October 24, 2012

New Technique for Finding Test Strips on the Floor

Fact of diabetes life: Used strips find the floor.

Puppy fact: They chew everything.

Skippy chews anything on the floor. His crate, my chair, his toys, the other dog, my feet and has a real skill at funding used test strips. I think he is less likely however to choke on a rawhide the size if his head.

- Posted using BlogPress from my iPhone

October 23, 2012

Wanted: Patients Voice in Diabetes and Emotional well Being

A few days ago I wrote about research were patients were not seen as a stakeholder in research. There were some good comments and I encourage you to go read them. If researcher are part of the problem so at times maybe are patients. I think at times we don't participate as much as we should (arguably because we don't see the results as being to our benefit or even accessible.) We need to step up when we can. Here is place we can. 

Glu has a survey for adult T1D about emotions of diabetes and T1D support. Any #DSMA regular knows this is an issue near and dear to the hearts of the DOC. Here is a chance to help patient views be part of the conversation. 

Here is how to share your voice:
  1. Join Glu www.myglu.org (if you haven’t already.)
  2. Scroll down to the bottom on the home page, in the glu u section click October’s Survey.
  3. Look over the terms and agree as appropriate, this is being run by real researchers so yes there is a real consent process. (I think that approachable research is a good thing). Enter you password so they know it's officially OK with you. 
  4. There are a number of questions each has its own page. A few of pages is a little cumbersome yes but it is a good start and an important topic. 
  5. Participate, spread the word and help make it better.
Full disclosure. I was part of a group that offered views on how to start this process and communicate it to the DOC. I would love to see it succeed not because I had a tiny part in getting the ball rolling but because I think patients voices need to be a bigger part of the research process. Here is a chance to do that. Lets all help make the effort a success so they keep doing it.

Why not parents? As I said this is being done by real researchers with review boards and all that that involves. Doing research with kids, even parents sharing information about their kids is anther level of dotting I(s) and crossing T(s). It should be.  Kids deserve to  be protected with a little extra diligence. In the mean time parents of T1D kids share this with friends in the adult T1D community OK? 


October 22, 2012

Do we need a FDA Office of Mobile?

A September 26 2012, article on Kaiser Heath News by Jenny Gold raises the question of Mobile regulation by the FDA. In that article Gold report a Congress member will introduced legislation to create an Office of Mobile Health. I have no idea if the legislation will amount to anything but it does raise an interesting topic of conversation: Should mobile be treated as a unique regulatory process?

Here is a section of the piece:
But a bill set to be introduced in the U.S. House of Representatives later this month aims to smooth the agency’s evaluation process. The Healthcare Innovation and Marketplace Technologies Act (HIMTA) would establish a special Office of Mobile Health at the FDA to provide recommendations on mobile health app issues. It would also create a mobile health developer support program at the Department of Health and Human Services to help app developers make sure they are operating within privacy regulations, including the federal law HIPAA that sets privacy standards. 
"Currently, our healthcare system works against small-to-large startup entrepreneurs with a multitude of barriers to entry," Rep. Mike Honda, D-Calif., who is introducing the bill, said in a statement. “Why have the principles of Silicon Valley, which I represent – competition, innovation, and entrepreneurship – not fully manifested themselves in the healthcare information technology space?  This bill gets us closer to that space.”
I have written about mobile and diabetes apps a few times ok maybe more than a few.... As Gold's article notes The FDA is expected to issue guidance on mobile soon. 

I think that diabetes care offers some unique challenges for the regulation of apps. The FDA appears to be interested in taking thing one step at a time or more precisely single mobile devices at a time. The FDA draft guidance said, “The FDA plans to address in a separate issuance mobile medical app intended to analyze, process, or interpret medical device data (electronically collected or manually entered) from more than one medical device.” 

Diabetes is managed by patients with multiple devices, meters, cgms, pumps, and logs of food, working out and other life activities. To be meaningful diabetes mobile apps will need to deal with more than one device.  To me that is more relevant than the structure of the regulatory office.

(edited to add) I would suggest that we keep an eye open to closed loop A.P. and to get there maybe a good step is an open loop app where users are involved in the process but supported by an app that integrates information from multiple devices.

ADA Discrimination Twitter Chat

Twitter Chat on Diabetes and Discrimination – Wednesday, Oct. 24

On Wednesday, Oct. 24, from 1 to 2 p.m. ET, the American Diabetes Association will hold a special Twitter chat on diabetes, discrimination and how to get help. Tweeting from the Association’s handle (@AmDiabetesAssn) will be special guest Katie Hathaway, Managing Director for Legal Advocacy, who will answer questions from the audience.

To participate, just log on to Twitter, follow @AmDiabetesAssn and search for #DiabetesRights. Those who do not have Twitter accounts can also follow along by visiting Twitter.com and searching for #DiabetesRights.


October 19, 2012

Less awake than I thought or why coffee matters.

I had an early flight Tuesday. Out of Baltimore because there was a direct flight and I would rather spend an extra hour in the car than a layover and extra time in the air. Not that I mind the air part.

By early I mean get up before 4:00 am. I’m a bit of an insomniac so that works out to just a few (2) hours of sleep. No worries, I thought, I can do this.

I got up showered, brushed my teeth and thought I need to grab my tooth brush. I kept my bag zipped open to remind me. So I dropped it in and zipped it up. 

I stopped for coffee and an extra shot of expresso to get into driving mode. Nice easy run down I-95. Simple quick Southwest flight. 

I freshened up for the memorial service and thought I should brush my teeth, ya'know for the coffee breath,  and found this in my bag:

No tooth brush. 
That extra shot of expresso may have been a far wiser choice than I initially thought. 

October 15, 2012

Vizzini's View of Diabetes Data Standards

One of the earliest YDMV posts stated out my view on diabetes data:
Type 1 isn’t all about the numbers. It is about kids living their lives. That said there are one hell of a lot of numbers. We gotta deal with the numbers, so we can love the kids as kids. Nobody need love the numbers. 
There are a ton of little electronic machines that produce billions and billions of numbers (and about as many strips on the floor). At times it seems we are floundering in a sea of data points (and strips on the floor). Unfortunately each machine speaks its own language. What we need is the UN. United Numbers.
It seems that I am not the part of the diabetes universe that sees data standards as a problem.  I recently read two articles that make the case for researchers to have a common diabetes data set. Data Standards in Diabetes Patient Registries (Journal of Diabetes Science and Technology May 2011) and A Strategy of Defining Common Data Elements to Support Clinical Care and Secondary Use in Clinical Research, (AMIA Clinical Research Informatics Summit 2010) both make the case that research would be better off with standards to facilitate data that researches, “collect once, use many times.”

As I understand the issue, research reinvents the diabetes data wheel with virtually every study. Each study collects what they are interested in but since it is not a common data set few studies have data that can be combined and used to further additional investigation.

One paper even has this lovely little graphic that helps demonstrate the overlap of parties that could benefit from common data. 

The second paper goes on to talk about these stakeholders in detail:
“There were no defined data standards for primary or secondary use in T1D at the start of this project, and so it is likely that the elements we have compiled will be subject to debate and revision when vetted in a broader T1D stakeholder community, which should include perspectives from diabetes care, research, population monitoring, and quality measurement.”
Notice anybody missing from that? 

I did. 

People with Diabetes.

It is their data.

In short if researchers want people to share their health information, there should be a value for participating. The ethical term is beneficence, that the research does some good for the participants.

I think that for diabetes research to find solutions that improve the lives of people living with diabetes those researchers need to ask the right questions. Starting with: Who is a stakeholder? As the risk of sounding like Vizzini, it seems inconceivable to effectively improve patient outcomes without seeing people with diabetes as a stakeholder in the process. 


Closed Loop = Better BG Control in Kids

Diabetes Care reports a study of closed loop (AP but I think I like the term closed loop better because an actual pancreas does more.)  This study shows kids do better, particularly over night. Sadly I don't have access to the full paper but here is the reader headline and conclusion form the abstract. 

Closed-Loop Insulin Therapy Improves Glycemic Control in Children Aged <7 span="span" years="years"> 
Closed-loop insulin delivery decreases the severity of overnight hyperglycemia without increasing the incidence of hypoglycemia. The therapy is better able to reestablish target glucose levels in advance of a subsequent meal. Younger children with type 1 diabetes may reap significant benefits from closed-loop therapy


October 12, 2012

Little Help? Spouses and Significant Others of Adult T1Ds

From the Behavioral Diabetes Institute: 

Just For PartnersDevelopment of an Online Program to Address Emotional Distress in the Spouses and Partners of Adults with Type 1 Diabetes

Help Needed!
WHO WE ARE: A joint project of the Behavioral Diabetes Institute (which is run by William H. Polonsky, PHD, CDE) and the Bringing Science Home initiative (directed by Nicole Johnson).
GOAL: We know that sometimes it can be tough and frustrating when you have a partner with type 1 diabetes.  So we are developing the first Web-based program that is designed to help you, the spouse or partner of an adult with type 1 diabetes, to cope more successfully.  In early 2013, this program will be available to partners all over the world at no cost.    
WHAT WE NEED: In this first phase, we are looking for partners/spouses of adults with type 1 diabetes to complete an online questionnaire.  We will use the initial results of this questionnaire to help us understand how partners are struggling and what might be needed to help them.  We will then use these findings to build the tools for the final online program.  
Please note that we will not be asking you for any personal information that will identify you in any way.   The questionnaire is completely anonymous.
WHO IS ELIGIBLE: Anyone who has an adult spouse or partner with type 1 diabetes.  Must be fluent in English.
WHAT WE WANT YOU TO DO: If you are willing to participate, please access our private and secure study website at: http://justforpartners.behavioraldiabetes.org.  The questionnaire will take approximately 15 – 20 minutes to complete. 
WILL THERE BE COMPENSATION: Well, no.  Sorry about that.  But you will have the pleasure of knowing you have helped us move this important project forward and that you will be contributing to a project to help other spouses and partners deal more effectively with type 1 diabetes!

October 10, 2012

Pennsylvanians, Please Act for Kids with Diabetes in School

 Hello my fellow Pennsylvanians. I know that sounds like the opening to a  political stump speech.

I hope this is more of a response to one.

Now is the time write our elected officials. Once again legislation is pending that would allow schools, parents and adult volunteers in schools to help kids with diabetes. Specifically in the administration of diabetes medications, insulin and glucagon. Yes in PA we need this law because as it stands now it is not legal for a school nurse to delegate giving glucagon.

ADA has a super easy fill in the form and customize letter generating process that we can use to share with our legislators.
Click here: https://donations.diabetes.org/site/Advocacy?cmd=display&page=UserAction&id=2378

Put in some details about your family and why safe at school matters.

Maybe if we act now our ligislators will too. 

October 8, 2012

"Don’t Freak Out Over a (T2) Diabetes Diagnosis"

Dexcom G4 Approved in USA aka Dexcom Platinum

From the press release today:
October 8, 2012
U.S. FDA Approves the Dexcom G4™ PLATINUM Continuous Glucose Monitor (CGM)
New Device for Diabetes Management is Most-Advanced CGM Available with up to 30% Improvement in Hypoglycemic AccuracySAN DIEGO--(BUSINESS WIRE)-- Dexcom (NASDAQ: DXCM), a leader in continuous glucose monitoring, announced today that the U.S. Food and Drug Administration has approved its eagerly anticipated new continuous glucose monitoring system, the Dexcom G4™ PLATINUM.
Clinical trials report up to approximately 19 percent improvement in overall accuracy for the Dexcom G4 PLATINUM compared to the Seven Plus, and approximately a 30 percent improvement in accuracy in the hypoglycemia range (i.e., when blood glucose is less than 70mg/dl). The overall accuracy and ease of use for the Dexcom G4 PLATINUM sets a new standard for commercially available CGMs, making the Dexcom G4 PLATINUM the most-advanced CGM system available.

Fulll press release:

October 6, 2012

CGM, Pregnancy, A1C and What are the Right Questions.

Just read this short write up of a CGM and pregnancy study: http://www.obgynnews.com/news/top-news/single-article/continuous-glucose-monitoring-offers-no-pregnancy-benefit/5699b76dcc1c8cbf0d16e9d4160a94bc.html I'll call the study Secher after the good doctor who did the study. 

It seems to me Secher et al studied intermittent use of a CGM because they thought getting full time compliance would be hard. They found that intermittent, what they more or less defined as non compliant, use was not a benefit. Another earlier study by Murphy, et al found the opposite: http://www.bmj.com/highwire/filestream/384096/field_highwire_article_pdf/0/bmj.a1680

I would love to see more detail but it seems the Secher study may be asking the wrong asking the question. It asks does partial CGM help not does CGM help. Is this normal research? - to only look at intermittent use that the designs see as a surrogate of non compliant use? What happen with more compliant use and dose that use lead to less total glycemic variability.

A statement in the article attributed to Secure's says, "By focusing on severe hypoglycemia, we might pay a price in hyperglycemic complications. " This seems to indicate that they were not focused on balanced control of BG but more hypo avoidance. The study is not reported out yet so one can not  know for sure. If so then, the complication of hyperglycemia were not addressed as highs weren't the focus. This seems to be the case as a write up of the study states that s secondary outcome of this study was, "Metabolic control in terms of HbA1c, blood sugar measurements and the occurrence of severe hypoglycemia in pregnant diabetic patients." (http://clinicaltrials.gov/ct2/show/NCT00994357) To me, and I am no expert, that suggests they were focused on lows not highs. However it is the highs, in the third trimester, that may be the issue.

The Murphy paper says, "Prepregnancy care is key to improved glycaemic control during the first two trimesters but does not reduce the risk of macrosomia, which we believe is more strongly associated with hyperglycemia in later gestation.12 Data from the Netherlands suggest that near optimal glycaemic control during early pregnancy (84% of women had a mean HbA1c level of 7.0% or less) failed to reduce the risk of macrosomia, present in 48.8% infants.1 This prompted us to consider new strategies, focusing on reducing postprandial hyperglycaemic spikes during the second and third trimesters. Observational data suggest a strong correlation between maternal postprandial glucose levels in the third trimester with an increased risk of macrosomia.13-17 Educational approaches incorporating additional glucose testing after meals to improve glycaemic control in late gestation have shown potential to reduce birth weight.18 19 " So it seems to me the issue isn't the device but how the moms to be are coached and supported to learn and manage BG with the CDM device. Still this second paper reports out A1Cs.

I would love to see these studies talk about variability, maybe measured as standard deviation, particularly in the third trimester, in addition to A1C. CGM is a tool to report and so facilitate management to minimize variability in ways finger stick can not. I would love a study that looks at the question - can women be coached and supported to manage glycemic variability with a CGM in ways that reduce third term hypers and hypos that has an impact on birth weights? Is this variability management more predictive of healthy birth weight than A1C? 

That seems to me to be closer to the right questions or is it just me?

ps. It was really hard for me not to make jokes here. Sadly I would think that if Secher is used to deny CGM insurance coverage as an option to help coach women in pregnancy it would be a case of Murphy's law not Murphy's study. 

October 4, 2012

Monday on 'Rents: Mark Fox

Mark Fox

Monday Oct 8, 9:00 pm eastern

Txt-abetes at MobiHeathNews.com Would it work for you?

MobiHealthNews.com has a story up about a text message based support system for diabetes education and support. I have read a number of papers about similar pilot programs and they seem to work. What are you thoughts? Do you think txt-abetes would work for you?

From the piece:
This week Voxiva, which powers the technology behind the federal government’s Text4Baby program, announced the official launch of Care4Life, a mobile-based diabetes education and support program that leverages text messaging, a mobile app and a web portal. HealthInsight, a multi-specialty care delivery network in the Utah Beacon community is currently evaluating Care4Life. 
“Since 99 percent of text messages are read and over 90% are read within three minutes, we know that this channel is effective in its ability to pace the delivery of education and reinforce desired behaviors on an ongoing basis,” Voxiva CEO Justin Sims stated, “numerous studies have demonstrated the efficacy of mobile communications in improving diabetes self-management. We know this works and will make people healthier.”

Full article at:

October 1, 2012


Eleven years ago we got a dog. 

Well she got us.

She was blob of chocolate, and brown and white that reminded the kids of a S'More. 
So that was her name.

So was:
Yapper Smoos-a-fat
Smoos-a-fatty dog
Your Majesty
Smooby Dobbie Do
Puppy Prewash (when doing the dishes)

She didn't do any of the stuff dogs are meant to do. She had no idea of fetch. Come was totally at her whim. Forget the idea of master, she was the queen of the we were her minions. Although on the up side one of her first royal actions was to actually eat my son's homework.  

Sometime she would go out with with other dogs...

...but only to steal attention from their people.

She was bread as a gun dog but has far too gentle soul and hid from thunder and fireworks.   

Kidney failure has run Smoo down. It has come to the point that she can't eat. She is sitting ant my feet shivering as I type so I have to go find a blanket. 

S'More have been a benevolent monarch.

A friend back in the 70s' loved the folk singer Ralph McTell.
He sang a song about an Old Brow Dog.
It has always made me cry.

Today more so than then.

All those time I said I hate dogs, 
that I don't love you. 
I lied. 

Good night S'More.