Do-It-Yourself Artificial Pancreas Systems: A Review of the Emerging Evidence and Insights for Healthcare Professionals.

Application of artificial pancreas systems in type 1 diabetes (T1D) represents a change in approach to managing complex glucose and insulin dynamics using automated features with higher levels of safety, precision, and reliability than those afforded by manual adjustments. To date, limited commercial systems and more widely used open-source, hybrid closed loop, Do-It-Yourself Artificial Pancreas Systems (DIY APS) have been used in nontrial real-world management of T1D. The aims of this article are twofold. First, itsynthesizes the emerging literature on DIY APS and identifies a range of evidence including research, reviews, commentaries, and opinion pieces written by DIY APS users, healthcare professionals (HCPs), and researchers. It summarizes the emerging clinical evidence for DIY APS and provide insight into how the DIY APS movement began, has been disseminated throughout diabetes online communities, and is reshaping self-management of T1D in real-world settings. Second, the article provides commentaries that explore implications of DIY APS to healthcare practice. DIY APS are radically changing T1D management. Automating the process of frequently analyzing glucose readings and appropriately titrating insulin delivery is liberating people with T1D (PWD) from some of the demands of intensive management. Within this super-specialized area of T1D management, the expertise of DIY APS users has outstripped that of many HCPs. While educational, ethical, and legal constraints need to be resolved, HCPs still need to stay abreast of this rapidly developing area. Further research is needed to inform policy and practice relating to DIY APS. Meanwhile, HCPs continue to learn from PWD's real-world experiences of building and using DIY APS to improve metabolic and psychological outcomes.

Optimising use of rate-of-change trend arrows for insulin dosing decisions using the FreeStyle Libre flash glucose monitoring system.

Continuous glucose monitoring and flash glucose monitoring systems are increasingly used by people with diabetes on multiple daily injections of insulin and continuous subcutaneous insulin infusion. Along with real-time updates on current glucose levels, these technologies also use trend arrows to provide information on the direction and rate of change of glucose. Two systems, the Dexcom G5 and the FreeStyle Libre, have recently been approved for use without the need for adjunct capillary blood glucose, and there is a need for practical guidance for insulin dosing which incorporates rate of change in the insulin dosing algorithm. Here, we review the integration of rate of change trend arrow information into daily glucose management, including rapid-acting insulin dosing decisions. Based on the FreeStyle Libre flash glucose monitoring system, we also review a practical decision-support tool for actions to take when using trend arrows in conjunction with current glucose readings.

Accuracy of flash glucose monitoring and continuous glucose monitoring technologies: Implications for clinical practice.

Continuous glucose monitoring and flash glucose monitoring technologies measure glucose in the interstitial fluid and are increasingly used in diabetes care. Their accuracy, key to effective glycaemic management, is usually measured using the mean absolute relative difference of the interstitial fluid sensor compared to reference blood glucose readings. However, mean absolute relative difference is not standardised and has limitations. This review aims to provide a consensus opinion on assessing accuracy of interstitial fluid glucose sensing technologies. Mean absolute relative difference is influenced by glucose distribution and rate of change; hence, we express caution on the reliability of comparing mean absolute relative difference data from different study systems and conditions. We also review the pitfalls associated with mean absolute relative difference at different glucose levels and explore additional ways of assessing accuracy of interstitial fluid devices. Importantly, much data indicate that current practice of assessing accuracy of different systems based on individualised mean absolute relative difference results has limitations, which have potential clinical implications. Healthcare professionals must understand the factors that influence mean absolute relative difference as a metric for accuracy and look at additional assessments, such as consensus error grid analysis, when evaluating continuous glucose monitoring and flash glucose monitoring systems in diabetes care. This in turn will ensure that management decisions based on interstitial fluid sensor data are both effective and safe.

The psychological and neurological bases of leader self-complexity and effects on adaptive decision-making.

Complex contexts and environments require leaders to be highly adaptive and to adjust their behavioral responses to meet diverse role demands. Such adaptability may be contingent upon leaders having requisite complexity to facilitate effectiveness across a range of roles. However, there exists little empirical understanding of the etiology or basis of leader complexity. To this end, we conceptualized a model of leader self-complexity that is inclusive of both the mind (the complexity of leaders' self-concepts) and the brain (the neuroscientific basis for complex leadership). We derived psychometric and neurologically based measures, the latter based on quantitative electroencephalogram (qEEG) profiles of leader self-complexity, and tested their separate effects on the adaptive decision-making of 103 military leaders. Results demonstrated that both measures accounted for unique variance in external ratings of adaptive decision-making. We discuss how these findings provide a deeper understanding of the latent and dynamic mechanisms that underpin leaders' self-complexity and their adaptability.

Hygienic drainage for healthcare.

Peter Jennings, technical director for ACO Building Drainage, which specialises in the development of corrosion-resistant drainage systems and building products, looks at the key issues to consider when specifying and installing pipework and drainage for hygiene-critical environments such as hospitals and other healthcare facilities.

Measuring and manipulating subjective organization after traumatic brain injury.

This study presents a method for assessing subjective organization (SO) after brain injury and techniques for planning cognitive rehabilitation therapy based on the survivor's SO ability. Eighty-seven college students, 50 persons with traumatic brain injury (TBI), and 30 participants with specific learning disability (SLD) learned two overlapping lists of unrelated nouns in which half of the second list were words that the person had learned on the first list. The study assessed whether different patterns of recall for the overlapping words versus the new words on the second list would discriminate persons with brain injury relative to college students and persons with SLD. The results indicated that college students and the SLD participants showed significantly diminished recall of overlapping words on the second list. However, the TBI participants showed significantly improved recall of the overlapping words. The results indicated that this task provides a simple diagnostic assessment of a participant's SO ability. The results also suggested that a TBI survivor's level of SO may moderate the success of prevocational cognitive rehabilitation therapies.

Effect of nutritionally enriched coffee consumption on aerobic and anaerobic exercise performance.

The purpose of this study was to compare nutritionally enriched JavaFit coffee (JF) to commercially available decaffeinated coffee (P) with regard to impact on endurance and anaerobic power performance in a physically active, college-aged population. Ten subjects (8 men, 2 women) performed two 30-second Wingate anaerobic power tests and 2 cycle ergometer tests (75% VO2 max) to exhaustion. Mean VO2 was measured during each endurance exercise protocol. Excess postexercise oxygen consumption (EPOC) and respiratory exchange ratio (RER) were recorded for 30 minutes following all exercise sessions. Area under the curve analysis was used to compare EPOC between JF and P for all exercise sessions. No differences were seen between JF and P in any of the power performance measures. However, time to exhaustion was significantly (p = 0.05) higher in JF (35.3 +/- 15.2 minutes) compared with P (27.3 +/- 10.7 minutes). No difference between JF and P were seen in EPOC in either the aerobic or anaerobic exercise sessions. A significant (p < 0.05) difference in average 30-minute postanaerobic power exercise RER was seen between JF (0.87 +/- 0.04) and P (0.83 +/- 0.03), but not following endurance exercise. A nutritionally-enriched coffee beverage appears to enhance time to exhaustion during aerobic exercise, but does not provide an ergogenic benefit during anaerobic exercise.

Thermogenic effect from nutritionally enriched coffee consumption.

BACKGROUND: The purpose of this study was to examine the effect of nutritionally enriched JavaFittrade mark (JF) coffee (450 mg of caffeine, 1200 mg of garcinia cambogia, 360 mg of citrus aurantium extract, and 225 mcg of chromium polynicotinate) on resting oxygen uptake (VO2), respiratory exchange ratio (RER), heart rate (HR), and blood pressure (BP) in healthy and physically active individuals. METHOD: Ten subjects (8 male, 2 female; 20.9 +/- 1.7 y; 178.1 +/- 10.4 cm; 71.8 +/- 12.1 kg) underwent two testing sessions administered in a randomized and double-blind fashion. During each session, subjects reported to the Human Performance Laboratory after at least 3-h post-absorptive state and were provided either 354 ml (1.5 cups) of freshly brewed JF or commercially available caffeinated coffee (P). Subjects then rested in a semi-recumbent position for three hours. VO2 and HR were determined every 5 min during the first 30 min and every 10 min during the next 150 min. BP was determined every 15 min during the first 30 min and every 30 min thereafter. Area under the curve (AUC) analysis was computed for VO2, whereas a session-average was calculated for RER, HR and BP. RESULTS: Initial analysis revealed no significant differences. However, seven of the ten subjects were considered responders to JF (had a higher AUC for VO2during JF than P). Statistical analysis showed the difference between JF and P (12%) to be significantly different in these responders. In addition, the average systolic BP was higher (p < 0.05) in JF (118 +/- 7 mmHg) than P (115 +/- 8 mmHg) in both the total sample and the subgroup of responders. No differences in average HR and average diastolic BP were observed between JF and P in both the total sample and the subgroup of responders. CONCLUSION: It appears that consuming a nutritionally-enriched coffee beverage may increase resting energy expenditure in individuals that are sensitive to the caffeine and herbal coffee supplement. In addition, this supplement also appears to affect cardiovascular dynamics by augmenting systolic arterial blood pressure.

Glycemic control in diabetic CAPD patients assessed by continuous glucose monitoring system (CGMS).

INTRODUCTION: From 20% to 40% of all patients commencing dialysis are diabetic. The quality of glycemic control is an important determinant of outcome. The aims of this study were to investigate the use of the continuous glucose monitoring system (CGMS) to assess overall 24-hour glycemic control and the effects of both nonglucose containing and more biocompatible alternative peritoneal dialysis solutions in insulin-treated continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS: We studied 8 insulin treated diabetic CAPD patients. A CGMS probe was inserted [allowing automatic measurement of interstitial fluid (ISF) glucose every 5 minutes, for a 72-hour period]. The patients were then allowed home with CGMS monitoring to assess the effect on glycemic control of three differing peritoneal dialysis regimes. Phase 1 consisted of three exchanges of 1.36% glucose and one of 3.86% glucose, utilizing a lactate/bicarbonate buffer. Phase 2 was identical but used lactate-buffered fluid alone. Phase 3 utilized a minimally glycemic combination of one amino acid, one icodextrin, and two 1.36% glucose lactate/bicarbonate-containing exchanges. RESULTS: ISF glucose measured by CGMS correlated well with venous glucose measurements (r2 = 0.82, P < 0.0001). There was a statistically significant difference in the mean ISF glucose between all three phases (P < 0.0001). The variation in glycemic control was tighter during phase 3 [mean coefficient of variation (CV) 0.21 +/- 0.03]. CONCLUSION: CGMS appears to be a clinically useful tool to gain additional insights into the glycemic control of diabetic CAPD patients. More biocompatible and nonglucose-containing dialysis fluids seem to be associated with improvements in glycemic control in this group of patients.