Effect of Ethanol Consumption on the Accuracy of a Glucose Oxidase-Based Subcutaneous Glucose Sensor in Subjects with Type 1 Diabetes.

Continuous glucose monitors (CGM) have improved the management of patients with type 1 diabetes (T1D), with glucose oxidase (GOx)-based sensors being the most used. However, they are potentially subject to both electrochemical and enzymatic interferences, including those related to changes of pH. The objective of this study is to investigate the effect of ethanol, given as beer along with a mixed meal, on the accuracy of a commercial GOx-CGM. Data from 12 T1D participants in a randomized crossover trial to evaluate the effect of meal composition and alcohol consumption on postprandial glucose concentration were used. Absolute error (AE) and mean absolute relative difference (MARD) were calculated. The differences between the alcohol and nonalcohol scenarios were assessed using the Mann−Whitney U and Wilcoxon signed-rank tests. The AE in the alcohol study was low, but significantly greater as compared to the study without alcohol (p-value = 0.0418). The MARD was numerically but not significantly greater. However, both variables were greater at pH < 7.36 and significantly affected by time only in the alcohol arm. In T1D, alcohol consumption affects the accuracy of a GOx-CGM. This effect could be at least partially related to the ethanol-induced changes in pH.

Assessment of Seasonal Stochastic Local Models for Glucose Prediction without Meal Size Information under Free-Living Conditions.

Accurate blood glucose (BG) forecasting is key in diabetes management, as it allows preventive actions to mitigate harmful hypoglycemic/hyperglycemic episodes. Considering the encouraging results obtained by seasonal stochastic models in proof-of-concept studies, this work assesses the methodology in two datasets (open-loop and closed-loop) recorded in free-living conditions. First, similar postprandial glycemic profiles are grouped together with fuzzy C-means clustering. Then, a seasonal stochastic model is identified for each cluster. Finally, real-time BG forecasting is performed by weighting each model's prediction. The proposed methodology (named C-SARIMA) is compared to other linear and nonlinear black-box methods: autoregressive integrated moving average (ARIMA), its variant with input (ARIMAX), a feed-forward neural network (NN), and its modified version (NN-X) fed by BG, insulin, and carbohydrates (timing and dosing) information for several prediction horizons (PHs). In the open-loop dataset, C-SARIMA grants a median root-mean-squared error (RMSE) of 20.13 mg/dL (PH = 30) and 27.23 mg/dL (PH = 45), not significantly different from ARIMA and NN. Over a longer PH, C-SARIMA achieves an RMSE = 31.96 mg/dL (PH = 60) and RMSE = 33.91 mg/dL (PH = 75), significantly outperforming the ARIMA and NN, without significant differences from the ARIMAX for PH ≥ 45 and the NN-X for PH ≥ 60. Similar results hold on the closed-loop dataset: for PH = 30 and 45 min, the C-SARIMA achieves an RMSE = 21.63 mg/dL and RMSE = 29.67 mg/dL, not significantly different from the ARIMA and NN. On longer PH, the C-SARIMA outperforms the ARIMA for PH > 45 and the NN for PH > 60 without significant differences from the ARIMAX for PH ≥ 45. Although using less input information, the C-SARIMA achieves similar performance to other prediction methods such as the ARIMAX and NN-X and outperforming the CGM-only approaches on PH > 45min.

Glucose Prediction under Variable-Length Time-Stamped Daily Events: A Seasonal Stochastic Local Modeling Framework.

Accurate glucose prediction along a long-enough time horizon is a key component for technology to improve type 1 diabetes treatment. Subjects with diabetes might benefit from supervision and control systems that accurately predict risks and trigger corrective actions early enough with improved mitigation. However, large intra-patient variability poses big challenges to glucose prediction. In previous works by the authors, clustering and local modeling techniques with seasonal stochastic models proved to be efficient, allowing for good glucose prediction accuracy for long prediction horizons. Continuous glucose monitoring (CGM) data were partitioned into fixed-length postprandial time subseries and clustered with Fuzzy C-Means to collect similar behaviors, enforcing seasonality at each cluster after subseries concatenation. Then, seasonal stochastic models were identified for each cluster and local predictions were integrated into a global prediction. However, free-living conditions do not support the fixed-length partition of CGM data since daily events duration is variable. In this work, a new algorithm is provided to overcome this constraint, allowing better coping with patient's variability under variable-length time-stamped daily events in supervision and control applications. Besides predicted glucose, two real-time indices are additionally provided-a crispness index, indicating good representation of current glucose behavior by a single model, and a normality index, allowing for the detection of an abnormal glucose behavior (unusual according to registered historical data). The framework is tested in a proof-of-concept in silico study with ten patients over four month training data and two independent two month validation datasets, with and without abnormal behaviors, from the distribution version of the UVA/Padova simulator extended with diverse sources of intra-patient variability.

A Comprehensive Review of Continuous Glucose Monitoring Accuracy during Exercise Periods.

Continuous Glucose Monitoring (CGM) has been a springboard of new diabetes management technologies such as integrated sensor-pump systems, the artificial pancreas, and more recently, smart pens. It also allows patients to make better informed decisions compared to a few measurements per day from a glucometer. However, CGM accuracy is reportedly affected during exercise periods, which can impact the effectiveness of CGM-based treatments. In this review, several studies that used CGM during exercise periods are scrutinized. An extensive literature review of clinical trials including exercise and CGM in type 1 diabetes was conducted. The gathered data were critically analysed, especially the Mean Absolute Relative Difference (MARD), as the main metric of glucose accuracy. Most papers did not provide accuracy metrics that differentiated between exercise and rest (non-exercise) periods, which hindered comparative data analysis. Nevertheless, the statistic results confirmed that CGM during exercise periods is less accurate.

Probabilistic Model of Transition between Categories of Glucose Profiles in Patients with Type 1 Diabetes Using a Compositional Data Analysis Approach.

The time spent in glucose ranges is a common metric in type 1 diabetes (T1D). As the time in one day is finite and limited, Compositional Data (CoDa) analysis is appropriate to deal with times spent in different glucose ranges in one day. This work proposes a CoDa approach applied to glucose profiles obtained from six T1D patients using continuous glucose monitor (CGM). Glucose profiles of 24-h and 6-h duration were categorized according to the relative interpretation of time spent in different glucose ranges, with the objective of presenting a probabilistic model of prediction of category of the next 6-h period based on the category of the previous 24-h period. A discriminant model for determining the category of the 24-h periods was obtained, achieving an average above 94% of correct classification. A probabilistic model of transition between the category of the past 24-h of glucose to the category of the future 6-h period was obtained. Results show that the approach based on CoDa is suitable for the categorization of glucose profiles giving rise to a new analysis tool. This tool could be very helpful for patients, to anticipate the occurrence of potential adverse events or undesirable variability and for physicians to assess patients' outcomes and then tailor their therapies.

Enhanced Accuracy of Continuous Glucose Monitoring during Exercise through Physical Activity Tracking Integration.

Current Continuous Glucose Monitors (CGM) exhibit increased estimation error during periods of aerobic physical activity. The use of readily-available exercise monitoring devices opens new possibilities for accuracy enhancement during these periods. The viability of an array of physical activity signals provided by three different wearable devices was considered. Linear regression models were used in this work to evaluate the correction capabilities of each of the wearable signals and propose a model for CGM correction during exercise. A simple two-input model can reduce CGM error during physical activity (17.46% vs. 13.8%, p < 0.005) to the magnitude of the baseline error level (13.61%). The CGM error is not worsened in periods without physical activity. The signals identified as optimal inputs for the model are "Mets" (Metabolic Equivalent of Tasks) from the Fitbit Charge HR device, which is a normalized measurement of energy expenditure, and the skin temperature reading provided by the Microsoft Band 2 device. A simpler one-input model using only "Mets" is also viable for a more immediate implementation of this correction into market devices.

Unannounced Meals in the Artificial Pancreas: Detection Using Continuous Glucose Monitoring.

The artificial pancreas (AP) system is designed to regulate blood glucose in subjects with type 1 diabetes using a continuous glucose monitor informed controller that adjusts insulin infusion via an insulin pump. However, current AP developments are mainly hybrid closed-loop systems that include feed-forward actions triggered by the announcement of meals or exercise. The first step to fully closing the loop in the AP requires removing meal announcement, which is currently the most effective way to alleviate postprandial hyperglycemia due to the delay in insulin action. Here, a novel approach to meal detection in the AP is presented using a sliding window and computing the normalized cross-covariance between measured glucose and the forward difference of a disturbance term, estimated from an augmented minimal model using an Unscented Kalman Filter. Three different tunings were applied to the same meal detection algorithm: (1) a high sensitivity tuning, (2) a trade-off tuning that has a high amount of meals detected and a low amount of false positives (FP), and (3) a low FP tuning. For the three tunings sensitivities 99 ± 2%, 93 ± 5%, and 47 ± 12% were achieved, respectively. A sensitivity analysis was also performed and found that higher carbohydrate quantities and faster rates of glucose appearance result in favorable meal detection outcomes.

A model of subcutaneous pramlintide pharmacokinetics and its effect on gastric emptying: Proof-of-concept based on populational data.

Pramlintide, an amylin analog, has been coming up as an agent in type 1 diabetes dual-hormone therapies (insulin/pramlintide). Since pramlintide slows down gastric emptying, it allows for easing glucose control and reducing the burden of meal announcements. Pre-clinical in silico evaluations are a key step in the development of any closed-loop strategy. However, mathematical models are needed, and pramlintide models in the literature are scarce. This work proposes a proof-of-concept pramlintide model, describing its subcutaneous pharmacokinetics (PK) and its effect on gastric emptying (PD). The model is validated with published populational (clinical) data. The model development is divided into three stages: intravenous PK, subcutaneous PK, and PD modeling. In each stage, a set of model structures are proposed, and their performance is assessed using the Akaike Information Criterion (AIC) and the Bayesian Information Criterion (BIC). In order to evaluate the modulation of the rate of gastric emptying, a literature meal model was used. The final pramlintide model comprises four compartments and a function that modulates gastric emptying depending on plasma pramlintide. Results show an appropriate fit for the data. Some aspects are left as open questions due to the lack of specific data (e.g., the influence of meal composition on the pramlintide effect). Moreover, further validation with individual data is necessary to propose a virtual cohort of patients.

Artificial Intelligence and Machine Learning for Improving Glycemic Control in Diabetes: Best Practices, Pitfalls, and Opportunities.

OBJECTIVE: Artificial intelligence and machine learning are transforming many fields including medicine. In diabetes, robust biosensing technologies and automated insulin delivery therapies have created a substantial opportunity to improve health. While the number of manuscripts addressing the topic of applying machine learning to diabetes has grown in recent years, there has been a lack of consistency in the methods, metrics, and data used to train and evaluate these algorithms. This manuscript provides consensus guidelines for machine learning practitioners in the field of diabetes, including best practice recommended approaches and warnings about pitfalls to avoid. METHODS: Algorithmic approaches are reviewed and benefits of different algorithms are discussed including importance of clinical accuracy, explainability, interpretability, and personalization. We review the most common features used in machine learning applications in diabetes glucose control and provide an open-source library of functions for calculating features, as well as a framework for specifying data sets using data sheets. A review of current data sets available for training algorithms is provided as well as an online repository of data sources. SIGNIFICANCE: These consensus guidelines are designed to improve performance and translatability of new machine learning algorithms developed in the field of diabetes for engineers and data scientists.

Accuracy of Two Continuous Glucose Monitoring Devices During Aerobic and High-Intensity Interval Training in Individuals with Type 1 Diabetes.

Background: This study aimed to evaluate the accuracy of Dexcom G6 (DG6) and FreeStyle Libre-2 (FSL2) during aerobic training and high-intensity interval training (HIIT) in individuals with type 1 diabetes. Methods: Twenty-six males (mean age 29.3 ± 6.3 years and mean duration of diabetes 14.9 ± 6.1 years) participated in this study. Interstitial glucose levels were measured using DG6 and FSL2, while plasma glucose levels were measured every 10 min using YSI 2500 as the reference for glucose measurements in this study. The measurements began 20 min before the start of exercise and continued for 20 min after exercise. Seven measurements were taken for each subject and exercise. Results: Both DG6 and FSL2 devices showed significant differences compared to YSI glucose data for both aerobic and HIIT exercises. Continuous glucose monitoring (CGM) devices exhibited superior performance during HIIT than aerobic training, with DG6 showing a mean absolute relative difference of 14.03% versus 31.98%, respectively. In the comparison between the two devices, FSL2 demonstrated significantly higher effectiveness in aerobic training, yet its performance was inferior to DG6 during HIIT. According to the 40/40 criteria, both sensors performed similarly, with marks over 93% for all ranges and both exercises, and above 99% for HIIT and in the >180 mg/dL range, which is in accordance with FDA guidelines. Conclusions: The findings suggest that the accuracy of DG6 and FSL2 deteriorates during and immediately after exercise but remains acceptable for both devices during HIIT. However, accuracy is compromised with DG6 during aerobic exercise. This study is the first to compare the accuracy of two CGMs, DG6, and FSL2, during two exercise modalities, using plasma glucose YSI measurements as the gold standard for comparisons. It was registered at clinicaltrials.gov (NCT06080542).

Safety and performance of a hybrid closed-loop insulin delivery system with carbohydrate suggestion in adults with type 1 diabetes prone to hypoglycemia.

AIMS: To evaluate the safety and performance of a hybrid closed-loop (HCL) system with automatic carbohydrate suggestion in adults with type 1 diabetes (T1D) prone to hypoglycemia. METHODS: A 32-hour in-hospital pilot study, including a night period, 4 meals and 2 vigorous unannounced 45-minute aerobic sessions, was conducted in 11 adults with T1D prone to hypoglycemia. The primary outcome was the percentage of time in range 70-180 mg/dL (TIR). Main secondary outcomes were time below range < 70 mg/dL (TBR < 70) and < 54 (TBR < 54). Data are presented as median (10th-90th percentile ranges). RESULTS: The participants, 6 (54.5%) men, were 24 (22-48) years old, and had 22 (9-32) years of T1D duration. All of them regularly used an insulin pump and a continuous glucose monitoring system. The median TIR was 78.7% (75.6-91.2): 92.7% (68.2-100.0) during exercise and recovery period, 79.3% (34.9-100.0) during postprandial period, and 95.4% (66.4-100.0) during overnight period. The TBR < 70 and TBR < 54 were 0.0% (0.0-6.6) and 0.0% (0.0-1.2), respectively. A total of 4 (3-9) 15-g carbohydrate suggestions were administered per person. No severe acute complications occurred during the study. CONCLUSIONS: The HCL system with automatic carbohydrate suggestion performed well and was safe in this population during challenging conditions in a hospital setting.

Modeling the effect of glucagon on endogenous glucose production in type 1 diabetes: On the role of glucagon receptor dynamics.

This paper validates a glucoregulatory model including glucagon receptors dynamics in the description of endogenous glucose production (EGP). A set of models from literature are selected for a head-to-head comparison in order to evaluate the role of glucagon receptors. Each EGP model is incorporated into an existing glucoregulatory model and validated using a set of clinical data, where both insulin and glucagon are administered. The parameters of each EGP model are identified in the same optimization problem, minimizing the root mean square error (RMSE) between the simulation and the clinical data. The results show that the RMSE for the proposed receptors-based EGP model was lower when compared to each of the considered models (Receptors approach: 7.13±1.71 mg/dl vs. 7.76±1.45 mg/dl (p=0.066), 8.45±1.38 mg/dl (p=0.011) and 8.99±1.62 mg/dl (p=0.007)). This raises the possibility of considering glucagon receptors dynamics in type 1 diabetes simulators.

Internal model control based module for the elimination of meal and exercise announcements in hybrid artificial pancreas systems.

BACKGROUND AND OBJECTIVES: Hybrid artificial pancreas systems outperform current insulin pump therapies in blood glucose regulation in type 1 diabetes. However, subjects still have to inform the system about meals intake and exercise to achieve reasonable control. These patient announcements may result in overburden and compromise controller performance if not provided timely and accurately. Here, a hybrid artificial pancreas is extended with an add-on module that releases subjects from meals and exercise announcements. METHODS: The add-on module consists of an internal-model controller that generates a "virtual" control action to compensate for disturbances. This "virtual" action is converted into insulin delivery, rescue carbohydrates suggestions, or insulin-on-board limitations, depending on a switching logic based on glucose measurements and predictions. The controller parameters are tuned by optimization and then related to standard parameters from the open-loop therapy. This module is implemented in a hybrid artificial pancreas system proposed by our research group for validation. This hybrid system extended with the add-on module is compared with the hybrid controller with carbohydrate counting errors (hybrid) and the hybrid controller with an alternative unannounced meal compensation module based on a meal detection algorithm (meal detector). The validation used the educational version of the UVa/Padova simulator to simulate the three controllers under two scenarios: one with only meals and another with meals and exercise. The exercise was modeled as a temporal increase of the insulin sensitivity resulting in the glucose drop usually related to an aerobic exercise. RESULTS: For the scenario with only meals, the three controllers achieved similar time in range (proposed: 85.1 [77.9,88.1]%, hybrid: 84.0 [75.9,86.4]%, meal detector: 81.9 [79.3,83.8]%, median [interquartile range]) with low time in moderate hypoglycemia. Under the scenario with meals and exercise, the proposed module reduces 4.61% the time in hypoglycemia achieved with the other controllers, suggesting an acceptable amount of rescues (27.2 [23.7, 31.0] g). CONCLUSIONS: The proposed add-on module achieved promising results: it outperformed the meal-detector-based controller, even achieving a postprandial performance as good as the hybrid controller (with carbohydrate counting errors). Also, the rescue suggestion feature of the module mitigated exercise-induced hypoglycemia with admissible rescue amounts.

Effect of meal composition and alcohol consumption on postprandial glucose concentration in subjects with type 1 diabetes: a randomized crossover trial.

INTRODUCTION: Meal composition is known to affect glycemic variability and glucose control in type 1 diabetes. The objective of this work was to evaluate the effect of high carbohydrate meals of different nutritional composition and alcohol on the postprandial glucose response in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: Twelve participants were recruited to this randomized crossover trial. Following a 4-week run-in period, participants received a mixed meal on three occasions with the same carbohydrate content but different macronutrient composition: high protein-high fat with alcohol (0.7g/kg body weight, beer), high protein-high fat without alcohol, and low protein-low fat without alcohol at 2-week intervals. Plasma and interstitial glucose, insulin, glucagon, growth hormone, cortisol, alcohol, free fatty acids, lactate, and pH concentrations were measured during 6 hours. A statistical analysis was then carried out to determine significant differences between studies. RESULTS: Significantly higher late postprandial glucose was observed in studies with higher content of fats and proteins (p=0.0088). This was associated with lower time in hypoglycemia as compared with the low protein and fat study (p=0.0179), at least partially due to greater glucagon concentration in the same period (p=0.04). Alcohol significantly increased lactate, decreased pH and growth hormone, and maintained free fatty acids suppressed during the late postprandial phase (p<0.001), without significant changes in plasma glucose. CONCLUSIONS: Our data suggest that the addition of proteins and fats to carbohydrates increases late postprandial blood glucose. Moreover, alcohol consumption together with a mixed meal has relevant metabolic effects without any increase in the risk of hypoglycemia, at least 6 hours postprandially. TRIAL REGISTRATION NUMBER: NCT03320993.

Artificial Pancreas With Carbohydrate Suggestion Performance for Unannounced and Announced Exercise in Type 1 Diabetes.

OBJECTIVE: To evaluate the safety and performance of a new multivariable closed-loop (MCL) glucose controller with automatic carbohydrate recommendation during and after unannounced and announced exercise in adults with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS: A randomized, 3-arm, crossover clinical trial was conducted. Participants completed a heavy aerobic exercise session including three 15-minute sets on a cycle ergometer with 5 minutes rest in between. In a randomly determined order, we compared MCL control with unannounced (CLNA) and announced (CLA) exercise to open-loop therapy (OL). Adults with T1D, insulin pump users, and those with hemoglobin (Hb)A1c between 6.0% and 8.5% were eligible. We investigated glucose control during and 3 hours after exercise. RESULTS: Ten participants (aged 40.8 ± 7.0 years; HbA1c of 7.3 ± 0.8%) participated. The use of the MCL in both closed-loop arms decreased the time spent <70 mg/dL of sensor glucose (0.0%, [0.0-16.8] and 0.0%, [0.0-19.2] vs 16.2%, [0.0-26.0], (%, [percentile 10-90]) CLNA and CLA vs OL respectively; P = 0.047, P = 0.063) and the number of hypoglycemic events when compared with OL (CLNA 4 and CLA 3 vs OL 8; P = 0.218, P = 0.250). The use of the MCL system increased the proportion of time within 70 to 180 mg/dL (87.8%, [51.1-100] and 91.9%, [58.7-100] vs 81.1%, [65.4-87.0], (%, [percentile 10-90]) CLNA and CLA vs OL respectively; P = 0.227, P = 0.039). This was achieved with the administration of similar doses of insulin and a reduced amount of carbohydrates. CONCLUSIONS: The MCL with automatic carbohydrate recommendation performed well and was safe during and after both unannounced and announced exercise, maintaining glucose mostly within the target range and reducing the risk of hypoglycemia despite a reduced amount of carbohydrate intake.Register Clinicaltrials.gov: NCT03577158.

Enhanced algorithm for glucose estimation using the continuous glucose monitoring system.

BACKGROUND: The CGMS Gold continuous glucose monitor presents a problem of lack of accuracy, especially in the lower range, sometimes leading to missed or false alarms. The new algorithm aims to improve the measurement accuracy and hypoglycemia detection. MATERIAL/METHODS: Twenty-one patients with type 1 diabetes were monitored for 3 days (1 day at the hospital and 2 at home) using the CGMS Gold. For these patients, blood glucose samples were taken every 15 minutes for 2 hours after meals and every half hour otherwise during the first day. A new calibration algorithm was developed and implemented using CGMS Gold intensity readings and capillary glucose. RESULTS: After 1 day, a comparison of results from either the CGMS Gold algorithm and the proposed algorithm, compared with results from blood (2450 points), showed an increase of data in zone A with the proposed algorithm (4.4% in the Clarke error grid analysis (EGA) and 5.0% in the Consensus EGA). After comparing for 3 days, a reduction of 24.7%, p<0.05, in the overall median relative absolute difference (RAD) was also obtained. In the hypoglycemic range, a significant decrease in median RAD was observed (64.4%, p<0.05). Furthermore, the undetected hypoglycemia events in capillary samples by the proposed algorithm were reduced by 59.8% compared to the CGMS Gold algorithm. CONCLUSIONS: The performance as measured with clinical and numerical accuracy criteria illustrates the improved accuracy of the proposed algorithm in comparison with the CGMS Gold algorithm. A significant improvement in hypoglycemia detection was observed.

Estimating plasma glucose from interstitial glucose: the issue of calibration algorithms in commercial continuous glucose monitoring devices.

Evaluation of metabolic control of diabetic people has been classically performed measuring glucose concentrations in blood samples. Due to the potential improvement it offers in diabetes care, continuous glucose monitoring (CGM) in the subcutaneous tissue is gaining popularity among both patients and physicians. However, devices for CGM measure glucose concentration in compartments other than blood, usually the interstitial space. This means that CGM need calibration against blood glucose values, and the accuracy of the estimation of blood glucose will also depend on the calibration algorithm. The complexity of the relationship between glucose dynamics in blood and the interstitial space, contrasts with the simplistic approach of calibration algorithms currently implemented in commercial CGM devices, translating in suboptimal accuracy. The present review will analyze the issue of calibration algorithms for CGM, focusing exclusively on the commercially available glucose sensors.

Detection and Control of Unannounced Exercise in the Artificial Pancreas Without Additional Physiological Signals.

The purpose of this study was to develop an algorithm that detects aerobic exercise and triggers disturbance rejection actions to prevent exercise-induced hypoglycemia. This approach can provide a solution to poor glycemic control during and after aerobic exercise, a major hindrance in the participation of exercise by patients with type 1 diabetes. This novel exercise-induced hypoglycemia reduction algorithm (EHRA) detects exercise using a threshold on a disturbance term, a parameter estimated from an augmented minimal model using an unscented Kalman filter. After detection, the EHRA triggers the following three actions: First, a carbohydrate suggestion, second, a reduction in basal insulin and the insulin-on-board maximum limit, and finally, a 30% reduction of the next insulin meal bolus. The EHRA was tested in silico using a 15-day scenario with 8 exercise sessions of 50 min at [Formula: see text] on alternating days. The EHRA was able to obtain improved results when compared to strategies with and without exercise announcement. The unannounced, announced, and EHRA strategies all obtained an overall percentage of time in range (70-180 mg/dl) of 94% and a percentage of time 70 mg/dl of 2%, 0%, and 0%, respectively. The EHRA was tested for robustness during exercise sessions of +25% and -25% intensity and results suggest that the EHRA is able to account for variability in exercise intensity, duration, and patient dynamics such as glucose uptake rate and insulin sensitivity.

Seasonal Local Models for Glucose Prediction in Type 1 Diabetes.

Linear empirical dynamic models have been widely used for blood glucose prediction and risks prevention in people with type 1 diabetes. More accurate blood glucose prediction models with longer prediction horizon (PH) are desirable to enable warnings to patients about imminent blood glucose changes with enough time to take corrective actions. In this study, a blood glucose prediction method is developed by integrating the predictions of a set of seasonal local models (each of them corresponding to different glucose profiles observed along historical data). In the modeling step, the number of sets and their corresponding glucose profiles characteristics are obtained by clustering techniques (Fuzzy C-Means). Then, Box-Jenkins methodology is used to identify a seasonal model for each set. Finally, blood glucose predictions of local models are integrated using different techniques. The proposed method is tested by using 18 60-h closed-loop experiments (including different exercise types and artificial pancreas strategies) and achieving mean absolute percentage error (MAPE) of 2.94%, 3.89%, 5.41%, 6.29% and 8.66% for 15-, 30-, 45-, 60-, and 90-min PHs, respectively.

Parallel Control of an Artificial Pancreas with Coordinated Insulin, Glucagon, and Rescue Carbohydrate Control Actions.

BACKGROUND: An artificial pancreas with insulin and glucagon delivery has the potential to reduce the risk of hypo- and hyperglycemia in people with type 1 diabetes. However, a maximum dose of glucagon of 1 mg/d is recommended, potentially still requiring rescue carbohydrates in some situations. This work presents a parallel control structure with intrinsic insulin, glucagon, and rescue carbohydrates coordination to overcome glucagon limitations when needed. METHODS: The coordinated controller that combines insulin, glucagon, and rescue carbohydrate suggestions (DH-CC-CHO) was compared with the insulin and glucagon delivery coordinated controller (DH-CC). The impact of carbohydrate quantization for practical delivery was also assessed. An in silico study using the UVA-Padova simulator, extended to include exercise and various sources of variability, was performed. RESULTS: DH-CC and DH-CC-CHO performed similarly with regard to mean glucose (126.25 [123.43; 130.73] vs 127.92 [123.99; 132.97] mg/dL, P = .088), time in range (93.04 [90.00; 95.92] vs 92.91 [90.05; 95.75]%, P = .508), time above 180 mg/dL (4.94 [2.72; 7.53] vs 4.99 [2.93; 7.24]%, P = .966), time below 70 mg/dL (0.61 [0.09; 1.75] vs 0.96 [0.23; 2.17]%, P = .1364), insulin delivery (43.50 [38.68; 51.75] vs 42.86 [38.58; 51.36] U/d, P = .383), and glucagon delivery (0.75 [0.40; 1.83] vs 0.76 [0.43; 0.99] mg/d, P = .407). Time below 54 mg/dL was different (0.00 [0.00; 0.05] vs 0.00 [0.00; 0.16]%, P = .036), although non-clinically significant. This was due to the carbs quantization effect in a specific patient, as no statistical difference was found when carbs were not quantized (0.00 [0.00; 0.05] vs 0.00 [0.00; 0.00]%, P = .265). CONCLUSIONS: The new strategy of automatic rescue carbohydrates suggestion in coordination with insulin and glucagon delivery to overcome constraints on daily glucagon delivery was successfully evaluated in an in silico proof of concept.