In less than an hour, primary care providers can get up to speed on type 1 diabetes through this information-packed talk from pediatric endocrinologist Gina Capodanno, MD. She covers everything from the impact of COVID – linked to a 9.5% rise in new cases worldwide – to which patient populations should be screened to the technological advances that can empower kids to manage their everyday care. Learn about new devices, including smaller continuous glucose monitors; customizable pumps; and systems that synthesize these technologies to keep blood glucose steady. Bonus: a list of simple ways to support the overall physical and mental health of kids with type 1 diabetes.
Some of the increased risk, um uh probably new cases and more severe presentation. And so, you know, in response to the growing links between nuanced pediatric diabetes and COVID and International group of diabetes, researchers established a global registry of patients with COVID related diabetes really need um the goal really looking to share, look at these shared features among nuance that patients and track outcomes to better guide on management. And in general, thinking about, you know, general guidance for you with diabetes of any form or so it's a with type two and obesity is to consider diabetes a high risk condition that may have the potential for more severe infection and complications. Um I'd say again, more so with type two diabetes more so with type one, with obesity more so with any form of diabetes, with comorbidities. Um A one CS that are well above target, um those that R and D and very well in range, you know, having more time, uh not, you know, about target or having infrequent DK admissions are considered to be less risk. Um So, you know, we still encourage to get vaccinated to um you know, keep an eye make sure that diabetes is more control during this pandemic because um there's this potential for an increased risk of complications and more severe um COVID disease. So kind of segue into this classic model for two ND pathogenesis, think of it as T cell dis regulation at the core. Um And here with this classic model in a healthy system, beta cells are protected from autoimmune destruction um by regulator T cells and they keep the CD four CD eight activation away and beta cells remain functional. But in type one diabetes, there's insufficient immune regulation that results in this auto immune response by auto reactive T cells, particularly provoked by beta cells. And that leads to beta cell destruction. So really crude mechanism here for thinking about how it works, how we discuss it with patients. But we know that it's way more complex than that. And a lot of newer areas of research are looking at ways to manipulate these pathways to see other ways that we can stave off, you know, t windy, maybe somebody who is starting to show this out of immunity that doesn't have dis regulated, you know, glucose metabolism yet, can you know, we prevent that from occurring? Can we prolong the stages of type one diabetes? That's, that's where all the immunological research is active right now. So another way to kind of look at this like many disease processes, you know, 2nd is thought to manifest through a you know, to hit mechanism. First being this genetic predisposition and second being an exciting event, whether viral illness or some type of stressor leading to immunological abnormalities and a progressive decrease in beta cell mass. Um that you know where the beta cells continue to decline until they reach a critical point. Um where insulin releases, affected with C peptide decline initially with mild this glitchy mia than with hyperglycemia where the symptoms of diabetes are seen. But the designation of type one diabetes is now brought in to include states of normal glucose where signs of auto immunity are present before hyperglycemia is seen. Okay. So kind of using that sort of structure here, American Diabetes Association, JDRF endocrine Society all support this new staged process of type one diabetes development where by having two or more pancreatic antibody's positive puts an individual on the path to T one D. So stage one is two or more antibodies positive with normal glucose. Stage two is two more antibodies positive with abnormal glucose and that dis regulated range. And stage three is two more antibodies positive with a clinical diagnosis and stage four is longstanding diabetes. So patients are now coming to us and to you earlier. Now, you know, stage one stage two with mildly abnormal or even normal glucose. But on the pathway to diabetes trial net um provides family members of people with diabetes free antibody testing, either through home finger stick kits or serum lab draws quest or labcorp where currently screening five antibodies. Um And if you're all antibody negative, you're really unlikely to develop type one. Although there are some cases that can switch later on, but exceedingly low response there. And if somebody has one antibody positive, they're offered yearly rescreening trial that's available to individuals. Age 2.5 through 45 with an affected first degree relative with two ND or 2.5 to age 20 with a second degree relative or half sibling. And you know, double edged sword here, it can help prepare and gradually ease families into a diagnosis. Um through trial that you know, can provide families with research opportunities looking to halt or slow the disease progression. But you know, it can be overwhelming and devastating to families maybe knowing, you know, having a second child eventually with type one diabetes or having a child that will eventually need treatment. I include this, you know, slide briefly just to show the diagnostic criteria for clinical diabetes hasn't changed in read the column on the right or diabetes range levels of fasting 1 26 or higher and random or post stimulation 200 or higher. And you know, a one C is increasingly used as a screen though confirming with impaired fasting and a random glucose and Wendy, it's usually the post stimulation that's affected before fasting kind of reaches that range. But that's really needed to still confirm the diagnosis or having a clearly defining event like DK. So, you know, we talk about most pediatric diabetes as fitting into type one or type two. I think increasingly we're thinking of our classic ways of thinking about type one or type two really as opposite ends of a spectrum and lots of different flavors in between. Still to realize that type one diabetes is over six times more common in youth um can occur at any age as we talked about. Um But really important to note that the presence of obesity does not preclude the diagnosis of type one and really any pre puberty child should be presumed to have type one. Okay. Um you know, increasingly, you know, get referrals for maybe like a six or seven year old that has a little bit of abnormal glucose, no A can Thanasis, but there may be obese and think, you know, this is, this is prediabetes. Yes. But if you know, there really isn't any, I can't Asus we really should be thinking that this is an evolution of type one, which is a very different conversation than just kind of thinking about diet and exercise modification. Right now, we're gonna switch over and talk about, you know, diabetes technologies. Um Just a quick, you know, talk about how glucose and ketone monitoring has evolved. Um some strategies for insulin delivery, glucose response systems and then, you know, some apps and software um quickly glue commenters, they haven't gone away I'm still going to be important. Everybody with diabetes needs to have one even if just for backup. Um but just wanted to highlight that, you know, we've got some, some smart meters a lot connect via Bluetooth to a smartphone app. Some can link directly to a pump. So patients don't have to manually enter a glucose level for dozing, which can be huge in the teenagers, you know, taking away one extra step of something, you know, can make all the difference between whether or not they're going to use the technology or not. Um As well. Ketone meters have evolved, you know, urine keto sticks still available still there, you know, welcome to use them in a pinch, but they can delay uh sort of showing whether or not ketones are positive by about six hours. So we have newer blood ketone meters. They are a separate meter than a glue commenter. They use separate strips than a glue commenter. Um But they can really tell you, you know, in real time whether or not ketones are being produced um and can, can really guide. So there's the little formula on the top as a guide but effectively the scale for positivity and minimal per liter, but less than .6 is normal and above 1.5 is high. So that can really, you know, guide family immediately. Hey, you know, we're starting to build ketones. It might not be an acidosis yet, but body needs you know, more insulin and some fluids to help with the dehydration right here. And right now, um, they know plus or minus whether or not these supplies are covered by insurance. Insurance might cover the meter but not the strips and the strips and not the meter and the strips are really expensive. You know, they're $10 each per strip. So, you know, we really try to get insurance to cover them. Um, families will get the urine keto sticks and then have these may be able just kind of in the background just having a few strips available. Um Pretty neat that we're able to detect those ketones. Um You know, a lot easier and more accurately, but really, you know, the game changers have been pumps and sensors, okay. So we're going to spend a lot of time talking about this and kind of knowing what all the pieces are, how they interact, interact with each other. Um So, you know, not for everyone, but um continuous glucose monitors have really changed the course of diabetes management for patients. They don't have to prick their finger 8 to 10 times a day for glucose data. Um They, you know, the first one was introduced in 1999. Early home versions became available around 2013 to adult patients with some lag by a few years to the younger patients. And not really until 2018, were they more ubiquitously available for patients? Um age two and older. Um, it's C C G M provides a semi continuous management of interstitial fluid glucose, measurements of interstitial fluid glucose, um every 1 to 5 minutes and allows you in most cases to see data in real time to help make treatment decisions. It can be used for any type of diabetes. Um not just type ones, not always covered by insurance outside of type one and specific brands might be more preferred, you know, for an insurance versus the other. But we really have, you know, some good advocacy in the endocrine side to get, you know, type of continuous glucose monitor from for most of our young patients. Okay. So the three components to A C G M R A sensor, a transmitter and a receiver, the sensor is used to detect that change in glucose. It's the small flexible probe that sits in the interstitial space. Um the transmitter um which may be fixed directly to the sensor or detached above the skin just above the sensor that sends the signal from the sensor skin um to a display device or receiver. Um and that uh receiver, you usually a separate device, but newer models can display directly on a, on a pump or connect to a smartphone or watch. And then that receiver, you know, is what the user sees um to, to really look at the current and past and sometimes predicted glucose trends. So, so pretty neat. The two types of C G M are real time and intermittently scanned or flash. Um real time shows an automatic display of data. It has alarms to alert the user of high and low glucose levels versus flash shows a few hours of continuous data when the user wants it maybe by scanning um this manual sensor and then there is professional C G M used to use that, you know, while back reason and research a lot, it's more for diagnostics. It's, you know, blinded to the user doesn't have any alarms, but it can provide useful information to the provider. Researcher, um sensors themselves can be uh subcutaneous lee inserted by the user. Those are the main ones we have in pediatrics, um or by the health care provider and implanted under the skin. So there's one implantable one, I'll show that to you in a second, but that's available for adults. And you know, the practical aspects of C G M as we talked about alarms, high and low glucose levels rise and fall rates, predictive alerts. They depending on how you have your receiver set up or what the app is on the phone. They can show trend graphs and arrows rise and fall rates and can be really helpful for helping to guide on whether or not insulin needs to be um dosed or, or adjusted. Um It allows real time intervention um and really to anticipate and prevent severe glucose events. And then, you know, families can or together with providers have been really, really helpful during the pandemic to look and review these reports of sea GM data, um, to view trends and make adjustments. So I don't have any affiliation with any of these companies here, but I think it's important to kind of know what all these pieces look like and which ones do, what, which ones connect two pumps just to kind of see when you, if you see one of your patients with one of these devices, you know, what's the thing that's doing the insulin? What's the piece that's displaying some, some data to to to the patient? Um So the two current continuous glucose monitor systems on the market that integrate with insulin pumps are the decks come and medtronic guardian, both are real time sensors about half an inch thick, fixed to the skin with the sensor filament less than half of a millimeter thick, just like this little metal like wire like piece that is inserted, transport a Gnaeus li um and the decks com sensor last 10 days. Um It's FDA approved to be used in lieu of finger stick checks for uh making insulin decisions, doesn't need calibration. Um And it has a share feature which is really wonderful and amazing. Um you know, for families to be able to see that data with their kid is at school, for instance, um the medtronic sensor last seven days does need finger calibration at this point. And uh during a warm up period and with new transmitter and new sensor and then every 12 hours. So finger pokes are still required with the medtronic one, both are approved for age two and older. And as you kind of increasingly see with all these things, the integration share features. These are all where families are trying to figure out which device technologies in which combination are the best ones for them. Uh Both sensors have similar approved locations for placement. Um here, abdomen for both adults and Children, upper buttocks for toddlers and Children, arms aged 14 plus for medtronic 18 plus for DX come, although you'll often see these sensors placed in unapproved sites by lower back arm and Children which may or may not work. I'd say from practical experience, these sensors really work in many, many other places. Um And families are aware when they're using a non approved site. If we get a lot of inconsistent or weird data will tell them to go back to where the approved sites are. Okay. Um The Freestyle Libre is a flash flash system. Um The sensor and transmitter are integrated as one. It's about a third of the thickness of others. Um The library to which had been out one of the main ones up until just recently a few weeks ago. So the size of a quarter um and now the newly released library three is the size of a penny, really, really tiny measures glucose every minute stores readings every 15 minutes and shows eight hours of glucose data history at a time. Um The older models needed a scanner. So there would be, you know, a device either using the app on your phone and using your phone as the scanner or an actual other device that you take and just kind of swipe over the sensor and then you can see the data, the new model, the library three doesn't have that anymore. And it just kind of shows you real time data similar to the next com um and medtronic and these also do not need calibration this ever since sensor. Um It's not approved in Children. Um It's an implantable sensor with the removable external transmitter. Um It sends data every five minutes that communicates to these are via body vibrating alerts and to a mobile device via Bluetooth. And then just some of the downsides to both of these is that neither has pump integration. Okay. So they're, they're great in, I'd say the library. It's, it's a, it's a plastic filament, maybe a little more hypo allergenic. Um So if the decks comes really causing severe allergies might switch to Libra. Libra is great in our type two patients and our folks maybe who are on shots, but I don't want to be on a pump, the library. It's great. There's just a little bit more customize ability and it's so teeny tiny. Yes. So arm for both the library and ever since I don't have any personal experience with the ever sense that it's still, that transmitter needs to be replaced every few months or sorry, the sensor that's underneath the skin every few months. So it's not just kind of a one and done deal so hard. I don't know, thinking about our teenage patients probably hard sell to have to come back and place that underneath the skin every few months. Um And it's kind of big. So just kind of showing the evolution of these just because the liberals just came out a few weeks ago and is so teeny tiny. Um The difference, it's 70% smaller than the previous one has an hour warm up, the decks come G seven is coming out very soon. It's been released in Europe in before five countries and us should be coming soon. 60% smaller than the existing one only has a 30 minute warmup period versus two hours, which is current. Um And so during those warm up periods, especially with pump integration that, you know, the the systems can't use that data just, you know, during the warm up. So seeing how small they are, I mean, it's gonna be a huge game changer for, I feel like with the decks comment are folks that have that pump integration. Um Yeah, so we know just kind of thinking about the pros and cons of C D M talked through a lot of these already eliminating the need for multiple finger sticks. Um provides alarms real time data. You know, parents, family, everybody can sleep, not having to worry about severe hypo events overnight. It shows trends and context for what the glucose is doing instead of a snapshot in time, you know, you get a blood sugar of 1 80. You don't know, hey, has it been stable? Is it rapidly coming down? Is it going up? So see GM can really provide context for, you know what's going on. Um and then as we said, it has an increase in integration with pumps. Um and some of the disadvantages, maybe more so with old systems limits on accuracy, especially with hypoglycemia or low glucose is um there's still a lag time between the interstitial and capillary glucose can be up to 30 minutes of the delay time and what the CGM is showing versus what's actually happening. Um Some of the systems, as I mentioned, still require calibration with fingertip, finger sticks for optimal performance. Um And then, you know, thinking about there's maybe an over reliance on data um leading more to issues when you're off when they're off of the C G M. Um that, you know, it's hard to keep up with all of the tasks because they're used to just kind of having it all done for them could be alarm, fatigue, risk of skin infections, you know, limited space on the body for all of the placement of these devices and then kind of similar as we'll see with pumps, just kind of psychological effects, you know, on the individual for wearing a device, having it be invisible to others. Um and kind of, you know, kids maybe being teased at that having some um pieces of technology on their body. So it was a candidate for C G M ensuring anyone with type one diabetes, you know, it's supported in the practice guidelines from the American Diabetes Association and the International Society for pediatric and adolescent diabetes specifically cites to improved A one C and and decreased hypoglycemia. Um, you know, with C G M and so we're usually not in any running into any trouble and getting see GM for our pediatric patients. Okay, any questions on C D M. So moving on to insulin delivery before kind of jumping into pumps, you know, pens and ports can be helpful for patients. Um, you know, who don't want a pump, you know, that's on their body, the smart pen, it's a reusable injector pen with a smartphone app. The in pen, um, recently acquired by Medtronic is the smart pen on the US market. Now, it uses these pre filled insulin cartridges, either human log or NovoLOG, separate pens for each. So they're not interchangeable for the type of insulin. Um, but they look exact the same and then through the app, you program all of the different settings just like a pump that you would want this calculator to do um how much insulin for carbs, how much insulin for, for glucose and at different times in the day and then it calculates your dose for you. And it also has an insulin onboard calculus piece of integration for its calculator. So if your dose and you feel like you need to dose more frequently than kind of your standard three hours with insulin from the last dose is still in your system. Um It'll subtract some from the calculation. So it really helps to take a lot of math out of things. Um and gives that advantage to patients who don't want to pump but are intrigued by the some of the capabilities that a pump can do for dose calculation. And it does provide reminders and alerts and notifications to the user. And so it's great, you know, for, for backup for, you know, our college patients who are going, you know, on a pump but want to take pump breaks sometimes. Um So we are prescribing that quite a bit and then this injection ports also by medtronic. Um it's a nice kind of segue or kind of introduction for somebody who's maybe on the fence for a pump. Um and it's effectively the insertion set of a pump just minus the actual pump in the tubing. So users can put the syringe through the ports without without having to puncture the skin with each shot. So like I said, Good bridge. Maybe somebody who needs a pump break and that is replaced every three days. Insulin pumps really common for 2nd management. Um it's a small computerized device worn on the body delivers continuous and customizable doses of rapid acting insulin 24 hours a day that mimics the body's normal release of insulin. Okay. There's no use of long acting insulin. Usually when you're on a pump, it's just fast acting insulin that we can program to do all of the things of long and short acting by a bunch of different settings. So insulin through a pump is delivered in two ways um through basil or background rates, um delivered continuously and expressed in units per hour and it's customizable. So you could have a different rate, different hours of the day if you wanted. Um And you know, basil customization is really helpful in pediatrics and different as different ages have different basil needs at different times in the day, just kind of based on their physiology. Um For instance, here, you know, Todd, looking at toddler. So above graph, just kind of shows this visual representation of how much insulin they need at different times of the day. Just if they weren't eating anything, just what we see from, you know, impacts of hormone, you know, different types of hormones and um and metabolism sleep. And so the bottom shows where how we could actually program those rates at different times of the day on a pump and change that over time versus puberty, all they really have a huge rise and it's still in first thing in the morning, insulin needs in the morning, you know, just kind of due to puberty hormones. Um And so that can also be, you know, programmed. And so you can see that evolution over time is really, really helpful. Um Bullet doses are surge doses delivered by the patient around mealtime snacks and for high glucose levels. Um and just in general, pumps are increasingly integrating with C G M for additional features to really see what, you know, kind of putting it together with how that insulin is delivered as the base herbalist therapy um visual here. Um we're trying to mimic normal physiology. So we see this graph of, you know, physiologic insulin secretion then overlaid with insulin action that we try to achieve with with M D I multiple daily injection regimen. So we see here um this basil insulin and orange um kind of for glucose control overnight in between meals that with the shots is, you know, through one or two injections of long acting insulin per day. And then this bullets, insulin comes into play for mealtime carbohydrate coverage snacks or for high glucose to bring it back to range. And so as we said, delivered by multiple shots of rapid acting insulin per day and there you have the mimicking, you know, through M D I multiple daily injection, that physiologic insulin secretion with the pump, we're using the same principle um of delivering basal bolus. So here the basil can be pro programmable. Um and then the user input um via different settings to get your bolus and pump settings, you know, have different settings for all of these different factors. Carb ratios, sensitivity factors target blood sugars, insulin duration, bullets, extension, you know, maybe for some heavy meals, later digesting meals, all these customizable features that, that are really neat. Um And thinking about what these factors, the main factors that can be a little bit confusing our carb ratios and sensitivity factors. So the insulin carb ratio is how many units of insulin for each gram of carbohydrate um that that individual is consuming. Um So you take total carbs for that meal or snack divided by your carb ratio and you get your dough for carbs. Your insulin sensitivity factor is how many points the blood sugar is expected to drop from being given one unit of insulin. So to calculate that manually, um you take whatever their blood sugar is minus whatever your target B G is, whether using 100 110 120 wherever you might want to do that, divide that by your I S F. So how many SFS are in that difference between the actual B G and your target? And that gives you your dose for your blood sugar and then they're supposed to add those two together the insulin for carbs, insulin for blood sugar and give that as a dose. A lot of math to do if they're on injections and having to do this all by hand, we always give cheat sheets, but of course, if it can all be programmed into a pump. So all you tell the pump what my blood sugar is or what the C D M give that information to the pump and then they just put in their carbs. Takes out so much of the math. Okay. The pump, this is this kind of a crude diagram here of kind of what a conventional pump looks like. Um You have your infusion set, which is this little like sticker that has a small cannula in uh inserted underneath the skin, the pump, then that actually holds the insulin and displays the information has all the buttons for managing it connects through plastic tubing to the infusion set And then the insulin flows from a reservoir attached, you know to the actual pump goes through the tubing. Um and then the patient can disconnect the pump um tube while leaving the set on like if they're gonna go um swimming or take a shower and those sets need to be changed at least every 2-3 days. So the three commercially available pumps in the US include two conventional pumps and one patch pump, the two conventional ones by tandem and Medtronic um tandem as this slim design touch screen, a little smaller than a smartphone. Um, and it allows for the smallest insulin delivery out of all the pumps. Um, really, really tiny, so, really great for toddlers and young ones where you're trying to get like 1000 of a unit per hour, you can really get fine tuned dozing through that. Medtronic has a larger design, but it's more durable about the size of an old ipod uses physical buttons, double a batteries. It's waterproof 12 ft and has a Spanish language option, which is really nice. And both of these do have C G M integration, the patch pump omni pod. Um It consists of a wireless disposable unit, the pod that attaches to the skin and then has a remote that controls all the settings and Bluetooth sit over to the pod itself. Um So you can see the insulin at the bottom those three pictures there. Um where you put the, the reservoir is filled with insulin, then the pod with the sticker placed on the skin, the remote, you press the button, then it primes it and just like in a few seconds, you press that start button 1 2/100 of a second. The cannula is auto inserted underneath the skin. Um There's no tubing unit doesn't get, you know, attached to something ripped off as easily. It's, it's 100% waterproof. It's really great for, for athletes, for swimmers or otherwise, maybe like taking off the pump. Um quite a bit. It's changed every three days similar to the insertion sets of your conventional pumps. And this is just kind of showing the evolution of the Omni pod. We do have all of them that are out right now. The newest one, Omni pod five is closed loop. Um, and just hear what the different controllers look like. Um, the neat thing about the old one is that it, that controller, that kind of old palm pilot looking advice actually has a built in Blue Comet or two. So not only could it deep all of the information over to the pot and you can control it, but for needing to do finger pokes, you can just use that device and put the test strip in there and your blood sugar. The dash and Omni pod five are the newer ones that have a controller that's, you know, much more visually appealing. You can see your CGM data and then the newer version Omni Pod five, both of these later generations are not only smaller, but they have just more customization on their controller. And you can see C G M and then Omni Pod five does have hybrid closed loop capability. So again, take aways with the pumps, it takes away from multiple daily injections provides flexibility, huge, fine tuning to very small insulin doses if needed, more easy to mimic um natural physiology. Um Large customization, advanced features to allow users to fine tune for situations when they may need more, less insulin. Like if they're having high activity on their period, they're sick. But, you know, it still doesn't do everything. You still need to count carbs and dose for food. There's a risk of infections without, you know, proper hygiene. Easy lipo hypertrophy from that continuous infusion effectively or just, you know, constantly, um aggravating the subcutaneous tissue. And so there's easy DK at that cannula is kinked, um, or becomes dislodged or to be this clogged and you know, it's something that's visible um might cause unwanted attention. Um Who's a candidate? Everybody with type one diabetes. Again, supportive language, these, you know, sensor augmented pump is just saying that there some an individual is using um a pump and a sensor and can see the information displayed, you know, together we have evolved from an open loop to know these closed loop systems. Um Just briefly kind of going through here thinking about closed loop is this pathway to the artificial pancreas or early systems? Um would be able to uh sort of shut off insulin deliver, low blood sugar was anticipated. Now, we have ability to have automatic insulin adjustment through hybrid closed loop system and where we're hoping to get soon, but it's not there yet as a fully closed loop system. So it is a hybrid closed loop system. There's a pump, continuous glucose monitor and control algorithm whereby uh insulin is auto adjusted in the background to kind of go up and down based on the blood sugars are doing, users still has to put in their carbohydrates to dose for. But then the pump should really do everything else. There are currently three FDA approved closed loop systems from each of these major companies. As I mentioned, Medtronic tandem and Omni pod. Medtronic is approved for two and older. The others are for six and older. Medtronic has their own sensor tandem and Omni pod use decks come and then you know, they do exist. Some of these D I Y systems developed over the last decade as the commercial systems have been really slow to release and you know, still have limits and and age restrictions. So a growing community that's based in the area, you know, identified with the hashtag we're not waiting have developed an open source code for D I Y looping systems. The two platforms are loop and open A P S and you know, we do have some patients who are using these families know that it's not FDA approved and do take on the responsibility of knowing that they're using it at their own risk. So here's just some cool examples, just kind of putting all of this together, right? So these next few slides showed these systems in action. So here we have uh so just to kind of orient you here, this is using a system called type pool that just kind of displays all the information together from a pump from a sensor up top, we see that continuous glucose data purple is above target, green is within target, above target is considered above 1 80. And then reds would be lows. And then middle bar shows all the dose in the bowl is dozing. The bottom bar shows all the basil rates of insulin that are pre programmed. So this is somebody here who's using sensor augmented pump technology. So they're using a pump, a sensor but they're not connected. Um And so you can really just, you know, see the tracing, see how they're interacting with their pump. Um So you can hear, see, hear that person dosed for lunch and a snack carbs only they didn't put in their blood sugar and then, you know, the rest of the day, you know, fairly even but can guide the user on maybe some adjustments that could be made with some of the background insulin. Here's somebody who before closing system came out there, these predictive low glucose suspend systems. Um And so at the bottom, you can see all these basal rates, shutting on and off, on and off, on and off frequently overnight, but getting, you know, perfect blood sugar range um that really can help, you know, especially like the younger kids really sleep and parents sleep through the night. You can see all the doses that they do throughout the day, but it really allowed for tighter control knowing that you could be maybe a little bit more aggressive with settings on the pump, knowing that the system is going to shut off if it's predicted to blood sugar is predicted to go low. And then here we have a closed loop system, hybrid closed loop system. You can see the user bullets regularly in the day for carbs. Um And then on the bottom side, you can see this dynamic variability of the basal rates that are just kind of going up and down, up and down in the background. These periodic like little tiny bullets is you see between these big Jumps that, that show where the carbs are delivered and those are automatic bullets. That's a system where the automatic insulin delivery, you know, it's not quite enough. And so the pump is automatically giving these additional bullets and you can see, but this individual pretty well in range almost 100% of the day. So pretty amazing. Here's, here's a user with a hybrid closed loop system who did nothing for two days. Okay. So this person eight and that system, yeah, there were still some peaks and blood sugars, but it came right back down. So instead of, you know, previously somebody, you know, missing some bonuses and staying high all day long, these hybrid closed loop systems really do help to bring that user back into range. So as you can imagine, average glucose is a one CS, you know, do improve over time and this just to highlight somebody on a D I Y loop system. This is a two year old. This is a two year old past honeymoon who is just snacking all throughout the day. Instead of having to get 10 shots a day for all those little micro nibbles of toddler food. This hybrid closed loop system, somebody just puts in, you know, two grapes of granola bar, all these little things that they're eating all throughout the day. Again, this individual there's diluted insulin in the pump but could really achieve amazing glucose control. Um I know we're just about out of time. So just highlighting that there's still, there are a lot of apps that are out there, some from the companies themselves and others that they can, you know, individuals can download. Calorie King, helps with calorie counting carb counting my sugar is great for tracking things on somebody who's on injections, type pool and glucose. Kind of put all the information together. Those are ones that we use all the time and just kind of showing here, this is just effectively showing with increasing technology use. We see a one CS improved, severe hypoglycemia improved with the addition of each added piece of technology and each added technology that's about an improvement on A one C by about half a percent. So pump and sensor over injections can improve a one C by um 1% point or more. Um So last, just a couple of slides here, you know, technology is a double edged sword, lots of new devices, there's data overload. Um fatigue from all these alerts, device, anxiety, things are BP and its like having constant pager on you all the time. It's customizable. But you know, having these little vibrations or alerts, especially in school can be really um you know, hard for kids and then teenagers as they're trying to develop their independence and yet all their data is, you know, shared with their parents and really kind of hinges on the border of privacy versus independence is they're trying to navigate this on their own. So, you know, diabetes burnout is a really big thing. And you know, we screen a lot for anxiety, depression disordered eating, which can be seen a lot with the Wendy. So a couple of things on the horizon, fully closed loop systems are not there yet, but you know, trials underway UCSF is a center that's gonna be doing some of these fully closed loop trials on kids, a single device that holds everything sensor and a pump bionic pancreas that holds not only insulin but Luke Agan. And then where the research is looking at immune modulation islet transplants. So this is how you guys can all be involved is really, You know, talking with your patients being advocates for them about these technologies which you know, you you're hearing about now and knowing what they do, what they should be able to get connecting them with the community so they can connect with other folks with T1D using appropriate language. Okay. We don't use the word diabetic. We use a person with diabetes. Diabetes does a thing separate from the individual and it's really encouraging them to interface with us to get a One CS check ins every three months. Um, and just reminders, hey, did you get your annual labs yet? Hey, for the teenagers and older eye exams, um every 1 to 2 years, um keeping them vaccinated. And of course, we rely on you for recognizing new onset or getting a lot of new onsets just from, you know, you're in checks just as part of and as part of general screens as something that might be evolving. We rely on you to treat infections, skin infections, U T I S, um skin irritations from all these devices, screening for depression diabetes overload, helping with local referrals and just generally keeping our patients healthy. Okay. So in summary here, you know, it's a lot of information but just kind of put it all together, you know, type one diabetes is a T cell mediated process without a cure. Insulin treatments remain at the core. We're still trying to look and figure out what is it about that auto immunity, how can we manipulate it? What are the things in the environment? How has the COVID pandemic really helped us to maybe get a little bit more information? About that process. Self management of T ONE D. It's an increasing reality with, you know, the advent of smart technologies, you know, even in our kids um pumps and see GM are associated with improvements in A One C um decreased hypoglycemia, improved glucose time and range and improve quality of life pumps. And see GM should be available to all pediatric patients with diabetes in particular for T ONE D which is more likely to be covered by insurances and everyone with diabetes need support. You know, that there's a lot of fatigue, overload different challenges and needs across ages and stages. So for you knowing how to screen, knowing how to recognize and direct and referral, um got a lot of different um websites and communities that they can use. Some of these are research based, some are for disconnection with other families, advocacy for screens and, and you know, here's, here's our team cross bay and across all of our satellites. Okay. So we've got, we've got satellites and we have a mission bay in Oakland. We've got some satellites and more in Walnut Creek, Santa Rosa and Selena's that manage our diabetes patients. And thinking about who should do refer all diabetes prediabetes, both abnormal glucose revolving diabetes, new onset. If you're thinking that this is a new onset, it's urgent, it shouldn't go through, you know, paper referral, it should involve a page to the endo um really to triage because sometimes it's either going to the emergency room or setting up for an in person visit, like the next day to get everything all taught. Okay.