Diabetes through my eyes. Rick Mauseth, M.D. W.A.D.E. April 2013
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1 Diabetes through my eyes Rick Mauseth, M.D. W.A.D.E. April 2013
2 Ant hills
3 Total Available Glucose utilized Two drops of urine in test tube Add 10 drops of water Added tablet Foamed and got hot Compared to color chart Calculated glucose concentration/100ml times urine volume giving amout of glucose unutilized
4 Total Available Glucose Add up Carbohydrates Determine grams of protein as 40% Determine grams of fat as 10% Subtract urinary losses Gave you grams utilized Adjusted insulin accordingly
5 Physiological and Psychological effects of one versus two shots/day 1. Regular/nph 2. 2/3 in am, 1/3 in pm 3. TAG system 4. Two to three days prior to q 3 month visits
6 Chemstrip Bicolored strips Compare to container Took 2 minutes if high Could cut in quarters Teenagers
7 Humalog Insulin Number of people with diabetes increasing Pork consumption decreasing Potential shortage of insulin??faster insulin
8 DCCT study patients years old 3. 6/7 disqualified 4. A1c <12 in control group 5. Adults 7.4% 6. Adolescents 8.3% 7. ADA goals 8. Control does make difference
9 DCCT results 76% reduction risk for progression of retinopathy 54% reduced clinical albuminuria 60% decrease in risk of neuropathy Cost for decreased risk was higher risk of hypoglycemia
10 2003 in Woodinville
11 Edmonton Protocol 1. Transplants 2. Immunosuppression 3. Funding 4. Didn t last and not enough islets
12 Pumps and meters 1. smaller 2. better 3. more user friendly 4. bolus calculators
13 Sensors Originally long needle Lots of Noise Lag period for blood sugar to venous sugar Biofowling Short duration
14 Participating JDRF/NIH AP Sites 17 sites worldwide running clinical trials, providing engineering resources, or doing both: Dose Safety Oregon W. Ontario Mayo Boston Yale Cambridge W. Australia Stanford Rensselaer Harvard Colorado Virginia Montpellier Pavia/Padova UCSB/Sansum Israel
15 Controllers 1. Proportional Integral Derivative 2. Model Predictive Controller 3. Fuzzy logic
16 Fuzzy logic Thermostat picture
17 Fuzzy Logic Response to Rising BGL D A B C E F G H BGL Rate (mg/dl/min): Very Negative, Negative, Zero, Positive, Very Pos. BGL Accel: (mg/dl/min/min) Negative, Zero Positive VN: < N: Z: 0.0 P: 1.25 VP: > 2.5 N Z P N Z P N Z P N Z P N Z P BGL Trajectory >250 mg/dl G H F E mg/dl mg/dl mg/dl A B D C < 80 mg/dl
18 JDRF Innovative Technology Grant 2008 Diabetes Technology meeting In silico testing Economy and JDRF funds
19 2:09 PM 2:29 PM 2:49 PM 3:09 PM 3:29 PM 3:49 PM 4:14 PM 4:34 PM 4:44 PM 5:04 PM 5:24 PM 5:44 PM 6:04 PM 6:24 PM 6:44 PM 7:04 PM 7:24 PM 7:39 PM 7:59 PM 8:19 PM 8:39 PM 8:59 PM 9:19 PM 9:39 PM 9:59 PM 10:19 PM 10:44 PM 11:04 PM 11:24 PM 11:44 PM 12:04 AM 12:24 AM 12:44 AM 1:04 AM 1:24 AM 1:44 AM 2:04 AM 2:24 AM 2:49 AM 3:14 AM 3:34 AM 3:54 AM 4:14 AM 4:34 AM 4:54 AM 5:14 AM 5:34 AM 5:54 AM 6:14 AM 6:34 AM 6:54 AM 7:14 AM 7:39 AM 7:59 AM Units of insulin 2:09 PM 2:29 PM 2:49 PM 3:09 PM 3:29 PM 3:49 PM 4:14 PM 4:34 PM 4:44 PM 5:04 PM 5:24 PM 5:44 PM 6:04 PM 6:24 PM 6:44 PM 7:04 PM 7:24 PM 7:39 PM 7:59 PM 8:19 PM 8:39 PM 8:59 PM 9:19 PM 9:39 PM 9:59 PM 10:19 PM 10:44 PM 11:04 PM 11:24 PM 11:44 PM 12:04 AM 12:24 AM 12:44 AM 1:04 AM 1:24 AM 1:44 AM 2:04 AM 2:24 AM 2:49 AM 3:14 AM 3:34 AM 3:54 AM 4:14 AM 4:34 AM 4:54 AM 5:14 AM 5:34 AM 5:54 AM 6:14 AM 6:34 AM 6:54 AM 7:14 AM 7:39 AM 7:59 AM mg/dl 75 gm meal 30 gm snack Dosing Picture of CGMS and dosing- a good patient- 50 Subject 204V1 Gender: Female, TDD: 30.8, PF: 5, IC: 10, CF: 40, BMI: 29.6 CGM Commanded Doses Dose
20 Protocol Pilot Study 26 hours Subject Give 75% bolus Subject Arrives Closed Loop Started Breakast 30g CHO Pilot Lunch 60g CHO End of Study 5:00p 6:00p 8:00p 8:00a 2:00p 8:00p Equipment: Omnipod insulin pump Dexcom Seven+ CGM UCSB ver 2.9 APS System Laptop PC Version 1.5 FL Controller YSI 2300 Plus Glucose Analyzer Enrollment: Initiation No pre-meal bolus or announcement Totally automated
21 Endpoints by time period (n=8) YSI Endpoints All Time Periods Hyperglycemia correction Diurnal Variation Small Meal Moderate Meal 8p-8p 8p-2a 2a-8a 8a-2p 2p-8p Average BG (mg/dl) Lowest BG (mg/dl) Highest BG (mg/dl) Time BG mg/dl (%) 76.3% 79.8% 97.6% 72.6% 55.4% Time BG < 70 mg/dl (%) 0.1% 0.0% 0.6% 0.0% 0.0% Time BG >200 mg/dl (%) 23.5% 20.2% 1.8% 27.4% 44.6% Low blood glucose index (LBGI) High blood glucose index (HBGI) Area above curve <70 mg/dl*min Area under curve >200 mg/dl*min
22 Overnight Endpoints (n=8) Overnight YSI Endpoints Midnight - 7:30a Midnight - 8:00a 9:30p to - 8:00a Time BG < 70 mg/dl (%) 0.0% 0.4% 0.3% Time BG mg/dl (%) 62.4% 62.1% 58.8% Time BG mg/dl (%) 91.9% 92.0% 84.4% Time BG >180 mg/dl (%) 8.1% 7.6% 15.3% Time BG >200 mg/dl (%) 6.2% 5.8% 10.0%
23 BG (mg/dl) Average Time Histories (n=8) Sensor BG Avg YSI BG Avg :00 22:00 0:00 2:00 4:00 6:00 8:00 10:00 12:00 14:00 16:00 18:00 20:00
24 In-silico Version Version Version
25 Our present system
26 Personalization factor 1. Can adjust for individuals 2. Can change for different circumstances, Thanksgiving, marathons 3. Designing to manage 95% of time 4. No premeal bolus, totally automated 5. Will be able to learn
27 Protocol High Carb Pizza Study Equipment: Omnipod insulin pump Dexcom Seven+ CGM UCSB APS System Laptop PC Version 2.0 FL Controller YSI 2300 Plus Glucose Analyzer Enrollment: Initiation No pre-meal bolus or announcement Totally automated
28 Selecting PF Selec ng PF PF5 No Low Low 1 st Test BGavg<160 BGavg>160 Done (Use PF5) PF4 PF6 No Low BGavg<160 Low No Low Low 2 nd Test BGavg>160 Done (Use PF4) Done (Use PF5) Done (Use PF6) PF3 PF7 No Low Low No Low Low BGavg>160 PF2 (if possible) BGavg<160 Done (Use PF3) Done (Use PF4) Done (Use PF7) PF8 (if possible) 3rd Test
29 Delta BG mg/dl (YSI) High Carb Study Summary (n=9) Subject PF5 PF4 100 PF Normalized Insulin use (PF 5, 4, 3)
30 Protocol Exercise Study Equipment: Omnipod insulin pump Dexcom Seven+ CGM UCSB APS System Laptop PC Version 2.0 FL Controller YSI 2300 Plus Glucose Analyzer Enrollment: Initiation No pre-meal bolus or announcement Totally automated
31 Exercise Study Result (n=2) Blood Glucose History (mg/dl) Starting BG (2:00p) Pre-Exercise BG Post exercise BG Pre-dinner BG Nocturnal hypoglycemia no no Ending BG (8:00a)
32 Pizza and exercise on different days Pizza- blood sugar rise Difficult May need to modify need for temporary Change in PF Exercise for 30 minutes moderate exercise Works Marathons??
33 Bihormonal APS
34 Utilize technology from worldwide artificial pancreas program for camp study University of Virginia Diabetes Assistant (DiAs) hardware used for closed loop research Android smart phone computational and communication platform Could the remote monitoring component of the DiAs system be used to reduce severe hypoglycemia at diabetes camps? University of Virginia DiAs on Sony Ericsson smartphone
35 Remote Monitoring on ipad at Night
36 Computer screen display of Dexcom G4/UVa remote monitoring system: 10 campers (11 sensors)
37 Australian Patient
38 Duration of Events Below Thresholds Remote Monitoring Control Nights Number of Nights <70 mg/dl <50 mg/dl >1 hour 7 33 > 2 hours 0 12 > 30 minutes 0 9 > 1 hour 0 6
39 Future systems 1. Android or I-phone 2. Sensor and patch pump in one device 3. Redundant sensor (one or two types) 4. Online transmission 5. GPS device 6. Motion sensor 7. Real time transmission to medical staff 8. Parents monitoring 9. Bipolar proteins 10. Single catheters 11. Faster insulin
40 Impact on Personnel Automated downloads Who s going to check download? Will this be reimbursed? Are you in control or is patient responsible? Will need to get hospital administrators and insurance companies to Buy In To idea May be more work less patient contact
41 When??? 1. Pizza (now) 2. Exercise (now) 3. Ad lib living in CRC (start July) 4. Remotely monitored in resort (January 2014) 5. Outpatient with daily transmissions automatically to medical staff (July 2014) 6. FDA approval, commercially available?????
42 Pathway to Prevention Did you know that your risk of type 1 diabetes is 15 x greater if you have a relative with t1d? Your risk can be determined through a simple blood test and follow up The risk test is available at no cost to family members of people with type 1 diabetes Three prevention trials are now open
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