analyzed 3,613 hospitalized diabetic patients who were admitted to the hospital between January 2003 and August 2004, were not hospitalized in an ICU, were not prescribed IV insulin or total parenteral nutrition (TPN), had a length of stay of at least 3 days, and had at least one point-of-care blood glucose measurement. A linear model was used to assess the relationship between intensification of antihyperglycemic medications and the average daily change in point-of-care glucose measurements. Results Hyperglycemia (>180 mg/dL) was documented at least once for 82.5% of patient admissions. Antihyperglycemic treatment was intensified for 22.0% of days with hyperglycemia. Intensifications of scheduled and sliding scale insulin, but not oral medications, were associated with a 11.1 mg/dL (p < 0.0001) and 12.2 mg/dL (p < 0.0001) reduction in the average daily glucose, respectively. Hypoglycemia (<50 mg/dL) was documented on 2.2% of days after antihyperglycemic treatment intensification. Conclusion In this cohort, lack of treatment intensification in response to inpatient hyperglycemia was common. Antihyperglycemic treatment intensification was strongly associated with decrease in average daily glucose, while hypoglycemia was uncommon. This suggests that increasing the frequency of treatment intensifications could lead to improved glycemic control in inpatients with diabetes. Conference Abstract: American Diabetic Association 2007     

Artificial Pancreas Systems: Closed-Loop Artificial Pancreas Using Subcutaneous Glucose Sensing and Insulin Delivery and a Model Predictive Control Algorithm: Preliminary Studies in Padova and Montpellier

New effort has been made to develop closed-loop glucose control, using subcutaneous (SC) glucose sensing and continuous subcutaneous insulin infusion (CSII) from a pump, and a control algorithm. An approach based on a model predictive control (MPC) algorithm has been utilized during closed-loop control in type 1 diabetes patients. Here we describe the preliminary clinical experience with this approach.Six type 1 diabetes patients (three in each of two clinical investigation centers in Padova and Montpellier), using CSII, aged 36 ± 8 and 48 ± 6 years, duration of diabetes 12 ± 8 and 29 ± 4 years, hemoglobin A1c 7.4% ± 0.1% and 7.3% ± 0.3%, body mass index 23.2 ± 0.3 and 28.4 ± 2.2 kg/m², respectively, were studied on two occasions during 22 h overnight hospital admissions 2–4 weeks apart. A Freestyle Navigator® continuous glucose monitor and an OmniPod® insulin pump were applied in each trial. Admission 1 used open-loop control, while admission 2 employed closed-loop control using our MPC algorithm.In Padova, two out of three subjects showed better performance with the closed-loop system compared to open loop. Altogether, mean overnight plasma glucose (PG) levels were 134 versus 111 mg/dl during open loop versus closed loop, respectively. The percentage of time spent at PG > 140 mg/dl was 45% versus 12%, while postbreakfast mean PG was 165 versus 156 mg/dl during open loop versus closed loop, respectively. Also, in Montpellier, two patients out of three showed a better glucose control during closed-loop trials. Avoidance of nocturnal hypoglycemic excursions was a clear benefit during algorithm-guided insulin delivery in all cases.This preliminary set of studies demonstrates that closed-loop control based entirely on SC glucose sensing and insulin delivery is feasible and can be applied to improve glucose control in patients with type 1 diabetes, although the algorithm needs to be further improved to achieve better glycemic control.     

Performance and Acceptability of a Combined Device for Insulin Infusion and Glucose Sensing in the Home Setting

Background:

The use of sensor-augmented insulin pump (SAP) therapy is increasing. Currently, glucose sensors and insulin infusion cannulas are inserted separately. A new device, MiniMed Duo, combines sensing and infusion capabilities on the same platform and is intended to simplify device insertion and site management. We evaluated the device’s performance with respect to insulin delivery and glucose sensing, and its acceptability with patients.

Methods:

Forty-five patients (mean ± SD age, 45.5 ± 10.9 years, 48% female) with type 1 diabetes and previous use of SAP participated. Each subject was to wear 5 devices connected to insulin pumps over 15 days (3 days/device) and test capillary blood glucose (SMBG) 7 times/day. The primary endpoint was the percentage of sensor-SMBG paired values within 20% of one another. Subject experiences were assessed via questionnaires.

Results:

Overall, 74.8% of sensor-SMBG paired values were within 20%, meeting the primary accuracy endpoint, and the mean absolute relative difference was 15.5 ± 17.1%. Consensus error grid analysis showed that >95% of points were within the A+B zones, exceeding the threshold for adequate clinical accuracy. Insulin dosage and SMBG values did not change significantly compared to prestudy values. The functional survival of the device entering day 3 was 90.5%. There were no serious adverse events. Mean questionnaire results indicated overall satisfaction with the device.

Conclusion:

Duo provided insulin infusion and glucose sensing capabilities in a single device, which provided accurate glucose readings during routine use, was safe to wear, and was acceptable to most patients. It may improve satisfaction and convenience for patients using sensor-augmented insulin pumps.     

Computer-Aided Learning in Insulin Pump Training

This technical report concerns a novel, computer-aided learning tool for patients with diabetes. The goal of the tool is to make training in the use of an insulin pump “painless,” practical, effective, and educationally rewarding. This learning tool (or application) is unique because it

• uses a virtual pump to facilitate learning and allow the patient to practice pump operation,
• presents training tasks in a standardized format, and
• provides corrective feedback to help patients better understand and manage their diabetes.

The application’s acceptability was surveyed by 126 health care professionals who are experienced in diabetes education and certified in pump training. Results suggest that use of Insulet’s OmniPod^®Interactive Training is associated with increased training efficiency and promotes a positive attitude toward insulin pump therapy.     

Robust Fault Detection System for Insulin Pump Therapy Using Continuous Glucose Monitoring

Background

The popularity of continuous subcutaneous insulin infusion (CSII), or insulin pump therapy, as a way to deliver insulin more physiologically and achieve better glycemic control in diabetes patients has increased. Despite the substantiated therapeutic advantages of using CSII, its use has also been associated with an increased risk of technical malfunctioning of the device, which leads to an increased risk of acute metabolic complications, such as diabetic ketoacidosis. Current insulin pumps already incorporate systems to detect some types of faults, such as obstructions in the infusion set, but are not able to detect other types of fault such as the disconnection or leakage of the infusion set.

Methods

In this article, we propose utilizing a validated robust model-based fault detection technique, based on interval analysis, for detecting disconnections of the insulin infusion set. For this purpose, a previously validated metabolic model of glucose regulation in type 1 diabetes mellitus (T1DM) and a continuous glucose monitoring device were used. As a first step to assess the performance of the presented fault detection system, a Food and Drug Administration-accepted T1DM simulator was employed.

Results

Of the 100 in silico tests (10 scenarios on 10 subjects), only two false negatives and one false positive occurred. All faults were detected before plasma glucose concentration reached 300 mg/dl, with a mean plasma glucose detection value of 163 mg/dl and a mean detection time of 200 min.

Conclusions

Interval model-based fault detection has been proven (in silico) to be an effective tool for detecting disconnection faults in sensor-augmented CSII systems. Proper quantification of the uncertainty associated with the employed model has been observed to be crucial for the good performance of the proposed approach.     

Computerized Insulin Order Sets and Glycemic Control in Hospitalized Patients

Background

The purpose of this study was to evaluate the impact of computerized provider order entry subcutaneous insulin order sets on inpatient glycemic control and ordering behavior.

Treatment Satisfaction and Quality of Life for an Integrated Continuous Glucose Monitoring/Insulin Pump System Compared to Self-Monitoring Plus an Insulin Pump

Background

Little is known about how the most advanced technology affects treatment satisfaction and health-related quality of life (HRQOL) in adults with diabetes. This study was designed to assess treatment satisfaction and HRQOL among users of an integrated real-time (RT) continuous glucose monitoring (CGM)/continuous subcutaneous insulin infusion (CSII) system compared with those using self-monitoring of blood glucose (SMBG) with CSII.

Methods

Participants were 311 adult respondents to an Internet survey, 162 using RT-CGM/CSII, 149 using SMBG + CSII (median age 43 years; type 1 diabetes 94%; diabetes duration >15 years 61%; median insulin use 15 years). Respondents completed instruments assessing glucose monitoring system and insulin delivery system convenience, interference, burden, glucose control efficacy, cost satisfaction, overall satisfaction, and treatment preference, as well as quality of life (diabetes-related worries, social burden, and psychological well-being). Real-time CGM/CSII users also assessed specific elements of the RT-CGM/CSII system. Group differences were assessed using analysis of covariance controlling for respondent characteristics.

Results

The RT-CGM/CSII group gave significantly better ratings than the SMBG + CSII group for their glucose monitoring system''s glucose control efficacy, overall satisfaction, desire to switch, and willingness to recommend, and significantly worse ratings for interference with daily activities. The RT-CGM/CSII group gave significantly better ratings than the SMBG + CSII group for their insulin delivery system''s convenience and glucose control efficacy, overall satisfaction, desire to switch, and willingness to recommend. Real-time CGM/CSII users gave positive ratings of all system features.

Conclusions

Users of the integrated RT-CGM/CSII system reported more benefits of treatment, higher treatment satisfaction and quality of life, and greater preference for this system than SMBG + CSII users.     

Diabetes Technologies and Hospital Care: Comparison of Insulin Pump Therapy (Continuous Subcutaneous Insulin Infusion) to Alternative Methods for Perioperative Glycemic Management in Patients with Planned Postoperative Admissions

Background

Patients with diabetes who use insulin pumps [continuous subcutaneous insulin infusion (CSII)] undergo surgeries that require postoperative hospital admission. There are no defined guidelines for CSII perioperative use.

Methods

This retrospective single-institution study identified type 1 and type 2 diabetes subjects by electronically searching 2005–2010 anesthesia preoperative assessments for “pump.” Surgical cases (n = 92) were grouped according to intraoperative insulin delivery method: (a) CSII continuation of basal rate with/without correctional insulin bolus(es) (n = 53); (b) conversion to intravenous insulin infusion (n = 20); and (c) CSII suspension with/without correctional insulin bolus(es) (n = 19). These groups were compared on mean intraoperative blood glucose (BG) and category of most extreme intraoperative BG.

Results

Differences were found on baseline characteristics of diabetes duration (p = .010), anesthesia time (p = .011), proportions receiving general anesthesia (p = .013), and preoperative BG (p = .033). The conversion group had the longest diabetes duration and anesthesia time; it had a higher proportion of general anesthesia recipients and a higher mean preoperative BG than the continuation group. There was no significant difference in mean BG/surgical case between continuation (163.5 ± 58.5 mg/dl), conversion (152.3 ± 28.9 mg/dl), and suspension groups (188.3 ± 44.9 mg/dl; p = .128). The suspension group experienced a greater percentage of cases (84.2%) with one or more intraoperative BG > 179 mg/dl than continuation (45.3%) and conversion (40%) groups Figure 1 groupings (p = .034).Open in a separate windowFigure 1Comparison of insulin delivery methods to percentage of surgical cases with intraoperative hypoglycemia and hyperglycemia. Chi-square = 13.43, p = .034; continuation group, n = 53; conversion group, n = 20; suspension group, n = 19. All groupings were mutually exclusive. Intraoperative BG is defined as all BG measurements performed in the operating room and the first postoperative anesthesia care unit measurement

Conclusions

In this limited sample, preliminary findings are consistent with similar intraoperative glycemic control between CSII continuation and CSII conversion to intravenous insulin infusions. Continuous subcutaneous insulin infusion suspension had a greater rate of hyperglycemia. Preoperative differences between insulin delivery groups complicate interpretations of findings.     

A Study of Patient Experience Using a Blood Glucose Meter With an In-Built Insulin Dose Calculator

Background:Accurate calculation and adjustment of insulin doses is integral to maintaining glycemic control in insulin treated patients. Difficulties with insulin dose calculations may lead to poor adherence to blood glucose monitoring and insulin treatment regimes, resulting in poor metabolic control. The main objective of this study was to evaluate ease of use and user preference of a high specification touch screen blood glucose meter, which has an in-built insulin calculator, compared to patients’ usual method of testing blood glucose and deciding insulin doses.Methods:Patients with diabetes on a multiple daily injection insulin regime used the Test Meter without the insulin calculator and 1 of 3 comparator meters, each for a 7-day period. They then used the Test Meter with the in-built calculator for 10 days. Patients completed an ease of use questionnaire after each 7-day period, a preference questionnaire after the second 7-day period, and a questionnaire comparing the Test Meter with their usual method after the final 10-day period.Results:Of 164 patients who completed the study, 76% stated a preference for the Test Meter as a diabetes management tool compared to their usual method. A small number of patients preferred familiar methods and/or calculating insulin doses themselves. The log book function of meters was important to most patients.Conclusions:The Test Meter system with in-built insulin calculator supports people to better manage their diabetes and increases their confidence. Patients have different needs and preferences which should be acknowledged and supported in a patient centered health service.     

Insulin Pump and CGM Usage in the United States and Germany: Results of a Real-World Survey With 985 Subjects

Background:

This survey collected and evaluated user responses about routine tasks and preferences regarding insulin pumps and infusion sets (IIS) with comparison of intercountry differences between the United States (US) and Germany (GER), chosen for their large insulin pump populations.

Methods:

A total of 985 subjects (534 US, 451 GER; 60% female) with type 1 diabetes on pump therapy anonymously answered 20 pump-related questions. US subjects also answered 11 questions about continuous glucose monitoring (CGM) usage.

Results:

Length of use of insulin cartridges is shorter in US than in GER, mean (SD) 4.3 (5.0) versus 5.3 (3.2) days (P < .001), while the IIS is used longer: 3.3 (1.0) versus 2.7 (1.1) days (P < .001). Lower self-reported HbA1c levels were associated with longer use of insulin cartridges (7.3% for >3 days vs 7.7% for <3 days; P < .01), and with use of an auto-insertion device (vs manual IIS insertion) in the US (7.2% vs 6.9%), but not in GER (7.7% vs 7.9%). Only 47% of pump wearers stated that they were “very satisfied” with their pump (49% US vs 45% GER, ns). However, 98% would recommend the pump to others (95% vs 93%, ns). Analysis of CGM questions showed that 297 (60%) of 496 US responders currently wore one. Of these, 84% said they would recommend CGM to others. CGM wearers who stated they were “very satisfied” with their CGM had lower HbA1c than those who said they were “partly satisfied” (6.9% vs 7.2%).

Conclusions:

This survey shows interesting differences in real-world use of insulin pumps in 2 large markets, and suggests areas where insulin pumps and CGMs might be improved.     

An Analysis of 2019 FDA Adverse Events for Two Insulin Pumps and Two Continuous Glucose Monitors

US Food and Drug Administration adverse event data for 2019 were analyzed for two insulin pumps and two continuous glucose monitors (CGMs). The analyses were selective—they were guided by the text described in the adverse events. They included (1) percent using auto mode for the Medtronic 670G pump, (2) distributions of hyper and hypo glucose values for Medtronic and Tandem pumps, (3) a Parkes error grid for Dexcom CGM vs glucose meter when the complaint was inaccuracy, and (4) the most frequent events for Abbott Freestyle. We found that for the 670G pump, there were more hypo events when auto mode was on than when auto mode was off. With Dexcom CGMs, users complained about inaccurate result when most results were in the B zone. With the Abbott Freestyle, the most frequent adverse event was an allergic skin reaction.     

Lessons Learned From a Pilot RCT of Simultaneous Versus Delayed Initiation of Continuous Glucose Monitoring in Children and Adolescents With Type 1 Diabetes Starting Insulin Pump Therapy

Uncertainty remains about effectiveness of continuous glucose monitoring (CGM) in pediatric type 1 diabetes (T1D). Success with CGM is related to CGM adherence, which may relate to readiness to make the behavior changes required for effective use. We hypothesize that readiness for change will be greater at initiation of insulin pump therapy than in established pump users, and that this will predict CGM adherence. Our objective was to evaluate the feasibility of a randomized controlled trial (RCT) in children with established T1D comparing simultaneous pump and CGM initiation to standard pump therapy with delayed CGM initiation. We randomized participants to simultaneous pump and CGM initiation or to standard pump therapy with the option of adding CGM 4 months later. CGM adherence was tracked via web-based download and readiness for change assessed with the SOCRATES questionnaire. Of 41 eligible children, 20 agreed to participate; 15 subjects completed the study (7 males; baseline age 11.8 ± 4.0 years; T1D duration 2.7 ± 2.7 years; mean A1C 8.2 ± 0.8%). Six of 8 simultaneous group subjects used CGM > 60% of the time for 4 months compared to 1 of 7 delayed group subjects (P = .02). Using SOCRATES, we could assign 87-100% of subjects to a single motivation stage at baseline and 4 months. This pilot study demonstrates the feasibility of randomizing pump naïve children and adolescents with established T1D to simultaneous pump and CGM initiation versus standard pump therapy with delayed CGM initiation. Lessons from this pilot study were used to inform development of a full-scale multicenter RCT.     

胰岛素抵抗与糖脂代谢

近些年,对胰岛素抵抗的认识逐渐增加,其在心脑血管疾病发展中所起的重要作用倍受关注.胰岛素抵抗时常伴有糖和脂代谢紊乱发生,通过异常的代谢途径最终使疾病向不可逆方向发展.因此,在改善胰岛素抵抗的同时,还要注重对糖和脂代谢的调节,即从整体对异常代谢环境进行治疗.     

Combining Insulin Pumps and Continuous Glucose Monitors; Where Are We to Go from Here?

Insulin pump development started in 1978, with the first commercially available glucose sensor marketed in 1999. Combining these two instruments is a logical step toward the closed loop. This article discusses three questions: Is pump development complete? How can a pump and a sensor be combined? Can the delay problem associated with the subcutaneous–subcutaneous approach for the closed loop be overcome?