Diabetes Technology Meeting 2023.

Diabetes Technology Society hosted its annual Diabetes Technology Meeting from November 1 to November 4, 2023. Meeting topics included digital health; metrics of glycemia; the integration of glucose and insulin data into the electronic health record; technologies for insulin pumps, blood glucose monitors, and continuous glucose monitors; diabetes drugs and analytes; skin physiology; regulation of diabetes devices and drugs; and data science, artificial intelligence, and machine learning. A live demonstration of a personalized carbohydrate dispenser for people with diabetes was presented.

A Glycemia Risk Index (GRI) of Hypoglycemia and Hyperglycemia for Continuous Glucose Monitoring Validated by Clinician Ratings.

BACKGROUND: A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data. METHODS: We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation. RESULTS: The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals. CONCLUSION: The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.

Frequency and duration of ambulance officer exposure to nitrous oxide and methoxyflurane in New Zealand.

OBJECTIVE: Nitrous oxide (Entonox®) and methoxyflurane (Penthrox®) are inhaled analgesics administered in paramedicine. Occupational exposure to nitrous oxide has been associated with negative health effects, and may inhibit professional capability. The effect of occupational exposure to methoxyflurane has not yet been clearly determined. This study identifies the frequency and duration of ambulance officer (AO) occupational exposure to nitrous oxide and methoxyflurane to provide a foundation for future assessments of occupational toxicity risk. METHODS: A retrospective database review of Patient Report Forms (PRFs) in 11 months between February 2016 and February 2018 was conducted. Nitrous oxide was available for the first 5 months studied, followed by 6 months methoxyflurane availability. AO-specific measures of attendance, rate of inhaled analgesic use, and duration of analgesic use were determined. Subgroup analysis by AO qualification and rostered work hours was undertaken. RESULTS: A total of 46,759 PRFs were examined, identifying 1,033 cases of nitrous oxide administration and 1456 cases of methoxyflurane was administration. There was a significant increase in the proportion of cases where inhaled analgesia was administered following the replacement of nitrous oxide with methoxyflurane. Relative risk of exposure to methoxyflurane compared with nitrous oxide was 1.22, while median duration of each exposure remained unchanged (32 vs. 33 min). CONCLUSIONS: Methoxyflurane via the Penthrox® inhaler was more likely to be administered than nitrous oxide. Most AOs are infrequently exposed to inhaled analgesics and are exposed for durations slightly greater than previously reported. Relative risk of exposure was greatest for lower-qualified AOs. Peak number of exposures and duration values suggest a subset of AOs with higher occupational health risk.

Serum fluoride levels in ambulance staff after commencement of methoxyflurane administration compared to meta-analysis results for the general public.

OBJECTIVES: Ambulance officers administering methoxyflurane as an inhalational analgesic may be exposed to trace vapor. Fluoride is a methoxyflurane metabolite, and has been associated with acute renal failure in anesthesia patients and skeletal fluorosis with chronic elevated serum levels from other sources. However, there has been no direct measurement of serum fluoride in occupationally exposed ambulance officers. Thus, this study directly measures serum fluoride over a prolonged period in order to determine renal toxic and skeletal fluorosis risk to ambulance officers who are administering methoxyflurane. MATERIAL AND METHODS: Serum inorganic fluoride concentrations were measured in a prospective observational study of 12 emergency medical technicians (EMTs). The study took 7 serum fluoride measurements over 24 months. A meta-analysis of healthy adult serum fluoride ranges was also conducted. RESULTS: The typical healthy adult serum fluoride range was determined to be 0.21-2.11 µmol/l (p < 0.001). The EMTs' baseline median (IQR) serum fluoride concentrations were 0.4 µmol/l (0.2; 1.0) with maximum 1.6 µmol/l. The EMTs' overall median serum fluoride was 0.4 µmol/l (0.2; 1.3) with maximum 4.0 µmol/l, usually within healthy reference ranges. All results were ≤10% of the suggested single-dose renal toxic threshold. One result was above a threshold for skeletal fluorosis. The highest measured serum fluoride was 24% of the lowest level associated with radiologic evidence of fluorosis. There was no evidence overall of increasing serum fluoride levels. CONCLUSIONS: There was no evidence that EMTs' exposure to methoxyflurane resulted in sustained increased serum fluoride. These results imply EMTs' occupational safety from acute renal toxicity when activated carbon filtration is used on patient exhalation. However, 1 serum fluoride result above a skeletal fluorosis threshold suggests that the risk of mild skeletal fluorosis cannot be excluded. Int J Occup Med Environ Health. 2021;34(6):767-77.

Assessment of Glycemic Control Protocol (STAR) Through Compliance Analysis Amongst Malaysian ICU Patients.

PURPOSE: This paper presents an assessment of an automated and personalized stochastic targeted (STAR) glycemic control protocol compliance in Malaysian intensive care unit (ICU) patients to ensure an optimized usage. PATIENTS AND METHODS: STAR proposes 1-3 hours treatment based on individual insulin sensitivity variation and history of blood glucose, insulin, and nutrition. A total of 136 patients recorded data from STAR pilot trial in Malaysia (2017-quarter of 2019*) were used in the study to identify the gap between chosen administered insulin and nutrition intervention as recommended by STAR, and the real intervention performed. RESULTS: The results show the percentage of insulin compliance increased from 2017 to first quarter of 2019* and fluctuated in feed administrations. Overall compliance amounted to 98.8% and 97.7% for administered insulin and feed, respectively. There was higher average of 17 blood glucose measurements per day than in other centres that have been using STAR, but longer intervals were selected when recommended. Control safety and performance were similar for all periods showing no obvious correlation to compliance. CONCLUSION: The results indicate that STAR, an automated model-based protocol is positively accepted among the Malaysian ICU clinicians to automate glycemic control and the usage can be extended to other hospitals already. Performance could be improved with several propositions.

Model-based glycemic control in a Malaysian intensive care unit: performance and safety study.

Background: Stress-induced hyperglycemia is common in critically ill patients. A few forms of model-based glycemic control have been introduced to reduce this phenomena and among them is the automated STAR protocol which has been used in the Christchurch and Gyulá hospitals' intensive care units (ICUs) since 2010. Methods: This article presents the pilot trial assessment of STAR protocol which has been implemented in the International Islamic University Malaysia Medical Centre (IIUMMC) Hospital ICU since December 2017. One hundred and forty-two patients who received STAR treatment for more than 20 hours were used in the assessment. The initial results are presented to discuss the ability to adopt and adapt the model-based control framework in a Malaysian environment by analyzing its performance and safety. Results: Overall, 60.7% of blood glucose measurements were in the target band. Only 0.78% and 0.02% of cohort measurements were below 4.0 mmol/L and 2.2 mmol/L (the limitsfor mild and severe hypoglycemia, respectively). Treatment preference-wise, the clinical staff were favorable of longer intervention options when available. However, 1 hourly treatments were still used in 73.7% of cases. Conclusion: The protocol succeeded in achieving patient-specific glycemic control while maintaining safety and was trusted by nurses to reduce workload. Its lower performance results, however, give the indication for modification in some of the control settings to better fit the Malaysian environment.

Towards Point-of-Care Insulin Detection.

Good glucose management through an insulin dose regime based on the metabolism of glucose helps millions of people worldwide manage their diabetes. Since Banting and Best extracted insulin, glucose management has improved due to the introduction of insulin analogues that act from 30 minutes to 28 days, improved insulin dose regimes, and portable glucose meters, with a current focus on alternative sampling sites that are less invasive. However, a piece of the puzzle is still missing-the ability to measure insulin directly in a Point-of-Care device. The ability to measure both glucose and insulin concurrently will enable better glucose control by providing an improved estimate for insulin sensitivity, minimizing variability in control, and maximizing safety from hypoglycaemia. However, direct detection of free insulin has provided a challenge due to the size of the molecule, the low concentration of insulin in blood, and the selectivity against interferants in blood. This review summarizes current insulin detection methods from immunoassays to analytical chemistry, and sensors. We also discuss the challenges and potential of each of the methods towards Point-of-Care insulin detection.