So, um, my name is from what I thought we'll go through together is kind of build up on what Dr Thompson talked about earlier, which is this whole concept of team approach in taking care of a patient with diabetes. Uh, trying to walk through some difficult scenarios. Uh, and, um, with the understanding that diabetes, unfortunately, is here and it's not going away when I did my. Uh, residency, I'm going to date myself. There were only 2 kinds of incident and pH and regular. Uh, life was kind of easy for an endocrinologist. Uh, then, you know, came on, then came on, then the ultra short acting incidents came on and then we were talking about pancreas transplants. I talked to Thompson alluded to. We thought this was going to be the next big thing. Uh, then, you know, a bunch of other drugs came on, then the weight loss medications now are here and we're going to talk about these more in the afternoon. So that's my little teaser. Uh, then technology came on and pancreas transplant kind of went a little bit to the side. And life became a little bit more complicated for, for us, uh, endocrinologists. So, we're going to spend a little bit of time talking about continuous glucose monitors. I know a lot of you are familiar with them. Uh, but as, you know, they, they do have a little inserted that goes under the skin kind of a little bit deeper and measures interstitial fluid block glucose. There are quite a few of them that are approved. Uh, in the market, uh, the cost varies. Depending on the, uh, insurers provider, the 3rd party payer. Now, something that I always try to remind myself is is not cheap. To treat diabetes, it's very easy for us to tell our patients, you got to check your blood sugar 4 to 5 times a day. Uh, you know, you're not compliant. How come you don't you're not showing me logs with with, you know, all those beautiful numbers 5 times a day. But roughly a tester costs a dollar. This is probably 1 of the cheapest ones if you go to a Walgreen CVS brand. Test strip, and if you're paying out of your pocket, of course, if you're blessed with having a 3rd party. Pay for it, then then life becomes easier, but at 1 dollar to test it. Let's say 4 times a day times 30 days, that's 120 dollars. Just for test trips, they haven't even started taking medications and using insulin and paying their copays and doing their tests. So, it's not cheap now, of course, we're balancing the cost of the test to the cost of the. So, again, you know, if if somebody's struggling to put food on the table, both are equally expensive. If somebody has the support of a 3rd party to help pay with their cost, then, of course, they're balancing. Convenience comfort I want to be stopped 4 times a day to check my sugar or do I want to put a continuous glucose monitor? I can wait it for 7 days, 10 days, depending on the brand. And then I take it off and I change it again. So convenience, comfort, cost, they're all. Factors in this, so here's how we'll go with our cases as we're ready to dive in. We're going to start with the case. We'll. Come up with some general recommendations together. We'll do a curve ball what I call a curve ball scenario, which is, you know, as we all know, patients don't read the textbooks. So, we have those beautiful, nice and tidy recommendations. And then we get a patient in front of us are like, wow, where do they fit in this recommendation? Because this is very different than the clear cut box. And then we'll try to address the curve ball scenario. Sounds like a plan. All right. Okay, study 1, this starts with. The lenses of us, the physicians, the providers, when we have limited resources. So, let's go through it together. So. I'm a primary care provider. I have a very busy. Practice I'm not in a big academic center. So, I don't have all the beautiful resources of, you know. The certified educators and a dietitian and the nurse and and, you know, maybe a research center and all the support. Around me, I have a significantly. Decent number of patients with diabetes, and now I'm, you know, a lot of them are getting those and I'm supposed to download those numbers and look at those numbers and deal with all of that. I don't know how many of you have followed on the news that very recently there is even 1 of those that has gotten approval to be used without a prescription. So, it's over the counter patients can go into a pharmacy if they want to pay for it. Get 1 and come to you and, like. I expect you to download this and read this because I didn't even need a prescription from you to. To use my. So that's very, very. Different world so good news and bad news. You want the good news 1st for the bad news 1st. Okay, well, let's start with the bad news. So bad news is yes, we have to. Install different portals on our desktops in the, in the office. Unfortunately, there is no way around that. A lot of those still don't use a single portal. So, they all have their own little proprietary way. So, it is as if you're installing on your desktop at work, whether you're using a Mac or a, or a PC, you have to download and install their own software. It's an initial time investment, so dedicate 1 time. So I'm going to download all those. Software as I put them on my, my computer right there in clinic for the nurse to use for yourself to use for whoever you designate as most appropriate. The good news is there is some reimbursement attached to it again. Not a lot, but at least something, whether it is the original code pointer. So, whether it is the original code, which is the 95249, the onboarding of the in the office. And we'll talk about what does that mean as well as the reimbursement for the reads. So, when the patient brings to you, asks you to download it, or whether they find a way to upload it in the cloud, and you can download it through the portal, which is another way of doing it without even coming into your office. But reading it, as long as there's at least 72 hours of. Data in there is reimbursable again, nothing earth shattering as far as dollars associated with it. But better than nothing, this is what I mean by onboarding. Which is usually the education that you all provide, or your staff provides to the patient about, you know, how to place a, how does it work? What is the warm up time? What are the high and the low alarms? Uh, what are your goals? Uh, how do you respond? How do you upload the data? This is all part of the onboarding and this is billable with the code that I just showed you this 1 here. Let me pause for a quick 2nd before the moving on any questions about that. Okay, I'll keep going. Then again, feel free to interrupt me. So there's multiple ones in the market. As I alluded to, there is 1 that just got clear. For over the counter use, and, um, the, you know, is there 1 better than the other? I would say it's probably all patient preference. Uh, some of them are smaller, some of them are bigger, some of them use a particular, uh. Portal that the patients really like, it's as if I go into discussion office, the iPhone better on Android better. You'll have people sweating by the benefits of each 1 and it's kind of hard to convert 1 to the other. Uh, they can be shared with you. They can be the data can be shared with their loved ones. So, if I'm a 16 year old kid, I can have my on and mom and dad can actually, if I give them access, they can have access to my data to see how I'm doing. Or if I'm in college that they kind of want to see. How am I doing? Especially if I have type 1 diabetes, but they can also share it with you. And that's part of the reading and the billing that you can. Use for reviewing their data and suggesting any changes. I don't think I need to convince you about the benefits of. C. G. M. a lot of benefits. Um, part of it is the alarms for the highs and the lows. Patients usually love that because now they can kind of live a relatively worry free life. They don't have to worry all all day. My sugar is my sugar up. What is my sugar down? Do I need to go to the bathroom and stick myself and see how how am I looking? They can just look at the, their phone, whatever it is that they're using as the reader and get an idea of what their sugars are now. I don't know how many of you have treated. Engineers who have. Diabetes anybody. Okay, the reason I say it is, as you know, our engineering colleagues have an engineering. Mine, which is if I get the same input, I should get the same output. And I've had long discussions with saying, well, how come my sugar here was 121 and I ate and did the same thing and here it is much higher than what it was yesterday. And. What's wrong with me and and, uh, so the reason I bring it up is. Gems are great, but if somebody's going to obsess about the numbers. Then they completely backfire. Uh, so it is kind of teaching our patients to learn that find balance where data is good. It's nice to see where you are. It's nice to see if you can adjust some. I've had patients find out that certain foods. Jump their sugars up a lot. And now they've learned this and now they avoid them. Okay. Well, I guess for you. Plums bring your sugar higher than we all expected. All right. Now, you know how to deal with it. But if somebody is really getting incapacitated by. Constantly obsessing about their sugars, it totally backfires. Now, again, I'm sure you're all familiar with that. Not all hemoglobin. A1Cs are created equal. That's the whole point of the. You can have 3 patients as whoops. Sorry. As in this scenario, 3 patients with exactly the same hemoglobin. A1C. But the 1 season average. And we can be averaging totally different set of numbers. We could be averaging. Numbers that are actually where they should be, or we should, we could be averaging a bunch of high numbers with a bunch of low numbers and getting with the same mean. In the middle, somebody earlier very astutely asked. Are we aiming for an A1C of 7 in everybody and Dr. Thompson rightfully said, no. Obviously, it depends on how safely we can do it. And this is part of that safety. So if somebody has a. Greater on C here, very different than somebody who's having a greater 1C, like, at the far most with 18% type of glycemia. We don't want that. We don't want somebody who looks wonderful with an A1C of 7. But actually suffering with 18% of the time, having their blood sugar below target. And again, more to illustrate that this is somebody's blood sugar during the day. As compared to another patient. You can see that the finger sticks will actually capture certain time. So, in this case, if they're doing finger sticks, that's. Fixed times, as we always tell them 4 times a day, for example, before each meeting at bedtime. They may look okay at the surface, but they're going all over the place. So, let me illustrate this very quickly by story. So I once had a patient. She was a very, very compliant patient. And she came to me and she said, I'm expecting. So, now, of course, her diabetes needs to be very tightly controlled since she's pregnant. We want to make sure that they want to use that target. So we. Give her the usual advice diet, checking your sugar regularly, checking your sugar before each meal 1 hour after each meal as, you know, we oftentimes. Are very, very strict about this was before, by the way, continuous glucose monitors became really standard of care. So she would. Do all that she would check her sugar before each meal. She would eat what we told her to eat. She will check her 1 hour after each meal. And then at bedtime, and she brought us all the records. The sugars look beautiful. And she was not making them up, so that's not a case of scenario where that. You know, inventing numbers, but once you would not go down. So, we were all puzzled and we're like, what's going on? That's weird. So, we had a continuous glucose monitor. We told her, why don't you go and wear this for 3 days, bring it back to us. We'll do the downloads. She did that exactly that. So the. Download showed us that, yes, 1, you know, before each meal, the sugars were where she told us they were. 1 hour after each meal, they were exactly where we wanted them to be. Then we would see a spike and then they would come back down. And then same scenario repeats for lunch and dinner. So, we asked her what's going on? Can you help us on this? And she's like, Doug, I'm doing exactly what you're telling me to do. I'm checking my sugar before breakfast, I eat the amount of carbs you tell me to eat. I check my sugar 1 hour after breakfast and I eat because I'm hungry and the carbs that you tell me don't give me any relief. So, she's being compliant. Besides omitting that you shouldn't eat in between them, which we didn't tell her, we thought that this is it. So, this is where the continuous glucose monitor really helped us understand how come this compliant patient on the surface was actually not getting her A1C down. So, I don't know how much you're comfortable with the reading of the CGM. I'll just go over it very briefly for you. I apologize if I'm boring you with it. So, as you know, it will show us the average time in range. So, we want it to be 70%. Then it was that usually is the green how much of that is of the blood sugars are in target. It will show us in red how much hypoglycemia we're getting. It will show us in yellow and orange how much hyperglycemia we're getting. So, ideally, we want the patient to be about 70% or more in range. We would like to avoid hypoglycemia as much as possible. So, below 4% of the time, ideally 0% if we can. We want the hyperglycemia to be as minimal as possible and we want the variability to be less than 33. This is what usually a typical CGM will show us at every download. Every graph may look a little bit different depending on the brand, but that's the general gist of it. And you can see how it will help us identify if there is hypoglycemia, hyperglycemia. We can drill down to the time of the day to the day of the week. So, if somebody, let's say, Monday to Friday has good numbers, but then Saturday, Sunday, things go crazy, you can find out and you can discuss their lifestyle at the time or vice versa. Or certain times of the day, if their sugar suddenly goes up a lot or down a lot, this is where you can have those discussions with them. So, the three-step approach to this is always fix the lows first. That's what I focus on. Get rid of the hypoglycemia, then fix the highs, and then try to flatten that curve as much as possible. That's the three-step approach in adjusting therapy based on what the Continuous Glucose Monitor is showing you. And in this case, the flatter we can get this curve, the better it is. Any questions about the first case, which was kind of the approach? Yes. I'm sorry, would you mind repeating it, and I'll come closer? So great question. So the question is, the assumption is, if the CGM is reading a low, the best treatment for that is actually to encourage them to eat. So yes, if they are awake, conscious, they can eat, absolutely. And I'm glad you pointed that out, because one of the advantages of the CGM is actually it alarms according to the rate of drop. So you can program it to say, let's say if my sugar was 250 five minutes ago, and then 200 two minutes ago, and then 150 now, I'm dropping really fast. So it will alarm. Although 150 is OK, but it will kind of alarm that, hey, you're dropping really quickly. You should do something about it. So it has two kinds of alarms. It has the alarm on the rate of drop, and it has obviously the absolute alarm, like you're 40. You've got to do something now. But yes, long answer to your question, short answer, yes, feed them, absolutely. Thank you for that. Any other questions? OK, let's tackle case two, which is the lovely third-party payer issues. So this was one of my patients, still is, one of my patients, Chuck, 62-year-old gentleman, has type 2 diabetes since age of 40. He's on insulin, checks his blood glucose multiple times a day, of course, forgets to bring those logs half of the time, and often tells me that nobody looks at them anyhow, so why should I bring them, especially when he's in the hospital? He always complained to me that we do a worse job when he's in the hospital than what he does at home, which is sadly sometimes true. He has an HMO for health insurance, has other comorbidities. And the important part is, though, yes, unfortunately, we have to work with the third-party payers, and different ones have different coverages. They would accept one of the brands and reject another one of the brands, and I usually go with whatever they accept to cover. So I'm not attached to any brand. As long as the patient gets ACGM, I really don't care which one they get. Now, of course, the third-party oftentimes likes to deny coverage. Has any one of you, so this is a fun fact, has any one of you used, tried to use one of the AIs, so CoPilot or Chad GPT or any one of those, to write an appeal for denial? I have, and it's so good. So you said you work in an urgent care. So I had a patient who had diabetes and was denied their CGM. So I went in and asked the AI to write me an appeal letter, and I said, write an appeal letter for, I won't name the third-party insurance, appealing a CGM for this patient who has type 2 diabetes, and it wrote a wonderful letter saying that CGMs have helped, among other things, they help detect hypoglycemia early, help prevent visits to the urgent care, which will be a huge cost saving for the third-party payer since, you know, a visit to the urgent care costs, blah, blah, blah, and it went into on and on about reasons why they should not deny this. And I sent it in, and they accepted it. So like, wow. So and the AI did it in like a minute better than what I would have done. So highly encouraged. Now, you may have read in the news that actually there has been regulation coming out against insurance companies using AI for the denials, which was news to me. I'm like, wow, they're using AI to deny patients. So it's kind of an arm race. Now we're using AI to appeal the denials. And then you're going to, you know, so it's a different world. It's a different world. It's my AI talking to their AI, essentially. And yes. Thank you. This is exactly that. Thank you. Thank you for saying. So yes. So before to get a patient on CGM was, was, you know, pulling teeth. It was, you have to have horrible hypoglycemia. I have retried everything, blah, blah, blah, multiple day, multiple shots a day of insulin. And that will be, maybe they would accept. But now, as you've nicely pointed out, you can see that if one of the criteria down here is met, third party payers will usually accept it. So if the patient has type one diabetes on insulin, which of course they should be on insulin. They have type one. If they have type two diabetes on insulin, if they have gestational diabetes, if they are on an insulin pump, if they have a history of hypoglycemia and definitely, definitely if they have hypoglycemia on awareness. So I mean, if you have a patient who has type two diabetes on insulin, does not have any hypoglycemia, is doing pretty well, fine. Maybe, maybe the insurance will deny it, but I guess that your patient's doing great otherwise. But most of our patients, unfortunately, get hypoglycemia despite our best efforts, despite their best efforts. And a lot of the insurance companies have been more lenient in accepting that as a coverage for CGM. So let me slide a slide about that. No. Okay. It's slightly different. So of course it varies. I made a broad statement. So it varies based on, you know, Blue Cross Blue Shield of Illinois versus Blue Cross Blue Shield of Iowa versus Medicare versus managed Medicare. Medicare advantage. Yes. Thank you. So it varies. Most of them, if you say that the patient has type two diabetes, which I'm going to imagine is the majority of your patients on insulin, has hypoglycemia despite compliance, despite efforts, they will accept it and they will accept coverage for that. And again, try AI. It will do your appeal in a minute and save you a lot of time rather than writing a big thing. Other questions. That was a great question. Thank you. Okay. So he is on insulin. I didn't give you those details for Chuck, but he is on insulin. Unfortunately, he was never trained on the appropriate timing or administration of insulin. He was admitted four times when I saw him for those episodes of confusion and difficulty walking, which were very suggestive of hypoglycemia, but he wasn't checking at home. So definitely would benefit from his CGM. I know the picture doesn't show it, but this is him when we first put the CGM on him. You can see a lot of orange. I don't know if it shows from the back, but there was a lot of orange there, which is very, very high blood sugars. And now on your right-hand side, you can see a lot of green afterwards. So when we repeated the CGM, actually a lot of his sugars became on target. We adjusted the medications and he went from 0% in target to 79% in target, which again, kudos to him. And now his average blood glucose went from 320 to 165. So huge success story. So let's recap it real quick for this case. Two benefits, and at the same time, this is where the third parties will accept to pay for CGM. So all patients who are treated with intensive insulin therapy, so multiple injections a day or an insulin pump, all patients with hypoglycemia, whether it's frequent hypoglycemia, nocturnal hypoglycemia, or hypoglycemia unawareness, children and adolescents with type 1 diabetes, pregnant women with type 1, type 2, or gestational diabetes, and patients with type 2 diabetes, even if they are on less intensive therapy, so even if they are on one shot a day of insulin, let's say an oral, if you're not able to get them at target, if you're getting hypoglycemia while you're attempting to get them on target, you have a pretty good case for CGM. Any questions about that? Okay, let's move on. So this is the little bit of the curveball scenario, and I think you alluded to Medicaid and Medicaid. So if somebody has problematic hypoglycemia, it's probably the biggest argument I usually make. Problematic hypoglycemia, frequent hypoglycemia, nocturnal hypoglycemia, hypoglycemia necessitating visits to the urgent care or to the ED, hypoglycemia needing their relative to help them at home with treating this hypoglycemia episode. Hypoglycemia and awareness, I don't know if you've ever had the misfortune of experiencing that with a patient, but having a patient sitting in front of you with a blood glucose of 29, talking and seemingly making sense, and the next minute completely collapsing, it's pretty scary. I had this once happen to me in clinic, and it was like, whoa, pretty scary. And then, you know, we checked them, and they were 29, and I'm like, wow, you were pretty coherent and looking okay for 29, definitely did not feel it. So again, as I think Dr. Thompson was saying in her talk earlier, never take a denial as the end all be all. Appeal it, and appeal it again, and appeal it again, especially if you have a good case that you can make for it. We will eventually convince the third-party payers that this is the right thing to do for our patients. All right, now let's talk about accessibility issues. So a 75-year-old gentleman has been struggling with type 2 diabetes for quite a while. A retired farmer lived quite far from medical facilities, and his son and daughter were both helping, actually, in taking care of him, bringing him to his appointments. And he's using intermittent CGM. Intermittent CGM, essentially, is a term to say that he would get the CGM from us from clinic, wear it for three, four days, send it back, mail it back, or have the son or the daughter bring it back to us for the download. But this was not his own device that he was using. And sharing the data with either his primary care provider or endocrinologist, and the primary care provider was doing her best in adjusting the medication and was on a combo of insulin, metformin, semaglutide, and he was having some hypoglycemic events. This is where telemedicine can help us. This is where remote monitoring can help us. For those of you who have incorporated telemedicine and still do, despite the fact that COVID has gone down, but I guess one of the silver linings of COVID, if any, was that it prompted a lot of us to use telemedicine more aggressively. And for patients who tell us that it's either they're relying on their son or daughter to bring them to clinic because they have a three-hour drive, or they take five to six buses to come to us to clinic, sometimes all what I need is to look at their blood sugars. That's the main reason I'm bringing them to clinic, because I did the regular physical not too long ago, and now it's kind of just follow-up to titrate the insulin. Relying on telemedicine is a blessing for them. So they can upload, as I alluded to before, they can upload the results through the portal that is being used by the CGM that they have adopted. We can review it in the office, analyze it, do a quick telemedicine visit, make recommendations for the adjustment. And as we've talked about before, this is reimbursable, whether either as a telemedicine in-person SYNC visit or an asynchronous visit because we did the review of the download with us. Now because life is never that simple, when this patient came to his appointment with his son, the son said that he's forgetting to inject insulin a lot, and a lot of time he finds out that the vials or the pens have not been used as we were anticipating them to use. There's quite a bit of insulin left in there, and the son has his own job, so he's unable to be all the time with his dad and to track how much the dad is using. So what can we do to help with that? So something that's a little bit less common than the CGMs but is out there are the connected insulin pens, where it's kind of your traditional insulin pen, but the difference is that the pen measures every time you use it. So it will send a notice, a log, into a portal saying this pen was used for breakfast today. Then the pen was used for lunch today. This is how much was administered. This pen was used for dinner today. But then let's say tomorrow, hmm, not used for breakfast, not used for lunch. This is where the son could call and like, hey, dad, what's going on? I saw you didn't take your insulin this morning, or I saw you didn't take your insulin at lunch. What happened? And kind of gently remind the loved one that, hey, you should get your insulin. Did you forget? Is the insulin expired? Is there any problem? Do you need a refill? Let me help you get it rather than going a few days without insulin therapy at all. So this is how it looks like. It can actually do more than what I told you. So not only it can log, but actually it can calculate the dose. So if you have your patient on a sliding scale, for example, or they're doing CART, they're supposed to do CART counting. And together with the sliding scale adjustment, it can actually take some of that computation away from them and do it itself and suggest the dose. So if a patient is having struggles and to like, all right, I have to check my sugar and I have to do this sliding scale and it's getting complicated for me, then the pen can do it for them in addition to doing that log. So it is one of the newer tools we have. How many of you are familiar with it or have used it or have had patients who have used it? It's still pretty new. So again, we'll see if it takes off, but I just wanted to make sure you knew that it's available and the coverage by third parties is still spotty. So not as frequent as CGMs. I'll skip through those. But the advantage of the pen doing the calculation is similar to the advantage of the pump doing the calculation, which is it takes out any mistakes we can make. So if the machine is, you're inputting in the machine that this is my blood sugar now and this is how many carbs of food I'm going to eat. It does its own calculation and suggests the insulin right there. So it takes away any human component from making an error, especially if somebody was starting to have cognitive issues, and you worry about them doing the right math for the injection. Any questions about that before we move on to case number four? It would, yes, definitely an option, yes. The Omnipod would also be an option for those. So again, blessing as well as the difficulty we're having with all the technologies, there is a lot of options for our patients now. And again, if any one of those insulin delivery devices will also become over-the-counter, then we're going to have a lot more adoption, but also a lot more of patients using them without us knowing. Yes. Yes, so actually, I try not to use the official names, but it's the Medtronic InPen. That's the one that's right there. Yes, thank you for that question. This is the name of the product in the market now. Again, fairly new. So all right. Case four, so for this, I have two cases, but maybe for the sake of time, I'll go over one of them, and then we'll move to case five. So the first one is a 19-year-old lady who I saw, she had type 1 diabetes since she was a kid. A1C is not doing good for any one of you treating teenagers with type 1 diabetes. It's not easy. It's not easy for them. It's not easy for their parents. It's not easy for the docs who are treating them. She was on an insulin pump. When she was on that pump, her sugar was doing good, but now she doesn't want things attached to her body. And again, I wore a pump with only saline in it, but I wore it for a weekend just to see what patients go through. And if anyone has done it, it makes you realize it's not easy. You have something in there. If you decide I'm going to go swimming, you're like, whoa, what am I going to do with this now? If you decide I'm going to go for a run, and is this going to fall off, or this is attached well? So for a teenager, it's not easy. And so she stopped using that pump. She went back to pens. She checks her sugars with a glucometer, but only in the morning and at night, because all day she's in college. She's attending classes. She's doing whatever teenagers do. So has other things to do in her mind than check her sugars four to five times a day. And rightfully so, her primary care was very concerned about the fluctuations. A1C9 at this young age is kind of a sure path to getting retinopathy and nephropathy. And I'm sure you've all treated patients who at age 30 are already blind or on their way to dialysis. And it's heartbreaking. It's really heartbreaking. So she had two ER visits in the past year. One was with DKA, and the other one was with severe hypoglycemia. So both ends of that spectrum. And I was combining two cases here because I had another patient, and I'll go over that one very briefly. This was my 77-year-old gentleman. So on the opposite end of her spectrum as far as age, but he also had type 1 diabetes since age 15. And when he was diagnosed, he was told, you probably won't live long. I mean, you'll probably die by 20 or 30 at best. And he's one of those who originally was on pork insulin. He was testing the urine by dipstick. This was his way originally to knowing if his sugars were OK or not. So he would have been in the BCCT trial. You know, this was the time where we didn't even know how strict did we need to be with the A1C. And he adopted technology, and he started using an insulin pump and an insulin sensor. Usually videos don't play well. Thanks for coming today. When were you told that you had type 1 diabetes? I'm 15 years old. Oh, no. So I'll skip it. I mean, he's a wonderful man, and he was sharing with us, and he gave us permission to use this video, obviously, here, but also... No, it's OK. It's OK. It's OK. Thank you. Thanks for that. And he gave us the permission to use his name, his picture, his video with anybody, you know, at a conference, but also with other patients. And when we showed our young lady how the 77-year-old gentleman is using technology and figuring it out and is getting his A1C in control, it was inspiring for her. So I'll tell her what she did. So, you know, we decided to work step by step. Rather than having multiple things attached to her, whether it's a sensor and a pump, and we said, OK, let's start with just one. Let's start with the CGM for you. Now, as you know, CGMs can be worn quite discreetly. Some people like to wear them on the back of their arm. Some people like to wear them on the side of their thigh. Some people like to wear them, you know, on their abdomen, depending what makes them feel more comfortable. And I usually tell them that's fine. The only caveat with where you wear it is, you know, make sure it's well-attached, it's safe. And, you know, cosmetically, if you're whatever you're comfortable with. Slightly different from a pump, for a pump, especially if somebody is active, because if they have an insulin pump on, they can also wear it in different sides. But if there's somebody who's exercising actively, if they're exercising that muscle, the insulin will be absorbed much faster. So I usually try to tell them, put the pump. So if you're somebody who's always doing abs, then maybe don't put the pump in your stomach. Maybe put it more on your thigh. If you're somebody who's a runner and that's your thing, put the pump in your abdomen, do not put it in the thigh. So little caveats there, especially for our patients who have a very, very active lifestyle. So we encourage them to wear the CGM. Highlighted to her that, you know, now she doesn't have to check her blood sugars in the morning and at night, which is what she was doing before. Because the CGM will do it for her. And that was the point I made earlier with the rate of drop. A lot of our patients, especially younger patients, are terrified by hypoglycemia. Rightfully so. If you've ever experienced hypoglycemia, it's not a fun feeling at all. So they like to keep their sugars higher just so that they don't go low. Or they're terrified because, you know, now they're out of the home for the first time. They go to college. They're in the dorm, and they're terrified that they're alone, maybe, and their sugars are dropping at night, and there is nobody to help them. This is where, if you set the rate of drop alarm on the CGM, it will wake you up if you're dropping too fast in the middle of the night. And that sound is very hard to miss. You cannot ignore the sound of the alarm with the CGM. So again, different companies that make different CGM, whatever the patient likes and whatever the insurance will pay for is the one I go to. Now, CGMs can connect with a pump. So if somebody has a pump, and you get them a CGM that works with that pump, then technically you have an artificial pancreas. Now you have an external artificial pancreas because they can do a loop. So the CGM can feed the sugars to the pump. The pump can adjust the insulin basal rate based on the sugar. And they can keep doing this pump, this loop quite safely, and adjust that basal rate. Because usually we program like one or two or three basals in the pump, and we assume that this should be okay. But I don't know how many of you have any very predictable day where you do exactly the same thing all the time, but so suddenly you're like, hey, I'm gonna go for a walk now. And now the pump has to adjust for lower basal because you're being more active. Well, the CGM will help do that with that pump. So very, very interesting technology there. Again, when it works and when the patients are willing to work with it, and when the third parties are willing to pay for it. So in our case, the curve ball was that she didn't wanna do the pump and the CGM. She just wanted to do one. We started with the CGM first, helping her get a lot of data, make decisions, avoid the visits to the ER. And then as she became more comfortable with the CGM, we introduced the pump. Any questions about this scenario before we go on the last five minutes? This is our last scenario, by the way. So if you were worried that there is 10 of them, we're doing good. All right, last but not least. So another example of how patients don't follow the textbook is their environment could change. They could change jobs. They could be a night shift person. Suddenly they got a night day shift job or vice versa, or they could be traveling and they wanna know what to do with travel and all this technology and all the stuff and their sugar. So let's go over this gentleman who was a young patient, has a full-time job, has type 1 diabetes, uses CGM, doesn't use a pump, travels frequently, he's a salesperson. Actually, he wasn't a salesperson. He has an interesting job. He works for a company that sells the machine that packages food. So every time they made a sale, they would tell him, you gotta go travel and teach the people locally how to use the machine to do their packaging. So he would go to Germany. He would have to go anywhere in the US at a very, very short notice. And his wife could not go with him because his travel was very, very short notice. Like, you gotta go tomorrow and the company will pay for his travel, but not for his wife's travel. Last minute tickets get very expensive. So he would often be on his own on the road trying to figure that one out. So the good news is with the portal I told you and the upload, he could still share his data with us. So even if he's overseas, even if one of his trips was in Japan, he could still send uploads if it's an extended trip and we could still help him with getting his incident adjusted appropriately. He could still use the CGM as the wake up alarm if he drops too low or if his rate was low when he's alone traveling without anybody with him in the hotel room. So that was a huge win for him. Now, interestingly though, this is the CDC recommendation for packing enough supply when you're traveling and you're using a CGM and or a pump. You have to take your supplies with you and you have to have the backup, the sub-Q incident as a backup and the glucometer as the backup. Why? Because if you are overseas, then your machine may not be approved there or it may not be available. Or if you're gonna pay for it out of pocket, it's gonna be very, very expensive to buy one overseas or in a different country. So lenses, lensing devices, the hypoglycemia emergency kits, extra batteries. Yeah, you're gonna pack all of that going away. And this is what happened to him. So when he was on that Japan trip that I was telling you about, he left everything in the backseat of the taxi, taxi was gone and he had no idea how to get this stuff back. So we got on a call with him. It was an odd time of the night, but we had him purchase all the traditional stuff, the lancets, the finger-strip testing, the test strips. Yes, we ordered a new CGM, but this will not come for him until he comes back home. So he had to do the testing by glucometer, whatever brand they had in Tokyo. And for his incident, we had to contact a physician there in Japan, the company's physician, actually, which was nice, they helped us set that up and disclose after his permission, all his medical history, his treatment, and the local physician was kind enough to put in the prescription for him. So it can get quite tricky if you lose all your stuff on the way. All right, so this is my last slide, which reminds us that we do all of this to control the complications. We don't control blood sugar so that we get a nice A1c. We don't control blood sugar so that they look, you know, we have a series of numbers that look nice on paper. We control blood sugar so that we don't get any of the complications, the retinopathy, nephropathy, macrovascular disease. That's our main goal. So it's doable. It's, again, getting more complicating for us, complicated for us, because we have now way more options than NPH and regular, and a finger stick or a urine dipstick. But on the other side of it is our patients have a lot of options, and now we can help them much more and individualize the treatment for them. So this is where I'll stop, and we have time for question and answers if you want, or a break. Yes, sir. Hippoglycemia is a tremendous sentiment and it's very, it's very scary. How do you coach your patients to not overwork? That's a great question. So the question is, hypoglycemia, as we alluded to, doesn't feel good. It brings the sense of impending doom. And how do we coach our patients not to overcorrect? Because a lot of time, patients just want to get back up, but next thing you know, they're 250. And if they have type 1 diabetes, they're kind of actually impending DKA now because they overcorrected. So it is one of those that comes with repeated coaching because no patient, the first time they experience it, will just take exactly 15 grams of glucose and wait 15 minutes and check again. And you know what the textbooks tell us to do. They'll be like, give me orange juice and give me... Actually, I once had a patient who their treatment of hypoglycemia was orange juice with three tablespoons of sugar in it. And this is what grandma taught them to do. So it's with repetition. It's like, okay, fine. You took three glucose tablets, well, three actually is the right one. You took 10 glucose tablets. Next time, try taking six and see what happens. And then when they realize like, oh, it worked with less, then next time you coach them to do a little bit less and a little bit less, and eventually they'll realize that they don't need to go full swing with panic mode. But it's not easy. And I think acknowledging it, like you said, acknowledging it with them that, hey, I know it feels like doom. It feels awful. Let's try to do it gently or gentler next time. We'll go a long way. Absolutely. Thank you.

team approach

managing diabetes

continuous glucose monitors

connected insulin pens

blood sugar control

hypoglycemia

diabetes management

individualized care

preventing complications