Feasibility of a New Approach to Initiate Insulin in Type 2 Diabetes.

BACKGROUND: Treatment inertia and prescription complexity are among reasons that people with type 2 diabetes (T2D) do not reach glycemic targets. This study investigated feasibility of a new approach to basal insulin initiation, where the dose needed to reach a glycemic target is estimated from two weeks of insulin and continuous glucose monitoring (CGM) data. METHODS: This was an exploratory single arm study with a maximum length of 84 days. Eight insulin naïve people with T2D, planning to initiate basal insulin, wore a CGM throughout the study period. A predetermined regime was followed for the first two weeks after which the end dose was estimated. The clinician decided whether to follow this advice and continued the titration until target was reached using a twice weekly stepwise titration algorithm. The primary outcome was the comparison between the estimated and the actual end doses. RESULTS: Median age of participants was 57 years (range: 50-77 years), duration of diabetes was 16 years (range: 5-29 years), and Bodi Mass Index (BMI) was 30.2 kg/m2 (range: 22.0-36.0 kg/m2). The median study end dose was 37 U (range: 20-123 U). The estimated end dose was smaller than or equal to the study end dose in all cases, with median error of 26.7% (range: 0.0%-75.8% underestimation). No self-monitoring of blood glucose values were below 70 mg/dL and no severe hypoglycemia occurred. CONCLUSION: While accuracy may be improved, it was found safe to predict the study end dose of insulin degludec from two weeks of data.

Short Term Blood Glucose Prediction based on Continuous Glucose Monitoring Data.

Continuous Glucose Monitoring (CGM) has enabled important opportunities for diabetes management. This study explores the use of CGM data as input for digital decision support tools. We investigate how Recurrent Neural Networks (RNNs) can be used for Short Term Blood Glucose (STBG) prediction and compare the RNNs to conventional time-series forecasting using Autoregressive Integrated Moving Average (ARIMA). A prediction horizon up to 90 min into the future is considered. In this context, we evaluate both population-based and patient-specific RNNs and contrast them to patient-specific ARIMA models and a simple baseline predicting future observations as the last observed. We find that the population-based RNN model is the best performing model across the considered prediction horizons without the need of patient-specific data. This demonstrates the potential of RNNs for STBG prediction in diabetes patients towards detecting/mitigating severe events in the STBG, in particular hypoglycemic events. However, further studies are needed in regards to the robustness and practical use of the investigated STBG prediction models.

Fast Assessment of Glycemic Control based on Continuous Glucose Monitoring Data.

Diabetes has become a major public health problem in the world. In this context, early assessment of glycemic control is essential in order to avoid life-threatening health complications. A panel of diabetes experts have recently proposed a list of recommendations when using Continuous Glucose Monitoring (CGM) for glycemic control assessment including a minimum of two weeks of CGM data. A recent study has further introduced a metric called Glucose Profile Indicator (GPI) for CGM based diabetes management including a subset of the recommended CGM metrics. In this pilot study, it was investigated if less than two weeks of CGM data would impact the performance of GPI compared to the proposed two weeks of CGM data. Furthermore, logistic regression (LR) was used to examine if an improvement could be achieved taking as input the CGM metrics used to quantify GPI. The population mean accuracy for accumulated day 1 to 13 varied between 72.8 ± 2.0% - 98.3 ± 0.4% with no clear sign of improvement using LR. Hence, this indicates a trade-off between the amount of available CGM data and the precision in which the GPI outcome using all 14 days can be achieved when considering features of the GPI alone. Future work is needed to investigate if this trade-off can be improved by the use of additional features of the CGM.

Pen needle design influences ease of insertion, pain, and skin trauma in subjects with type 2 diabetes.

OBJECTIVE: Pen needles used for subcutaneous injections have gradually become shorter, thinner and more thin walled, and thereby less robust to patient reuse. Thus, different needle sizes, alternative tip designs and needles resembling reuse were tested to explore how needle design influences ease of insertion, pain and skin trauma. RESEARCH DESIGN AND METHODS: 30 subjects with injection-treated type 2 diabetes and body mass index 25-35 kg/m2 were included in the single-blinded study. Each subject received abdominal insertions with 18 different types of needles. All needles were tested twice per subject and in random order. Penetration force (PF) through the skin, pain perception on 100 mm visual analog scale, and change in skin blood perfusion (SBP) were quantified after the insertions. RESULTS: Needle diameter was positively related to PF and SBP (p<0.05) and with a positive pain trend relation. Lack of needle lubrication and small 'needle hooks' increased PF and SBP (p<0.05) but did not affect pain. Short-tip, obtuse needle grinds affected PF and SBP, but pain was only significantly affected in extreme cases. PF in skin and in polyurethane rubber were linearly related, and pain outcome was dependent of SBP increase. CONCLUSIONS: The shape and design of a needle and the needle tip affect ease of insertion, pain and skin trauma. Relations are seen across different data acquisition methods and across species, enabling needle performance testing outside of clinical trials. TRIAL REGISTRATION NUMBER: NCT02531776; results.

Test-enhanced learning may be a gender-related phenomenon explained by changes in cortisol level.

CONTEXT: testing increases memory of a topic studied more than additional study or training. The mechanisms by which this occurs are not clearly understood. Testing can be stressful and studies suggest that the stress hormone cortisol has modulating effects on memory, predominantly in men. The aim of this study was to investigate whether cardiopulmonary resuscitation (CPR) skills testing induce a cortisol increase, whether the cortisol increase enhances retention of CPR skills, and how this relates to gender. METHODS: we randomised a convenience sample of medical students attending a mandatory course to one intervention and one control group. Students received a 4-hour course on CPR skills. During the final half-hour of the intervention course, participants were tested in CPR scenarios, whereas the control group underwent additional training. We assessed learning outcomes 2 weeks later by rating student performance in a CPR scenario using a checklist and a single blinded assessor. We measured salivary cortisol pre-course, half an hour before the end of the course and post-course, and compared learning outcomes and cortisol responses between groups and genders. RESULTS: in total, 146 of 202 (72%) students completed the study. We found a significant difference in learning outcome between the intervention and control groups for both genders (mean ± standard deviation, 5.0 ± 3.5; p = 0.006). We found a significant effect of increase in cortisol on learning outcome in men. The correlation between learning outcome and cortisol increase was medium to large for men (r = 0.38), but not for women (r = -0.05). CONCLUSIONS: cardiopulmonary resuscitation skills testing induces a rise in cortisol in men, which is related to the better retention of skills in men. Cortisol modulates test-enhanced learning in men.

The effect of testing on skills learning.

OBJECTIVES: In addition to the extrinsic effects of assessment and examinations on students' study habits, testing can have an intrinsic effect on the memory of studied material. Whether this testing effect also applies to skills learning is not known. However, this is especially interesting in view of the need to maximise learning outcomes from costly simulation-based courses. This study was conducted to determine whether testing as the final activity in a skills course increases learning outcome compared with an equal amount of time spent practising the skill. METHODS: We carried out a prospective, controlled, randomised, single-blind, post-test-only intervention study, preceded by a similar pre- and post-test pilot study in order to make a power calculation. A total of 140 medical students participating in a mandatory 4-hour in-hospital resuscitation course in the seventh semester were randomised to either the intervention or control group and were invited to participate in an assessment of learning outcome. The intervention course included 3.5 hours of instruction and training followed by 30 minutes of testing. The control course included 4 hours of instruction and training. Participant learning outcomes were assessed 2 weeks after the course in a simulated scenario using a checklist. Total assessment scores were compared between the two groups. RESULTS: Overall, 81 of the 140 students volunteered to participate. Learning outcomes were significantly higher in the intervention group (n = 41; mean score 82.8%, 95% confidence interval [CI] 79.4-86.2) compared with the control group (n = 40; mean score 73.3%, 95% CI 70.5-76.1) (P < 0.001). Effect size was 0.93. CONCLUSIONS: Testing as a final activity in a resuscitation skills course for medical students increases learning outcome compared with spending an equal amount of time practising the skills.