European Launch of the MiniMed 670G - Switzerland

The Medtronic Mothership poised for takeoff

I was chuffed to be invited to join bloggers and diabetes advocates from Belgium, the Netherlands, Switzerland, Sweden, Finland, the UK and other places I have almost certainly forgotten for the Medtronic Diabetes Community Exchange 2018 at Medtronic's European HQ in Tolochenaz, Switzerland.

I was particularly pleased to be invited to walk in the footsteps of the legendary Alison and Tim from Shoot Up or Put Up and to needlessly and completely unnecessarily rekindle the rumours that Medtronic have an entire department dedicated to the drowning of puppies in their relentless pursuit of evil. Rumours which are, of course, entirely untrue. And completely made up by Tim. Or are they?

We arrived on Thursday afternoon and were swiftly transported to the impossibly quaint, beautiful and strangely fragrant 'Chalet Suisse' restaurant where we were treated to a slap-up meal composed of cold meats, pickles and industrial quanities of gently bubbling cheese into which we enthusiastically dunked hunks of white bread. Fluffy white bread, a vat of cheese and a little alcohol. What easier meal could there possibly be for a tableful of pancreas impersonators to contend with? As inevitably happens at these events, people with diabetes quickly feel at ease with each other and conversation flowed to a burbling soundtrack of bleeps and buzzes from various bits of diabetes kit. It was a very lovely evening. Thanks Medtronic!

All those friendly faces and barely a functioning pancreas between them.

European Launch of the MM670G
It was perhaps no surprise that Medtronic had invited us during this particular week - in which their latest hybrid closed-loop insulin pump system launched in Europe. The launch begins with the UK, the Netherlands, Belgium, Sweden, Italy and Slovenia as of 10th October, with Finland and Denmark following hot on our heels next week. I have been using Medtronic pumps for the past 7 years or so, but others around the table used other brands, pods or MDI injections.

Inevitable device timeline pic. No future dates, naturally.

The MiniMed 670G launched in the US in June 2017, and the version launching in Europe is almost exactly the same. If you are new to the snazzy concept of 'sensor augmented pumps' (and why wouldn't you be?) the basic idea is that you combine an insulin pump and CGM (continuous glucose monitor) into one device. At it's simplest, the pump acts as a receiver for the sensor glucose and allows display of current glucose values and can alert the wearer if levels are rising, falling or generally going off kilter. The really clever stuff starts to happen though, when the pump uses an algorithm to act independently on the basis of the received sensor glucose values. On my MM640G I allow Threepio to silently and automatically take action and cut off my basal insulin if my BG is predicted to fall below 3.9 within 30 minutes. This has saved me countless low level hypos whenever I have been able to afford a sensor. If you're interested in the details there's a little animation explaining how this works here.

The MiniMed 670G adds extra oomph to the mix by also having the ability to increase basal insulin where sensor glucose is rising. Gary Scheiner, who wrote 'Think Like a Pancreas' wrote a review of the MM670G after it launched in the US which has a good deal of detail if you are interested, but which also prompted several questions for me.

What I thought I knew
The MiniMed 670G uses two main targets, neither of which can be changed by the user. Overall it aims to direct your glucose value towards 120mg/dl (6.6mmol/L). Where it is taking corrective action for elevated sensor glucose, it aims towards a target of 150mg/dl (8.3mmol/L). These were the launch values in the US, and will be exactly the same for the UK version.

A number of options that experienced pump users might expect to be able to use (temporary basal rates, dual (combo) wave, and square (extended) wave boluses are unavailable in auto mode.

From what I can tell, things like differing basal patterns for weekdays/weekends do not apply in auto mode either.  Nor can you alert the system that you are about to undertake exercise in advance.

In fact there seems to be very little you can adjust and tweak in auto mode aside from insulin:carbohydrate ratios and Duration of Insulin Action. If you are planning to exercise you can temporarily set the pump to aim for the higher target, but that's about it.

All of this may fill you with dread and impending frustration. Or it may elate you with gratitude of being able to hand over responsibility almost entirely.

Users can, of course, use the pump in 'manual' mode whenever they wish. This would give them effectively the same choices/options as the MM640G, but doesn't take advantage of the additional automation on offer.

Is there anything else like this?
No. Well... not regulated, approved and currently commercially available no. But of course the MM670G is not being released into a vacuum. There are other emerging sensor augmented pumps (eg Tandem T:slim) which incorporate predictive low glucose suspend (rather like the MM640G). Alongside which there is a growing community of enthusiastic loopers who have decided #wearenotwaiting and use a variety of homespun, and significantly more tweakable, options. Of course not everyone has the confidence to build their own diabetes device - I am assured that these are no longer cobbled together from bits of string and paperclips, but nevertheless still do require careful configuration, software and in some cases additional DIY hardware. Additionally many loop solutions currently require older out of warranty insulin pumps. This may not be the case for long, nor might OpenAPS and Loop's unregulated status continue, now that Tidepool have committed to developing Loop as a supported, regulated app available for users on a range of in-warranty devices.

What I found out
It's fair to say that I was very enthusiastic about the prospect of the MiniMed 670G about a year ago. But things are moving so fast these days, that this is already beginning to feel like an older model. And as an inveterate fiddler the idea of so few settings being settable by me is a bit... well... unsettling.

What I found very interesting, was the observations Medtronic have made from 3.2 million days of data since its launch in the US. Essentially, they suggest the MiniMed 670G tends to work better in people who don't fiddle and try to come up with their own ways of working around not being able to alter settings. Often people who are new to an insulin pump, who have not already built up a library of hacks, tricks and strategies to bully their pump into doing what they want it to. People who simply give the MM670G the information it requests and heed the alarms, who keep the sensors well calibrated, and who count and supply carb information of meals and then let the pump do its thing, are the ones who tend to get the better results.

I am aware from my own relentless tweakery that at least some of it is frequently down to constant changes in insulin sensitivity and insulin need (and working around times when my pump settings aren't quite right).  I suspect that one of the main reasons behind the lack of tweakability on the MM670G is the closely guarded algorithm. This updates up to 17 different parameters at midnight every single day, based on the previous 24 hour's worth of data along with a rolling average of the previous 5-6 days. Essentially the pump is continually adapting and tailoring itself to you. So those unmovable targets may not seem to be what you have chosen, but the intention of the MiniMed 670G is to keep your BGs as stable as possible to increase your time in range, to reduce glucose variability and to reduce hypoglycaemia to almost nothing. At least... that's the idea. Medtronic are quite upfront that this is the first iteration of this algorithm, based on dozens and dozens of research papers, and that it is intentionally cautious. Other more 'aggressive' versions with greater user control are being strongly hinted at.

A consequence of the 'machine learning' of the pump adapting to you as an individual though, is that it does take a few days of sensor wear for auto mode to become available (48 hours from midnight following sensor start). I'm not exactly sure how that would impact occasional-sensor-users like me, who cannot afford full-time coverage, but it's clear that only a portion of each sensor for me would be auto-able. In theory sensors can be restarted just as they can on earlier enlite-using pumps (sorry Medtronic!), but this newer pump uses Guardian 3 sensor technology, and because the MiniMed 670G has more control over insulin delivery it makes more checks that the sensor data being received is of high enough quality. Without having used it, it's impossible to tell whether it would get twitchy and drop restarted sensors earlier than I am used to.

Case study
It was a delight to meet Rob Howe a Texan ex-pro basketball player and MiniMed 670G user. Tall, slim, athletic, and with that easy, effortless charm that seems to be the gift of so many Americans. He shared his experiences and took part in a Facebook Live broadcast after which we were able to ask more questions.

Rob was an enthusiastic MM670G poster-boy, and having moved from MDI/CGM to an insulin pump with an impressive HbA1c of around 6.2% (44mmol/mol) he was obviously no slouch when it comes to BG juggling.

When asked about changes he had noticed during his year on the pump, one of the most striking was that his regular weekly order of two 1 gallon containers of orange juice he kept in his fridge to treat overnight hypos started to go off before he could use them. They simply weren't needed any more. As a basketball player and all around active type, he also seems to have put the MM670G through its paces exercise-wise, from high intensity BG boosting sprints/weights to longer distance runs of 6-10 miles. Rob was able to keep the pump connected throughout exercise and allowed it to manage his activity, with great success it would seem. Initially Rob said his HbA1c rose a little, perhaps up to the mid 6's (48mmol/mol), but seems to have settled back to the low 6s since. So while the fixed settings on the MM670G algorigthm seem to target an HbA1c of approx 6.7% (50mmol/mol), it looks as though, once again, Your Diabetes May Vary.

What next?
It will be fascinating to see more accounts from real users 'in the wild' across Europe. Several people in the group were about to start with MM670G in November. There was an extended discussion during the end of the afternoon where bloggers raised concerns and questions. There are plans to subtly alter the materials and structure of the MM6xx cases to help avoid those battery compartment cracks (which in turn will mean Medtronic don't have to replace those pumps), plus small alterations to clips, and clip rails. Medtronic are planning a version of the MiniMed 670G which will be able to communicate to phone via Bluetooth. It is notoriously difficult to predict how long it might take to get devices through regulatory approval (and goodness knows what additional chaos Brexit might add to the mix for us in the UK), but reading between the carefully veiled lines it seemed that they were hoping it might be in the next year or two. No promises etc etc. Perhaps even more interestingly... this version of the MM6xx series would have the ability to receive updated software/firmware after distribution. This is something that Medtronic have been inching towards for some time, and could significantly accelerate the takeup of new and better pump versions where the hardware is essentially identical, and it is only the algorithm which needs updating.

One thing is for certain. The rate of change in diabetes devices doesn't look to be slowing down any time soon.

Disclaimer. Medtronic Diabetes invited me to attend the MiniMed 670G European launch in Switzerland. They paid for my economy travel, transfers, accommodation, the welcome meal and lunch at their offices. I wasn't asked or paid to write this blog post or any other social media posts connected to the event. They also included a nifty little Medtronic branded battery power pack thing in a 'welcome' bag. Oh and a pen too.

Dinkleflakes, diabetes, discussions and #DXStockholm

DxStockholm doesn't make sense, I'm pretty sure it doesn't actually exist. And if it *did* exist, then I'm almost certain I wouldn't make the list. It must be a particularly vivid dream, probably someone else's. I suspect Philippa's Dinkleflake-(me neither)-bacon-pancake-apple-sauce-and-double-cream breakfast is causing some sort of hallucination and I'm in it. Grand, wide, impeccable streets strewn with petals. Impossibly blue Scandinavian skies. More than two dozen storytellers with barely a beta cell between them, weaving tales in half a dozen languages. And yet, this time last week I was there.

But what is it for?

It is very easy to get cynical about these things. As a middle-aged Brit it's virtually compulsory. Any company that puts an event like this together obviously wants something. For all the compliance form-filling about not expecting anyone to write anything, surely it's just bribery plain and simple. Chuck 'em a few treats, show them some shiny new toys and let them spread the word for you through the FaceTwit-o-sphere.

Except that didn't happen.

Stockholm's 20's themed Haymarket Hotel, once a swanky department store

DxStockholm was the second of Abbott's European Blogger weekends. Last year saw one held in Berlin. There was an event in Sydney a month or two ago. I can't speak for the other events, but in Stockholm there was only one short session, led by Abbott's Principal Research Scientist Chris Thomas, that came anywhere close to mentioning product, and that was the only session where all participants were explicitly forbidden from saying anything about what they heard.

The rest of the weekend was an amazing opportunity to meet, mingle and share experiences among a group of bloggers from the UK, Germany, France, Holland, Sweden and Italy. A diverse bunch of people all at different stages of life, and at different points along their own unique diabetes journey (sorry... let's just all agree to forget that I actually used the 'J' word, apparently without irony, and never speak of it again). There was a programme of talks and interactive workshops that covered everything from personal creativity to the potential timing of being subjugated by our newly created super-intelligent hyper-machine overlords. We ate, we chatted, we shared, we learned, we laughed, we moved robot cat ears with the power of our minds.

I am hugely grateful to have been invited. Honoured doesn't begin to cover it.

DxStockholm really did feel like a genuine attempt on the part of Abbott to engage with the patient community. To support it and recognise it as a 'good thing', to encourage it and feed it. Living with a long term condition like type 1 diabetes is easier when you are walking alongside others. Where people can stand by you when you wobble, or understand the tiny, joyful victories of inexplicably well behaved BG levels after some food extravagance. The cloud of voices sharing their stories across Europe as grown enormously since we started writing this blog and I am proud to be a tiny part of that. In the same way that a building feels very different when you know that there is someone else in it - even if they are several rooms or floors away - my life with diabetes is more settled, easier to face, when I know I am connected in some abstract way with many others facing the same daily irritations, triumphs and disasters.

Abbott's theme for the weekend was 'My future, my choices', which led to a very engaging and interesting programme of content. If you'd like a really good summary of the weekend, with some cracking pictures this post by Jen Grieves is a good one. See also this, this, this or this. Honestly! Invite a bunch of bloggers to an event and suddenly you are up to your eyeballs in posts, all better than this one.

A few things that stood out to me over the weekend:
Stockholm is a really cool place. And it's always sunny. Always.

People are inherently creative, even if they don't think they are. Even the simplest snippets of conversation have a unique rhythm to them. Unique insight. Unique voice. You don't have to try too hard, or try to be like anyone else, or do what they do. You just have to be you. No-one on earth can do that like you can.

People and things.

The future is a really exciting place. Things, people and information are getting more seamlessly connected and the Next Big Thing is just around the corner. What sounded like crazy science fiction 5 years ago is happening now and will be everywhere soon. But all of this wearable technology, interconnectedness, captured data, stored knowledge and artificial intelligence has no moral compass. We will have to provide the ethical framework for this exponential future. Above all we will have to remember not to lose sight of the value of people (Dalai Lama quote in that pic rather sums this up).

BioHacking is alive and well outside the diabetes world just as it is with the #wearenotwaiting brigade. Hannes Sjoblad introduced BioHacking as 'science where n=1'. Which sounds very much like what people living with type 1 diabetes face every day. Personal experimentation, data collection and the quantified self. Being aware of what data can be collected and how it can be used for and against you.

Snapchat is apparently a thing. And I still really don't get it.

Mindfulness is relaxing, but not ideal in a warm room at the end of the day with an impromptu scooter rally collecting in the street below.

Separated at birth?

One of the funniest things in the world is waiting while a very hungry Grumpy Pumper is about to be served a handful of toasted cauliflower croutons on an enormous, elegant white soup plate before the (delicious) soup starter is poured. If you've ever wondered if that frown can get any more frowny... I can confirm the answer is a big, solid YES.

Other Europeans are amazing with languages and our laziness and lack of ability as a country makes me cringe. 

Type 1 diabetes likes nothing more that to bring you down to earth with a bump. On Friday, as I landed in Stockholm and stood to move from my seat I happened to notice a young girl in the row behind with a familiar-shaped disc on the back of her arm. It turned out to be one of the German bloggers Lisa - the very first person I met at #DxStockholm. We got chatting and ended up sharing a taxi to the hotel with a few others on the same flight. My German stretches about as far as "Lumpi ist mein hund", "ich bin zwölf jahre alt" and "sprechen sie Englisch" but we all managed to chat away in the taxi thanks to their rather better command of English. Just before breakfast on Sunday morning as people were gathering and chatting away, Lisa suddenly collapsed. A rapid and unexpected crash into hypoglycaemia really knocked her for six and she slumped by the buffet table. Of course, there are few places you could be where you would get more immediate and knowledgeable help, and Lisa was on the way to recovery before the paramedics arrived. But it served as a bit of a reality check to all of us. These events lurk in the corners of each of our lives and while we sometimes splash our insulin around with casual abandon, there is a real and present danger quietly hovering in the background. But even these events are part of our stories. The highs and lows of a life with type 1 diabetes.

As a community we are better together. Different voices, different experiences, different perspectives, different needs and hopes and aims. But all fundamentally connected by our wonky pancreases and our dark sense of humour. Put two or three people with diabetes in a room and they can talk for hours - even if none of them speak the same language.

Huge thanks to Abbott for the opportunity of taking part in #DxStockholm. It was an honour to meet so many amazing bloggers from all over Europe and to feel connected to a wider world.

Obligatory #DxStockholm Group Shot

More about #DxStockholm
A Storify summary by Eglantine LeRoi
Our future, our choices… and our f**king disease by Antje

Googlytranslatable posts...
Abbott DxStockholm by Lisa (including an account of *that* hypo)
About dextrose lulls exit row and more by Sarah
DxStockholm by Sofia

Disclaimer. Abbott Diabetes sponsored my attendance at #DxStockholm and paid for travel, accommodation and organised the event itself. They also treated us to a smashing dinner at Kung Carls Bakficka restaurant on Saturday night and provided a beautiful cookbook on swedish cuisine. I have not been asked, or paid to attend, write about or publicise the event - frankly I think they have been more than generous!

Normal service will be resumed as soon as possible

Apologies for the interruption - the fluffy four-footed addition to our household has made finding time for blogging very difficult in recent months. Which is unfortunate really, because I have at least three or four posts waiting in the wings that I would really like to put together!

We picked up our young Clumberdoodle pup at the beginning of April and time has absolutely flown by since. For a couple of months before Marvin's arrival we were busily DIYing and generally attempting to puppy-proof (ha!) the house and garden a little. It's all been a bit of a blur to be honest and reminded Jane and I of a heady combination of those weeks with a newborn babe, mixed in with a good dollop of toddler mischief and a hint of teenage experimentation and boundary-pushing. Fortunately Marvin is a dog who likes a nap, and can be persuaded to do pretty much anything for the promise of a bit of chicken or nibble of Schmacko.

Around the middle of March I was chuffed to be invited by the wonderful Dr May Ng to speak at the North West Children and Young People's Network Education Day - if you'd like to get a glimpse of what went on I put together a Storify of the tweets. Alternatively, everyone's favourite Diabetes Dad, Kev Winchcombe wrote a great, but altogether far too modest blog post about the day. His talk was far more packed with laughs and interesting detail about diagnosis, transition, DIY APS and Nightscout than my blathering about spurious similarities between daily management of type 1 diabetes and Scalextric!

In the coming months I am really hoping to post a follow up to my reflections on DPC2016 detailing what I picked up from Iain Cranston's fantastic presentation on interpreting CGM data and Ambulatory Glucose Profile reports.

Additionally I have seen a number of conflicting reports/research about cholesterol and Statins in recent weeks and I'd really like to post something about that - if only to be able to process it a little myself.

Thirdly, I am honoured to have been invited by Abbott to attend an event in Stockholm in June called 'Dx' which looks to be really very interesting indeed.

Lastly I have been quietly working with a few other DOC legends (quite how I managed to scrape into their hallowed company is beyond me) on something I am only half-jokingly calling "Project Enormous". We hope that soon - perhaps in the next month or two - it will reach the point where we can release it into the wild and see if it has any 'legs', and lives up to the promise of the idea.

Exciting times.

Hope your BGs play fair in the meantime and thanks, as ever, for reading.

Disclaimer. For my attendance at the North West Diabetes Network Education Day my travel and accommodation expenses were generously paid, but no speaker's fees were offered or received.

Diabetes UK Professional Conference 2016 - Education, Individualisation and steps in the right direction

Between Wednesday and Friday last week I found myself in sunny Glasgow immersed in the insanely intense experience that is the annual Diabetes UK Professional Conference. I had been lucky enough to attend last year as one of Diabetes UK's bloggers and tweeters. This year Diabetes UK wisely ran a competition to throw the net a little wider for patients interested in attending the event and spreading the word. Thankfully they had the good sense to ignore my application and selected five people who did a significantly better job of sharing the content of the conference with the #doc (Diabetes Online Community) than I did last year. Hats off (alphabetically) to Andy, Bob, Charlotte, Ellie and Helen - you did an amazing job. In particular, Andy Broomhead has really put the work in covering many sessions of the conference in a series of excellent blog posts. Ignore this turgid waffle and go and read them instead - they are far better.

Undeterred by not making the cut with DUK, I contacted the lovely folks at Abbott Diabetes to ask whether they would be prepared to sponsor any patient attendance to the conference. I was delighted when they said that this was going to be a possibility, and was subsequently asked if I would be prepared to share some thoughts of my experience as a patient who has used Freestyle Libre off and on for a year or two.

And so it was that I hopped on a plane early Wednesday morning and was able to make the opening sessions of the conference in the architecturally-spectacular SECC in Glasgow. The Diabetes UK Professional Conference really is quite hard to describe. At least this year I was a bit more mentally prepare for its scale. There are upwards of 3,000 people from all over the world who specialise in diabetes, and everywhere you look people are making connections, comparing notes, absorbing new research and knowledge and generally seeking to see, or create, or develop better diabetes care. The programme is so packed full of sessions and opportunities that however much you try to cram in you are left with the feeling that you have missed out on really good stuff. Additionally, having been to a few events over the last year or two I am beginning to find the concourse a more hazardous environment - particularly if timings between sessions are tight. It's all too easy to bump into someone you've met before and grabbing a 'quick five minute' catch-up can leave you scurrying to your next session and having to creep in at the back with the apologetic shrug of a guilty latecomer.

I cannot possibly do justice to all the excellent sessions that I saw over the three days, so instead here are a few edited highlights.

Overall themes that struck me: Education; individualisation of care; leveraging (ugh! sorry) apps and technology; empowering and engaging young people; treating people, not numbers.

New outcome trials in type 1 diabetes
The opening plenary session on the first day included three talks, one of which was Simon Heller presenting results from the REPOSE trial (The Relative Effectiveness of Pumps over MDI and Structured Education for Type-1 diabetes) which is due for publication very soon. Essentially, REPOSE has shown that pumps, on their own, make less difference than might be supposed. Yes they *are* more flexible, yes they *are* more precise and offer additional techniques and possibilities such as extended boluses and temporary basal rates - but as Simon Heller said, "You can't take someone with a high HbA1c and say, 'You need a pump, that will fix it', because it simply isn't true." His argument was that as good as the technology is, people need a lot more help, support and training in managing their own diabetes in order for that technology to work well. People can do very well on pumps, people can do very well on MDI - but it is the help and support they have received in making better decisions that will make the biggest difference. It also makes me wonder whether, for some people, approval for pump therapy forms a sort of catalyst to re-examining their day-to-day management strategies. And what T1 care really needs in the UK is more engaged, better supported and individually encouraged patients who are equipped to wrestle their own particular diabetes monster as best they can.

Everyone's second-favourite rabble-rousing superstar endo Partha Kar summed this up quite nicely in his round-up blog post:.

It isn't about the latest super insulin, it isn't about the flashy technology, it isn't about the "cloud", it isn't about Apps or offering education programmes... it's only about one thing- YOUR ability as a professional to engage and communicate with the patient- move away from the "how's your blood sugars?" to "how are you"... till that day, we will not be able to improve outcomes - however much resource we magic up.

Colin Dayan then spoke about peptide immunotherapy (more on that later) followed by Rob Andrews and Parth Narendran presenting results from the EXTOD trial (exercise in type one diabetes). One result of the trial that really struck me was that when polled the majority of HCPs felt confident to advise around exercise and type 1. However when those same professionals were tested with a detailed questionnaire, they were often not able to give reliable information in response to the questions. EXTOD.org is a resource that aims to offer good information for heathcare professionals and to support patients with type 1 seeking to exercise.

Apps and web-based technology: fad or future for diabetes care?
A topic quite close to my heart this one. I was gutted to miss Nick Oliver sharing about automated dose adjustment (that bloomin' concourse again!) but hugely encouraged to hear from patients and HCPs at both Kings (Geraldine Gallen, Imogen Lee) and Newham (Mark Norman, Shanti Vijayaraghavan) about their experiences of 'virtual clinics' using Skype and other web-based technologies to support people with diabetes wherever and whenever they need it. A more flexible, less attendance-at-clinic-based-approach improved engagement, patient satisfaction and outcomes, particularly with young people. To be honest it sounded very like being connected to the #DOC, but with added 'doctoriness'.

Lastly Andy McQueen and Deborah Wake went on to describe the successful 'My Diabetes, My Way' project in Scotland.

Glucose Monitoring in Diabetes
Another selection of three talks. Andrew Farmer spoke about self-monitoring in type 2 diabetes. Unfortunately his studies always seem to come down on the side of 'no' for the general T2 population, and always talk about 'adherence to diet' rather than transforming your diet by 'eating to your meter'. Interestingly David Owens who chaired the session asked "is there a group of patients outside the guidelines who are willing to use SMBG to change their behaviour?" to which Prof Farmer did concede, "there is no evidence at a population level, but if someone says it really helps - then it is open to try it out". Sadly I was right at the very back of the auditorium, too far away from the microphone and wasn't able to ask about Dr Farmer's reaction to Jane Speight's interesting paper on the STEP study which concludes that structured testing for T2s not on meds can be very beneficial. This certainly seems to be borne out by experiences of people I see on diabetes forums who are able to reduce or eliminate medication using SMBG to define a diet that their body is able to metabolise properly by experimentation rather than guesswork or 'adherence' to what someone else says they should be eating.

The session on deciphering CGM data by Iain Cranston was probably my favourite of the whole conference. I'd like to go into that in rather more detail so I'll cover it in a separate post.

Finally for that session Lalantha Leelarathna spoke about emerging technologies, bolus calculators, Libre, CGM and encouraging results from sensor augmented pump and artificial pancreas trials.

In the exhibition hall
Later in the afternoon I gave the first of my 10 minute talks about the ups and downs of juggling type 1 and how I have been using the Freestyle Libre as an occasional part of my toolkit for the past few years. Slightly unnerving just having to start talking on the Abbott stand with people milling about, but just as they had for the brilliant Peter Hammond, people soon began to stop and listen to my rather less edifying wittering and a small crowd formed.

One other intriguing discovery on day one was a stand for a new blood glucose monitor (the Keya Smart), due to launch in the Summer (the UK being first in the world) which simultaneously measures blood glucose and ketones on the same strip from the same sample. Cynically I have to say I assumed that the strips would be priced perhaps halfway between 'normal' BG strips and the significantly more expensive blood ketone strips. However, the people on the stand suggested approximately £15 a pot - which is fairly average among BG strips. I'm not one who seems to struggle with ketones, and I am quite content with urine strips, but the possibility of ketone monitoring alongside each BG test could be hugely reassuring for anyone who has struggled with DKA. The meter offers a traffic-light style readout through green, amber and red to alert you if ketones are present and worsening - so you can instantly tell if you BG is simply annoyingly high or if you need to be taking more drastic action/considering A&E. It will be interesting to see if the product lives up to the hype when it launches.

Day two

Immune Pathways in Type 1 Diabetes: will they lead to a cure?

Mark Peakman's mind-bending Dorothy Hodgkin Lecture picked up where Colin Dayan had left off. All I can say is that it made a great deal of sense at the time, but really the science is way beyond me. It seems they can already identify people who will go on to develop Type 1 Diabetes at some point with some certainty, even in infancy. The tantalising possibility is to use peptide immunotherapy to alter the errant immune system action and prevent the onset of type 1. The signs are very encouraging, but (almost inevitably) still at a very early stage.

Hypoglycaemia

Chaired by Pratik Choudhary and Jackie Elliott, these 6 short talks covered many aspects of hypoglycaemia, brain function, risk, inpatient experience and models of care. One extraordinary and very unexpected statistic related to the average age of people admitted to hospital with Severe Hypoglycaemia. I would have assumed that the challenge lay primarily with children, or perhaps young people and teens. However the data presented clearly showed that the distribution is shifted towards elderly patients, often those living alone. I can't imagine how frightening this would be. However a new model of care developed in the East of England, including a 'single point of contact' had made significant progress in reducing repeat-caller rates and with increased referral to education has provide significant savings both in terms of money (more than enough to pay for itself), but more importantly the major cost in terms of quality of life.

Individualising targets in diabetes: NICE or not NICE?
Of course I was not able to resist this discussion about the role of NICE guidance in informing diabetes care. Chaired by Nicola Milne and Paul Newman, four speakers offered their opinion on the role of NICE guidance. Laura (ninjabetic1) gave a wonderful patient perspective covering structured education, test strip allowances, targets and inpatient care. Many good things in the guidance, but how many are being done? Whether the new tighter HbA1c guidance to avoid complications might induce feelings of judgement and failure.

Brian Frier from Edinburgh then gave some harrowing accounts of people being treated to inappropriate glycaemic targets. Chasing potential long-term benefits for the avoidance of complications in elderly patients gradually introducing treatment on top of treatment until they ran the risk of falls or injury related to hypoglycaemia. QoF came under a good deal of scrutiny, particularly in the way it discourages individualisation of care.

David Millar-Jones, a GP from south Wales dissected whether the type 2 guidance was fit for purpose. The published version had come a long way from the initial consultation draft he said, but there were still question marks over whether it could be easily used in real-world practice clinics.

Lastly Partha Kar offered his thoughts on whether the Type 1 guidance was realistic, or simply a utopian fantasy. He made it clear that he felt that the guidance itself was excellent, but asked the more difficult question of what the outcome of the publication was likely to be, particularly in the light of less-than-rosy National Diabetes Audit reports for Type 1. Whether the guideline production machine was actually able to achieve much in the cash-strapped reality of the 21st Century NHS.

This was probably one of the most lively sessions I attended with many questions and comments being made at the end of each of the talks. We were fortunate that Stephanie Amiel the hugely respected chair of the Type 1 guideline development group was there to clarify one or two points. And I may have accidentally stood up at the end to offer a few thoughts of my own, and to confess to the lower A1c target which was, after all, mostly my fault.

Summary
There was much to be encouraged about during the conference. A genuine desire to see diabetes outcomes improve, to share and promote better ways of doing things and to make tangible progress towards more people living better with diabetes.

Here are a few quotes that really resonated with me during the three days.

All in all a fantastic time and lovely to be able to meet up with so many faces old and new. Lis, Laura, Sandie, Charlotte, Ellie, Helen, Emma, Sophie, Dani, Hannah, Jackie, Becky, Stephanie, Andy, Bob, Peter H, Partha, Pratik, Pete D, Kris, Jonathan, Neil, Sacha, Sheldon and many more I know I have forgotten. Here are a few of us gathered in the bar of the Crowne Plaza on Thursday evening.

Disclaimer. Abbott Diabetes kindly paid for my travel, accommodation and entry to the conference. They also paid a modest honorarium to cover the time taken to prepare and deliver my short talks. I was not asked to say anything in particular and if I thought the Libre was terrible I would have said so. I have not been paid to write this post or any Tweets relating to the conference. The chance, as they say, would be a fine thing.

Thoughts from the Diabetes UK Professional Conference 2015

I'm a bit late posting this, but I just wanted to jot down a few thoughts following last week's Diabetes UK Professional Conference 2015 (#dpc15). I was, as the saying goes, dead chuffed to be invited to be one of the bloggers/tweeters co-opted onto Diabetes UK's Press Team for the three day conference in London's sunny docklands where the great and the good of the world's diabetes healthcare professionals, researchers and pharma companies gather for a good old chinwag about all things pancreatically challenged.

DPC is one of the biggest events in the global diabetes calendar and patients are not normally allowed to attend for complex reasons involving a Pharmaceutical Industry code of practice (and possibly also so that they can speak fluent doctor-technobabble unhindered and don't have to watch what they are saying about how bloomin' annoying patients are and how the whole business would be much easier without us). However as honourary members of the Press Team we were encouraged to tweet, blog and generally feed information from the conference to the world at large, including you lot.

It was the first time I have been at an event anything like this and it was absolutely huge. Whatever presentation you were attending you got the distinct impression that there were at least six other things running simultaneously that you'd like to be having a look at. Attendance this year was apparently bigger than ever, though #DOC peeps who had been to previous conferences commented that Excel's cavernous spaces made it seem a bit more spread out.

At least as valuable as the presentations themselves seem to be the incidental networking and bumping-into opportunities. Everywhere you went people near you were meeting up, rekindling connections and sharing information. People who have attended more than a few of these conferences must have quite a hard time getting to any sessions at all, because there are so many people to chat with as you move from one place to another.

On a personal level it was great to be able to meet again, or for the first time with so many amazing members of the DOC incuding, Grumps, Annie A, Laura, Sandy, Charlotte, Hannah, John, Annie C, Kath, Roz, Lis, Partha, Pratik, Pete, Neil and others whom I have doubtless forgotten (sorry!). It was also a great privilege to meet with Barbara Young, Chief Executive of Diabetes UK who took time out of her hectic schedule to meet with the bloggers/tweeters and stayed chatting longer than she had intended. She was quite an inspiration, and seemed genuinely interested in listening to feedback and input from the diabetes coal face - about what matters to people with diabetes and their families. Someone commented that Diabetes UK often get a hard time about occasional gaffes, but rarely seem to blow their own trumpet when they do make a positive impact (like here, where they have got the Government to change ther mind about prescription fines). It was only a brief conversation, but it was quite uplifting and I got the feeling that DUK was in very safe hands. It was great too to be able to meet up with representatives of various pharma and device companies that I have bumped into over the last few years to get a feel for any exciting new toys that might be in the pipeline.

Between us, the bloggers/tweeters tried to divide up and 'live tweet' from as many sessions as possible. This proved to be quite a challenge as the talks are short and intensely packed with information, new research data and other interesting snippets. By the time you have tried to compose a phrase which is as close to a quote as you can remember, with or without a photo of the projected slide and then edited for 140 characters, the speaker has chased on at a rate of knots and you are playing catch up.

Here are a few thoughts from some of the sessions I covered, based on the hasty notes I took:

Could intermittent fasting have a role in diabetes management? Michelle Harvie, Manchester
Short answer, yes. For people with type 2 diabetes various intermittent fasting apporaches (eg 5:2) seem to be easier to stick to and more effective for weight loss than continual energy restricted approaches. Fasting days in the research data tended to be approx 650cals and low carb, but results were equally good if low carb but not calorie restricted. For those in whom the approach worked there tended to be an effect on the non-fasting days too. Even though people *could* eat more freely, they did not necessarily do so.

Fermentable carbohydrates: Their role in diabetes management Nicola Guess, London
Not something I'd really heard of, but fermentable carbohydrate (think dietary fibre... pulses... resistant starch... oats...) seem to have promising effect in the context of type 2 diabetes. Results were a little mixed across different studies, not least perhaps because it can be quite hard to evaluate how much FC is in different foods. It may act as a sort of appetite suppressant. When 21g was given as a dietary supplement it resulted in reduced energy intake for the diet of people with Type 2 even if they were not asked to eat less. Fermentable carb was shown to have a positive effect on the phase 1 insulin response of people with type2 and even non diagnosed family members. Insulin sensitivity has been shown to improve in the presence of fermentable carb too. Unfortunately too much fermentable carb can have unfortunate gastric side effects - the gas released from the fermentation of pulses in the gut being an obvious example.

Advancing inpatient diabetes care 5 presentations chaired by Gerry Rayman, Ipswich
This was an extremely data-rich overview from some new JBDS data, including effective new protocols for management of people on corticosteroids and variable rate insulin infusion (sliding scale) in inpatient settings. Also presented a was a huge new piece of research by Norfolk and Norwich Hospitals into nationwide outcomes/detail of DKA management. Some of which was pretty scary stuff - the risk to inpatients with diabetes of experiencing Severe Hypoglycaemia for people with diabetes is 1 in 50 and risk of developing DKA while in hospital is 1 in 200. As alarming as this presentation might have been there was certainly a sense of concerted effort to tackle the challenges of inpatient management of diabetes and establish effective protocols that improve outcomes.

3DFD Integrating Diabetes Care into an individual's world Mary McKinnon Lecture by Carol Gayle and Khalida Ismail, London
I was really taken by this presentation. It outlined a 'three dimensional' model for improving diabetes care by fully integrating clinical, psychological and social approaches. Both type 1 and type 2 diabetes are associated with every major type of psychological disorder, and people with any of these mental health challenges find self-management of this complex and fickle condition additionally challenging. In addition, people living with severe social deprivation are significantly less able to self-manage. Put simply, diabetes is way down on their list of priorities. Address other areas in patients' lives (housing/debt/mental health) and they are released into better self care.

The 3DFD is a short-term intervention with a lasting impact and has moved from an interesting research idea to become a commissioned service in several UK locations. Initially seen as a 'luxury service' it is not only cost-effective, but actually pays for itself several times over in terms of savings made in other areas.

Lessons from the study of hypoglycaemia RD Lawrence Lecture, Rory McCrimmon, Dundee
Some really interesting stuff here about what happens when the body is subjected to repeated mild hypoglycaemia. The exact brain and body chemistry that is at work in the loss of hypo warning signs, and also the loss of counter-regulatory hormone response (epinephrine/glucagon/liver dump). Initially the brain fires all it's warning bells when blood glucose levels drop too low, but soon enough it learns to adapt. Attempting to 'perform better' at those lower levels and not expending the energy of those warning signs. Ultimately though, the brain can no longer function at the lower and lower glucose concentrations that can be reached without warning. Avoidance of hypoglycaemia can reverse this and 'reset the switch', but many struggle with undetected nocturnal hypoglycaemia which sets back their efforts.

Integration of psychologists into paediatric services 3 presentations chaired by Mark Davies
It was really good to see psychological support given so much coverage at the conference. Particularly in relation to children and young people where effective and timely psychological interventions can have such a dramatic effect.

Workshop: Psychological techniques for addressing hypoglycaemia unawareness Nicole de Zoysa and Victoria Francis, London
Great stuff here from the folks behind DAFNE HART, a successful pilot which demonstrates the importance of psychological support in changing people's behavior and understanding of their own relationship with hypoglycaemia. It was particularly good to see the 'compare and contrast' conversation scenarios between healthcare provider and PWD. The difference between people feeling told off/lectured and people being supported to make positive change through responsive listening and motivational interviewing.

Social Media, Why Bother with a Fad? Partha Kar, Annie Cooper, Roz Davies and Laura Cleverly
Great to see social media and peer support getting such a good response at a conference like this. Topics covered ranged from social media in support of nursing practice; tackling isolation and the building of patient communities; and whether social media could be the 'missing part' of someone's diabetes care. Not only that, but Partha Kar opened his talk by suggesting that the term 'non compliant' be removed from the diabetes phrasebook as a result of some social media interactions at the conference. The session ended with a frantic live Tweet Chat and I just hope that some of those who saw the presentations might begin to consider how to integrate social media/peer support into their own practice.

Cognitive decline in people with diabetes 3 presentations chaired by Richard Holt, Southampton
A bit of a mixed bag across these three presentations. Both type 1 and type 2 diabetes seem to associate with 'cognitive decrement' (which I don't like the sound of to be honest), though this only subtle and does not seem to worsen over time. When it comes to type 2 diabetes the Edinburgh study suggests that vascular changes may be the predominant factor. Blood pressuse has little effect, HbA1c has a small effect but smoking has much more of an effect. Overall, improved diabetes management and lack of diabetes complications seem to be a good thing as far as keeping your marbles is concerned. Conversely people with both Alzheimers and T2D are at significantly increased risk of severe hypoglycaemia.

When it comes to young people, there did not seem to be much evidence that mild hypoglycaemia was associated with impaired cognitive function in the long term. Though there may be small risks to very young children who experience severe hypoglycaemia and coma, the brain quickly becomes more resilient in older children and young people.

Hot topics - Diabetes and cardio-vascular risk 4 presentations chaired by Naveed Sattar and Jiten Vora
I was particuarly struck during Miles Fisher's presentation about assessing cardio-vascular risk in people with diabetes when he described the decision to recommend statins for the primary prevention of CVD in people with type 1 diabetes as an 'OBSAT' decision. With a twinkle in his eye he explained the acronym as 'old boys sat around a table'. He suggested that the research evidence did not support the recommendation and that there was a risk of 'over medicalising' the population. His opinion was that the presence of micro-abuminuria was a more reliable marker for prescribing statins for primary prevention in T1D.

In general terms intensively managing blood glucose levels, the earlier the better, significantly protects against CHD for people with diabetes.

Physical activity and Type 1 3 presentations chaired by Jason Gill, Glasgow
This was my last session of the conference and the one that provoked perhaps the greatest interest on Twitter. One of the slides in Rob Andrew's presentation showed a flow chart which seemed to contradict itself. Beamed off into the ether without the explanatory dialogue many people responded, "Ehhhhhhh?!" but the presentation had moved on apace. A lesson learned perhaps in the perils of trying to share complex ideas in 140 characters at speed. There was a lot of detail from Rob Andrew about managing exercise and type 1 diabetes, you can find more information here when the site launches soon. Some interesting snippets too from Richard Bracken about bone strength in T1D. I had not realised that type 1 was associated with an increased risk of fractures, but it seems that resistance training can help improve bone condition and strength.

Summary
On the whole I was really encouraged by the conference programme, and by the tangible sense of passion and commitment from those working in the field who are aiming for better outcomes and more personalised care for people with diabetes. Huge thanks to Diabetes UK for inviting me to be a part of the event.

Disclosure: My travel, accommodation and entry to the conference were paid for by Diabetes UK. I was not paid to write this post or any tweets relating to #DPC15.

Medtronic MiniMed 640G 'SmartGuard' Pump - Preview

The Medtronic 640G launches Feb 2015

I was absolutely made up to receive an email a few weeks back that invited me to go along to the Medtronic UK 'Bloggers and Patient Advocate' meeting in sunny Watford today. It seems that Medtronic are keen to connect a little more with the diabetes online community in the UK, share a little of what they are up to and generally get some grass roots feedback. The group is a mix of MDI and pump users (Medtronic, Animas and Roche, with and without various CGM alternatives all present). It includes both people with diabetes and parents of children or young people with diabetes. It was lovely to meet up with a glittering array of familiar and less familiar faces, Annie (@understudypanc), Lesley (@INPUTdiabetes), Laura (@ninjabetic1 and #ourD), Lindsay (@LwSweetpea88), Sue (@desangsue), Dave (@SowerBee), Chris (@grumpy_pumper), Paul (@TheTeamBG and #GBdoc), Gavin (@Diathlete), Kris (@diabeticbanana), Kyle (of @mysugr), plus @JDRFUK youth ambassador George (and his mum!). We were joined by 6 folks from Medtronic who were very excited by some of their new toys that are just about to launch. I believe that this group has met several times before with more of a 'brain-picking' workshop feel, but today was much more of a full-on sales pitch with a sneak peek of the new MiniMed 640G insulin pump which launches in the UK, Sweden, Denmark and Australia on the 1st 2nd of February (regrettably it looks like FDA approval for the US could take years). We were lucky enough to get a short amount of hands-on time to play with the 640G and I just wanted to share a little of what I saw today. I won't be able to go into too much detail for a full-on review here I'm afraid, because there was LOT of information shared and while I tried to take some notes, all too quickly we had to hand the devices back in. Plus since the official website doesn't launch for another couple of weeks I've nothing to check against. I will try to get someone from Medtronic to glance over the post and set me straight if any of this is complete nonsense. I'll post (and add think about ignore mark) corrections as necessary :)

Those familiar with Medtronic's Veo may have come across the term 'Low Glucose Suspend', the facility where overnight the Veo (when used with Enlite CGM sensors) can automatically stop basal insulin supply if the pump detects a predetermined low glucose threshold has been passed. This has been shown to significantly reduce the severity and duration of overnight hypoglycaemia in clinical trials and was welomed (particularly by parents of T1 children) as a major step forward towards developing the 'artificial pancreas'.

The MiniMed 640G takes this approach to a whole new level with 'SmartGuard', an algorithm that begins to take effect significantly before you have hit your 'low' level, attempting to dodge some of those pesky hypos altogether. The sensors are Enlites again, but with a new (and apparently much improved) 'Guardian Link' transmitter to boost performance.

More on that later, but first a quick overview:

• Colour screen which apparently reads easily in sunlight
• Waterproof (yay!) including swimming
• Reservoirs available in either 180u and 300u
• Up to 5 different basal patterns with up to 48 rates per 24 hours each.
• Pairs with Contour Next Link USB (new 2.4 version)
• Limited bolus options via meter, full bolus wizard on pump
• Completely re-worked interface with many more 'user-friendly' options and updates
• More customisable alarms (and at louder volumes)
• Already licensed for use by children
• Size-wise it's very similar to the Veo, just a few millimeters taller, wider and deeper

SmartGuard
The thing Medtronic were clearly most excited about was obviously 'SmartGuard', so it's probably worth trying to note down what I can remember about how that works. SmartGuard builds significantly on the premise of Low Glucose Suspend by making the whole thing much more predictive. While Low Glucose Suspend only kicks in when you are already registering low, SmartGuard acts earlier trying to head off the low by temporarily stopping basal (in much the same way I started doing while wearing a Libre sensor - see 'new technique'). They had a snazzy graph in the presentation to explain how it works, which I've attempted to recreate here. On the pump you set a 'low' limit that you do not wish to fall below - anywhere between 2.8 and 5.0 in 0.2mmol/L increments. Above that the pump sets additional 1.1mmol/L and 3.9mmol/L guides. SmartGuard is triggered if sensor glucose values fall below that upper line (3.9 above your low limit) AND are falling sharply enough that you are predicted to fall below the 1.1 line within 30 minutes. All insulin is stopped for at least 30 minutes from that point (including basal and any partial dual or square waves still in progress). If your numbers stay down, the insulin stays off for a maximum of 2 hours. Basal delivery (only) automatically resumes once you have risen above the 1.1 line AND are predicted to remain there for the next 30 minutes. Users can, of course, cancel the SmartGuard intervention at any point (eg if they would prefer to treat the impending low with some tasty fast-acting carbs. Rather neatly you can also choose whether or not the 640G alarms or alerts at any of those points and even tailor what times of the day (or night) to switch SmartGuard on or off. Alternatively you can simply run the system as the current Low Glucose Suspend works.

It was claimed that in the 'Pilgrim' study, the same algorithm that powers SmartGuard was able to avoid 80% of potential hypoglycaemic events both day and night. If those results could be reproduced 'in the wild' it would be nothing short of groundbreaking. A handful of people have recently been able to use the 640G on a trial basis at Kings College Hospital and two of them (including @desangsue) shared their experiences. Responses from other hands-on users are also very encouraging and seem to suggest that many found SmartGuard alone was sufficient to cope with moderate exercise. After a short while to build trust, many were also happy to simply let SmartGuard do its thing silently and alarm-free, only realising when checking the pump later that they had been spared a low-level dip here or there by some automated basal jiggery-pokery. The only mandatory alarm that sounds would be if your sensor glucose fell below your 'low limit'. This is a good thing. But the customisability of those alarms, while preventative action is automatically taken without confirmation being required seems to go a long way to prevent CGM 'alarm fatigue'.

Fancy new meter
The 640G pairs with a Bayer meter that looks just like the existing Contour Next USB, but this souped-up '2.4' version has some extra cleverness under the hood. For starters you can use it to deliver a quick manual bolus of any number of units you choose without having to fish the 640G out of your pocket. You can also create up to 8 bolus presets (which can include predetermined square or dual-wave options and doses) on the 640G that can be fired from the meter. Frustratingly you cannot vary the doses of these presets from the meter itself at the point of delivery - which would make this much more useful for me - and neither can the meter act as a fully fledged bolus wizard as it does with Roche pumps. However *some* meter bolus options are certainly better than none, and I can see that these could be very useful for snacks and preset mini-corrections or standard preboluses. The new BG meter also acts as the USB conduit for uploading data to the Carelink software package which (mercifully) is also getting a complete overhaul very soon.

Sensors schmensors
That's all very well you may say, but I'm about as likely to get funding for full time sensors as I am to become the next Pope - is this all about SmartGuard, or is there anything here for non-CGMers?

It is true that Medtronic are putting a lot of emphasis on SmartGuard - they are keen to describe the 640G as a 'system' rather than just a pump. It seems they are trying to work with Healthcare Professionals and NICE, seeking to allow more people to access this sensor augmented, 'virtual pancreas' approach. Swift murmerings were made about price points and volume but no real detail given as to if (and how much) sensor cost may fall if there is a greater uptake.

However even without all that sci-fi automation there is much here to please regular pumpers.

A colour screen is pretty much a given these days, but the layout and icons here are well thought through and in themselves allow quick access to a detailed and drillable overview, similar to but richer than the 'back button' on old MiniMed pumps. Bolus and basal adjustments are available direct from the 'home' screen, and everything is navigated by the 4-way/OK controller plus two other buttons - one for 'menu', the other for 'back'. Pleasingly, pressing and holding the 'back' button takes you directly to the home screen however deeply you are embedded in within menu options, which is a nice touch.

A great deal of attention seems to have been paid to the available options to make the pump more customisable and personalisable for individual users. For many things (such as basal patterns) you can now choose named versions eg 'work day' or 'illness' that make them more self explanatory to use, alternatively you can still opt for the more usual numbered options. You also have the option of setting all sorts of presets, including temporary basal rates of predefined length/intensity (again with named alternatives). Whatever you choose to populate from the available options in setup screens get shown in the selection menus, but you don't have to wade through dozens of items that you never use if you don't want to set them up. So you might choose to set just two of eight available TBR presets one for 'moderate activity' and another for 'light activity', then when setting a TBR you can choose either of those or dial in a custom one. Overall it felt logical, intuitive and that several regular tasks would be faster to achieve. The added complexity might mean an additional button-press here or there for one or two things, but in the hour or so we had to play with the 640G most things I wanted to access within a few presses I could.

Battery life is anticipated to be around 2-4 weeks, depending on use. The 640G needs the slightly larger AA batteries (rather than the Veo's AAAs) to power the colour screen. In the top menu bar the battery (and other) icons re-colour to indicate their status. On the battery front, as well as the usual 'low battery' warnings at 25% and again (if I remember right) at 5% there is also an inbuilt 'get out of jail' rechargeable battery that will allow the pump to limp on for up to 8 hours if you find yourself stranded in a motorway traffic jam or somewhere with no shops over a Bank Holiday having paid no attention to the icons/alerts when you set off. I also unwittingly tested the "what happens if you need to change battery in the middle of things" situation and a trial TBR I had set running happily carried on after I took the battery out to have a look. Another neat trick is that the standard-issue belt clip can be swiftly detached and is moulded in such a way that it can be used instead of a coin to unscrew the battery cap. Just a nice bit of attention to detail which speaks highly of the amount of effort Medtronic have put into the design of things.

Infusion sets and reservoirs are exactly the same ones used in the Veo, but special mention must go to the 'Infusion set change' alarm which you can set as a reminder. This particularly caught the imagination of Paul B who said that as a feature, it was pretty much enough to win him over on its own.

My biggest disappointment on the day was to discover that those infernal (and entirely useless) TBR hourly chimes are still present on the MiniMed 640G and it doesn't look like you can turn them off either. After all the effort that has clearly gone into usability and user-experience... The mind boggles. [EDIT: This turns out not to be the case after all. See the end of my compare/contrast video blog for details.]

To be honest I'm going to have to stop there - it's suddenly got rather late and I had thought I was just jotting down some quick notes. It was a very interesting day and there were other snippets (such as the iPort) that will have to follow later.

In short, I will have had Artoo for 4 years in November this year, at which point the warranty runs out and my robot counterpart begins to live on borrowed time. While I'm not champing at the bit for a new pump, I had absently been wondering what I might look at next. I am still interested to find out more about Roche's Insight pump. Omnipods don't feel right for me, and until today I was fairly certain that the Animas Vibe was my front runner because of Dexcom integration (and longer sensor life if I ever take the plunge to self fund). I know that for many the lack of a fully functioning remote handset on the 640G will be a dealbreaker, but that really doesn't bother me much. Today has given me much to think about and Medtronic's new offering very clearly sets itself apart in the market by doing something that absolutely no other pump can do.

Video blogs now available

Update: I have been given the opportunity of trialling the MiniMed640G for 64 days and will be posting video diaries of my experiences. Watch the videos.

Disclosure. Medtronic generously paid my train fare and laid on a tasty lunch. I was not asked and have not been paid to write this post or publicise their products in any way, but thought you lot might be interested.

Abbott Freestyle Libre review - BG monitoring goes all flash

In recent weeks the mentions, rumours and tidbits about Abbott's shiny new gadget have been reaching fever pitch. If you are of a Twittery persuasion and follow more than about two UK-based-diabetes-type tweeters you cannot fail to have noticed this. Abbott's 'Freestyle Libre' has it's official European launch at EASD today (EASD is a massive professional conference for all things European and pancreas-challenged). I was thrilled to be invited to meet with some folks from Abbott on Friday last week along with a select group of bloggy and tweety types with borderline legendary status for a sneaky peek before the official launch. Quite how I managed to swing an invite remains something of a mystery. We gathered in an upper room in a trendy Soho establishment, were treated to a tasty breakfast and we were sworn to secrecy until 1pm today. Much to my surprise it transpired that we were not just going to be able to handle the technology on the day, but were actually going to be given a chance to experience the Libre ourselves for 28 days, being supplied with a reader and two sensors to take home. It was suggested that we might want to consider writing a post or perhaps tweeting a few characters about our experience, but this was by no means mandatory. Nor did we even have to try the Libre at all if we didn't fancy it.

What on earth are you on about?
In the unlikely event that you have never heard of the Libre, or Flash monitoring, here's a brief overview: It's not quite a CGM. It's not quite a Blood Glucose monitor.

Too brief? Oh, OK... here's a bit more detail: The Abbott Freestyle Libre is a new kind of blood glucose monitoring technology that sits somewhere between existing CGM options and traditional SMBG (fingerstick) monitors. It measures interstitial glucose levels using what Matt (Abbott's techical bod) described as 'wired enzyme technology' and Fiona (communications lead) referred to as 'special sauce'. If you've not looked into CGM before, interstitial glucose is not quite the same as blood glucose. It is measured in the fluid that surrounds the cells in tissue rather than from the blood itself. Typically these levels lag slightly behind BG by up to 10-15 minutes, but Abbott are using an algorithm to adjust readings which they claim reduces this lag to 5 minutes or less on the Libre. The measurement is performed with a tiny, flexible filament inserted under the skin and attached to a small, flat, circular sensor, roughly the size of a £2 coin. Abbott recommends that the sensor is worn on the back of the upper arm which seems to give optimum results and is less likely to be knocked off by doorframes. If you are writing a blog post, you will also notice that this location is virtually un-photographable one-handed - see below. The Libre's sensor measures glucose levels once every minute and stores 8 hour's worth of data. One of the main differences between the Libre and traditional CGM is that the data are not sent via transmitter/receiver continually. To access the information you simply wave the reader (or is it 'flash'? or perhaps 'swipe'?) over the sensor and you will be given a glucose concentration reading taken at that moment along with a graph of data from the previous 8 hours. Data points on the graph are created every 15 minutes averaged from the readings taken at 1 minute intervals. You also get the 'trend arrows' which will be familiar to CGM users and give an indication of which direction, and how fast glucose concentrations are changing. The near-field communication works anywhere between 1cm and 4cm and will happily ready through clothing, even as much as a skiing jacket they said. I've already smiled to myself as I walked down a street and checked my levels by swiping my reader over the arm over my coat.

Sensor shenanigans
I was hugely impressed with how easy it was to insert the sensor. It was also absolutely painless, significantly less 'stabby' than a set insertion for Artoo. Everyone around the table inserted their sensors at the same time, and noone seemed to feel a thing. The sensor came in two parts that needed to be pushed together which seemed to 'prime' the self-serter. Then you chose the back-of-arm location you fancied and applied gentle pressure to the composite gizmo which gave a reassuring click. Interestingly Abbott mentioned that an awful lot of care, attention and engineering boffinry had gone into the seemingly simple process. Including the 'click' which happens only as the inserting spring/needle withdraws. As a result you don't tense up on insertion, because by the time you hear the click - it's all over. Dave (@sowerbee) did ask whether much of the resulting plastic was recyclable, but it seems that almost none of it is - to keep the process as simple, reliable and precise as possible the idea of a reusable inserter seems to have been dropped quite early on. Long term Libre users will probably also need to get a bigger sharps bin - much like the self-serting Mio sets for the Veo, most of the plastic leftovers need to head for incineration. Once you have inserted the sensor the handset begins a 60 minute countdown before the first reading is available. The sensors are being described by Abbott as 'factory calibrated'. While traditional CGM sensors have required occasional BG/fingerstick calibration throughout their life, Libre sensors are manufactured in such a way that this is not necessary. I did ask what would happen if you had forked out your own hard-earned for a sensor only to find that it was stubbornly and continually miles out from your BG monitor and it was suggested that this would be a 'contact customer services' moment. I got the impression that if you could demonstrate that a sensor was massively misbehaving through no fault of your own they may well send a replacement.

Sensor life is 14 days.

From what I can tell there is no way to extend or restart sensors. Each is electronically paired to the handset and begins to count down 14 days from the initial 60 minute 'Start New Sensor' countdown. Smart cookie Chris (@grumpy_pumper) asked what might happen if your reader developed a fault at some inconvenient time - say 5.45pm on the Thursday before Easter. It would be days before a replacement receiver could be sent, so even if the new reader could be paired with the old sensor (and thinking about it now, I'm not even sure it could) several days of 'sensor life' would be lost. Without promising anything concrete, again Abbott seemed to suggest that they would try to behave fairly. Certainly in a market where they must anticipate a significant number of customers will be self-funding they are aware of the need to be seen to be fair if any problems occur. Abbott's research data suggest that sensor accuracy is likely to be slightly further out from BG meter readings during the first 24 hours after insertion, and then more accurate through days 2-14. Early days for me, but this certainly seems to have been my pattern with the first sensor. It is remaining very comfortable after the first few days. I'm currently on day 3 and on the whole I would not know it was there. If I had my insertion time again I might attempt to make sure it was just higher up my arm than my t-shirt sleeve line, but the sensor is very discreet and if anything just looks like a nicotine patch to everyone else so it's not particularly problematic if it is on show. It certainly doesn't scream 'medical device'.

The reader
The reader looks very like a normal BG monitor. It has a single button and then uses a decently responsive touch screen to navigate between various functions, displays and data handling options. Nice clear colour screen too. It was really easy and straightforward to set up and is very intuitive to use. No real need to go digging around in the handbook so far. The reader stores 90 days of data, and provided that you swipe your arm at least 3 times a day at the right moments you get a full 24 hour picture of changes in glucose levels. So far I have been swiping with such frantic, gleeful regularity that I can't actually tell you what happens to graphs where you've run over the 8 hour sensor storage limit, but I suspect you would just see a gap. Along with the 8-hour graph that you can see each time you swipe you can also dig back through a logbook of recent swipes, which you may have tagged with references to insulin, food, medication, exercise etc or view daily graphs 24-hours to a screen or check a variety of analytical screens.

The handset will also function as both a standard blood glucose monitor or blood ketone monitor (using the appropriate Freestyle Optium strips). Somewhat inevitably, the Abbott bumpf suggests that you check your BG level with a fingerstick meter if your levels are changing rapidly (where the potential difference due to lag between interstitial readings and blood glucose readings could be more marked) or if the result on the Libre doesn't match how you are feeling. It's nice to know then, that with a few strips and a fingerpricker in your pocket the Libre reader gives you access to fingerstick checks without the need to carry a whole extra bag of kit. On the whole though, the marketing claim is that you could use results from the Libre in place of almost all your normal fingerstick tests. I'm really interested to see whether I would have the confidence to do this so I'm currently testing at my usual SMBG schedule alongside Libre swipes to see what sort of differences I find. Those of us with more than a few years T1 mileage will already be aware that BG meters themselves are not exactly the most consistent performers, meter-to-meter or even strip-to-strip on the same meter.

The reader can also function as a bolus wizard in a similar way to the Insulinx or Accu-Chek Expert, though you need the support of a healthcare professional to get this set up and access this functionality. Like most meters the reader has an operating temperature range of 10-45C so while you can apparently scan through a ski jacket, you would probably need to keep the reader toasty in an inside pocket to avoid it grumbling about being a bit chilly. Battery-wise the sensors are unpowered and the reader is recharged via USB. A full charge is expected to last around 7 days of normal use.

Alarming
As has been mentioned, one of the main differences between the Freestyle Libre and conventional CGM is that the data is not pushed by transmitter to the receiver. This means that the Libre cannot alert you with beeping/buzzing noises if your levels are soaring or crashing. This may be a significant concern for some, particularly when it comes to night-time, but part of me is quite glad. I always had a sneaking concern over how I would respond to a CGM repeatedly wittering and warbling to remind me that I'd made an almighty hash of estimating yet another buffet meal and that my glucose levels were still stubbornly stuck in orbit. The fact that the checking on the Libre is always initiated by me and can occur as often as I want it to is, if anything, something of a relief.

Data crunching
The handset offers a number of nifty, inbuilt analytical functions which can really help you to get your head around this avalanche of new data. I think I'm going to leave a detailed description of these for a separate post as I suspect many of you are losing the will to live by now. Briefly though, you can view results for 7, 14 30 and 90 days for Average Glucose, Time in Target, number of Low Glucose Events (where levels have stayed below 3.9mmol/L for over 15 minutes) or view a Daily Patterns graph, provided you have more than 5 days of glucose data stored. You can also export data via USB cable to be compiled into PDF reports and which can use something intriguingly called AGP (ambulatory glucose profiling). More on that later when I've got more data stored, but it looks really interesting. Helpfully several of the views display results grouped/averaged by time period so, for example, you can easily spot which time of day I've been having most fun with in the past 3 days.

What does it cost?
Abbott are offering a Starter Pack for £133.29 which includes a reader and two sensors. Otherwise the reader (on its own) costs £48.29 and sensors £48.29 each. These prices are ex-VAT so people would need to fill in the paperwork to get their VAT exemption on medical grounds. At those prices a full year's sensor coverage runs to just over £1,250 which is certainly not cheap, but when comparing with existing CGM options it is probably worth bearing in mind the significantly greater cost of handsets/receivers and transmitters for those options. Especially where transmitters are only guaranteed to last 6 months.

Freestyle Libre sensors/receivers will be available to purchase from Abbott's online shop from the end of September/beginning of October 2014 and once you have a receiver you could choose to buy sensors to cover as much or as little of the year as your budget allowed.

What has it been like so far?
In a word, amazing.

I have never had access to any kind of continuous data before, so I guess it was always going to be an eye opener, but I have been really impressed with the similarity between my standard fingerstick readings and results on the Libre. In a follow-up post once this first sensor has run its course I intend to do a little compare-and-contrast number crunching of the results, but already I am wondering what it might be like to more or less 'fly solo' with the Libre for the second sensor and only cross-check with SMBG if things felt wrong.

For the first time ever I have a full picture of what has been going on overnight every single morning. And if I wake up blearily overnight I am FAR more likely to swipe the Libre for an instant check than I am to get up, go downstairs and test. Not only that... but swiping the Libre does not involve turning any lights on or faffuing about with strips and finger-squeezing so there is far less chance of disturbing Jane in the rare event that my BG meter happened to be upstairs. I've already caught one sneaky overnight low that I am 100% sure I would have simply ignored/not checked via SMBG. Much comment has been made about the Libre for under 18s. Currently it is only licensed/available for adults but it was made very clear on Friday that Abbott are leaping through the regulatory hoops for a paediatric license as fast as they can. The phrases used were 'actively pursuing' and 'great need'. Sadly Abbott cannot predict the timeline, but certainly gave the impression that this was something they are already working towards as a priority. I can imagine that swipe-the-lump-under-the-duvet monitoring would hugely appeal to parents of children with diabetes who choose to test during the nighttime.

One of the other things I have already noticed is that the Libre makes glucose monitoring so effortless that I am inclined to check more frequently rather than less. Certainly in these early 'novelty' days. Part of this, I know is my own foolishness. I have been carefully logging and recording my BG levels, food, exercise and all manner of other details for several years now. It was one of the changes that made a massive difference to my own management and understanding of how my diabetes behaves and really helps me spot patterns and fix things. I made an agreement with myself early on that I would stick to a regular testing schedule and add in extras if things needed checking, but (importantly) that I would log every BG check I made to ensure I wasn't kidding myself by only writing down the good ones. Perhaps it's just me, but as noble as that set-up is I still find that there are occasions where I suspect I might be a tiny bit higher or lower than I'd like but don't want to mess up a good week's worth of results with another red flag so I'm tempted to make a small correction on instinct and hope to solve an imagined problem by the time I next test. This can be particularly the case if I'm having a week where I've had frustrating red flags peppering my results because results are 0.1 mmol/L past the cut-off rather than being real, proper, decent mess-ups. Yes it is silly. I know it's silly. But I do it anyway. And sometimes I end up treating a hypo-that-never-was and sending myself sky high in the process. Jane says it's because I am too much of a perfectionist. Too competitive with myself. And she's right. Again.

But with the Libre I am released from this - at least in part. If I want to check how a correction is going I don't need to wait until I think I'll be out of red flag territory. The curve on the graph will be there whether I check or not, so I might as well actually know. This, for me I think is going to be something of a Big Thing. Less double guessing and more data-driven responses. I may never play Uncertainty Tennis again while I have a sensor in my arm.

I am very interested to see how things progress over the next few weeks and will transfer some results into Excel (manually unfortunately as there is no direct .csv export from the Libre software) to try to understand how close or otherwise the results have been between fingerstick SMBG and Freestyle Libre. Unsurprisingly though, the trend arrows and graphs are already winning me over.

Does it replace fingersticks? My first few days certainly look really promising. Abbott themselves concede that there will always be at least some continuing requirement for good old fashioned punctured fingers. I'll write an update in a few more days with some of my own n=1 observations about numbers.

Left-right: Me, Dave, Jen, Laura, Chris and Sue

Brucie bonus
Aside from meeting the fab folks from Abbott and PR gurus WeberShandwick who laid on a really interesting and engaging event, one of the very best parts of the morning for me was getting the chance to meet face to face with some amazing folks from the #DOC. Jen (@missjengrieves), Laura (@ninjabetic1), Sue (@desangsue), Dave (@sowerbee) and Chris (@grumpy_pumper) are every bit as lovely as you would imagine. I look forward to reading their thoughts on the Libre later on.

Try these other posts too:
Laura (@ninjabetic1): FreeStyle Libre - Flash Glucose Technology
Laura (@ninjabetic1): FreeStyle Libre downloaded data
Jen (@missjengrieves): Freestyle Libre Review – a gamechanger for diabetes management?
Dave (@sowerbee): New Kit! - Freestyle Libre Review: Part 1
Dave (@sowerbee): Libre FGM v Enlite
Sue (@desangsue): New Freestyle Libre Sensor System


UPDATE: Abbott Freestyle Libre vs BG meter

Disclaimer. Abbott kindly paid my train fare, treated me to breakfast and allowed me a trial 'starter pack' of the Freestyle Libre which I am allowed to keep. They encouraged me writing a blog post about my experience, but said they would have been quite happy if I hadn't bothered. They certainly didn't insist that I only said nice things - if at this point I'd thought the product was rubbish I would have said so. I've not been paid to write this post or publicise the product in any way.