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Objective: Since the introduction of continuous glucose monitoring (CGM) technology, developers have rigorously researched the feasibility of creating a noninvasive glucose monitoring device. In a recent pilot study, investigators reported a strong correlation between glucose values obtained from novel noninvasive monitoring device (GWave) values to venous and capillary glucose measurements. Research Design and Methods: We investigated whether the level of accuracy observed in the pilot study could be reproduced in a larger cohort, using a smaller third-generation manufacturable device (Gen III GWave) containing a standardized sensor chip that can be mass produced for commercial use. The evaluation assessed concordance with capillary blood glucose, reproducibility between two Gen III devices, and accuracy during insulin-induced hypoglycemia. Results: Assessment of samples from 75 subjects (type 2 diabetes, n = 6; type 1 diabetes, n = 28; nondiabetic pregnant subjects, n = 10; and nondiabetic, n = 31) showed that 97% of values were in Zone A with 3% in Zone B of the Clarke Error Grid, with a mean absolute relative difference of 6.7% from reference blood glucose. Comparison between two independent Gen III GWave devices demonstrated reproducibility between the sensors (R2 = 0.95), with 100% of values within Zone A. In the hypoglycemia assessment, measurements from the Gen III sensor tightly followed the capillary glucose measurements down to 42 mg/dL (2.3 mmol/L), whereas the CGM measurements from two different CGM only converged with the GWave and capillary glucose readings after 90 min of decreasing glucose levels. Conclusion: Our results show promise as potentially the first noninvasive technology. Future studies will focus on larger number of people in all glucose ranges. Real-time noninvasive blood glucose monitoring is possible using GWave technology. [ABSTRACT FROM AUTHOR]

The article titled "Should We Bury HbA1c?" explores the use of glycated hemoglobin (HbA1c) in diabetes care. It acknowledges that while HbA1c is commonly used and cost-effective, it has limitations due to various factors such as red blood cell turnover, certain diseases, and race/ethnicity. The article suggests the need to consider these limitations and explore alternative methods for managing diabetes. It also discusses the use of continuous glucose monitoring (CGM) as a real-time tool for monitoring glucose levels, but highlights the limited availability and accessibility of CGM, leading to healthcare disparities. The article emphasizes the importance of policy changes to improve CGM access and recognizes HbA1c as a complementary metric to CGM for predicting diabetes complications. [Extracted from the article]

This article, titled "Ranting in 2024: It's Not More of the Same," discusses various issues in the medical system as of 2024. The author highlights the challenges and inefficiencies of the preauthorization process, which can lead to delays in treatment and impact patient outcomes. They also address the high cost of certain medications, particularly glucagon-like-peptide-1 receptor agonists (GLP1-RAs), and the role of pharmacy benefit managers (PBMs) in driving up prices. The article further explores the politicization of public health, particularly during the COVID-19 pandemic, and the need for better care for older adults with type 1 diabetes (T1D). The author concludes by acknowledging that while many frustrations exist within the medical system, there are also individuals who accept and even enjoy these challenges. [Extracted from the article]

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and public insurers. Moreover, recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. However, despite increasing evidence supporting CGM use for individuals treated with less-intensive insulin therapy or noninsulin medications, insurance coverage is limited or nonexistent. This narrative review reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in T2D individuals treated with basal insulin only and/or noninsulin therapies and presents an evidence-based rationale for expanding access to CGM within this population. [ABSTRACT FROM AUTHOR]

Background: We investigated the potential associations between race/ethnicity and adherence to prescribed glucose monitoring in a sample of Medicare beneficiaries with diabetes and how adherence to the method used impacted diabetes-related inpatient hospitalizations and associated costs among beneficiaries with intensive insulin-treated diabetes. Methods: This 12-month retrospective analysis utilized Centers for Medicare & Medicaid Services data to identify Medicare beneficiaries who used intensive insulin therapy from January through December 2018 and classified them into four groups: (1) persons using real-time continuous glucose monitoring (rtCGM), (2) persons using any method of blood glucose monitoring (BGM) who followed prescribed use patterns (adherent), (3) persons who were prescribed BGM but were nonadherent in its use, and (4) no record of any form of BGM. Analyses compared these groups and the role that comorbidities (Charlson Comorbidity Index [CCI]), and race/ethnicity played on group assignment, diabetes-related inpatient hospitalizations, and costs. Results: Among the 1,329,061 persons assessed, 38.14% had no record of glucose monitoring and 35.42% were BGM nonadherent. Similarly, among the 629,514 beneficiaries with a CCI risk score of ≥2, 466,646 (74.13%) were either nonadherent to BGM or had no monitoring record. The percentage of White (3.65%) rtCGM adherent beneficiaries was significantly larger than Black (1.58%) and Hispanic (1.28%) beneficiaries, both P < 0.0001. Hospitalizations and costs were higher for Black and Hispanic beneficiaries versus Whites within the risk score ≥ 2 group regardless of glucose monitoring method. Conclusions: Race is associated with increased hospitalizations and costs associated with diabetes care and absence of any form of BGM was associated with higher rates of comorbidities. Persons of color were less likely to use rtCGM despite Medicare coverage. New initiatives that promote diabetes self-management education and support services are needed to improve utilization of glucose monitoring within the Medicare diabetes population. [ABSTRACT FROM AUTHOR]

When "in a corporation, every employee will rise in the hierarchy through promotion until they reach a level of respective incompetence."[1] What made Dr. Peter so prophetic is that many of the health care bureaucrats who make our lives so difficult are at a level of personal incompetence. I Speak when you are angry - and you will make the best speech you will ever regret. i -Laurence J. Peter Although Dr. Peter was not a medical doctor, his wisdom guides me in medicine with every insurance company and pharmacy benefit manager bureaucrat who claims we need to be more cost conscious (despite following the guidelines) in our patient care. The reason is this is THE Dr. Peter, the same Dr. Peter who championed "the Peter principle." To this day, I have patients with diabetes who developed polio before Dr. Salk's landmark development. [Extracted from the article]

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with diabetes. Within ongoing innovations in CGM technology, individuals now have an expanding array of options that allow them to select the device that meets their individual needs and preferences. Although demand for CGM in primary care continues to grow, many clinicians are reluctant to prescribe this technology due to their unfamiliarity with the various devices, uncertainty about which devices are best suited to each patient and the feasibility of using CGM. This article reviews the features and functionality of the most recent commercially available CGM devices and provides guidance for integrating CGM use into clinical practices. [ABSTRACT FROM AUTHOR]

Antidiabetic medications and mortality risk in individuals with pancreatic cancer-related diabetes and postpancreatitis diabetes: a nationwide cohort study. Treatment guidelines do not exist for diabetes of the exocrine pancreas. Reduction of blood glucose by plant extracts and their use in the treatment of diabetes mellitus; Ancient Asian systems such as traditional Chinese medicine, Japanese Kampo medicine, and Indian Ayurvedic medicine, as well as African traditional medicine and many others, have pinpointed various plants that have been anecdotally reported to treat diabetes; there are likely more than 800 such plants for which there is scientific evidence of their benefits, mostly from studies using varying models of diabetes in experimental animals. New medications for the treatment of diabetes are usually an exciting topic. [Extracted from the article]

Background: Although guidelines advocate similar continuous glucose monitoring (CGM) targets for insulin-treated persons with type 1 diabetes (T1D) and type 2 diabetes (T2D), it is unclear how these persons differ with respect to hypoglycemia, glucose variability, and other CGM metrics in clinical practice. Methods: We used data from 2 multicenter randomized-controlled trials (GOLD and MDI-Liraglutide) where 161 persons with T1D and 124 persons with T2D treated with multiple daily injections were included and monitored with masked CGM. Results: Persons from both cohorts had similar mean glucose levels, 10.9 mmol/L (196 mg/dL) in persons with T1D and 10.8 mmol/L (194 mg/dL) in persons with T2D. Time in hypoglycemia (<3.9 mmol/L [70 mg/dL]) was 5.1% and 1.0% for persons with T1D and T2D, respectively (P < 0.001). Corresponding estimates for the standard deviations of mean glucose levels were 4.4 mmol/L (79 mg/dL) versus 3.0 (54 mg/dL) (P < 0.001), for coefficient of variation 41% versus 28% (P < 0.001), and for time in range 38.2% versus 45.3%, respectively (P = 0.004). Mean C-peptide levels were 0.05 nmol/L and 0.67 nmol/L (P < 0.001) for persons with T1D and T2D, respectively. Conclusions: Persons with T1D compared with persons with T2D treated with multiple daily insulin injections spend considerably more time in hypoglycemia, have higher glucose variability, and less "time in range." This needs to be taken into account in daily clinical care and in recommended targets for CGM metrics. [ABSTRACT FROM AUTHOR]

In my letter, I pointed out how this patient with 40 years of type 1 diabetes has impaired hypoglycemia awareness, and that it was nonsensical that we prescribe a Krispy Crème donut when the insurance was already paying for an insulin pump, a continuous glucose monitor, and a PSCK-9 inhibitor. I am still speechless about a patient several years ago, admitted with euglycemic DKA, who at the time was diagnosed with type 2 diabetes (later found to have type 1 diabetes), receiving an SGLT2 inhibitor, and the drug was not discontinued, even while he was an inpatient! The patient is in her 70s, type 1 diabetes for >40 years, and is now living in an assisted living facility, which allows her to receive fixed doses of prandial insulin with correction doses. Take, for example, my 60-year-old male patient with type 1 diabetes and a previous myocardial infarction who needed a glucagon prescription. [Extracted from the article]

In academia, there are more evaluations from students, residents, and fellows, but all of us who see patients are now dependent on patient evaluations that come in all forms. I received a hospital discharge summary from an outside hospital where a patient of mine with type 1 diabetes was admitted for intravenous antibiotics for sepsis. Currently, it is family advocacy that is the primary protector for patient safety when admitted to certain hospitals for type 1 diabetes. [Extracted from the article]

Achievement of well-controlled blood glucose is essential for preventing complications in patients with type 1 diabetes. Since the inception of continuous subcutaneous insulin infusion, the aim has been to develop an artificial pancreas, with the ability to use an automated algorithm to deliver one or more hormones in response to blood glucose with the intent to keep blood sugar as close to a prespecified target as possible. Development and rapid improvement of continuous glucose sensor technology has recently allowed swift progress toward a fully closed-loop insulin delivery system. In 2017, Medtronic began marketing the 670G insulin pump with Guardian 3 sensor. When in auto mode, this is a hybrid closed-loop insulin delivery system that automatically adjusts basal insulin delivery every 5 min based on sensor glucose to maintain blood glucose levels as close to a specific target as possible. Patients receive prandial insulin by entering carbohydrate amount into the bolus calculator. Early studies show improvement in HbA1c in both adults and adolescents with this technology. Initial safety trials showed no occurrence of diabetic ketoacidosis or hypoglycemia. The utility of this device is limited by blood glucose targets of 120 and 150 mg/dL that are unacceptably high for some patients. Notwithstanding recent advances, we are far from a system that is able to replicate islet function in the form of a fully automated, multihormonal blood glucose control device. [ABSTRACT FROM AUTHOR]

Background: The potential clinical benefits of continuous glucose monitoring (CGM) have been recognized for many years, but CGM is used by a small fraction of patients with diabetes. One obstacle to greater use of the technology is the lack of simplified tools for assessing glycemic control from CGM data without complicated visual displays of data.Methods: We developed a simple new metric, the personal glycemic state (PGS), to assess glycemic control solely from continuous glucose monitoring data. PGS is a composite index that assesses four domains of glycemic control: mean glucose, glycemic variability, time in range and frequency and severity of hypoglycemia. The metric was applied to data from six clinical studies for the G4 Platinum continuous glucose monitoring system (Dexcom, San Diego, CA). The PGS was also applied to data from a study of artificial pancreas comparing results from open loop and closed loop in adolescents and in adults.Results: The new metric for glycemic control, PGS, was able to characterize the quality of glycemic control in a wide range of study subjects with various mean glucose, minimal, moderate, and excessive glycemic variability and subjects on open loop versus closed loop control.Conclusion: A new composite metric for the assessment of glycemic control based on CGM data has been defined for use in assessing glycemic control in clinical practice and research settings. The new metric may help rapidly identify problems in glycemic control and may assist with optimizing diabetes therapy during time-constrained physician office visits. [ABSTRACT FROM AUTHOR]

We review clinical instances in which A1C should not be used and reflect on the use of other glucose metrics that can be used, in substitution of or in combination with A1C and SMBG, to tailor an individualized approach that will result in better outcomes and patient empowerment. [ABSTRACT FROM AUTHOR]

A review of the articles including "Performance of cleared blood glucose monitors" by Klonoff DC, one related to treatment of Diabetes mellitus by Ngaosuwan K, and "Accuracy of a simplified glucose measurement device-the hemoCue glucose 201RT" by Segerhag E which appeared in the previous issue.

The author comments on unnecessary barriers that Medicare creates for both patients and their providers, peer-to-peer discussions for approval of a medication or device by the insurer, and the benefits of using electronic medical records.

A personal narrative is presented which explores the author's views on the predicaments of medical system in the U.S.

The article presents the author's views on insulin therapy for type- diabetic patients.

The authors comment on several studies related to self-monitoring of blood glucose, performed by researcher P. Holt, H. Lunt, and F. Fang, published in the journal "Nurs Stand," "The New Zealand Medical Journal," and "Aging Male," respectively. Topics discussed include blood glucose monitoring in diabetes, glucose level associated with nocturnal hypoglycemia in elderly male type 2 diabetes patients, and self-monitoring of blood glucose in type 2 diabetes.

The article focuses on various studies related self monitoring of blood glucose published in various journals in 2012-2013. Topics include standards of self-monitoring of blood glucose by S.K. Garg and colleagues, published in "US Endocrinol," association between frequency of self-monitoring of blood glucose and hemoglobin A1c levels by K.M. Miller and colleagues, published in "Diabetes Care" and a study related to recommendations on measurement of blood glucose by S. Finfer and colleagues.

Abstract Background: Most current model-based approaches to closed-loop artificial pancreas systems rely on mathematical equations describing the human glucoregulatory system; however, incorporating the various physiological parameters (e.g., illness, stress) into these models has been problematic. We evaluated a fully automated 'fuzzy logic' (FL) closed-loop insulin dosing controller that does not require differential equations of the glucoregulatory system and allows clinicians to personalize dosing aggressiveness to meet individual patient requirements. Subjects and Methods: This pilot study evaluated the FL controller in the setting of bed rest in a very controlled environment. Two carbohydrate-controlled meals were given (30 g at 8 a.m. and 60 g at 2 p.m. without meal announcement or premeal bolus. The primary end point of the study was avoidance of hypoglycemia, defined at <60 mg/dL. Multiple end points related to the frequency and severity of hyperglycemia and hypoglycemia were also assessed. Results: Of the 12 subjects we recruited, 10 were enrolled, and seven completed the study. Two of the enrolled subjects were discontinued because of hypoglycemia; the other was discontinued because of sensor failure. Seven of the 10 subjects who completed the study had average blood glucose values of 165 mg/dL and were within a specified target blood glucose range (70-200 mg/dL) for 76% of the 24-h study period. Conclusions: Our findings suggest that the FL controller provides a viable alternative to model-based controllers as a component of a closed-loop insulin delivery system. Furthermore, our FL controller allows clinicians to easily specify the level of glucose control based on each patient's clinical needs. [ABSTRACT FROM AUTHOR]

A personal narrative is presented which explores the author's experience of being a physician who focuses on diabetes management.

In this article, the author reflects on diabetes and several case studies related to it. He mentions about three metrics for patients with diabetes, including glycated hemoglobin, low-density lipoprotein-cholesterol, and blood pressure. He reports case studies of a 80-year-old women who suffered from profound hypoglycemia unawareness and of a 32- year-old man with cystic fibrosis?related diabetes, and further discusses cheaper human insulin alternatives.