Changes In Diabetes Care A History Of Insulin & Pumps Past, Present, and Future John Walsh, P.A, C.D.E. jwalsh@diabetesnet.com Online slide presentation.

Changes In Diabetes Care A History Of Insulin & Pumps Past, Present, and Future
John Walsh, P.A, C.D.E. Online slide presentation

What We Will Cover Early history of diabetes Discovery of insulin
When insulin was found to not be the full answer High glucose as the culprit Lack of change in the A1c since the DCCT Why the dumb insulin pump has not helped What smart pumps offer The promise of intelligent devices The Super Bolus How simple and intelligent timers can help Screen shots from an intelligent device © 2004, John Walsh, P.A., C.D.E.

In 1500 BC Diabetes First Described In Writing
Hindu healers wrote that flies and ants were attracted to urine of people with a mysterious disease that caused intense thirst, enormous urine output, and wasting away of the body © 2004, John Walsh, P.A., C.D.E.

250 BC The Word Diabetes First Used
Apollonius of Memphis coined the name "diabetes” meaning "to go through" or siphon. He understood that the disease drained more fluid than a person could consume. Gradually the Latin word for honey, "mellitus," was added to diabetes because it made the urine sweet. © 2004, John Walsh, P.A., C.D.E.

150 BC Aretaeus the Cappadocian
Diabetes is a wonderful affection, not very frequent among men, being a melting down of the flesh and limbs into urine…The flow is incessant, as if from the opening of aqueducts…it takes a long period to form, but the patient is short-lived…for the melting is rapid, the death speedy. Moreover, life is disgusting and painful; thirst unquenchable; excessive drinking…and one cannot stop them either from drinking or making water... they are affected with nausea, restlessness, and a burning thirst; and at no distant term they expire. © 2004, John Walsh, P.A., C.D.E.

Early Diabetes Treatments
In 1000, Greek physicians recommended horseback riding to reduce excess urination In the 1800s, bleeding, blistering, and doping were common In 1915, Sir William Osler recommended opium Overfeeding was commonly used to compensate for loss of fluids and weight In the early 1900s a leading American diabetologist, Dr. Frederick Allen, recommended a starvation diet © 2004, John Walsh, P.A., C.D.E.

Early Research In 1798, John Rollo documented excess sugar in the blood and urine In 1813, Claude Bernard linked diabetes to glycogen metabolism In 1869, Paul Langerhans, a German medical student, discovered islet cells in the pancreas In 1889, Joseph von Mehring and Oskar Minkowski created diabetes in dogs by removing the pancreas In 1910, Sharpey-Shafer of Edinburgh suggested a single chemical was missing from the pancreas. He proposed calling this chemical "insulin." © 2004, John Walsh, P.A., C.D.E.

Near Miss In 1908, a young internist in Berlin, Georg Ludwig Zuelzer created a pancreas extract named acomatrol. After injecting acomatrol into a dying diabetic patient, the patient improved at first, but died when the acomatrol was gone Zuelzer filed an American patent in 1911 for a "Pancreas Preparation Suitable for the Treatment of Diabetes” Disappointing results, however, caused his lab to be taken over by the German military during WWI © 2004, John Walsh, P.A., C.D.E.

Other “Pancreas Extractors”
American scientist E. L. Scott was partially successful in extracting insulin with alcohol A Romanian, R. C. Paulesco, made an extract from the pancreas that lowered the blood glucose of dogs. Some claim Paulesco may have been the first to discover insulin about 10 years before Banting and Best. © 2004, John Walsh, P.A., C.D.E.

1922 Leonard Thompson In Jan, 1922, Banting and Best injected a year-old "charity” patient who weighed lb with 7.5 ml of a "thick brown muck" in each buttock Abscesses developed and he became more acutely ill However, his blood glucose had dropped enough to continue refining what was called "iletin” insulin 6 weeks later, a refined extract caused his blood glucose to fall from 520 to 120 mg/dL in 24 hours Leonard lived a relatively healthy life for 13 years before dying of pneumonia (no Rx then) at 27 © 2004, John Walsh, P.A., C.D.E.

Insulin Production Begins
First produced as “Connaught” by the Univ of Toronto On May 30, 1922, Eli Lilly signed an agreement to pay royalties to the University to increase production First bottles contained U-10 insulin 3 to 5 cc were injected at a time Pain and abscesses were common until purer U-40 insulin became available © 2004, John Walsh, P.A., C.D.E.

Impact Of Insulin On Life Expectancy By The 1940’s
Age at start of diabetes 50 30 10 Avg. age of death in 1897 58.0 34.1 11.3 Avg. age of death in 1945 65.9 60.5 45.0 Years Gained 8 26 34 © 2004, John Walsh, P.A., C.D.E.

Not A Cure Some early users died of hypoglycemia, but insulin seemed a remarkable cure. By the 1940’s, however, diabetic complications began to appear It became clear that injecting insulin was not the full answer © 2004, John Walsh, P.A., C.D.E.

What Caused Complications? High Glucose Versus Genes
During the middle of the 20th century, it was unclear whether better glucose control could prevent diabetes complications © 2004, John Walsh, P.A., C.D.E.

DCCT And Other Studies Research studies between 1970 and 2000 showed that complications could be prevented by lowering high glucose levels Studies DCCT EDIC 1996 UKPDS Kumamoto Results Better health Fewer complications Improved sense of well-being More flexible lifestyle Although research in the 1960’s through 1980’s strongly suggested that it was high glucose levels that were causing eye, kidney, nerve, and cardiovascular problems in diabetes, it was not until these large scale studies were done that a causal connection was confirmed. © 2004, John Walsh, P.A., C.D.E.

Little Change In A1c Since DCCT
8.6% in 396 Canadian Type 1s in 19922 9.7% in 1,120 German children in 19963 9.7% in in U.S. in NHANES III, 1988 to 1994 8.6% in 2,873 European children and adolescents in 19971 9.2% in 62 Canadian Type 1s in 2004 Unfortunately, A1c levels, a measure of glucose control over the previous 6-8 weeks, have not changed much since the DCCT results were published. A1c levels have certainly not reached the goal of 6.5% that is considered safe. Normal A1c levels are when between 4% and 6% of the hemoglobin molecules in the blood have glucose attached to them. GOAL: A1c < 6.5% HB Mortensen et al: Diabetes Care May;20(5):714-20 Diabetes Care May;20(5):714-20 Horm Res 1998;50:107–140 © 2004, John Walsh, P.A., C.D.E.

We Know What Controls The A1c
Several factors control the A1c. One is how often a person tests their blood sugars. Frequency of testing 378 pump (pre-smart) users Paul Davidson et al: Diabetes © 2004, John Walsh, P.A., C.D.E.

Controls The A1c Frequency of daily boluses
Another is how often injections or boluses for food or high blood sugars are given. Frequency of daily boluses yo pump users, r = TJ Battelino et al: Diabetes 2004 For injections: MP Garancini et al: Diabetes Care, 1997, 20, #11: © 2004, John Walsh, P.A., C.D.E.

1. Bode et al: Diabetes, 1999, 48 Suppl 1: 264
Controls The A1c Recording of BGs 0.5% drop in A1c in several studies Diet Approach1 CHO Counting Regulated WAG 7.2% 7.5% 8.0% Simply recording blood monitoring results leads to a lower A1c. Carbs are what raise the blood sugar after a meal. Carb counting lowers the A1c level more than “eating the same thing” or the Wild Ass Guess diet as Dr. Buce Bode likes to call it. 1. Bode et al: Diabetes, 1999, 48 Suppl 1: 264 © 2004, John Walsh, P.A., C.D.E.

Pre/Post DCCT A1c Results
On 4 inj % (0.4%) 72.6% (6.4%) or a pump Median A1c 8.3% 8.3% This study was done in over 18,000 German children who had A1c tests done over an 11 year period before and after publication of the DCCT results. No change was seen in the median A1c during this period despite a three fold increase in MDI and some increase in the use of insulin pumps from 0.4% to 6.4%.Small improvements were seen in some age groups and Regular insulin was still widely used in 2003, but this study and others have not been encouraging. 18,403 German children W Hecker et al: 2004 ADA, poster 22B © 2004, John Walsh, P.A., C.D.E.

What Causes High A1cs? Inaccurate carb counting *
Insulin doses that are incorrect, misunderstood, or missed entirely * Too hard to log all the data * Not adapting to spontaneous events * Complexity of the challenge * Unclear accountability * We know what causes high A1c levels. All of the factors above have the potential to be improved by intelligent and easy to use devices. * handled by well-designed intelligent device © 2004, John Walsh, P.A., C.D.E.

Our Current Diabetes Approach Does Not Work
Noncompliance is not a patient problem. It is a system failure. Dr. Paul Farmer First to successfully use complex drug regimens to treat AIDs and TB in Haiti Our current health care system approach to diabetes is not working. Infrequent medical visits, lack of recorded data, and the lack of helpful advice about insulin doses as diet and lifestyle decisions that affect control are made each day, all contribute to the poor A1c results. © 2004, John Walsh, P.A., C.D.E.

Current Treatment Interval (CTI)
Unlike many other chronic diseases where CTI is not critical, the current treatment interval in diabetes with a doctor’s visit every 3 to 4 months does not work © 2004, John Walsh, P.A., C.D.E.

Required Treatment Interval (RTI)
The required treatment interval in diabetes is every 2 to 5 hours rather than 3 to 4 months This is the typical time interval between decisions that significantly affect glucose levels, such as BG monitoring, food intake, and activity Only something that is both available and intelligent can assist the person with a chronic disease like diabetes © 2004, John Walsh, P.A., C.D.E.

When a system is not working for patients, trying harder will not work
When a system is not working for patients, trying harder will not work. Only changing the care system or our approach to care will work. The ability of health care workers to become smarter or work harder is very limited. We cannot treat diabetes effectively with an old health care system model. © 2004, John Walsh, P.A., C.D.E.

Convergence Toward Automation
I n s u l i n D e l i v e r y Insulin & syringes You are here Pumps Pens Closed Loop Connectivity Open Loop Data Management Advice/Feedback M o n i t o r i n g Home Monitors We are on a peth to automated blood glucose control. The workload of health care personnel will stay high through the current “self-management” stage. Only when useful devices which assist the user in making critical day to day control decisions become widely available will the medical workload begin to diminish. Clinic Monitoring HCP Self Management Automation Convergence Toward Automation © 2004, John Walsh, P.A., C.D.E.

Dumb Smart Intelligent Automatic
The features a device offers are nice, but the pumps, meters, and other devices offered to people with diabetes should be judged by a single goal: do they lower A1c levels and improve glucose stability. Results over Features! Do not judge a device by how cool it is, but by whether it lowers the A1c. © 2004, John Walsh, P.A., C.D.E.

Today’s Smart Pumps Carb boluses Correction boluses
Personalized carb factors for different times of day Easy carb bolus calculations Personalized carb database (soon) Correction boluses Personalized correction factors for different times Easier and safer correction of high BGs Reveal when correction bolus is high, ie > 8% of TDD Combined carb/correction boluses Automatic bolus reduction for Bolus On Board (BOB) Today’s Smart Pumps are leading the way. They offer easier bolus calculations and protect against bolus stacking. © 2004, John Walsh, P.A., C.D.E.

Today’s Smart Pumps Track Bolus On Board
Improved bolus accuracy Avoids stacking of bolus insulin Helps prevent hypoglycemia Requires BG reading for accuracy Guide whether carbs or insulin are needed Does not yet warn when carbs are needed © 2004, John Walsh, P.A., C.D.E.

Today’s Smart Pumps Reminders to Direct BG entry from meter
Test blood glucose after a bolus Warn when bolus delivery was not completed Test blood glucose following a low or high BG Give boluses at certain times of day Change infusion site Direct BG entry from meter Eliminates errors in data transfer Ensures that all blood glucose data will be entered into a database or logbook format Pump reminders are a big help with day to day control. © 2004, John Walsh, P.A., C.D.E.

Smart Pumps Do Not: Today’s pumps collect the information needed (insulin doses, BGs, carb intake, and timing), but they do not: Identify problem patterns Automatically test basals and boluses or warn when they are out of balance Suggest dose adjustments Warn of pending lows or suggest carb intake needed for excess BOB Warn when excess correction boluses are used Account for GI differences between foods Guarantee an improved outcome These are a few of the things that today’s Smart Pumps could do with the data they now collect or readily incorporated into a pump. © 2004, John Walsh, P.A., C.D.E.

Intelligent Devices Today’s “smart” pumps are migrating to better pumps, pens, and PDAs Calculus rather than formulas to set bolus amounts Auto analysis of BG patterns Fuzzy and artificial intelligence Provide automatic (retrospective) carb/insulin balance Use of A1c to focus therapy © 2004, John Walsh, P.A., C.D.E.

The Intelligent Device Hypothesis
Intelligent devices: provide meaningful advice, * improve lifestyles, * improve medical outcomes with diabetes.* * Yet to be proven Made by Unidentified company here © 2004, John Walsh, P.A., C.D.E.

Smart Vs Intelligent Devices
Feature Smart Intelligent Carb list Alphabetic By recent use Basal testing By user Automatic Bolus testing Exercise NA Timer Manual Corr. bolus Ignored Redistributed Super Bolus None # of hypos Communication Verbal Bidirectional © 2004, John Walsh, P.A., C.D.E.

Intelligent Devices Pumps Pens PDAs Smart Phones Meters
A central reporting station where data is filtered for minor versus major problems and who is to be alerted (user, guardian, MD/RN) Intelligence can be built into a wide range of devices. Part of the control solution has to come from a centralized monitoring station. This would involve computers and people who monitor real time or near real time BG and other data. Communication methods such as Bluetooth, telephone, and internet will be required. © 2004, John Walsh, P.A., C.D.E.

Demands On Intelligent Devices
Intuitive interface and language Must be impartial and fair Outcome driven – user feels better and is more confident about control Compatible with clinic workflow Well funded Able to rapidly evolve as errors appear Must close the data loop between user and MD © 2004, John Walsh, P.A., C.D.E.

Intelligent Device Ingredients
Automatic BG timer Automatic basal decrease Super Bolus Automatic basal/bolus balancing Automatic adjustment when correction boluses are overused Carb list and carb counter Exercise intensity and duration Database intelligence © 2004, John Walsh, P.A., C.D.E.

Intelligent Device Benefits
Provide immediate advice on situations Identify common or infrequent patterns Constant surveillance of data for changes Provide real meaning to BG values Integrate well with continuous monitoring and artificial intelligence © 2004, John Walsh, P.A., C.D.E.

Smart Phones And PDAs Fast internet & email communication
Convenient remote insulin delivery Larger food and carb database Better graphics for BG analysis, display of patterns, etc Larger event database for long-term analysis External controllers like these will be preferred by some users. For instance a cell phone could deliver a bolus discretely to a pump worn under clothing, or a PDA could hold a massive carb and nutrition database for someone who eats a wide variety of food, or who is on a sodium or phosphorous restricted diet. © 2004, John Walsh, P.A., C.D.E.

Intelligent Devices 300 personal carb selections with accurate carb counts Carb factor (1:1 TO 1:100) Correction factor (1:4 to 1: 400) 5 sec microdraw BG meter 0.1 unit precision motor Non-volatile memory 3,000 events Bluetooth data transfer Devices can come in all forms. Not yet in production, this is my design for an intelligent insulin pen which accurately delivers increments as small as 0.1 unit, calculates carb and correction doses, tracks bolus-on-board (BOB), predicts where the blood glucose will go when sufficient BG test data is available, communicates easily via a Bluetooth connection, and suggests the best time to begin eating after a meal bolus has been given, such as alerting the user when an elevated premeal blood glucose has reached a preselected value, such as 150 mg/dl (8.3 mmol). The dial to the right of the LCD scrolls through the choices on the LCD, and the button to its right will select that choice or the button to the left of the LCD will move the previous screen. © 2004, John Walsh, P.A., C.D.E.

Thoughts And Developments For The Future
© 2004, John Walsh, P.A., C.D.E.

Old Basal/Bolus Concepts
Basal insulin ~ 50% of daily insulin need Limits hyperglycemia after meals Suppresses glucose production between meals and overnight Bolus insulin (mealtime) Immediate rise and sharp peak at 1 hour 10% to 20% of total daily insulin requirement at each meal Our current concepts for basal and bolus insulin are becoming outdated. © 2004, John Walsh, P.A., C.D.E.

New: Rapid Basal Reduction
This is a simple example of how some of today’s pumpers deal with excess Bolus on Board at bedtime. This person has a 2 unit excess of bolus insulin even though their bedtime reading is slightly high at 150 mg/dl (8.3 mmol). To compensate, they use a temporary insulin reduction to remove 2 units from their basal delivery. This eliminates the need for a bedtime snack if the basal has been correctly set. This could be done automatically by today’s pumps. An intelligent device could provide precise estimates about when a basal reduction would work. For instance, in a situation where the BG is 90 mg/dl (5 mmol), but the amount of BOB suggests that the BG will drop too far before a reduction in basal delivery could begin to offset this drop, an intelligent device would not offer a basal reduction as an option for treatment and instead suggest how many carbs will be required to counter the BOB. A rapid basal reduction offsets excess BOB and eliminates the need to eat at bedtime. © 2004, John Walsh, P.A., C.D.E.

New: The Super Bolus A Super Bolus can be activated at a user-selected quantity, such as 40 or 50 grams The Super Bolus borrows basal to pay bolus. By stacking insulin at the time of a bolus, more insulin becomes available sooner. The corresponding reduction in basal delivery prevents hypoglycemia. A Super Bolus helps cover high GI foods and prevent postmeal hyperglycemia. A 3 or 4 hour block of basal insulin is turned into a bolus to speed its effect. © 2004, John Walsh, P.A., C.D.E.

New: The Super Bolus To ensure safety and success, the Super Bolus will require some clinical testing: How long can basal delivery be stopped or reduced without increasing the risk for clogging of the infusion line How long (3, 4, 5 hours?) can the basal be lowered before a rebound high will occur once the Super Bolus is gone? Is a reduction of the basal delivery rather than complete stoppage a better policy? If a person sets their basal delivery too low or too high, will this affect a Super Bolus? Although this is a fairly straightforward idea, some testing will be required. Pump companies have already done testing to determine how long a basal delivery can be reduced or suspended before occlusions become more common, and research has already been done on the decay in insulin action after basal delivery is suspended. © 2004, John Walsh, P.A., C.D.E.

New: High BG Super Bolus
Use of a Super Bolus to lower high blood sugars increases the velocity to goal and reduces glucose exposure greatly. If a pumper misjudges the carb content of a meal, a super bolus enables a faster, safe correction. © 2004, John Walsh, P.A., C.D.E.

New: A Reminder Timer This simple concept is brilliant and was brought to my attention by a Roche employee (call me with your name please!) after a presentation I gave for them. Ideally, all meals would be started 20 to 30 minutes later to allow insulin, which has almost no effect on the blood glucose for the first 20 minutes, to begin to work before the quick impact of a meal begins. A simple timer alerts the user 25 minutes after a bolus that it is safe to begin eating a high GI meal. © 2004, John Walsh, P.A., C.D.E.

New: An Intelligent Reminder
An intelligent pump alerts the user when their BG is likely to cross a selected threshold value, such as 120 mg/dl. They can then eat without exposure to extremely high readings. An intelligent device takes this further. A pump or device has all the data it needs to predict where the blood glucose will be up to 4 or 5 hours later and can alert the user to test their BG at the time they are likely to cross a certain desired threshold. © 2004, John Walsh, P.A., C.D.E.

New: Less Glucose Exposure
The lower the blood glucose is at the start of a meal, the less exposure to glucose there will be. This is why a smart timer is important. The A1c level rises higher the more we are exposed to glucose. Here, a pumper finds they have a BG of 300 mg/dl (16.7 mmol) before a meal. Should they eat right away? The “area under the curve” above reveals glucose exposure when a timer alerts the user to begin eating when their blood glucose has reached 100 mg/dl (5.6 mmol) as shown in blue, compared to if they begin to eat right away shown in red (plus green plus blue). © 2004, John Walsh, P.A., C.D.E.

New: An Intelligent Reminder
An intelligent pump alerts the user when their blood glucose is low enough to begin eating Here, a Suger Bolus is added for a faster drop in the glucose level, while a Smart Timer sounds when they have likely reached 120 mg/dl. They can then retest their glucose to ensure it is OK to eat. An intelligent device would also use this second BG test to check its own accuracy and check over time to ensure the basals and boluses are correctly set. © 2004, John Walsh, P.A., C.D.E.

Future Intelligent Devices
Screen shots from an intelligent device showing a simple reminder on top that today’s pumps could do, and on the bottom more detailed information provided by an intelligent device that predicts what the blood glucose level will be at a particular time or when a particular threshold will be reached. Useful reminders © 2004, John Walsh, P.A., C.D.E.

Future Pattern Management
Finding problem patterns enables solutions Set BG targets Gather and record data Analyze patterns in data Assess factors that influence patterns Recommend action © 2004, John Walsh, P.A., C.D.E.

Only A Few Patterns The relatively low number of BG patterns in diabetes makes them easy to identify: High most of the time Frequent lows High mornings (lunches, dinners, bedtime) Low mornings (lunches, dinners, bedtime) Postmeal spiking High to low Low to high Poor control with little or no pattern © 2004, John Walsh, P.A., C.D.E.

Overnight Basal Patterns
300 basal too low Dawn Phenomenon just right 200 just right 100 too high Checking the overnight basal lets you sleep soundly. A middle of the night test clarifies how to adjust these basals. bedtime 2 am breakfast Goal for overnight BG change = +/- 30 mg/dl © 2004, John Walsh, P.A., C.D.E.

User Interface – Critical Component
Despite 30 years of pump and meter development, device communication to the user is still in it’s infancy. © 2004, John Walsh, P.A., C.D.E.

Contains a 500 food or larger personally selected database or carbs, glycemic index, calories, fat, etc, to allow for exact determination of carb and calorie intakes. A carb bolus recommendation is made immediately after the entire meal is selected. Carb database for accurate carb counts. © 2004, John Walsh, P.A., C.D.E.

Carb intake can be tracked and recommendations given, such as in the top screen where a certain carb intake would be higher than the user’s preselected daily limit. The built-in food database can track total calories as well as carbs to reach a weight goal. The bottom screen shows a specific carb intake needed at that time to cover a low blood glucose, taking into account the BOB. Suggestion for carb intake or to limit intake based on weight/calorie/carb goals © 2004, John Walsh, P.A., C.D.E.

The user enters the intensity (based on a 1 to 10 personal scale) and duration (in 5 minute increments) of exercise or activity. The device can then make specific recommendations for carb intake or insulin dose reductions. The device can “learn” over time how to evaluate one individual’s interpretation of the intensity of their exercise from their resulting blood sugars. A timer could be automatically started to alert the user when to test during or after exercise based on the intensity and duration. Recommended carb intake (or insulin reduction) to balance activity. © 2004, John Walsh, P.A., C.D.E.

Here, the device alerts the user about an elevated current A1c value obtained via the Bluetooth connection, an excessive use of correction bolus insulin from data stored in the pen, and that low blood sugars are rare at this time from the BG record also stored in the pen. An increase in insulin doses is recommended based on the information. Entry of the Lantus or other long-acting insulin dose is done on another screen. New dose recommendations based on A1c, % of TDD given as correction boluses, and frequency of hypoglycemia © 2004, John Walsh, P.A., C.D.E.

Here specific patterns are addressed. In the bottom screen, due to a pattern of night lows following a certain intensity and duration of exercise that day, a basal reduction of a certain percentage and duration can be recommended to prevent a night low. The device keeps track of how well this basal reduction works to make more precise adjustments in the future. Pattern alerts and advice © 2004, John Walsh, P.A., C.D.E.

Bluetooth allows fast transfer of lab results and other information, such as this A1c result from the doctor’s office. Fast lab results without calling. Messaging allows physician to make recommendations. © 2004, John Walsh, P.A., C.D.E.

Pump Plus Continuous Monitor
Automatic basal and bolus testing Trends allow exact short-term BG predictions for rapid recognition of pending highs or lows Both user and device can relate problems to their source Unfortunately, insulin delivery from an external pump is too slow to create an effective artificial pancreas with this combination © 2004, John Walsh, P.A., C.D.E.

The Closed Loop Will Close Slowly
Patents impede device development FDA is slow to allow medical care from a device or via telemedicine Slow acceptance by medical personnel and people with diabetes Liability issues Large financial incentives in current meter and pump technology Even so, truly intelligent and helpful devices could be created soon. © 2004, John Walsh, P.A., C.D.E.

Changes In Diabetes Care A History Of Insulin & Pumps Past, Present, and Future John Walsh, P.A, C.D.E. jwalsh@diabetesnet.com Online slide presentation.

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Changes In Diabetes Care A History Of Insulin & Pumps Past, Present, and Future John Walsh, P.A, C.D.E. jwalsh@diabetesnet.com Online slide presentation.

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Presentation on theme: "Changes In Diabetes Care A History Of Insulin & Pumps Past, Present, and Future John Walsh, P.A, C.D.E. jwalsh@diabetesnet.com Online slide presentation."— Presentation transcript:

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