Consensus Recommendations for the Use of Automated Insulin Delivery (AID) Technologies in Clinical Practice

International audienceThe significant and growing global prevalence of diabetes continues to challenge people with diabetes (PwD), healthcare providers and payers. While maintaining near-normal glucose levels has been shown to prevent or delay the progression of the long-term complications of diabetes, a significant proportion of PwD are not attaining their glycemic goals. During the past six years, we have seen tremendous advances in automated insulin delivery (AID) technologies. Numerous randomized controlled trials and real-world studies have shown that the use of AID systems is safe and effective in helping PwD achieve their long-term glycemic goals while reducing hypoglycemia risk. Thus, AID systems have recently become an integral part of diabetes management. However, recommendations for using AID systems in clinical settings have been lacking. Such guided recommendations are critical for AID success and acceptance. All clinicians working with PwD need to become familiar with the available systems in order to eliminate disparities in diabetes quality of care. This report provides much-needed guidance for clinicians who are interested in utilizing AIDs and presents a comprehensive listing of the evidence payers should consider when determining eligibility criteria for AID insurance coverage

Closed-loop insulin delivery in adults with type 1 diabetes

Achieving tight glucose control safely in type 1 diabetes with currently available methods of insulin delivery is challenging. Aggressive regimens carry an increased risk of hypoglycaemia, particularly overnight. Both alcohol consumption and exercise predispose further to low glucose levels. The demands are even greater in pregnancy where, in addition to limiting hypoglycaemia, avoidance of postprandial hyperglycaemia is critical to minimising adverse obstetric outcomes. The aim of my studies was to evaluate feasibility and safety of a closed-loop or ’artificial pancreas’ system linking insulin delivery with continuous glucose monitoring (CGM), in adults with type 1 diabetes in a controlled setting. Three randomised crossover studies compared closed-loop insulin delivery with conventional insulin pump therapy on two separate occasions, matched in meals and activities. During closed-loop visits, CGM values were entered into a computer containing a model predictive control algorithm which advised on basal insulin infusion for subcutaneous delivery, every 15 minutes. During control visits, usual insulin pump regimen was continued. The feasibility study evaluated overnight closed-loop in 12 adults (seven females, mean age 37.7 years, HbA1c 7.8%) following 60g- carbohydrate evening meal. A follow-up study assessed overnight closed-loop in 12 further adults (seven females, mean age 37.2 years, HbA1c 7.8%) following 100g-carbohydrate meal and (mean 564 ml) white wine. The third study evaluated 24 hours of closed-loop in 12 pregnant women (mean age 32.9 years, 19 to 23 weeks gestation, HbA1c 6.4%) during normal daily activities, including low and moderate intensity exercise. Activity and glucose levels were also measured during free-living. CGM performance during exercise was evaluated. Overnight closed-loop insulin delivery in adults, compared with conventional pump therapy, increased time spent with plasma glucose in target range (3.9−8.0 mmol/l) following both standard meal (81% versus 57%; p = 0.012) and large meal accompanied by alcohol (70% versus 46%; p = 0.012). Glycaemic variability, and time spent in hypo- and hyper- glycaemia were lowered. In pregnant women, day and night closed-loop insulin delivery was as effective as usual pump regimen (81% versus 81% time spent with plasma glucose 3.5−7.8 mmol/l; p = 0.754). Hypoglycaemia occurred following exercise, although closed-loop prevented nocturnal episodes. Glycaemic control during free-living was suboptimal, compared with controlled diet and exercise conditions. Accuracy of CGM was lower during exercise. In conclusion, these studies confirm the feasibility and efficacy of overnight closed-loop insulin delivery in adults with type 1 diabetes. Closed-loop is safe during pregnancy and may be beneficial in women with suboptimal glycaemic control. Meals and physical activity currently limit optimal daytime use of closed-loop

Clinical Practice Guidelines for Primary Care Providers\u27 Evaluation of Patient Fitness to Fly

Commercial air travel is amongst the safest forms of transportation yet the environment within the aircraft cabin to which the passenger is exposed may have adverse physiological and psychological effects on passengers, especially for those with pre-existing medical issues. A comprehensive, systematic review and analysis of current literature was performed to develop evidenced-based guidelines for evaluation of passenger fitness to fly for integration into primary care practice. Recommendations from the most current fitness to fly guidelines and disease-specific published research related to in-flight medical issues were evaluated and the Grades of Recommendation Assessment, Development and Evaluation (GRADE) method was utilized to assess the quality of available evidence and the strength of guideline recommendations. The clinical practice guideline provides an overview of the major health systems affected by air travel and conditions that warrant healthcare provider review for clearance to fly. The need exists for randomized trials and large group research to further identify and evaluate health conditions that are impacted or affected by commercial air travel. True incidence of health related issues and further guidance for research would benefit from the establishment of a universal health related incidence reporting method or repository to collect data of in-flight health events. The guidelines developed as a result of this capstone report will change practice and contribute to the development of evidence-based guidance to primary care providers and clinicians who are required to provide fitness to fly clearance exams for commercial airline passengers

Holistic System Design for Distributed National eHealth Services

publishedVersio

Telemedizinische Versorgung chronisch kranker Personen. Auswirkungen auf ausgewählte Aspekte der Versorgung am Beispiel von COPD, Diabetes und Hypertonie

Der rasante Fortschritt im Bereich der Telekommunikationstechnologie birgt zahlreiche Chancen für die medizinische Versorgung durch die Überwindung der physischen Distanz zwischen ÄrztInnen und ihren PatientInnen. Mit den Mitteln der interaktiven Telemedizin können hier neue Wege beschritten werden, die zahlreiche praktische Probleme adressieren. Die vorliegende Studie dient insbesondere dazu, die Auswirkungen von Telemedizin auf unterschiedliche Aspekte der Versorgung im Detail zu beleuchten